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Helmet laws and health
  1. Caroline Acton
  1. Department of Paediatrics and Child Health, Royal Children's Hospital, Herston Road, Herston, Brisbane, Queensland, Q4029, Australia
  1. Correspondence to:
 Dr Acton.

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In 1884, Louis Pasteur told his students that “when meditating over a disease, I never think of finding a remedy for it but, instead, a means of preventing it”.

That laws enforcing helmet wearing for cyclists do more harm than good is an ethical, philosophical, and scientific debate. As stated by Unwin in 1996, the law has principles, precedence, and consequences, all of which have undergone much evaluation and heralded benefits. These are a reduction in the number of head injuries in cyclists as well as a reduction of their severity in most Australian states.

Pasteur's principle of prevention may be applied to either the incident or the injuries resulting from it. The effectiveness of an approved helmet in preventing head injury, both serious and minor, is proven worldwide by case-control studies.

The riding behaviour of injured cyclists has been examined rigorously and most investigations negate the “risk compensation” theory, that is, that riders who wear helmets take more risks. This is the argument mooted by those who do not advocate such a simple safety measure.

It could also be asked whether the health benefits of this intervention outweigh the disadvantages of any lost civil liberty. This liberty comprises an exposed head, which in the event of a crash may result in the owner not being able to think clearly, talk, or walk if they receive a hard enough blow to their head. It is common for cyclists to hit their heads and children do so more often. Rarely does this involve a motor vehicle.

Even if a helmet is considered an imposition or a reduction of civil liberty, the long term effect of a head and brain injury on a victim's family, carers, and society is worse. For the child or adolescent with many fulfilling years ahead of them, the event may be devastating.

The three established principles of injury prevention are education, engineering, and enforcement. Enforcement cannot happen without laws to make helmet wearing mandatory. The precedents for doing so are numerous, for example, motorcycle helmets and seat belts in cars. The current debate is similar to the one for motorbikes but differs for cars because the public regards a car essential but a bicycle or motorbike not so.

The benefits of wearing a bicycle helmet, like a seat belt, are proven. However, there is a supposed health risk due to a reduction in exercise, particularly bike riding, if helmet wearing is compulsory. This is said to reduce the health, fitness, and longevity of those discouraged from cycling. I wonder about the enthusiasm for cycling if a piece of light polystyrene on people's heads is such a deterrent.

A study reported in 1990 of a cohort of 9376 people showed they could reduce their chances of coronary artery disease and premature death by regular, lengthy, and hard exercise. However, the resulting fitness needed constant maintenance and could not be stored.

Therefore, the short term effect of any reduction in cycling caused by the laws is unlikely to translate into long term harm, because people are already remounting their bikes five years after introduction of the bicycle helmet law in Queensland. Adolescents comprise the largest number of non-wearers of helmets. They have said that, to be effective, a safety measure needs mandating, with punitive measures for non-compliance. The harm emanates from lack of enforcement rather than the laws themselves.

In 1997 nine Queenslanders died due to a bicycle incident and most of these were children younger than 18 and all died of head injury. In my own study of 150 young people admitted to hospital following bicycle trauma, more than 50% had a head and brain injury. Cycling could be called a dangerous pastime if most of the injuries were not preventable. However, most are definitely preventable.

A well fitting, tightly fastened helmet will reduce the chance of serious head injury by 60–80%. The alleged harm inflicted by helmet laws is as yet unproven in the long term, but the benefits are evident now. The reduction in head and brain injury resulting from helmet wearing will generate financial benefits, to the health budget, as did the introduction and enforcement of car seat belt wearing.

A detailed study by colleagues and myself documented 813 children in one year in Brisbane injured in bicycle trauma. Of these, 294 hit their head and 66 sustained loss of consciousness, that is, serious head injury. The long and short term morbidity of these youngsters is a burden to be carried by society.

Why do we undertake this when mandating a safety strategy may avert the damage? None of the 66 children was wearing a helmet at the time of the incident.

In 1992, 198 cyclists in Australia died in bicycle crashes; the following three years this number fell by about 50 and increased to 161 in 1997. These annual figures would be similar from one year to the next had helmets deterred many cyclists from their ride. The risk compensation argument against helmet wearing needs critical appraisal in that helmet wearers may take more risks.

However, the contrary may also be true.

Where is the evidence? A US study has demonstrated that helmeted cyclists would have to increase their risk taking fourfold for the argument helmet wearing encourages greater risk taking to be plausible.

Thucydides, in the fifth century BC, wrote: “Justice will come [to Athens] when those who are not injured are as indignant as those who are”. Some injured cyclists may not have the mental capacity following their head injury to achieve indignation. It is up to us, therefore, as health care professionals to encourage justice on their behalf.


Caroline Acton is an oral and maxillofacial surgeon at the Royal Children's and Royal Brisbane hospitals. She is a foundation member of the International Society for Child and Adolescent Injury Prevention and has authored articles on bicycle trauma in Australia.