Mandatory Bicycle Helmets for Cyclists: Tell us What You Think

I hope the CJSM and CJSM blog readers have had the chance now to take a look at this month’s CJSM to read the CASEM statement on mandatory bicycle helmet use and the accompanying editorial by Murray Maitland. We wrote a blog post about the subject earlier this week and have heard back from some of you on our twitter feed @cjsmonline.

I wanted to give more of the on-line a community to share their thoughts, and so I’ve set up a poll (below).  Please vote,  and I also want to encourage you to scroll to the bottom of this blog post where you can leave your comments to engage with us and others in an on-line discussion about this important, controversial sports medicine and public health issue.

Exercise your right to vote!  Make your voices heard!  As Dr. Maitland writes, “Don’t say something by not saying something.”  Vote and “Leave a Reply,” but please remember to be civil.  All comments are moderated.   Thanks for your engagement!

p.s. I’ve received so many comments on this and the previous post, especially from folks in Australia and New Zealand where MHL is in place, that I wanted to share a monograph from the Centre for Accident Research & Road Safety (CARRS).  It is a comprehensive review of so many of the aspects of this issue brought up by the people writing in:  CARRS’ Bicycle Helmet Research, Monograph 5.  Check it out.

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About sportingjim
I work at Nationwide Children's Hospital in Columbus, Ohio USA, where I am a specialist in pediatric sports medicine. My academic appointment as an Associate Professor of Pediatrics is through Ohio State University. I am a public health advocate for kids' health and safety. I am also the Emerging Media Editor for the Clinical Journal of Sport Medicine.

70 Responses to Mandatory Bicycle Helmets for Cyclists: Tell us What You Think

  1. Larry Meadors says:

    From a personal safety standpoint, I believe it is a good idea, but I get concerned that we have to have “Big Brother” mandate how we are to conduct our lives, plus our law enforcement agencies are pre-occupied with a lot of other more important issues.

    • Richard Oddy says:

      Helmets are compulsory in New Zealand and Australia. I never wear one and have an exemption from Transit New Zealand. In my view the emphasis should be on prevention of the crash – far too many cyclists ignore traffic signals and don’t have lights at night, but wear a helmet. The benefit of a helmet is overated. The have also deterred some people from biking and give the impression that cycling is dangerous. Wear one if you wish by all means but focus on matters that prevent the crash. I have biked for the last 55 years and not worn a helmet or had the need for one – I have cycled up to 30,000 km in a year. I own a cycle tour company. If you want to encourage cycling, the last thing to do is make helmets compulsory.

      Richard. Auckland

      • Lets not forget to also focus on motorist/driver responsibility and make sure that they are educated and held accountable for how they drive. In this country if you don’t flee the scene, are sober, and claim you didn’t see cyclist you go free and avoid murder charge, jail time, fine, etc. no matter how reckless they may have been.
        But totally agree that educating, and enforcing cyclists to obey traffic laws is of vital importance as well. Unfortunately, some of the violations occur to protect cyclist from the auto. I will occasionally run stop signs/red lights (when safe to do so) to get myself away from traffic and the chaos that often ensues at intersections. I know cars don’t look before turning for cyclists whether light is red or green.

    • sportingjim says:

      Very balanced point of view Larry, thanks for your comment.

  2. Peter Ward says:

    It’s an absurd idea to mandate cycle helmet use. Firstly, the risks involved are in the same risk bracket as driving and walking. As cycling struggles in Canada the last thing it needs is the image problem of being grouped with high risk pursuits.

    Secondly, the research suggesting helmets actually work has been superseded by research of higher quality suggesting the opposite. Cycle helmets do not seem to work well.

    Thirdly high helmet use does not seem compatible with high levels of cycling. No jurisdiction has combined high cycling levels with high helmet use and in places with lots of cycling you see few helmets. Cycling has to be kept simple and easy if it is to take off.

    A recent editorial in the BMJ came to a completely different conclusion than the CJSM, demonstrating how the evidence can me easily manipulated to suit whatever belief you might have.

    • sportingjim says:

      Peter thank you for those thoughts.
      Several points you make are interesting and would love to see
      1) the higher quality research you mention suggesting cycle helmets do not work well
      2) the recent editorial in the BMJ you mention
      And if you could clarify what you mean by the risks (of cycling) being in the same ‘bracket’
      as driving and walking, I’m not sure I understand.
      Thanks again.

      • Peter Clinch says:

        Peter Ward may wish to add further info, but for starters…

        The recent BMJ editorial can be found at http://www.bmj.com/content/346/bmj.f3817 and is well worth reading. It refers initially to a Canadian study (http://www.bmj.com/content/346/bmj.f2674, Helmet legislation and admissions to hospital for cycling related head injuries in Canadian provinces and territories: interrupted time series analysis, by Dennis et al) and goes on to point out how it doesn’t suffer from quite such large holes as a lot of the work in the field before moving on to the cultural aspects of the infamous cycle helmet debate.

        The risks of cycling being in the “same bracket” as other modalities is something we can see by checking the UK government’s Department for Transport statistics, freely downloadable from their web site. You can also check pre-digested analysis of such information, e.g. Assessing the actual risks faced by cyclists, Wardlaw MJ 2002. Traffic Engineering + Control: Dec 2002 p352-356

  3. Avery B. says:

    Concussion is a major issue in helmeted sports. No one can say for certain that helmets do not exacerbate head injuries, potentially turning a laceration or minor skull fracture into a brain injury. The mechanism for this would be the changing of direction of the force and the angle of impact to the head. The most serious head injuries result from rapid rotation of the head.

    It is also not known whether it explains results from actual experience among large populations.There has been a failure to demonstrate much benefit from mass helmet use despite very high expectations. This poses an ethical issue, as mandating helmets would violate the health care principle of “do no harm”. It’s for this reason I do not wear a helmet when cycling and I cycle a lot.

    Besides the dubious efficacy of helmets, ordinary cycling ie competent and lawful cycling, is not a dangerous activity. Encroachment on an individual’s right to manage his/her own risks would be a gross injustice.

    • sportingjim says:

      Thanks for your thoughts, I especially found interesting the idea that the introduction of a new
      ‘rule’ (whether it be bicycle helmets, or, say, a change in tackling in football) for safety
      reasons may indeed introduce a new, unforseen consequence adversely affecting a
      population (in your example the possibility of increased concussions). Certainly that would
      be something one would need to follow out with studies if mandatory helmet legislation were
      introduced. Finally, I’m curious about your comment that there has been a “…failure to demonstrate
      much benefit from mass helmet use.” To be clear, I have done no research myself, I have no
      more insight than what you and I both would glean from the CASEM statement and review of the
      literature, but that paper states 63% to 88% decrease in head injuries with helmet use. Are you
      aware of studies showing different results?

      • I have to agree with sportingjim. there have been studies that clearly show that helmets reduce injuries. It is true that they do nothing to prevent brain injury, but I find it highly unlikely that they would increase it. I never used to wear helmets, and it was only due to getting into triathlons that changed that. To race, I had to wear helmet during race, and anytime on a bike anywhere near race venue whether for warm up, to transport bike to or from transition, cool down, etc or risk disqualification. I started wearing regularly to get in habit so I wouldn’t forget race day. Since then I have had 2 nasty crashes where the only thing that kept me from the emergency room was my helmet. Both were freak occurrences that could happen to anyone, not just racers. Helmets may not prevent all injuries, but they do work. However, choice should be the individuals, not the governments.

        • Dr P Martin says:

          I too do Ironman races and you don’t have to wear a helmet on the bike anywhere near the race venue at all – only while racing (or checking in your gear)!

          In Kona, for the World Championships, where helmets are not compulsory for cyclists, it is very, very common to see competitors going for gentle preparation rides on their time trial bikes without their helmets and also riding about the village of Kailua. Many spectators on bikes ride helmetless, wearing hats instead which is far more sensible! It’s just not an issue at all.

          During the race it’s clearly a different story and quite reasonable to insist on helmet use at all times when touching the bike. It also makes it easier to ID competitors, particularly if they have a mechanical.

          Bicycle helmets are useful for preventing scalp lacerations and spreading out a point impact over a larger area – all well worth avoiding, particularly in a race situation, but for truly catastrophic impacts they’re useless and there’s no evidence to suggest they prevent concussions (which is a brain injury) – just look at helmet use & head injuries in American Football compared to the Rugby codes. Risk compensation in action.

          I agree that the choice should be with individuals, except for competitions, and it should be left at that. It’s important for cyclists who enjoy choice in their country (ie. not me here in Australia, sadly) to continue to fight for it whenever people (usually non-cyclists) start suggesting that bicycle helmets should be compulsory.

          Cheers & happy Ironman. 🙂

          Dr Paul Martin
          MBBS, FANZCA
          Specialist Anaesthetist.

        • sportingjim says:

          Thanks for those thoughts Paul. And listen, I’m not a big fan of American football (I’m from the good ol’ USA but
          I think that sport has a big crisis on my hands) so I’m not arguing in favor of say that sport over rugby,
          but I would want to point out that the mechanism of injury protection provided by a bicycle helmet is different than
          that provided by a football helmet. Bicycle helmets act like car bumpers: they are supposed to deform on impact, they
          are one collision devices: one crash, one dent, and you’re supposed to get rid of them. They are very different devices
          than American football helmets.

          I’ve been a lifelong bicyclist and have been a bike commuter for over 20 years. I agree that MHL is a ‘sticky wicket,’
          but I am a strong advocate for increasing bicycle helmet use overall because I think the data point to (at least in
          the USA) a correlative increased use in children, the most important population for their use. The data in the USA
          that relate increased bicycle helmet use in kids to decreased severe head trauma in the same population are fairly clear.
          I would support all nudges and voluntary initiatives to seek that end, here in the States, and at the end of the day, unless
          the evidence were overwhelming that MHL would decrease bicycle ridership markedly, would vote in favor of MHL in the USA.

          Thanks for reaching out.

      • Peter Clinch says:

        88% (along with 85%) are numbers that set off alarm bells for anyone who is familiar with the literature on helmet efficacy, as these were the predicted saving of head and brain injury in Thompson, Rivara & Thompson’s A case-control study of the effectiveness of bicycle safety helmets, New England Journal of Medicine 1989, Vol 320 No 21 p1361-7.

        This is a landmark paper because it has the highest predicted benefit for helmet efficacy and is the most quoted, partly because of that high efficacy prediction and partly because the authors happen to be the Cochrane database editors for cycle helmets and cite their own work there. It is not a landmark paper because it is any good: in fact it has been so thoroughly debunked ovee the years that its claims have been withdrawn from US federal government websites after data quality challenges by a bicycle advocacy group that support helmet use! (see http://greatergreaterwashington.org/post/19036/feds-will-stop-hyping-effectiveness-of-bike-helmets/)

        One key aspect of good science is that it is reproducible, and no other studies have approached these figures. There is little agreement on any particular number in other work supporting helmet use and methodologies vary, but most of the benefit predictions come from case/control which are very ill-suited to self-selecting populations well aware of the interventions they are using. Most of the work suggesting that these studies are poor comes from whole population studies which have their own issues (generally caused by data resolution and quality) but consistently fail to show much or any tangible benefit across a range of scenarios (enforced compulsory helmets, gradual voluntary increase in helmet use, unenforced compulsory helmets) in different places. These population studies certainly do not damn helmets as useless or irrelevant to all users, but they do strongly suggest that there is no sensible basis to mandate their use. This would also, I suspect, be the basis of the suggestion that there has been a “…failure to demonstrate much benefit from mass helmet use”, and http://www.bmj.com/content/332/7543/722.2 is an example.

  4. Peter says:

    One may feel that it is important enough to protect kids heads but the number of kids riding bikes at all especially to school will dramatically decrease. You will save a few child bicyclist lives through attrition but create a net health deficit through decreased excercise.

    • sportingjim says:

      Peter thanks for writing, most of the comments we’re getting share a general, almost visceral opposition to MHL in general. Would you say you are even opposed to the more limited application of mandatory helmet laws for kids?

      • Peter Clinch says:

        A good piece as general background for carers interested in the safety of their children on bicycles is Tim Gill’s piece commissioned by UK charity National Children’s Bureau. I like it to cite in this area because the author is a helmet-wearing father so obviously has no objection to helmets in principle so is not dismissed as having some anti-helmet agenda, but the ~20 pages of discussion in the Annex on helmets appears to conclude there is insufficient hard evidence to even promote helmets for children. Cycling and Children and Young People can be accessed at http://www.ncb.org.uk/media/443203/cyclingreport_2005.pdf

        It is UK-centric but the same basic arguments should apply to other countries.

      • Avery B. says:

        Why is it that so many healthcare professionals don’t trust parents to make the right decisions for their kids? It’s one thing for the state to take measures to protect the vulnerable but advocates need to recognize that parenting is not one of them. Child helmet laws are symbolic of the larger problem of the growth of the modern bureaucracy and the resulting need to justify its existence.

        • sportingjim says:

          Thanks for writing, Avery would you say you feel the same way about child auto safety seats? About child-proof medicine bottles? Thanks again.

        • Avey B. says:

          sportingjim says (in post below … blog has reached “reply” function max.):
          November 16, 2013 at 9:20 AM
          >Thanks for writing, Avery would you say you feel the same way about child auto safety >seats? About child-proof medicine bottles? Thanks again.

          Jim,

          You skirted my question concerning healthcare professionals. Since you are one you might wish to address it.

          … regardless my answers are,
          1. Yes I feel the same. In Ontario, my grandchildren cannot ride in my car on those few occasionals there might be a need.
          2. Yes, although really a non-sequitur. Child-proof bottles are passive devices normally regulated by government consumer protection agencies.

          “Health and safety may seem to be moral absolutes of our time, as religious dogma used to be for naturally bossy people to throw their weight around.”

          Auberon Waugh

        • sportingjim says:

          Thanks again for writing. I didn’t mean to skirt your question.
          Thought it might have been rhetorical, and
          just fielding an enormous amount of commentary on this issue
          and trying to answer what/where I can.

          As a physician and a public health advocate, I don’t see it as a matter of trust, or
          the lack thereof. I would take trust out of the equation.

          I see it, as I argued in my post,as a matter of human
          behavior, the irrationality inherent in that. An understanding
          that most people may have good intent. That, for instance,
          in the USA, most people would not want to see a child die
          from a gun shot. That we could avoid most of those issues
          if we had in place a few pretty simple interventions (e.g.
          locked gun storage) rather than rely on ‘trust.’

          It’s a matter of letting people live another day if they make a mistake. It’s a matter
          of trying to reduce the risk of a child inadvertently downing a whole
          bottle of their mother’s medicine; of an unrestrained child in the
          back of a car dying when they might needn’t have; of a child falling off
          their bike when doing some BMX tricks and not incurring serious head trauma, etc.

          I am familiar with Auberon Waugh, the entire Waugh family. My favorite
          novel of all time is Evelyn Waugh’s ‘Brideshead Revisited.’ I am
          sure they would be among the dissenting voices on issues like this
          (of course, Evelyn would, as a fervent and practicing Roman Catholic,
          have probably adopted a ‘bossy’ religious posture; he surely was a very bossy man in his life).

          I would be praising their literary output while disagreeing with them on these issues.

          I have found these numerous comments (not just yours, all the ones coming in) very interesting, and I plan on posting
          another poll, most especially enquiring specifically about what chief issue
          dissenters have with MHL (i.e. is it because of personal infringement of liberties?
          because of evidence they see that MHL reduces bike participation rates? etc.)

          Thanks for writing, all the best.

  5. The research on cycle helmets is clear, for avarage cyclists the added risk they introduce (increases chance of collision, increased surface area = more chance of sustaining head injury, increased risk of cervical spinal injuries) outweighs the very small amount of protection (from pain, not serious head injury) they offer.

    There are also disadvantages as whole. Mandatory helmet laws reduce overall nubers cycling, leading to all the related disadvantages to societal health, added congestion and poorer air quality.

    The majority of people, health professionals overestimate the advantages offered by cycle helmets, far bettr to take the lead from cycle advocates, who seem to know there stuff, than medics.

    • sportingjim says:

      Sara thanks for writing, you bring up a lot of points, can you help me by sharing some of the references that would support your statements.

    • Ride2Wk says:

      I agree with the comments about helmets. Check with your local advocacy group though on their position as sometimes they are pro MHL since they are run by keen cyclists who accept helmets themselves and don’t realise not everyone shares their “religious” belief in bikes & MHL. Here in Australian it’s the State cycle advocate organisations like Bike Victoria and Bike Qld, often with government links & funding, who toe the government line the most. Only Bike NSW recently had the guts to come out and oppose MHL since newer research is showing MHL is not as good as everyone thought.

      (Or maybe it’s because Sydney is considering a helmet exemption so they can introduce a city bike scheme & they saw that Melbourne & Brisbane schemes have failed. Sydney Vs Melbourne have had city rivalry for over 100 years so I’m sure Sydney would love to put Melbourne’s bike scheme to shame 🙂

      From the Bike NSW website – http://bicyclensw.org.au/advocacy/positions/legal/helmets/ (Note the comment about the medical fraternity and motoring organisations ! Motoring organisations have wanted bikes out of the way and have been claiming bikes ideas, road surfacing & inventions as their own for 100 years now. Refer to http://www.roadswerenotbuiltforcars.com/ )

      There is significant evidence to show that the introduction of New South Wales mandatory helmet laws in 1991 produced a 30% decrease in cycling numbers [1]. This decrease in cycling numbers not only decreases the Benefits of Bicycling experienced by individuals, business and society, but results in an environment that is inherently less-safe for bicycle users [2].

      As Peter Jacobson notes, “policies that increase the numbers of people walking and bicycling appear to be an effective route to improving the safety of people walking and bicycling” [3]. Thus, policies that decrease the number of people bicycling reduces the safety of the environment for bicycle users.

      While head injury rates did decrease after the laws were introduced, this was part of a continued decline in cycling injuries since the 1970s [4]. The evidence suggests that there were other factors besides mandatory helmet laws such as general road safety media campaigns and the introduction of random breath testing in 1982 that contributed to an overall improvement in road safety. The steady decline in Australian cyclist deaths from 1950 to 2000 mirrors that of The Netherlands, Denmark, Germany, the United Kingdom and the USA, none of which introduced mandatory helmet legislation [5].

      What is hard to quantify is the damage that has been done to cycling culture by mandatory helmet laws. While the medical fraternity and motorist organisations are keen to encourage the wearing of helmets, little weight has been given to the fact that every country that benefits from a high cycling mode-share allows adults to ride a bicycle without a helmet. If we are to learn from world’s best practice, then bicycle users should be free to choose to ride without a helmet.

      Bicycle NSW recommends that a review is held to determine the net benefit of the mandatory helmet laws in Part 15 (Additional rules for bicycle riders) of the Australian Road Rules. If no significant benefit is found, Bicycle NSW recommends that the law is revoked if not entirely, then at least for adult bicycle users.

      [1] Smith N, Milthorpe F: An observational survey of law compliance and helmet wearing by bicyclists in New South Wales – 1993. . Roseberry: Roads and Traffic Authority; 1993.
      [2] Robinson DL: No clear evidence from countries that have enforced the wearing of helmets BMJ 2006, 332:722e725
      [3] Jacobsen PL: Safety in numbers: more walkers and bicyclists, safer walking and bicycling. Injury Prevention 2003, 9:205-209.
      [4] Rissel C: The impact of compulsory cycle helmet legislation on cyclist head injuries in New South Wales, Australia: A rejoinder. Accident Analysis and Prevention 2012, 45.
      [5] Pucher J, Dijkstra L: Making walking and cycling safer: lessons from Europe Transportation Quarterly 2000, 54:25-50.

      Bike share schemes are currently thriving in many European cities. The success of such programs can easily be explained in countries such as Holland and Denmark where there is already an established bicycle culture. But the success of bike share in places such as Dublin provides a clear example of what can be achieved in a city which has never been seen as a cycling capital.

      In order to explain the success of bike share in Dublin, it is worthwhile to compare it to the bike share program in Melbourne which has similar characteristics. Both cities have a cool, wet climate and both cities have a relatively low bicycle mode share. Even the density and reach of the bicycle share programs are very similar. However, while Dublin’s bike share program is being expanded due to its success, Melbourne’s program is floundering.

      The failure of bike share programs in Melbourne and Brisbane may be the result of a very simple but very powerful deterrent. While most cities around the world allow adults to choose whether to wear a helmet, these particular cities require the use of a helmet. This makes it difficult to just grab a bike for an impromptu trip [1].

      Bicycle users who perform predictable journeys from home or work such as commuting or recreational riding usually have easy access to a helmet just as they have access to a bicycle. However, bicycle users who have impromptu and unpredictable transport needs require an impromptu solution. While bike share schemes in Australia are able to supply the bicycle in a convenient and cost-effective manner, supplying helmets doubles the complexity and cost of the transaction [2].

      Bicycle NSW recommends that riders using bike share bicycles be exempt from the mandatory helmet laws in Part 15 (Additional rules for bicycle riders) of the Australian Road Rules.

      [1] Fishman E, Washington S, Haworth N: Barriers and facilitators to public bicycle scheme use: A qualitative approach. Transportation Research Part F 2012, 15:686–698.

      [2] Fishman E, Washington S, Haworth N: Bike share: a synthesis of the literature. Transport Reviews 2013, DOI:10.1080/01441647.2013.775612.

      • sportingjim says:

        Really enjoyed your post, so very thoughtful. Loved the references. And I wholely agree with you as a scientist: as new evidence evolves, we may need to reevaluate previously held notions. So, it’s interesting to hear about the Bike NSW experience you are sharing. Thank you for all the links, they look great.

  6. Commuter Cyclist says:

    From a community health standpoint, it’s a really bad idea.

    The data show that helmet laws have little effect on the percentage of cyclists with head injuries. For example: “After taking baseline trends into consideration, however, we were unable to detect an independent effect of legislation on the rate of hospital admissions for cycling related head injuries.”http://www.bmj.com/content/346/bmj.f2674

    The data for Alberta show that after helmet laws were enforced, children’s cycling halved, yet injuries increased, representing a **more than doubling** of injuries per cyclist – http://www.cyclehelmets.org/1250.html

    Yet for adult cyclists, who were not affected by Alberta’s law, cycling increased, and injuries per cyclist decreased. All studies based on comparable pre- and post-law data relating injury rates with the amount of cycling show *increased risk of injury* after helmet laws are introduced, compared to other road users such as pedestrians. Both risk compensation and reduced safety in numbers are possible explanations for this phenomenon, which also happened in Australia – http://www.sciencedirect.com/science/article/pii/0001457596000164

    The CASEM position seems to be based on the results of studies comparing cyclists who choose to wear helmets with those who do not. It seems unwise to base recommendations about helmet laws on such data, because real-life outcomes of helmet laws appear to be totally different!

    Reduced cycling has many other detrimental effects on community health – less exercise, more brain damage from heart attacks and strokes, increased [pollution and greenhouse gas emissions when healthy and environmentally friendly form of transport is discouraged.

    • sportingjim says:

      Really appreciate those thoughts and especially the sharing of references, citations. Thanks for contributing to the conversation.

  7. Peng says:

    There is something wrong in a country with a law which criminalise a cyclist riding sans helmet on an off- road dedicated bike path.

    • sportingjim says:

      Thank you for your thoughts. I think you bring up a good point, at least indirectly, when you use the word ‘criminalise.’ I’m not a legislator myself, and of course, we are all merely commenting on a position paper not an actual law. But I think I might reframe what you are describing as likening not wearing a helmet in a jurisdiction with MHL more to, say, putting out one’s garbage unsorted in a jurisdiction requiring recycling thank I would to the ‘crime’ of pickpocketing, burglary, etc. That is, MHL if enforced may result in a fine but I am unaware of any jurisdiction with MHL that might require someone to serve jail time for instance. Thanks again for sharing.

  8. Alan Todd says:

    James, you may not be a legislator, but let me clear, those who advocate for MHLs are advocating for a legislative change, requiring sanctions against those who disagree with them. And no, its not like failing to sort your garbage. When you cycle without a helmet in an MHL jurisdiction, you show a clear, public and persistent disregard for the law. In Australia, this has led to an inordinate amount of police interest in this totally trivial “safety” law. To flout the law in public is really a red rag to a bull where the police here are concerned. The experience in Australia has been the wholesale fining of dissenting cyclists, leading in some cases to imprisonment where fines have not been paid. Penalty notices to cyclists in Victoria increased by 900% when the law was introduced, and helmet offences still, twenty three years on, account for 66% of all fines issued to cyclists. Hardly guaranteed to encourage cycling. This has led to a seismic shift in the cycling population, with the slow, the safe the young and elderly practically absent from our roads. Female participation is woeful. The profound discouragement of cycling has been particularly bad in outer suburban, rural and regional areas, including all provincial cities.

    The CASEM statement in favour of helmet mandation is profoundly flawed. Of the three statements on which it is based, one is contentious (the effectiveness of a helmet in the event of an accident, with no consideration for rider and driver behaviour change making accidents more likely to occur), one is trivial (mandating helmets makes more people wear them – so what, unless you assume the benefit you set out to prove) and one is plain wrong (that helmet mandation does not reduce participation). The sole basis for this last claim was a paper from Ontario, showing that child participation did not decline when helmets were mandated for children. What that paper failed to note was that the legislation has never been enforced in Ontario, making helmets mandatory in name only. Where it is enforced, participation always suffers.

    Canada would be ill advised to go further down the path of bike helmet mandation than it already has. That is, unless you want to cut your fledging bike culture off at the knees, ensure no further public bike share programmes are introduced, and turn the sight of women riding to the shops and children to school into the category of quaint things they do in other countries.

    • sportingjim says:

      Alan: Clint Trass, one of the other commenters, passed on something from NZ research that addresses some of your points, http://journal.nzma.org.nz/journal/125-1349/5046/content.pdf If you have references that underscore some of your points, by all means pass them on, and I’ll make sure they show up on the comment board. The data you’re sharing sound compelling: can you reference them? Thanks

  9. Clint Trass says:

    Jim, I did get a chance to read the article. There is nothing compelling about it and I would have to agree with Alan Todd’s comments. It presents a flawed argument.

    And also, what is going on with Murray Maitland (the author)? Why the hell is he falling off his bike so often? It beggars belief. Rather than force MHL’s on the entire population, perhaps a basic handling course would be better suited to help him avoid these frequent accidents?

    And re your correction to my comment above – “….for riding a bike without the required helmet!” – you can change my statement as much as you like, but at the end of the day, people have ridden their bicycles in Australia and they have been incarcerated. I don’t see how adding “without the required helmet!” is supposed soften how ludicrous the situation is?

    Throwing someone in clink for not having a piece of plastic on top of their head while cycling is bizarre – and we don’t need to try to convince ourselves that it isn’t.

    • sportingjim says:

      Clint have enjoyed your comments. Honestly though, if there is a law (and you make a very good case for their not being one) but if there is one, then when one chooses not to abide by it and not pay the requisite fine, that is something like ‘contempt of court.’ It is its own issue. Sounds like the people are not being put in jail for riding a bike. They are being put in jail, you are telling me (since I don’t live in Aus, I used to live in NZ), for riding without a helmet and for not paying the requisite accumulated fines. That is civil disobedience. More power to those folks. But that is different than being put in jail first and foremost for riding a bike. Full stop. This is not splitting hairs I would argue.

      I have a friend in USA who refuses to wear seat belts. He finds it to be an infringement on his civil liberties, an expression of the nanny state, a frank collusion between big business/insurance/the government. He has been fined on more than one occasion by the police. He has paid the fines, because he knows if he doesn’t, he would eventually probably be facing license seizure, maybe criminal proceedings.

      I found Murray Maitland’s essay very thorough. I find the comments on this issue here on the comment board, mostly coming from AUS/NZ equally thoughtful, and compelling coming from apparently the two nations where MHL are in place (NZ and AUS).

      Thanks again for sharing, I have appreciated your contribution to the discussion. please when/if you right back keep the ad hominem comments (e.g. on Maitland’s riding style) to a minimum.

      • Clint Trass says:

        Hey Jim

        We probably reach a junction where we are unable to agree. Though I do understand the ‘contempt of court’ principle, I don’t think it is that black and white.

        If that were the case then any old law could be passed, no matter how ridiculous, and if citizens decided to protest by being disobedient, their ultimate incarceration can be (ethically) justified by some other means (i.e. you are going to jail now for civil disobedience, nothing to do with not wearing a helmet).

        The NZ government might decide that, since there are far more injuries to pedestrians than cyclists each year (http://www.nzta.govt.nz/resources/road-deaths/toll.html) it is in my best interest to wear a helmet as well as knee and elbow pads when I am walking down the street. If I chose not to comply (and not pay a ticket) I would have to serve time.

        At the end of the day, the issue that caused me to be disobedient in this case, is the fact that I didn’t want to wear a helmet, knee pads and elbow pads. Society needs to ask the question – ‘is the issue important enough, so that if someone decides to be non-compliant, we are happy with them spending time in jail?’. If the answer is yes (like it would be for things like theft, assault, fraud etc) then great. If the answer is no, then maybe we need to re-think.

        I thought you might be interested in this article – http://www.nzta.govt.nz/resources/road-deaths/toll.html

        I think it is really sad that, in Australia, it is deemed ok to put children in jail for minor offenses.

  10. A says:

    A potentially useful source of information on research on this subject can be found at http://www.cycle helmets.org if your not aware of it.

    Personally I prefer the extra 8cm that motorist will on average give to non-helmeted cyclists when overtaking them.

  11. Peter Clinch says:

    Peter Ward has already mentioned the BMJ editorial by Goldacre and Spiegelhalter (http://www.bmj.com/content/346/bmj.f3817) that addresses the fact that it is not so much the evidence that drives these debates as the “cultural, psychological, and political aspects of popular debate around risk”.

    That there are different cultural attitudes to helmets is quite evident to me in my particular existence. At the one extreme I may be visiting my in-laws in the Netherlands, where there are lots of bikes, few helmets and hardly any cares about them. At the other I may be doing coaching sessions at my local “Go-Ride” club, a British Cycling sport-cycling initiative where the very simple rule is no helmet, no ride. The latter is coming from a sporting culture, and of course this is a comment on a sports medicine perspective, so perhaps it is instructive to look further at the sporting end of the spectrum and how much it does and how much it should cross over in to the world of the A to B transport/utility (i.e., “normal”) cyclist.

    British Cycling is, above all else, a body concerned with sports cycling. It is affiliated to the UCI and controls the majority of competitive cycling in the UK, but especially with the great success the UK’s competitive cyclists have had in recent years on the world stage it has grown another head and has now started to recruit non-sporting members and campaign on transport cycling issues. The public face of much of this effort (and also the strategic policy advice behind it) has come from former Olympian and time-trial great Chris Boardman. Having done time on the (now defunct) National Cycling Strategy Board and with a reputation for exhaustive research and perfectionism, Boardman is well aware of the differences between “normal” and sporting cycling and while the BC website is basically pro-helmet (depending on where you look they range from “essential” to highly recommended) he is hosting information videos for BC quite pointedly in a bare head (e.g., http://vimeo.com/71878922) and the BC campaigning section (http://www.britishcycling.org.uk/campaigning) and Safety Manifesto (http://www.britishcycling.org.uk/zuvvi/media/bc_images/bc_campaigning/BC_ROAD_SAFETY_MANIFESTO_FINAL_DIGITAL.pdf) scarcely mention helmets.

    In contrast to that, tomorrow I will be attending an assessment of my BC Level 2 Coaching course where I will be running sessions for and with fellow aspiring coaches at fairly low speeds on grass with easy access to first aid and excellent instructor:pupil ratios. There will be low chances of falls, very low chances of any falls resulting in head impacts and vanishingly low chances of any serious head injuries (it’s on a field where people might be expected to play rugby with no head protection beyond a gum-shield, with 15 people actively trying to smash you in to the floor as hard as they possibly can, for a bit of perspective on relative, and widely judged acceptable, risk), yet everyone will have to wear a helmet. The Level 1 Coaching Guide implies that it would be unethical for me to do my shopping on a bike without a helmet in case my charges should see me do that, as they have to wear with no questions.

    So there we have two almost polar-opposite messages from within the same organisation. It is interesting to note that the one that is backed up with citable material and careful argument is the one for utility/transport cycling, that very tellingly plays down the use and importance of helmets, while the case for helmets is pushed with simple assertions based on assumptions.

    An interesting contrast in the risks of sports riding and “normal” riding comes from the Netherlands, where very few utility riders (less than 1%) wear helmets, but many sportive riders do. 13% of hospital admissions of cyclists are helmeted (Rijkswaterstaat, Ormel W, Wolt KK, den Hertog P, . Enkelvoudige fietsongevallen. Ministerie van Verkeer en Waterstaat, 2008), and that’s not because they are wearing helmets but because they riding in a sporting context where a speed/safety balance is more tipped to speed and risk than is the case for the commuter. So does it make sense to use a sporting basis to push transport and utility riders in to helmets? About as much as the lessons of motor racing show we should adopt full roll cages and fireproof suits (and helmets, of course) to drive to the store for our groceries.

    In 2006 I wrote to the BMJ (http://www.bmj.com/content/332/7545/852.3) reacting to discussion of Robinson’s article on effect of helmet legislation (http://www.bmj.com/content/332/7543/722.2) pointing out that with the amount of effort put in to telling us that cycling is dangerous it’s little wonder we think it is. If Murray Maitland visits the Netherlands he might be separated from the traffic by the excellent infrastructure, but not from unpredictable small children and dogs, so two things he feels are important enough to warrant comment in an editorial supporting a massive public health intervention potentially affect millions of cyclists who don’t use helmets but who still come out with the lowest head injury rate going… why do we worry about these things for cycling, but not for other comparably risky activities (like going down the stairs, and getting in and out of the bath, both of which kill many with head injuries)? It simply makes no sense. My more recent correspondence to the BMJ (http://www.bmj.com/content/346/bmj.f3817/rr/650881) is pleased to note that in the UK the debate is getting less focused on “dangerising” cycling, though it appears from the CASEM statement and supporting editorial that Canada is unfortunately lagging in that respect. It remains the case that cycling is good for health (and environment, and reducing congestion, and child independence etc. etc.) and anyone discouraged from doing it is an own-goal on many levels. That anyone is proposing to criminalise people for adopting a healthy, environmentally friendly lifestyle where Australia and NZ don’t have any clear track record of such a measure giving any truly tangible benefits is a triumph of hope (and fear, uncertainty and doubt) over realistic expectation.

    • sportingjim says:

      Thanks for that lengthy and well thought out essay Peter, really good read.

      • Peter Clinch says:

        There is no shortage of further cultural artefacts in the helmet debate. An interesting juxtaposition is shown in the editorial title “Don’t Say Something by Not Saying Something”. Dr. Maitland uses it in the sense of highlighting the importance of the promotion of helmets, but in the UK I see it far more often in the reluctance of official bodies to say anything that could be construed as critical of cycle helmets.

        Earlier this week I finally managed (after two years of chipping away) to get the government body Road Safety Scotland to amend their message about helmets on http://www.road-safety.org.uk/cycling/what-to-wear/ from being “essential” to repeating the line of the Bikeability Scotland Level 2 Cyclist’s Guide (handed out to 10-12 year old children doing an on-road cycle training course), “A helmet will not prevent an accident. However, if it is fitted properly, it may help to protect your head if you have an accident”. The Trainer’s Guide, by contrast, states, “When talking about helmets Trainers should include discussion with trainees of both the pros and cons in order to allow them to make informed decisions in the future”, so as a trainer I can tell my charges about the active downsides of helmets, but the literature they receive themselves does not do this and the message from the local authority authorising the training is simply “no helmet, no ride”. Furthermore, the only reason my children’s’ school (where I deliver Bikeability Scotland training) does not require helmets for any pupil cycling to school and does not repeatedly indoctrinate its pupils on the necessity of helmets is because I have gone out of my way to argue the matter with the Head and Depute Head teachers. I am an NHS scientist with full access to a clinical research library, I am an accredited cycling instructor and I don’t shy away from helmet arguments, but that is an unusual combination unlikely to be the case for most parents of primary school (I think that’d be elementary school in Canada) children, so in most primary schools the culture will be that the children either should or must wear helmets and nothing critical will be said about them.

        Cycling Scotland (who oversee the Bikeability Scotland training course and are the quango responsible for cycle promotion in Scotland) have recently posted their draft helmet policy online (http://www.cyclingscotland.org/wp-content/uploads/2013/10/Cycling-Scotland-Helmet-Policy-March-2011.pdf). I cannot be 100% sure but I suspect it was created to brief Road Safety Scotland in response to my request to my MSP (Member of Scottish Parliament) for RSS’s “essential” helmet message to be changed, as its production coincided with RSS consulting CS about the matter and it never saw the public light of day until recent questions I sent to CS regarding their helmet position, and it hasn’t changed in those 2 years from being a draft. CS seem quite reluctant to say anything much at all about helmets (use the search facility on their website to see, noting how well tucked away and unreferenced the helmet policy draft is as well as a dearth of other information) and have been for some years, and when you look at any debate about helmets it’s no stretch to assume it is because they know that what they say will probably generate a lot of heat and remarkably little light. it is a politically and culturally very edgy thing to say something that is in any way negative, or even not positive, about cycle helmets in the UK at the level of public policy. The general perception of cycle helmets in the UK is such that people feel empowered to shout abuse at me in the streets for not making my children wear them (that would be my children who are generally fitter and more independent than their peers thanks to their cycling for transport), and in that environment people much prefer to Not Say Something than say things which line them up for such ill-treatment.

        Dr. Maitland has perhaps unwittingly struck the nail on the head, but rather than the problem being the case that people are afraid to selectively promote cycle helmets, I see the problem as being they are afraid to point out the large number of rather big holes in the case for mandatory helmets as a public health intervention. People that do that are frequently pilloried, as I unfortunately know from personal experience.

        It is widely assumed that we are giving the benefit of the doubt in promoting or requiring helmets, that they cannot possibly do any harm. But every time we emphasise the dangers of cycling we are creating cultural barriers to its uptake. This is why British Cycling’s campaign site says “We know that the biggest barrier to people getting on their bikes is the perception that the cycling is a risky activity. It is not, you are just as likely to injure yourself walking as you are cycling. Everything we do we want improve the perception and reality that cycling is a safe and normal activity”. It is why the Dutch government do not promote cycle helmets, and given the number of active cyclists in NL and active government promotion to bring that about I think their opinion has considerable weight.

        While Boardman’s messages for BC and the similarly well researched messages of the UK’s other main cyclist organisation CTC (see http://www.ctc.org.uk/campaigning/views-and-briefings/cycle-helmets) are starting to buck the trend of uncritical helmet promotion it remains the case that there is no shortage of people and organisations who are very happy to Say Something to promote helmets, and that is actually part of the problem because they are drowning out people who are trying to say “hang on, that doesn’t stack up!” and they are turning people away from a healthy, beneficial activity.

  12. I’m VERY pro-helmet, and have been for many years. I will admit I was one those that for many years didn’t see a need and rode without, but not anymore. I was forced to wear helmet when I got into triathlon, and since have had a couple of accidents where helmet kept me out of the hospital. I firmly believe in them and refuse to ride with anyone, no matter how close a friend or family member, unless they wear a helmet. However, I won’t support efforts to pass helmet laws at this time. I strongly believe that this is a much smaller concern to safety of cyclists then what the danger of automobiles present. I think the argument was best stated by: http://blogs.bicycling.com/blogs/roadrights/2013/10/29/theres-another-way/
    I think the money, time and effort that goes into creating and passing a law would be better spent on making drivers accountable for their actions. This will improve safety of not just cyclists, but runners and walkers as well. The amount of good that can out of that legislation is much greater then what would come from passing a helmet law that is unlikely to be enforced except as an occasional harassment of cyclists (yes, there are plenty of police that do just that). There is unlikely to be much of an increase in cyclists wearing helmets, but the law will then allow insurance companies to not cover claims for any cyclist that gets in an accident while not wearing a helmet, regardless of whether helmet would have prevented injuries.
    If you want to pass a law and improve safety, pass it on driver accountability. If you want to decrease number of cyclists not wearing helmet, work on improving education of the dangers associated with it.

  13. I’m VERY pro-helmet, and have been for many years. I will admit I was one those that for many years didn’t see a need and rode without, but not anymore. I was forced to wear helmet when I got into triathlon, and since have had a couple of accidents where helmet kept me out of the hospital. I firmly believe in them and refuse to ride with anyone, no matter how close a friend or family member, unless they wear a helmet. However, I won’t support efforts to pass helmet laws at this time. I strongly believe that this is a much smaller concern to safety of cyclists then what the danger of automobiles present. I think the argument was best stated by: http://blogs.bicycling.com/blogs/roadrights/2013/10/29/theres-another-way/
    I think the money, time and effort that goes into creating and passing a law would be better spent on making drivers accountable for their actions. This will improve safety of not just cyclists, but runners and walkers as well. The amount of good that can out of that legislation is much greater then what would come from passing a helmet law that is unlikely to be enforced except as an occasional harassment of cyclists (yes, there are plenty of police that do just that). There is unlikely to be much of an increase in cyclists wearing helmets, but the law will then allow insurance companies to not cover claims for any cyclist that gets in an accident while not wearing a helmet, regardless of whether helmet would have prevented injuries.
    If you want to pass a law and improve safety, pass it on driver accountability. If you want to decrease number of cyclists not wearing helmet, work on improving education of the dangers associated with it.

    • and for the record, I am a runner, a cyclist, and an athletic trainer. And as an athletic trainer I work with head injuries and brain trauma all the time. I am VERY concerned with safety, especially for the brain.

    • sorry to keep adding to this, but just noticed that poll was only referring to passing laws in regards to road cyclists. Unless going to pass it uniformly for all cyclists, it makes even less sense. All cyclists, regardless of where they ride, are at risk of falling and of head injury. Should be all or none…

  14. Avey B. says:

    Jim,

    1. Maitland’s editorial was deficient in that it failed to address the mountain of problems detected in published research that favours helmet use. He admitted this shortcoming himself. That leaves only a couple of his own anecdotes worthy of any scrutiny. All there is to be said about such is that no one knows what occurs when an unstable piece of material on a head in motion collides with one or more objects (in motion or otherwise). The mechanics are just too complex to even speculate.

    2. The references to source data you have asked from a number of us can be found at http://www.cyclehelmets.org the site of the Bicycle Helmet Research Foundation (BHRF). Maitland cited BHRF as a source of doubt over helmet efficacy in his piece. Much published helmet research in Ontario, Canada has been authored by advocates. This is a problem, since the temptation to “cherry pick” data to support an agenda is ever present. Alison Macpherson, a prominent helmet law activist in Ontario, had to admit in 2010 that declines in head injuries could not be associated with helmet legislation in Canadian provinces http://injuryprevention.bmj.com/content/16/Suppl_1/A228.3.abstract Her work had long been criticized on the BHRF website, yet she has had, and still has, influence beyond Ontario’s borders. Even in CASEM’s position paper, her work is cited three times. There is also the issue of research methods and the omission of confounding factors inherent in most helmet studies. The BMJ critiqued this issue recently, see June 2013 at: http://www.vehicularcyclist.com

    What’s the point of legislating when the evidence is so flimsy?

    Avery Burdett

    Declaration of interests. Member of the editorial board of the BHRF. Live in Ontario and led the Ontario Coalition for Better Cycling’s partially successful campaign against universal helmet legislation starting back in 1992. Host of the website The Vehicular Cyclist: vehicularcyclist.com which represents a selection from work over a 25 year period starting when I first became curious as to why so many myths were associated with ordinary cycling.

  15. The proponents of bike helmet laws never (as far as I’ve seen) even attempt to put the benefits of helmet legislation into any kind of context, or to weigh them quantitatively against the costs.

    For example, the CASEM statement mentions the possible effect of a helmet law on reducing cycling, but there is no calculation of how great the effect would need to be in order to erase the law’s benefits. My own calculation shows that a reduction in cycling of 0.4% would be enough. Different assumptions here will lead to different estimates, of course, but any estimate will have to lie somewhere in the range of 0.1% to maybe 1.5%. These are obviously very small reductions, far below those observed in many regions. It will not do not make an argument from ignorance, that no reduction has been proven in some places, so none exists. Even an effect that is too small to observe can overcome the law’s tiny benefits.

    Why describe the law’s benefit as ‘tiny’? Since they are indeed tiny by any reasonable measure, if anyone bothers to calculate such things. For example, if a person who cycles for one hour wears a helmet, what is the expected reduction in health care costs? Answer, something like 3-10 cents. What is the increase in life expectancy from an hour of helmet use? Perhaps about one minute. Compare that to the increase of 60 or more life-minutes from an hour of cycling itself!

    In Canada, where large numbers of people wear helmets by choice, and many will defy a law if one exists, a law is going to change the behaviour of something like 25% of people. Thus the benefit of a helmet law per person is no more than about 1/4 of the tiny benefits of helmet use. When one looks at the numbers in context, the case for helmet legislation disappears.

    • sportingjim says:

      Richard thanks for that, when you are doing your analyses, how are you defining benefit? Are you thinking
      QALYs, or are you thinking dollars/cents? Thanks

      • I was calculating the mortality and morbidity separately, using simple life-years for mortality costs and benefits, and health care dollar costs + savings for morbidity.

        But I was just mentioning a few numbers to highlight the fact that such details are always entirely absent from pro-legislation arguments. They’re pure hand waving.

    • Ride2Wk says:

      In Australia we had a 30-40% reduction in cycling. On the cost – benefit basis it is a complete and utter failure.

      In some areas like Byron Bay, NSW, police have publicly admitted they have given up even trying to enforce the law anymore so it’s achieved nothing but discourage some police fearing people (especially kids) from cycling.

  16. Dr P Martin says:

    Compulsory? No. Recommended for ‘road cyclists’, by which you mean people cycling on road bikes for sport I presume? Then, yes… but not compulsory.

    The problem is that cycling is too quickly pigeonholed into some thing that is largely for sport & recreation – a type of cycling unaffected by helmet compulsion as they’d wear them anyway – rather than considering how broad an activity it is.

    Compulsory helmets for riding a bike to the shops, to work or to school? No.

    If you want to make cycling safe, focus on the environment. PPE should always be the LAST line of defence in hazard mitigation.

    We should be focussing on making cycling safer, not making crashing safer…

    Helmet laws discourage all but the riskiest of cyclists and change the demographics of cycling and the injury profile. Fewer cyclists makes cycling less safe for those who remain.

    Dr Paul Martin
    MBBS, FANZCA
    Specialist Anaesthetist

    • sportingjim says:

      Great thoughts Paul, insightful, thank you for sharing.

    • Ride2Wk says:

      “We should be focussing on making cycling safer, not making crashing safer…”

      And that basically sums up the whole problem with road safety. Road safety experts, road and car engineers spend most of their effort on making crashes survivable instead avoided.

      In road engineering we have things like –
      “clear zones” – areas off the side of the road with no obstacles where possible so that any car that looses control or fails to concentrate can slow down and recover before crashing.
      Guard rails to stop wayward cars going over the edge.
      “Slip bolt mounts” on things like light posts and large signs so that they cause less damage to cars when hit.
      “Rumble strips” and “vibraline” to warn drivers as they cross edge lines.

      In cars we have crumple zones, air bags & seat belts but they only make “crashing safer”. Now we have ABS and are starting to get electronic avoidance sensors to avoid crashes.

      But there is very little to make drivers concentrate on the road and drive safer. It’s the “nut behind the wheel” that causes almost all crashes in the first place and that is where we need far more road safety activity. But human behaviour is far more difficult than simple engineering.

      And politicians won’t let road safety get in the way of winning votes unless they can cut a ribbon on a new road and say “aren’t I wonderful for giving you this”.

  17. Ride2Wk says:

    In all of this debate on helmets there are 2 major & disruptive things that really annoys me.
    1/ Why do we have a small sector of the population so insistent on forcing everyone to do it their way?
    2/ Cycling head injuries are only a tiny percentage of all head injuries so why force it only on cyclists and not others like motorists?

    If you want to wear a helmet and believe they are good – go for your life, do what you want and by all means tell me how good you think they are. But don’t call for MHL to force others what to do.

    Even debating introducing MHL on everyone else who don’t share your “religion” is not only an infringement of our right to live life as we see it. But it’s also a distraction from the main issues – general cycling advocacy and improving road safety for all road users.

    • sportingjim says:

      I would advocate for a robust debate always, I don’t think it has to be a distraction from the other issues you properly identify as very important; general cycling advocacy and improving road safety for all road users (pedestrian, cyclists, cars).

  18. quall says:

    I would not repeat all people those are against MHL, just add two things I’ve noticed. I’ve been riding with a helmet for a year every day and now I ride without a helmet for at least half a year. I found that:
    1. I feel much safer on roads. All drivers instantly threat me as a vulnerable road user if I have no helmet on my head. They give me much more space overtaking and if there is not much space – just drive slowly behind without risking.
    2. Non-cyclists treat cycling as very dangerous activity. Somehow it all transforms into the rule “if you need a helmet, then it is very dangerous”. Like being a mine-worker or mtb-downhiller-freerider. So “helmets === extreme sport”

    I always wear helmet doing mtb/downhill rides – it is for sure must-have thing for any kind of extreme sport. But using a helmet for commuting is just ridiculous (if it is compulsory of course). If one wants to feel safer on a bike path or city road – there is nothing bad in it. Is it actually safer – don’t think so.

  19. Pingback: The Thunder From (mostly) Down Under | Clinical Journal of Sport Medicine Blog

  20. Dr N Perry says:

    Asking the question whether bicycle helmets should be made compulsory is jumping the gun; safety laws are introduced to address a need, before you even consider a solution and a law you require a need.

    It is well accepted that the benefits of bicycling outweigh the costs (e.g. see the Active Travel Strategy, UK Department for Transport & Department of Health, 2010) and that bicyclists on average live longer than non-cyclists.

    So if cyclists are living longer, benefitting their own health, and (incidentally) saving the rest of Society money – everything from lower demands on the health services to reduced road congestion and pollution – where is the need?

    Given the lack of need those promoting bicycle helmets have turned to dangerization (yes not really a word) to create a false need – standard marketing and political tactics of course, but it does not make it valid.

    So asking whether an MHL should be introduced is actually asking: “Should individuals be fined for (a) improving their health, (b) living longer, and (c) benefitting the rest of Society; but only if they do this by riding a bicycle?”

    Who would be brave enough to answer “Yes”?

    MHL’s are at best simply stupid – fining someone for saving you money is not smart. At that is probably the least of the problems.

    The question of whether an individual should choose to wear a helmet is entirely different. Sadly it is harder than it should be for individuals to make a balanced decision on that due to the marketing of cycling as dangerous. How many people swear they’d never cycle without a helmet due to the risk yet don’t know that motorists kill and injure far more pedestrians than cyclists, and kill and injure far more (seatbelted and airbag protected) car occupants than pedestrians – activities they happily do bare headed?

    • sportingjim says:

      Thanks for those thoughtful comments. I’m not sure I would label MHL ‘stupid’, but I appreciate your insight
      as you seem to come from NZ and there have been a lot of respondents from Down Under as you already have MHL.

      It’s interesting to me, this discussion. I’m an American, live in the USA (have practiced medicine on two occasions
      for three months each time in NZ–you have a lovely country), practice pediatric sports medicine. Here in the USA only MVAs exceed bike accidents for hospital and E.R. visits for kids. Bikes cause more traumatic injury in the U.S. than sports, trampolines, pools, skateboarding etc. There is most definitely a need for helmets for kids in the States I would argue.

      And I find the evidence cited in the CASEM statement that adults wearing helmets influences the behavior of kids. That’s one of the issues, not brought up much in these comment threads, that stimulates my interest in bicycle helmet use.

      I agree with you about the distinction between MHL and drives to increase bicycle helmet wear voluntarily. Given the strong response from the crowd in opposition to MHL, it might be best for Canada and USA to continue down the path of pushing the increase in voluntary wear as best we can.

      In any case, thanks for sharing, I (and CJSM, and the readers) appreciate it.

      • Dr N Perry says:

        Why do you want to continue to push voluntary wearing of helmets?

        You are falling into the well prepared trap – you are assuming there is a problem here. Cyclists (on average, everything is averages) live *longer*. There are activities which (on average) shorten lives, cycling is not one of them.

        Take a different area – diet. Eat a good balanced diet and it will benefit your health, don’t and you may join the ever increasing obesity statistics. Given a certain amount of $’s to improve health through diet would your first choice be to target those who already have a good balanced diet and make them even healthier, or those who eat a bad diet? Silly question.

        The great success of the helmet promoters, both voluntary & law seekers, is to convince people there is a problem in the first place. Unfortunately their success is Society’s massive loss.

        In Australia & New Zealand we’ve now had a few decades where many children have grown up cycling less. Not because they didn’t want to wear helmets and mess with their hair – the usual pro-law way of dismissing this – but because their parents were persuaded that cycling was too dangerous for their kids because helmets were required.

        Where those parents told that more pedestrians are killed each year? Of course not. How about being informed about the injury risks to car occupants (consider how many parents now drive their kids to school)? Of course not.

        Looked at the obesity rates for Australia and New Zealand recently?

        We have an activity, cycling, which improves the individuals health, increases their longevity, and saves the rest of Society money; and we tell everyone it is dangerous and its participants must be fined unless they take additional (and clearly questionable) precautions.

        You say you wouldn’t call that stupid, what would you call it? Some would pick discriminatory, or a violation of basic human rights, or abusive, but stupid really does cover it rather well.

        A New Zealand Government transport spokesperson once said, during an unguarded moment in a public meeting, that with the helmet promotion campaign and subsequent law “we shot ourselves in the foot”.

        Stupid indeed.

        • sportingjim says:

          well, i’m sure anything i write won’t be satisfactory but

          1) i just would avoid altogether inflammatory words like ‘stupid’ when i’m interacting on social media, just a social etiquette rule i follow. i think i would rather stick to looking at the facts, the pros and cons, and not try to frame things with emotional content. i honestly come close to wanting to use words like stupid when i’ve been involved with gun control legislation here in the states, but i just don’t think those words are helpful. maybe i would go with ‘wrongheaded,’ ‘misintended,’ something like that.
          2) and i’ve written some posts, and the CASEM folks and murray matiland have written their pieces in the new CJSM, and i’ve commented a lot already on these posts here in the comments so i won’t rehash the why of being still behind as many voluntary users of bicycle helmets as i could get out there. i would simply, if i needed to give one more piece of evidence that i would look to to advocate for this, 1) point the person to this website: http://www.bhsi.org/ and 2) allow for the fact that maybe ‘things’ are different here in the states than where you stand in nz, because it is quite clear to me that especially for kids the right thing to do is promote the use of helmets.

          tell me, and i mean this sincerely and it’s off topic, where in nz do you live? i worked for a few months in dunedin and, on a separate occasion, a few months on the n island, in matamata and otorahanga. what a beautiful country you live in. has spring arrived yet where you are?

          cheers.

  21. Peter Clinch says:

    US kids may be getting hurt a lot, but they’re the same basic design as very safe Dutch kids, and the latter are not wearing helmets much. So the problem is the environment and that’s what you need to change, not a bit of encouragement to wear a helmet that is only designed to mitigate minor injuries and certainly not to protect from collisions with motor vehicles. In other words, I think that if helmets are an answer then we’re asking the wrong question, and I’ve stolen that particular phrase from Chris Boardman. Check out some solid sense on bicycle safety from him at http://www.youtube.com/watch?v=kjaHH8YR7Pg and at 2:20 he’s interviewed and focuses very much on the real issues.

    • sportingjim says:

      don’t disagree, would argue that while we work on changing the environment, ppe makes sense especially for the kids. these initiatives needn’t be mutually exclusive, they are not either/or.

      many of the kids visiting the e.r. with bicycle head injuries are not getting them from car on kid, they are getting them from doing their ‘normal’ kid behavior (doing tricks, falling while learning, etc.) i, and most advocates i know, keep coming back to the idea: let’s let them walk away with an injury, rather than suffering a serious head injury. but by all means i would not want to stop there. i am huge proponent of making the environment (especially the dense urban environment) more multi-user friendly, nudging the structure of the city toward a promotion of active commuting, of pedestrian safety first, then bike, then car, toward a promotion of mass transit. many readers have demonstrated their concern and share data about declines in bike ridership, and i agree: let’s get more people riding, biking, let’s do it safely. thanks for writing.

      • Peter Clinch says:

        But the Dutch kids are doing “normal kid things” too… For a perspective on falling off a bike and what it means check out the following video clip. It isn’t meant to be making a point or how-to, it’s just joie de vivre of learning to ride a bike: http://www.youtube.com/watch?feature=player_embedded&v=zkPYPeR97rU

        Our learner falls off several times and, just as we used to do in Britain and I imagine in N. America and Oz and NZ before the end of the 80s, rather than being sent to ER/A&E they just get back on and start again. Yes, it does go wrong occasionally but exactly the same can be said of learning to use stairs, and running across hard ground, and climbing on things, playing in playgrounds etc. etc. These children are the same as your children and my children, but they learn to ride bikes and they learn to do cool things with bikes routinely and typically at an earlier age, and they’re not giving their government or carers any reason to deck them out in PPE.

        In this country (UK) the adults present would quite likely be branded as irresponsible for letting a young child learn without a helmet, I suspect in N. America too, and of course in NZ and Oz it would actually break the law! And yet the country with most in the world to lose *if* learning to ride without a helmet were a genuine problem makes a point of not doing anything to encourage helmet adoption because they regard riding as too beneficial to want to put anyone, children included, off. If the Dutch don’t do it for a reason it might be smart for us to follow their example: they do appear to have quite a good track record of kids on bikes!

        Cycling can, just like using the stairs or getting out of the bath, get you dead. But not often enough that anyone bothers with PPE for either. And cycling isn’t especially more dangerous than these things, or productive of serious head injuries unless maybe if you mix in motor traffic. And if you do mix in motor traffic then a standard cycle helmet has vanishingly low chances of doing much about it. Cycle helmets are designed to mitigate minor injuries. There’s nothing wrong with mitigating minor injuries, but there’s no particular point in singling out cycling as an arena where that must be done, or expecting it to reduce serious injuries appreciably.

        • sportingjim says:

          peter
          good points i don’t disagree per se with anything you have said
          i would point out though that in certain populations we do
          think of ppe/interventions where one might not intuitively expect…..to wit,
          kids and bicycle helmets (at least i’d argue that point) and
          in the case of getting out of bath and using stairs in the
          geriatric population we are frequently, as physicians, encouraging
          folks to get non stick rugs, have hand railings placed in showers,
          etc.
          i appreciate all your input, thanks for that video clip, thanks
          again for reading and sharing.

        • Peter Clinch says:

          Putting a handle in a shower or a non-slip mat in the bath or a handrail on a stair are mainly to make life a bit easier, and I would suggest are seen that way. It is no harder for me to use an adapted toilet, shower etc. than a normal one, but encouraging people in to cycle helmets places two significant barriers to cycling. Partly it’s an inconvenience to some degree, but principally we are telling people implicitly that cycling is dangerous: “why should I wear this thing?”; “Because there is a significant enough chance of serious head trauma that we’re worried if you don’t”, appears to be the answer, but it is not a reassuring one.

          Again I return to Boardman’s work at British Cycling, where at http://www.britishcycling.org.uk/campaigning this (generally pro-helmet) organisation is saying, “We know that the biggest barrier to people getting on their bikes is the perception that the cycling is a risky activity. It is not, you are just as likely to injure yourself walking as you are cycling. Everything we do we want improve the perception and reality that cycling is a safe and normal activity.”

          “Safe and normal” is not the same as “dangerous enough that you ought to wear PPE”, so if you push PPE you are, irrespective of intent, also pushing the perception that cycling is dangerous and thus, for a lot of the people a lot of the time, undesirable.

          And as others have noted here, every time you put someone off cycling you have scored an own-goal for public health, and you’re actually paying money to do that.

  22. Avery B. says:

    My observations over 20 years suggest that advocates lack a credible case. Even when bothering to present a case, it’s on the questionable assumption that a bicycle helmet possesses near magical powers. The normal modus operandi is to turn to exaggerating the problem with anecdotes and “out of context” statistics. I wrote about this five years ago http://www.vehicularcyclist.com/lobby.html

    Context for our discussion are US estimates drawn (directly or by deduction) from the US CDC website: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a1.htm?s_cid=mm6039a1_w and http://www.cdc.gov/traumaticbraininjury/factsheets_reports.html

    1.7million traumatic brain injuries (TBI) annually to emergency departments, of these 29k hospitalized

    400k – 475k TBI’s age 0 to 14 years of age, of these;
    110k Sports and Recreation (7k plus hospitalized or 6.5%)
    17k bicycle (4.25% of total age group TBI’s)

    So 95.75% of TBI’s suffered by children involve activities other than cycling.

    Jim, as an ER physician, your position is understandable but you see the catastrophic side of the equation only. Context from your perspective is missing as the data shows child TBI’s from bicycle use are a tiny portion of the total*. You are seeing TBI’s from other activities (auto use?) in much greater numbers.

    Is there really any justification for the amount of attention and resources given over to the draconian measure of requiring all adult cyclists to wear helmets, when 95.75% of “the problem” is accepted as statistically inevitable, and thus largely ignored by the public and media?

    * If Ohio, your state of ~11million, is representative of the rest of the USA (~320 million pop.), you receive annually ~ 57000 TBI’s, ~600 are child cyclists and ~40 hospitalized. No doubt you will have more accurate figures but I believe the scale indicated is likely not too far out.

    • Jim, I’m a fellow Ohio resident, and have strong interest in this issue. You may wish to read the following, from the website of the Ohio Bicycle Federation:
      http://www.ohiobike.org/misc/CyclingIsSafeTLK.pdf
      and this, from the Bicycling Life website:
      http://www.bicyclinglife.com/SafetySkills/SafetyQuiz.htm
      I’m the author of both pieces.

      Both summarize data showing that bicycling is not an unusually risky activity. It is not a significant contributor to serious TBI. In fact, it’s hard to see why cycling is singled out for this attention.

      I’d also caution against conflating the terms “head injury” and “brain injury” (i.e. TBI). Many helmet promoters have (perhaps deliberately) inflated the fear of TBI by stating data regarding _head_ injuries, which can include even minor scratches.

      Most notorious, in my mind, is the 1989 Thompson & Rivara paper (of “85%” fame) that counted cuts to ears, etc. as “head injuries.” Laymen, medical professionals and legislators were fooled into thinking their purported helmet benefit applied to much more serious injuries.

      – Frank Krygowski

      • sportingjim says:

        Thanks Frank I will take a look at those links, good to hear from a fellow Ohioan on this matter.

  23. sportingjim says:

    Linda Ward from Menzies School of Health Research contacted me and submitted this to add to the comment thread:

    In stating that ‘No one can say for certain that helmets do not exacerbate head injuries, potentially turning a laceration or minor skull fracture into a brain injury’, AveryB seems to have overlooked the evidence in several bicycle helmet studies . . .

    As noted above, the results of Elvik’s meta-analysis (http://www.ncbi.nlm.nih.gov/pubmed/?term=elvik+meta+helmet) showed that for brain injuries the OR was 0.42 (95% CI 0.34-0.53), and 0.23 (95% CI 0.08-0.66) for fatal (head) injury.

    Also as noted above, the injury results in the Carr study (http://www.monash.edu.au/miri/research/reports/muarc076.pdf) showed that in Victoria

    – the proportion of serious/severe (AIS3/4) cyclist head injury hospital admissions dropped by 40%

    – the number of AIS3/4 cyclist head injury admissions dropped by 60%, when the number of pedestrian head and cyclist non-head admissions each dropped by 20%

    With respect specifically to rotational injuries (DAI) . . .

    The study by Bambach et al., of the 6745 cyclist hospital admissions following collisions with motor vehicle in New South Wales between 2001 and 2009 for which helmet use was known (http://www.ncbi.nlm.nih.gov/pubmed/23377086), noted that ‘Only 8 individuals sustained loss of consciousness on a time scale satisfying one of the requirements for the diagnosis of DAI (more than 6 h, AAAM, 2005), thus in the current study DAI could have occurred in no more than 8 cases of brain injury (2.9%)’.

    An experimental study by McIntosh et al., which tested Curnow’s ‘hypothesis’ that bicycle helmets increase angular acceleration (http://www.ncbi.nlm.nih.gov/pubmed/23697898), concluded that the study demonstrated that ‘helmets do not increase angular head acceleration’ and that it ‘confirmed the significant benefit in terms of linear and angular acceleration through the use of a helmet’.

    Walter et al. (http://www.ncbi.nlm.nih.gov/pubmed/23339779) noted that the McIntosh study showed that helmets reduce ‘both linear and angular acceleration by a considerable margin’.

    In stating that there has been ‘a failure to demonstrate much benefit from mass helmet use’, AveryB appears to have overlooked results in the Carr study described above, and the results of studies by Marshall and White, Hendrie et al., Walter et al., and Olivier et al.

    The Marshall and White (https://www.bicyclenetwork.com.au/media/vanilla/file/SA%20Helmet%20eval%201994%20SA%20Marshall.pdf) study showed that in the 2 years after the law, compared to the 2 years before the law, in South Australia

    – there was a 27% reduction in non-cyclist concussion admissions, and a 54% reduction in cyclist concussion admissions

    – cyclist non-preventable injuries reduced by 9%, and cyclist potentially preventable injuries excluding concussion reduced by 41%

    The Hendrie study (http://www.ors.wa.gov.au/Documents/Cyclists/ors-cyclists-report-helmets-evaluation.aspx) found that there was a significant (p<0.001) reduction in the proportion of cyclists with a head injury (compared to the proportion of pedestrians with a head injury) following the introduction of the helmet legislation in Western Australia.

    Walter et al. (http://www.ncbi.nlm.nih.gov/pubmed/21819836) found that a 25-29% reduction in cyclist head injuries was attributable to the helmet law in New South Wales.

    Olivier et al. (http://www.ncbi.nlm.nih.gov/pubmed/23026203) found that 'the initial observed benefit of the MHL has been maintained over the ensuing decades'.
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