The pros and cons of mandatory bicycle helmets are hotly contested, as regular Croakey readers will know.
In the article below, Daniel Vujcich offers a suggestion for how to move the debate forward.
Laying down a challenge to all sides of the bicycle helmet debate
Daniel Vujcich wries:
The debate about the appropriateness of mandatory helmet laws has resurfaced recently. Lower than anticipated levels of public interest in both the Brisbane and Melbourne city cycle schemes has been attributed by some to the inconvenience of having to wear a helmet or risk a penalty.
In this blog, comments on previous posts regarding the health benefits of helmets have closely resembled Newton’s Third Law – that is to say, almost every empirical claim has a tendency to be met with an equal and opposite counter-claim.
The babel of a statistical warfare can often be hushed by the clear voice of a Cochrane Review.
A 2008 review (up-to-date as of September 2009) accounted for the methodological quality of available studies and “found positive evidence that bicycle helmet legislation both increases bicycle helmet use and reduces bicycle related head injuries”, with the proviso that “enforcement is necessary to ensure compliance”.
However, the conclusion was accompanied by a number of caveats – namely, (1) it is difficult to obtain full and accurate information about actual helmet use; and (2) it is difficult to determine whether decreases in head injury rates are a product of helmet laws or other factors such as changes in hospital admission procedures, or lower levels of bicycling.
While the Review only included studies with a comparative control group so as to discount alternative explanations, five of the six studies compared child head injuries (following the introduction of a mandatory child-specific helmet law) with those of an adult control group. The Review authors noted that “comparing adults with children may be problematic”.
Three years on and the promise of a statistical cease-fire has proved ephemeral.
Yet, to employ a school yard analogy, there is only so much that one can achieve by countering every “is not” with an “is so” when it comes to political debates.
Until the day that the much coveted Study-to-End-All-Studies is delivered, I argue that pro-helmet proponents need to bolster their discursive arsenal if they are to effectively defend their position in the face of a recurring media appetite for reform.
Aside from statistics, one weapon that is currently invoked by pro-helmet advocates is the ‘precautionary policy principle’ – the idea that, in the absence of scientific consensus, policy makers are justified in adopting a course of action which allays a suspected risk.
However, the precautionary principle leaves us wanting. As Cass Sunstein (2003) has forcefully argued, the central weakness of the precautionary principle is not that “it leads in bad directions, but because … it leads in no direction at all. The principle threatens to be paralysing, forbidding regulation, inaction, and every step in between.”
Protecting society from the suspected risk of increased rates of head injuries in turn exposes it to the suspected risk of a potentially less active population, and all that that entails. Thus, through an application of the precautionary principle, the two warring camps once again find themselves at an impasse.
From my perspective, a better strategy for helmet law proponents is to rely on the economic/cognitive behavioural theory of loss aversion. In short, the theory states that most people favour avoiding losses to making gains.
Thus, in the present situation, when faced with a lack of scientific consensus, the general public should prefer to maintain the status quo. This is because if the current law is lifted there is a plausible risk that bicycle-related injuries and mortalities might increase, which would constitute a loss to society.
Since avoiding plausible losses is preferable to making plausible gains, the promise of a potentially more active (and perhaps more healthy) society than we currently have would be considered insufficient to justify the risk.
The onus therefore shifts to those in favour of reform to demonstrate that the potential societal health gains are big enough (and inevitable enough) to warrant a deviation from the default preference for loss aversion.
Should the pro-reformers manage to achieve this, those arguing for the status quo would rightly be left helmet in hand.
• Daniel Vujcich is a graduate of the University of Western Australia. He is currently on a Rhodes Scholarship to the University of Oxford where he has completed a Master’s degree in International Development, and now reads for a doctorate in Public Health. His research relates to the way in which Indigenous Australian health policies are formulated.
The Cochrane review is invalid.
A study published in the British Medical Journal showed that the health benefits of riding a bicycle outweigh the risks by a ratio of 77.
Australia, comparison of cyclist to pedestrian fatalities, 1986 to 2008
From 1986 to 2008 population increase and road safety has changed, e.g. Road safety has improved, Queensland fatality rate per 100,000 population, 1991 – 13.2 and in 2008 – 7.6, down about 42%.
The 4 years before helmet laws started in Australia, 1986 and 89, percentage cyclist to pedestrian deaths was 16.2% (342 cyclists /2082 pedestrians). Comparing with 2005 –08, 148/851 =17.4%. Census shows a substantial fall in cycling but the percentage of cyclist to pedestrians has increased. Additionally the number of children cycling reduced by 36% in Victoria and by 44% in NSW. The data suggests that cyclists have not benefited from wearing helmets and helmet legislation has caused a drop in cycling.
Queensland fatality aspects
The Monograph 5 review details for Queensland 1993 to 2008 there were 146 cyclist fatalities, 44 not wearing helmets, 82 worn, 20 unknown (Table 13, page 30). In fatal type accidents helmets can dislodge and on inspection it may not be known if the rider was wearing or carrying a helmet. The data suggest of known cases 65% were wearing helmets. Various reports have detailed some of the differences that can occur with helmet wearers and non-wearers, income type groups, wearing hi-viz safety vests, drinking habits, riding habits and age. The adults have a higher wearing rate than teenagers also tend to have more experience and this results in a lower risk per km of travel and they would have this lower risk regardless of helmet use.
Road traffic crashes Queensland data (1999 to 2004) also details the number of cyclists killed wearing and not wearing helmets. The reports show 51 deaths in the 6 years, 35 wearing, 10 not wearing and 6 unknown. Of known cases 77.7% were wearing helmets. The 2001 survey on helmet wearing reported 5117 cyclists were observed of which 77 percent were wearing a helmet, up from 71 percent in 1997 and 52 percent in 1991
Tin Tin S, Injuries to pedal cyclists on New Zealand roads, 1988-2007, Tin Tin et al. BMC Public Health 2010, 10:655 http://www.biomedcentral.com/1471-2458/10/655
It reports – Results
“The highest rate of cycling injuries was observed among the 5-14 year olds (Figure 1). In this age group, from 1996-99 to 2003-07, there was a substantial increase in injury risk from crashes not involving a motor vehicle. However, this trend was not observed when analyses were restricted to those with serious injuries. Males had a higher rate of collision and other injuries compared to females (Figure 2).”
Fig 1 shows a major increase in the accident rate for 5-14 age group, almost doubling the rate. Road safety improved in NZ from 1990 – 2009, roughly 50%+ reduction. Therefore a fall in serious cyclist injuires would be expected.
It reports- Discussion
“Of particular concern are children and adolescents who have experienced the greatest increase in the risk of cycling injuries despite a substantial decline in the amount of cycling over the past two decades.”
Table 1 in their report details the cyclist accident rate per million hours, 25.6 in 1988-91, 30.7 in 2003-07.
It appears that most of the increase in risk was to children. This outcome appears very similar to Victoria and New South Wales in both reducing safety for children and discouraging them from cycling.
A Parliamentary inquiry to investigate why Australia was misled is needed.
Applying Freedom Rider’s precautionery principal to other risky endeavours in life would surely mean that all new cars should be immediately fitted with full harness restraints and helmets be made compulsory for all vehicle occupants. Similarly given the exhorbitant rate of injury and death by motor cycle riders compared to all other transport modes means they should be immediately banned outright now.
These changes wont happen. We as a people have accepted that while there is risk, we are happy to accept that risk for the other perceived benefits. I suspect the bike helmets got through at a time when it was essentialy only children were riding bikes and of course we must think of the children.
In the end I see this type of law as sensible and sane as all the other prohibitions that have been tried “for our betterment” over the last 100 years.
Your argument is an excellent example of why people should do nothing about climate change – there is a plausible additional cost, offset by ‘prospects’ of new jobs installing home insulation, renewable energy systems and avoiding losses to coastal cities from potential sea level rises.
Despite the lack of complete scientific consensus, most people (myself included) who have read and understand the issues, believe that the cost of not addressing climate change could cost much more in the long run.
Bicycle helmet laws are the same. The Cochrane review is misleading, because its author relies mainly on her own study that found a downward trend in head injuries. She conveniently omitted to mention that there was no long-term increase in helmet wearing, and failed to mention a similar downward trend for pedestrian injuries – see graphs at http://www.bmj.com/content/332/7543/722.2.extract/reply#bmj_el_243531
The generally-accepted way to evaluate a road safety intervention is to look for a response when the measure in introduced. That’s how we know that speed cameras and random breath testing work – the response was immediate and sustained.
There was an immediate and sustained response to Victoria’s helmet law – see Fig C at: http://www.bmj.com/content/332/7543/722.2/suppl/DC1#fb The problem is that non-head injuries fell almost as much as head injuries. Helmets don’t prevent non-head injuries, but we’d expect fewer non-head injuries if there were fewer cyclists.
In other words, the biggest, most noticeable effect of the law was that is discouraged cycling. We know this not only from the reduction in non-head injuries, but also the comprehensive surveys at the same 64 sites and observation times and the same time of year – post law, 36% fewer cyclists were counted.
An evaluation in 1996 pointed out that head injuries per km cycled actually increased compared to what would have been expected without the law. At the time, this was not easy to explain. But subsequent studies have shown that reduced cycling leads to reduced safety in numbers. A clear effect of risk compensation in relation to bicycle helmets has also been demonstrated.
Drivers leave significantly less room when overtaking a helmeted cyclist. The researcher, Dr Ian Walker, was hit twice when conducting this research – by a truck and a bus – both times when he was wearing a helmet! http://www.eurekalert.org/pub_releases/2006-09/uob-wah091106.php
Another study found that that cyclists accustomed to wearing helmets ride significantly faster (implying greater risk tolerance) when wearing helmets than without – see http://www.cycle-helmets.com/P885.pdf. This is likely to increase the risk of crashing.
Having taken the time to read the Cochrane Review, I hope you will read the other evidence and decide which is more plausible. The Cochrane Review that found a downward trend in head injuries (in Canadian provinces that implemented helmet laws compared with those that did not), but failed to mention:
a) Pedestrian injuries in helmet law provinces showed a similar downward trend compared to non-law provinces
b) The helmet law wasn’t enforced. Surveys of helmet wearing showed that it soon returned to pre-law levels – there is no plausible reason why a non-enforced law that didn’t increase helmet wearing should have reduced head injuries.
In contrast, if helmet laws worked, the review in the British Medical Journal – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1410838/?tool=pubmed should have found them.
Substantial health benefits were found for users of Barcelona’s the public bicycle sharing scheme. Compared with car users, the estimated annual change in mortality of the Barcelona residents using Bicing (n=181,982) was 0.03 deaths from road traffic incidents and 0.13 deaths from air pollution. As a result of physical activity, 12.46 deaths were avoided (benefit:risk ratio 77:1) see http://www.bmj.com/content/343/bmj.d4521.full
So with no clear evidence that helmet laws actually reduced head injuries, and indeed evidence that they increased because of risk compensation and reduced safety in numbers, isn’t it time to repeal the laws?
Daniel Vujcich’s principle of status quo in support of mandatory helmet-wearing assumes that removing compulsion would plausibly result in injuries that are only balanced by general health gains from cycling. However, it can plausibly be argued that compulsory helmets actually increase risk.
Bath University research showed drivers were twice as likely to get particularly close to cyclists wearing helmets. If, as many cyclists believe, road and driving culture are the biggest dangers to cyclists’ safety, then increasing drivers’ sense that cyclists are vulnerable and increasing the number of cyclists on the road by removing mandatory helmet laws would be the most plausible way to reduce cycling injuries.
Yes, people who believe helmets reduce injury should bolster our discursive arsenal. Just like people who think that seatbelts, lower car speeds, crumple zones, speed cameras, booze busses, better roads, air bags,……. reduce the road toll should boost theirs. That’s because despite all the evidence people tend to make emotional decisions like ‘I don’t like wearing a helmet therefore helmets are bad’ and then rationalise them. Simple facts like the ever increasing number of bikes sold and bike sales eclipsing car sales are ignored by people who either choose to misrepresent evidence or who simply don’t have the skills to accurately interpret data (a plural btw freedom rider)
Study after study after study finds helmets reduce injury but the fact is no amount of evidence will convince the anti-camp and it’s a waste of time trying. Far better to put effort into showing non-aligned stakeholders like parents, riders and law makers the proven benefit of augmenting your heads ability to reduce shock being transmited to the brain than trying to convince people who Moses and the prophets gave up on.
@ Freedom rider,
This is a completely invalid conclusion.
You need to consider one of the few valid arguments put forward by climate change deniers – correlation is not causation.
The number of children cycling has reduced since 1986 – 1989. This happens to coincide with the introduction of helmet laws. It is a logical fallacy to draw a causal link between the two without trial by the scientific method or evidence of causation.
One could draw a graph which “proves” by this flawed logic, that the reductions in children’s cycling were “caused” by the proliferation of mobile phones.
Or, we could look overseas to see how they cope without mandatory helmets. I am afraid I dont have time to indulge in dredging through reports that I am sure exist, but… Based on what I have seen when in Europe my gut instinct is we should ditch the laws that are inhibiting the bike hire schemes. I have seen these schemes in a number of French cities including Bordeaux and Paris, also German cities. In each case they seem to be a tremendous benefit for not only the locals who use them but also tourists. The cities where I have seen the schemes operating also have very congested traffic and often pebble roads. I have not seen anyone come a croppa on the bikes although I am sure it happens, I suspect not often though. The benefits are obvious.
Making helmets mandatory is an obvious show stopper for the scheme. People will not carry a helmet around, just in case they may hire a bike. They dont want to wear one someone else just had on their head and of course vanity & hair will come into it.
I ride a bike regularly at home and always wear a helmet when on the road and would recommend anyone wear one if riding at speeds say over 25 Km/h and on highways. I do think making this mandatory for every instance you get on a bike is an overkill and the downside from this law far outweighs the upside.
The author seems to have been running for a deadline and left the analysis incomplete. The plausible gain, to be drawn from his introduction, is that the quantity of cycling would increase from relaxing of helmet laws. Another plausible gain is that adults should have the freedom to choose – and the evidence for safety benefits is marginal at best – so why is Australia leading the pack in front of safety-oriented societies such as Sweden, on imposing decisions of marginal value?
Trevor wrote: “Or, we could look overseas to see how they cope without mandatory helmets.”
Israel enacted all-age mandatory bicycle helmet laws four years ago. Early this month the Israeli Knesset (parliament) repealed the helmet law for adult cyclists in cities and towns.
The Israeli politicians obviously didn’t ditch the adult helmet law on a whim … they studied the results in their own country, in Australia and in New Zealand. There were three countries with national all-age helmet laws – now there are two.
Submissions to the Knesset drew on various Australian studies and records of cycling participation, head injury, all-body injury and affiliated repercussions from the helmet legislation – including from http://www.cycle-helmets.com
I suspect the Israelis recognised that studies of what might happen don’t correlate with what actually has happened in the few legislatures that punish people who choose cycling exercise instead of driving a tonne or two of polluting and potentially lethal metal.
The bike share failures in Melbourne and Brisbane simply reflect what’s been happening for 20 years – a public health disaster that discourages regular recreational exercise in one of the world’s fattest countries, at the same time increasing the ratio of injuries per cyclist on the road.
Incidentally, Mexico City also repealed its mandatory helmet law in early 2010 so that its Ecobici bike share scheme had a chance of attracting users.
Thanks largely to soaring petrol prices, Australian cyclist numbers have been increasing since the late 1990s but remain below the numbers recorded by the ABS prior to hemet law enforcement starting in 1990.
It’s an absurdity that within a year Australia will have some of the world’s most punitive carbon dioxide legislation yet is one of just two countries with national laws that actively discourage the use of a safe, non-polluting mode of transport.
As Dr Paul Biegler stated in the linked SMH article, I think this debate needs to give consideration to the lack of quality and consistency of cycling infrastructure in Australian Cities. European cities have better infrastructure and consistent networks which can more safely accommodate tourist cyclists or other casual cyclists. I think if the helmet law was changed to promote tourism it should be considered in the context of a properly designed network of cycling infrastructure in the first instance.
Chris Gillham rather than quote a partisan web page with no academic credibility read the study entitled “The impact of compulsory cycle helmet legislation on cyclist head injuries in New South Wales, Australia, by Scott R. Walter, Jake Oliviera, Tim Churches, and Raphael Grzebietaa
“Head injury rates decreased significantly more than limb injury rates at the time of legislation among cyclists but not among pedestrians. This additional benefit was attributed to compulsory helmet legislation. Despite numerous data limitations, we identified evidence of a positive effect of compulsory cycle helmet legislation on cyclist head injuries at a population level such that repealing the law cannot be justified.”
“We set out to perform the most comprehensive analysis possible on the subject while addressing any data limitations and possible confounding factors,” said study author Dr Jake Olivier.
“What we found provides compelling evidence that the legislation has served its purpose in reducing bike-related head injuries and any repeal of the laws would only put lives at risk,” he said.
But then you probably favour the monkton view of the world
Wearing a bicycle helmet is a good thing, and if it become optional for adults to wear a helmet I’m sure that many people would continue to wear them.
So the question becomes the health benefits of the small increase in head injuries from not making helmets compulsory for adults compared to the health benefits from getting more people to cycle. I would expect that the overall health benefits would outweigh the extra head injuries.
Of course the other question is at what stage it is appropriate for government to make things compulsory or illegal? As there is now only one other country that mandates helmets for adults, we are definitely at the nanny-state end on this issue.
And even if helmets are to remain compulsory, I still think it would make sense to have an exception for those riding the city hire bikes. Either that or those involved in the schemes planning should have had the common sense to know that the scheme would not work with compulsory helmets.
Captain Planet wrote
Posted August 24, 2011 at 10:54 am | Permalink
@ Freedom rider,
“Census shows a substantial fall in cycling but the percentage of cyclist to pedestrians has increased. Additionally the number of children cycling reduced by 36% in Victoria and by 44% in NSW. The data suggests that cyclists have not benefited from wearing helmets and helmet legislation has caused a drop in cycling.
This is a completely invalid conclusion.”
The Melbourne surveys, 64 sites at 10 hours per site, showed 30 more teenagers wearing helmets but 623 fewer cycling. The main effect of the law was to discourage cycling.
Robinson 1996 report, Table 2 shows data for children in NSW. The equivalent number of injuries for pre law level of number of cyclists increased from 1310 (384 head + 926 other injuries) in 1991 to 2083 (488 head + 1595 other injuries) in 1993. For NSW the helmet laws discouraged cycling and reduced children’s safety. The increased injury rate was 59%, from 1310 to 2083.
Robinson DL; Head injuries and bicycle helmet laws; Accid Anal Prev, 28, 4: p 463-475, 1996 http://www.cycle-helmets.com/robinson-head-injuries.pdf
In 2008 Curnow concluded, “Compulsion to wear a bicycle helmet is detrimental to public health in Australia but, to maintain the status quo, authorities have obfuscated evidence that shows this” and “Cycling declined after the helmet laws by an estimated 40% for children, with loss of the benefits of the exercise
for health. As serious casualties declined by less, the risks to cyclists, including death by head injury, increased.” A link to the paper is at http://www.ncbi.nlm.nih.gov/pubmed/18481926 ,
Erke and Elvik 2007 stated: “There is evidence of increased accident risk per cycling-km for cyclists wearing a helmet. In Australia and New Zealand, the increase is estimated to be around 14 per cent.”
Assessment of Australia’s Bicycle Helmet Laws, refer ‘Mandatory’ can have unanticipated consequences – Civil Liberties Australia web site, 25 Nov. 2008. Providing details of the effects of the legal requirement to wear cycle helmets.
The UK’s National Children’s Bureau (NCB) provided a detailed review in 2005 stating “the case for helmets is far from sound”, “the benefits of helmets need further investigation before even a policy supporting promotion can be unequivocally supported” and “the case has not yet been convincingly made for c