Promoting walking and cycling as an alternative to using cars: systematic review
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38216.714560.55 (Published 30 September 2004) Cite this as: BMJ 2004;329:763All rapid responses
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I guess we will all see the BMJ study through our own eyes! There
has been much discussion in the cycling policy discussion group. The
study rightly says that not much will change, but when the system is
designed to prevent any modal shift towards cycling, walking or public
transport, what surprise is that?
It is quite clear to me that the physical environment we now live in,
has been made into a barrier, and every day practice reinforces the
barrier affect. The effect of forty + years of segregating residential
development by design (Radburn Layouts and DB32, (Guidance for Residential
Development)); the mindless use of Design Manual for Roads and Bridges
(DMRB) (because national policy regarding integrating mixed-use streets
was that they would disappear - therefore guidance for them was
irrelevant) and the bizarre approach of Planning in general that only
segregated development was acceptable, have, together made walking,
cycling and public transport all but impossible. That is particularly so
for most new development since the 40s.
The segregation by physical layout is now deeply embedded and if you
propose even a foot route through a cul-de-sac development you will
discover the depth of negative feeling.
With buyers, developers, DC Officers, Highways and the dreaded
Highways Safety Audit all (mostly) working against integration and mix,
the job of promoting the benign modes is at least, vexed.
It is continually surprising to me that those interested in public
health and increasing obesity; those interested in 'Bobbies on the beat';
those interested in the efficiency of the emergency services; those
interested in making bus journeys more desirable; those who moan about the
food deserts created by ever larger superstores; and those who bemoan the
loss of the local high street (to name but a few) have not raised more of
a cry about the mind numbing consequences of DoT, DoE, DETR, ODPM, DfT
policies regarding urban layout. Everything is focused on maximizing
capacity and in increasing speed for motorized private travel.
Oxford is a surprising disbeneficiary of this thinking at a local
level!
Competing interests:
None declared
Competing interests: No competing interests
With all due respect to Dr Blaj, these "Rapid Responses" are an
ongoing discussion. Individual contributions cannot be understood unless
one reads the previous ones. "Exercise fascism" (or "exercise fascists")
is not my term at all but Dr Hardy's. (above) I was simply responding to
his provocative comment.
Competing interests:
None declared
Competing interests: No competing interests
When Dr Leavitt says, "the more one looks at the complications the
more it seems that some exercise fascism may be unavoidable if we want to
improve public health," then there indeed lies the rub. He raises a very
valid point.
On the one side, some people will contend that ALL medical
interventions are fascist or dictatorial; on the other side, some people
will say this is merely 'friendly advice' that the patient is free to take
or leave. Deciding which is which might prove to be a difficult matter.
Competing interests:
None declared
Competing interests: No competing interests
We agree with Carnall, McGrath and Stevens that many of the
interventions about which we found evidence were unlikely to have large
effects in the face of strong economic and personal interests to the
contrary, and with Yeates that many of these interventions had rather
limited ambitions or evaluation timescales. We also agree with Lingwood
that the complexity of transport-related behaviour and interventions makes
it difficult to establish causal relationships between interventions and
outcomes.
However, these do not constitute arguments against the approach we
have taken. The evidence about barriers to cycling, to which Lingwood
refers, is undoubtedly relevant and contributes another piece in the
jigsaw of evidence. But we cannot simply assume that measures which appear
to address these factors will necessarily lead to the desired
results [1] — a point well illustrated by Smith. The UK Department for
Transport has recently admitted that the National Cycling Strategy (NCS),
to which Lingwood also
refers, has had no effect on the overall level of cycling in England
despite its good intentions. [2] One reason identified by the NCS board is
a lack of political will to address the deeper causes and competing
interests to which Carnall and King refer. [3] The NCS board also notes
that transport policy can often appear to be pursuing conflicting goals —
a point well illustrated by Sinclair.
We hinted in our discussion that more ambitious measures might be
more effective, and our findings are consistent with (if not proof for) a
view that much more radical changes in society would be required to
achieve significant population health gain through a modal shift towards
walking and cycling. Carnall complains that we have treated driving as a
disease and ignored the social forces which underlie it, but this is not
the case. We set
out with an entirely open mind as to what types of “intervention” might be
relevant, and searched for evidence accordingly (readers can verify this
by examining our search strategy on bmj.com). We hoped to find evidence
about the effects of policies on, for example, car advertising and
suburban planning and would certainly have included such evidence if we
had found it. The “weakness” he mentions is not a weakness of the
“evidence-based” approach, but a lack of relevant primary research on the
factors he identifies.
Qureshi makes the remarkable assertion that our review is biased in
favour of using cars and underplays the potential health benefits of
walking and cycling. Qureshi has chosen to attack a straw man. As we
indicated (albeit briefly) in our introduction, the belief that promoting
a modal shift would be desirable on public health grounds was the starting
point for our review. It was not a review of epidemiological evidence
about the health benefits of walking and cycling; it was a review of
effectiveness to find out what actually works in achieving these potential
benefits in populations. We found relatively little evidence with which to
answer this particular question at present, but this is completely
different from saying that walking and cycling are not beneficial to
health or that promoting a modal shift is not a desirable goal of public
policy. Kern is another correspondent who fails to distinguish between
evidence that cycling is good for people and evidence of what works in
promoting a modal shift. He also misquotes us: we did not say that Phoenix
or Eugene are healthy places, we merely identified them as places where
relevant research has been carried out.
These and other readers may have been unduly influenced by the
editors’ summary in “This week in the BMJ”, which contains an error of
fact (“Reviewing 22 studies analysing
the effect of targeted behaviour change programmes”) and opens with the
statement that “Encouraging people to use alternative and healthier modes
of transport may not be
enough to improve the health of the population”. Readers will struggle to
find such a statement anywhere in our paper. The authors did not see the
piece in “This week in the BMJ” before publication and do not endorse it
now.
References
1. Macintyre S, Petticrew M. Good intentions and received wisdom are
not enough. J Epidemiol Community Health 2000; 54: 802-3.
2. Department for Transport. Walking and cycling: an action plan.
London: Department for Transport, 2004: 7.
http://www.dft.gov.uk/stellent/groups/dft_control/documents/contentserve...
3. Bike for the future: the NCS board for England's strategic action
plan - "more people cycling, more safely, more often". London: National
Cycling Strategy Board, 2004: 5-6.
http://www.nationalcyclingstrategy.org.uk/fileuploads/ncsb/NCSB098.pdf
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
May I bring your attention to a recent publication "The Drive to Work
in O & G",(2000)Barts and The London Chronicle,2,28-29, which revealed
additional benefits for senior academics who walk or cycle to work.
Our survey of the professoriate at that time, 53 of the 57 professors
responding to the questionnaire, showed a clear correlation between
locomotion and publication rates seen.
The youngest professor at that time had never driven to work and went
on to receive a £20,000,000.00 MRC sponsored grant.
Perhaps all academics will soon have their method of locomotion to
work assessed.
Yours sincerely
Gedis Grudzinskas
Competing interests:
None declared
Competing interests: No competing interests
Madam: I note that Frank J Leavitt uses his favourite expression
'exercise fascism' four times in three paragraphs (and title). I am
really at a loss trying to understand this new concept; would Mr Leavitt
be kind enough to let us know whether exercise communism/socialism would
be more suitable for us?
Competing interests:
None declared
Competing interests: No competing interests
I would like to agree with Dr Hardy about coercion. I am an exercise
freak, but who can favour any fascism, including exercise fascism? If
someone doesn't want to exercise, that is his or her business. And don't
plenty of fat, soft lazy people live to healthy old age? Let's all accept
each other's ways of life and stay friends.
But Dr Hardy's criticism leads to an important question for the
ethics of public health. Can exercise-promoting public health
interventions be designed to be non-coercive? This is complex because your
coercion (restricting your motorcar or cigarette use for example) can be
my protection from your polluted air, deadly vehicle, etc.) Again, where
is the line between education and coercion? If we don't provide schoolbus
service to children who live within a certain radius, are we educating or
coercing? Also, encouraging bicycling is not necessarily totally benign.
Michael Vandeman has written about ecological damage done by mountain
bikers
(http://home.pacbell.net/mjvande/scb7.htm Accessed 16th October 2004)
So it seems that any intervention aimed at encouraging one way of
life risks coercing those who prefer other ways. As I started to write
this response I wanted to join Dr Hardy's opposition to exercise fascism.
But the more one looks at the complications the more it seems that some
exercise fascism may be unavoidable if we want to improve public health.
Competing interests:
None declared
Competing interests: No competing interests
I am part-time GP in a sub-urban practice on the North East coast and
I cycle to work twice a week (round trip 17 miles). I also do home visits
on my bike (usually 3-5 miles but has been upto 18 miles), as do both of
my partners (though one only does so on sunny summer days!). All the
equipment needed can easily be carried in a ruc-sac/single pannier and
patients are generally positive about a GP turning up in a day-glo jacket.
The only days that I don't cycle to work are those when it is
actually raining when I look out of my bedroom window in the morning, if I
am unwell, or if my partners are on holiday and I can sense a 13 visit
day!
Due to the rush-hour congestion, my journey time is comparable to
that in my car, and I feel this is very important point. There are few
structural cycle "iterventions" on my route to work, but most of those
that there are I ignore. This is because they slow my journey down (eg. to
get around a roundabout on the cycle path can involve giving-way to the
car traffic 4 times), are littered with glass, have a terrible road
surface, or just take me on a large detour. If cycling was going to make
my journey take twice as long I wouldn't do it. As well as being 'safe',
cycle paths have to make journey times shorter. To do this they have to go
where people want to go, give priority to cyclists over cars, not be
covered in broken glass and not be used as a local residents' parking
lane.
Competing interests:
The bike I use for work was bought out of Prescribing Incentive Savings as a health promotion activity.
Competing interests: No competing interests
We should thank Ogilvie et al for their work and research - they
highlight the crucial issue of the need to promote cycling and walking as
a way of promoting individual health. But I am concerned that their main
conclusion, viz:
"interventions that engage people in a participative process and
address factors of personal relevance may be more effective than those
that simply aim to raise awareness or impose changes in the physical and
economic environments".
may be taken a little too seriously by at least those in the area of
health promotion.
I think there is a mismatch of philosophy and technique. I am always
amazed how medical studies can produce meaningful results from small
sample sizes. Transport planning and travel behaviour do not allow such
easy interventions or conclusions. We are dealing with a very dynamic
environment - a combination of such factors as the road environment,
financial costs, personal circumstances, national and local policy, travel
assumptions etc etc. Within this environment it is very difficult to prove
that any single intervention will have a significant effect.
There is however a weight of evidence which shows what the barriers
to cycling are and the kinds of interventions that will make cycling more
attractive. The single most prominent is the perception of safety, for
which the speed, volume and behaviour of car and other motorised vehicle
drivers is the determining factor. The conclusion of this is that there is
no use by itself promoting cycling unless cyclists can make their journeys
in a cycle friendly road environment.
As the authors point out, the difference in cycling levels between
nations and towns is of the magnitude of 50 from perhaps 50% of trips in
Groningen to around 1% in several UK cities. It is difficult to explain
these differences by any one factor - I have tried out correlation tests
on data from around 100 European towns, UK census data and all
industrialised countries. The really significant correlation (around 0.95)
is the historical level of cycling - ie a country or town with high or low
levels of cycling will continue to have high or low levels of cycling or
put another way, behavioural change is slow.
Throughout Europe in most northern countries, cycling is already
relatively high and on the increase. UK along with Spain and Portugal is
at the bottom of the pile and decreasing. One fact highlights the
discrepancy - in Netherlands, 50% of all children's journeys are by cycle
and increasing, in UK it is 1% and decreasing.
Through our ERCDT (English Regions Cycling Development Team) reports
(on the National Cycling Strategy website
www.nationalcyclingstrategy.org.uk
with an 2004 update shortly to be posted) we have highlighted a range of
factors and changes necessary by local authorities to increase cycling.
The most important issue currently is for the those involved in
health promotion to work with local authorities in preparing their second
round of local transport plans (2006-2011) to ensure that the promotion of
walking and cycling (by the whole range of interventions) is central to
future policy.
Competing interests:
English Regions Cycling Development Team (ERCDT)
Competing interests: No competing interests
Does physical exercise reduce car use?
Sorry to write so many responses here. But an important aspect of
this discussion has not yet been touched.
I participate in stenuous physical exercise, with training sessions
at least four evenings every week. I also bicycle quite a bit for physical
fitness. I live too far from work for bicycle commuting, however. So I
keep my bicycle at work and use it primarily for fitness, and for
transportation in the region of the university. The vast majority of my
kilometrage is by car. Also, needing some substantial equipment for
training sessions I use the car to take my equipment to and from the
training hall, even though it is within very short walking distance from
my office. One of my trainers lives far from the training hall and drives
at least an hour and a half each way, twice a week, to come and teach us.
I also use the car quite often to get to training sessions in far away
cities. Although I am not a competitive cyclist or serious bicycle
tourist, I often see bicycles carried on racks on cars on their way to or
from meets or touring take-off points. Maybe some inverse correlation
obtains between physical exercise and car use. But factors of the sort
which I have mentioned would seem to make it very hard to establish such a
correlation.
Competing interests:
None declared
Competing interests: No competing interests