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The Cochrane review by Rivara and the Thompsons found evidence that if you bang your head the consequences will be less severe if you are wearing a protective helmet.1 Based on this review they recommend that cyclists should be “encouraged” to wear helmets. The form of encouragement that they favour is compulsion.
We accept the principal finding of their review—that protective helmets protect in the event of an accident—but not the policy conclusions that they derive from it. The issue that divides us is risk compensation—does the behaviour of cyclists change as a consequence of wearing a helmet in ways that offset the protective benefit of helmets in accidents? After briefly referring to selected references from the safety literature on cycling, motorcycling, and driving, Rivara and the Thompsons assert that “the empirical evidence to support the risk compensation theory is limited if not absent”. Certainly such evidence is limited or absent from the sources they choose to cite—with a notable exception which we discuss below. We find abundant evidence for risk compensation.
It is important to distinguish between evidence for risk compensation in general—which is overwhelming, and evidence relating to cycle helmets—which is limited. Let us consider the general evidence first. Rivara and the Thompsons recommend readers to consult James Hedlund's article in Injury Prevention entitled “Risky business: safety regulations, risk compensation, and individual behaviour”.2 We strongly support their recommendation. They quote James Hedlund: “I believe the evidence is overwhelming that every (our italics) safety law or regulation is not counterbalanced by compensating behaviour”. But Hedlund also makes clear that the evidence is overwhelming that some laws and regulations, as well as safety measures voluntarily adopted, are counterbalanced by compensating behaviour. He states:
“We all change our behaviour in response to changes in our environment. Safety …
"Risk compensation theory should be subject to systematic reviews of the scientific evidence" (Thompson, Thompson, and Rivara) and "The risk compensation theory and bicycle helmets" (Adams and Hillman) plus authors' responses have been republished electronically in a different order at the authors' request to avoid any potential confusion. They can be found in June 2002 (Injury Prevention 2001;8:e1).
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