China: a return to the “kingdom of bicycles”?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k94 (Published 15 January 2018) Cite this as: BMJ 2018;360:k94
All rapid responses
One of the best ways to build a healthy and safe cycling environment is to encourage more people to cycle and so increase safety in numbers. Cycling has not only flourished in many cities that introduced bike-share schemes, safety has improved considerably.
New York’s scheme had 8.2 million bike-share trips in its first year (2013) yet deaths and serious injuries in the bike-share zone fell by 17%. Deaths and serious injuries per 100 million bike trips in the entire city fell from 446 in 2006-2010 to 292 in 2011-16 .
Dublin’s scheme launched in 2009 with 450 bikes. There were over 2,200 trips per bike (more than 6 trips per bike per day) in its first year . It was considered to be very safe with no reported injuries in the first 10 months and only one bike going missing .
As cycling flourished in Dublin, it became much safer. Before the bike-share scheme, only 3.8% cycled to work in the Dublin Regional Authority (2006 census), increasing to 5.0% in 2011 and 6.7% in 2016. In Dublin city, 10.3% now cycle to work (2016 census); 13.9% of those aged 19+ and 8.6% of 13-18 year olds cycle to school, college or university. Annual counts of cyclists entering Dublin from 7-10 am increased from 6,143 in 2008 to 12,089 in 2016 ; cycling now accounts for 12.9% of traffic in central Dublin . Despite these substantial increases, road deaths to cyclists in Dublin have not increased, implying that cycling is now safer as well as more popular .
Prof Kay Teschke collated statistics on cycling to work in four North American cities that introduced bike-share schemes, compared to five that did not. There was a substantially greater increase in bicycle commuting in the bike-share cities, yet the total number of injuries decreased in bike-share (but not control) cities, again showing that more cycling means safer cycling .
Sadly, Melbourne and Brisbane’s bike-share schemes (with only 0.3 to 1.0 trips per bike per day, a tiny fraction of Dublin’s 9, Barcelona’s 6, or China’s 3 trips per bike per day [8-10]) have not generated the same increases in cycling nor safety. In a survey about Melbourne Bike-Share, 61% of respondents identified helmets as the main barrier to using the scheme .
Two recent studies associated helmet use with increased injury rates. 1) Individuals with documented helmet use had 2.2 times the odds of non–helmet users of being involved in an injury-related accident ; 2) helmet use by transport cyclists was associated with being injured while cycling in the past 2 years, OR=2.81 .
In a study of Canadian cyclist injuries, helmet legislation was not associated with reduced hospitalisation rates for brain, head, scalp, skull or face injuries. Females had lower hospitalisation rates than males, and higher cycling mode share was consistently associated with lower hospitalisation rates for traffic-related injuries, suggesting a ‘safety in numbers effect’ .
New Zealand introduced helmet laws in 1994. Travel surveys (conducted in 1989 and 1997) show big declines in time spent cycling per week, from 28 to 15 minutes per child aged 5-12, from 52 to 31 minutes for 13-17 year olds and 8 to 5 minutes per week for adults. The declines in cycling were accompanied by increased injury rates per million hours of cycling . Evidence from Australia also suggests that injury rates per cyclist increased, compared to what would have been expected without the helmet law . Cycling injuries continue to increase in Australia  without any increase in participation .
Hu and Yin discuss the major health and environmental benefits of cycling for transport, but then advocate helmet laws, which have resulted in substantial reductions in cycling, e.g. a 48% drop in numbers of teenage cyclists counted in Melbourne a year after the introduction of the helmet law.
The recommendation for helmet legislation seems to be misguided. The most likely outcome is that fewer people will cycle than without the law, leading to lost health and environmental benefits, together with increased injury rates from risk compensation and reduced safety in numbers.
1. NYCDT, Safer Cycling: Bicycle Ridership and Safety in New York City. New York City Department of Transportation. Available at: http://www.nyc.gov/html/dot/html/bicyclists/bike-ridership-safety.shtml, 2017.
2. Daly, M., What's the secret of the Dublin bike hire scheme's success? The Guardian Bike Blog, http://www.theguardian.com/environment/bike-blog/2011/aug/04/dublin-bike..., 2011.
3. Mangan, S., More than 37,000 use bike scheme, in Irish Times, Dublin. Available at www.irishtimes.com/news/more-than-37-000-use-bike-scheme-1.6355482010.
4. Kelly, O. More than 12,000 cyclists a day commute into Dublin city. Available at: www.irishtimes.com/news/environment/more-than-12-000-cyclists-a-day-comm.... 2017.
5. Cycle, I. Pedestrians-and-cyclists-nearly-50-of-traffic-in-dublin-city-centre-counts. Available at: http://irishcycle.com/2018/01/22/pedestrians-and-cyclists-nearly-50-of-t.... 2018.
6. Cycle, I. Cyclist deaths and injuries on Irish roads. Available at: http://irishcycle.com/collisions/. 2017.
7. Teschke, K. and M. Winters. Letter to the Editor of the American Journal of Public Health, available at: http://cyclingincities-spph.sites.olt.ubc.ca/files/2014/06/Graves-AJPH-a.... 2014.
8. Rogers, M. and C. Keenan, Making Dublin More Accessible:The dublinbikes Scheme, http://trics.org.uk/conference12/martin_rogers.pdf, 2012.
9. Fishman, E., Bikeshare: A Review of Recent Literature. Transport Reviews, 2016. 36(1): p. 92-113.
10. Hu, G. and D. Yin, China: a return to the “kingdom of bicycles”? BMJ, 2018. 360.
11. Fishman, E., et al., Barriers to bikesharing: an analysis from Melbourne and Brisbane. Journal of Transport Geography, 2014. 41: p. 325-337.
12. Pedroso, F.E., et al., Bicycle Use and Cyclist Safety Following Boston’s Bicycle Infrastructure Expansion, 2009–2012. American journal of public health, 2016. 106(12): p. 2171-2177.
13. Porter, A.K., D. Salvo, and H.W. Kohl Iii, Correlates of Helmet Use Among Recreation and Transportation Bicyclists. American Journal of Preventive Medicine, 2016. 51(6): p. 999-1006.
14. Teschke, K., et al., Bicycling injury hospitalisation rates in Canadian jurisdictions: analyses examining associations with helmet legislation and mode share. BMJ open, 2015. 5(11): p. e008052.
15. Trends in Cycling, Walking & Injury Rates in New Zealand. Available at: http://www.cycle-helmets.com/new-zealand-road-users.html. 2014.
16. Robinson, D.L., Head injuries and bicycle helmet laws. Accid Anal Prevent, 1996. 28: p. 463-475.
17. Beck, B., et al., Road safety: serious injuries remain a major unsolved problem. The Medical Journal of Australia, 2017. 207(6): p. 244-249.
18. Munro, C., Australian Cycling Participation Survey. Results of the 2017 National Cycling Participation Survey, 2017, Commissioned by the Australian Bicycle Council. Available at: http://www.bicyclecouncil.com.au/publication/national-cycling-participat....
Competing interests: No competing interests
It is welcome to observe that China is appreciating the consequences of mass motorisation, and taking steps to retrieve its famous culture of mass bicycle use . It is a pity that bicycle helmet compulsion has gained credibility in Chinese policy thinking.
Industry applies the “Hierarchy of Hazard Controls” to reduce risk. The Hierarchy stresses that the greatest effort must be invested in removing sources of danger, in order to prevent injuries from happening. In contrast, the use of safety equipment, such as helmets and high visibility clothing, occupies the lowest priority, on the basis that these measures are comparatively ineffective .
Applying this to bicycling, risk reduction must focus on reducing traffic speeds and volumes, and separating bicyclists from fast moving, heavy traffic. This has been applied in countries with extant high levels of bicycle use, such as the Netherlands, with telling effect in having sustained the bicycle as normalised, safe daily transport. In contrast, twenty years of UK government policy to promote bicycling have failed .
The key issue in considering the use of helmets is of course the risk. In recent years, more detailed assessment of risk in personal travel in England has been published . This shows that risk varies considerably more by age than by mode of travel. The range of risks experienced in bicycling are in the same range as faced in walking or driving, except possibly for the most elderly bicyclists.
In conclusion, there is no objective reason to consider even the promotion of helmets for bicycling, in the absence of similar measures for all other road users.
1. Hu G, Yin D. China; a return to the “kingdom of the bicycles”? BMJ 2018 doi: 10.1136/bmj.k94
2. “Management of Risk When Planing Work.” Health and Safety Executive. http://www.hse.gov.uk/construction/lwit/assets/downloads/hierarchy-risk-...
3. Wardlaw M. History, Risk, Infrastructure: perspectives on bicycling in the Netherlands and the UK. https://doi.org/10.1016/j.jth.2014.09.015
4. Feleke R, Scholes S, Wardlaw M, Mindell J. Comparative fatality risk for different travel modes by age, sex and deprivation. https://dx.doi.org/10.1016/j.jth.2017.08.007
Competing interests: No competing interests
As has been widely reported and reasonably widely appreciated, bicycles are both preventative and cure for many modern ills and as such fully deserve a place at the table of public health discussion. What is less well appreciated when cycling is discussed is the degree to which cycle helmets and bright clothing make a difference to safety: as we see in the editorial by Hu & Yin it is often assumed they make a significant difference, but as Ben Goldacre and David Spiegelhalter noted in their BMJ editorial of 2013 it is not that simple where helmets are concerned and there is also a lack of supporting evidence beyond "common sense" that bright clothing makes any tangible difference.
The "Get Britain Cycling" enquiry of 2013 produced a report from 6 weeks of expert evidence on how to grow cycling in the UK, and in specifically recommending that "Cycling should be promoted as a safe, normal, enjoyable and aspirational activity for people of all ages, backgrounds and abilities" and "Cycling imagery should show diverse people, wearing smart or ‘normal’ clothing" it took a clear line that showing cycling as an everyday thing is preferable to highlighting dangers and trying to alleviate them with measures that have been seen to put people off cycling in the first place and have no solid track record of doing good for cycling populations.
Much of the encouragement of helmets and hi-viz is down to a genuinely well meaning belief that cyclists are safer if they wear them, and I suspect this is why they are being suggested by Hu & Yin, but in the absence of clear evidence that this is really the case, and until it is properly shown that their promotion does not affect cycling levels (since we know that more people on bikes means better public health), it is at best unhelpful to keep on pushing for their promotion or requirement as policy.
The paramount principle needs to be that any barrier to cycling is a public health own-goal, and consequently barriers need to be removed rather than erected. The more strongly we tell people that they should use special safety equipment to ride a bike the more strongly we tell those that are averse to using such equipment for any reason that they should not be riding a bike.
 Bicycle helmets and the law, Goldacre, Spiegelhalter , BMJ 2013;346:f3817 doi: 10.1136/bmj.f3817
 Get Britain Cycling, Goodwin, All Party Parliamentary Cycling Group, https://allpartycycling.files.wordpress.com/2013/04/get-britain-cycling_...
Competing interests: Member of Cycling UK
I enjoyed the editorial by Hu and Yin until the last paragraph plug for compulsory helmets and high viz. I ride a bike every day to get to work and for house calls and don't like helmets and high viz. Firstly they 'dangerise' cycling, implying cycling as unusually hazardous and productive of head injuries. Secondly, they demonstrate the wearer has bought into the idea that they are safer wearing one despite all the evidence to the contrary.
Cycling has an image problem. One doesn't wear a helmet during other low risk activities like walking or driving; most would view such activities as too safe to warrant it, but cycling is somehow different. In a DfT survey in 2014 (1) 64% of people considered it too dangerous for them to cycle on the road. But this perception is false. Cycling is safer than walking per km travelled and is comparable to riding in a car per hour spent (2). A typical urban cyclist in Britain exposes themselves to similar risk as a Dutch cyclist (3). Helmets and high viz reinforce cyclists as an 'out' group and put people off cycling. Cyclists benefit from a safety in number effect (4) so anything that reduces cycling makes it less safe. There is overwhelming evidence that cycling, helmeted or not is health enhancing (5). Helmets laws have skewered cycle hire schemes in Australia and Seattle (6, 7, 8). In Israel and Mexico City cycle hire schemes only took off when helmet laws were repealed (9, 10). No jurisdiction exists that combines high helmet use with high cycle use. In the safest cycling countries like the Netherlands and Denmark people wear normal clothes and few cycle with helmets. Cycle helmets and high viz are a barrier to cycling.
An BMJ editorial from 2013 nicely summarised the debate about helmet effectiveness (11). One can pick and choose from a weak evidence base either way, but the promised benefits of helmet wearing from case control studies have never materialised in real life. One would hardly expect great things from the design envelope of a cycle helmet, which is supposed to withstand about a 13mph impact (12). Those racing down hills at 35mph may as well wear a rabbit foot around their neck as a helmet for all the good it'll do them.
If cycling is to flourish as the authors wish, an absence of helmet laws will help. The Australian and NZ experience with large falls in cycling since their laws were enacted should be enough of a warning to China (13, 14). I found it surprising that the authors think it will encourage more people to cycle by punishing those who don't wear helmets. Cycling organisations the world over oppose compulsory helmets for good reasons, it was so sad to see it plugged in this editorial.
1. British Social Attitudes Survey 2014, DfT.
2. Reported road casualties in Great Britain, main results: 2015
3. History, risk, infrastructure: perspectives on bicycling in the Netherlands and the UK,
Malcolm J.Wardlaw, Journal ofTransport&Health1(2014)243-250
4. Safety in numbers: more walkers and bicyclists, safer walking and bicycling, P L Jacobsen, Injury Prevention 2003;9:205-209
5. Health on the Move 2. The Transport and Health Study Group. http://www.transportandhealth.org.uk/?page_id=32
8. On your bike: the best and the worst of city cycle schemes , The Guardian. https://www.theguardian.com/money/2017/feb/25/best-and-worst-city-cycle-...
9. How did we revise the compulsory helmet law in Israel? Sustainabilitiy.org.il http://www.sustainability.org.il/home/bike-news/How-did-we-revise-the-co...
11. Bicycle helmets and the law, Goldacre, Spiegelhalter , BMJ 2013;346:f3817 doi: 10.1136/bmj.f3817
12. Heads Up, Walker, B. Cycle Magazine, Jun/Jul 2005 http://www.cyclehelmets.org/1215.html
13. Australian per capita cycling participation in 1985/86 and 2011. Chris Gillham, Chris Rissel, World Transport Policy and Practice, Volume 18.3 May 2012
14. Cycling New Zealand Household Travel Survey 2011 - 2014
Competing interests: Contributor to the charity Roadpeace and member of Cycling UK.