My name is Master Sergeant Chairat Noppakovat and I am stationed at
the Madigan Army Medical Center located at Fort Lewis, Washington. I am
in the United States Army and have served proudly for nearly 22 years. The
reason I am writing this letter is to share with you the story of my son.
His name is Apichai Kevin Noppakovat. He was just 18 years old and passed
away on 14 August 2006. He had just g...
My name is Master Sergeant Chairat Noppakovat and I am stationed at
the Madigan Army Medical Center located at Fort Lewis, Washington. I am
in the United States Army and have served proudly for nearly 22 years. The
reason I am writing this letter is to share with you the story of my son.
His name is Apichai Kevin Noppakovat. He was just 18 years old and passed
away on 14 August 2006. He had just graduated from the Clover Park High
School (CPHS) in Lakewood, Washington this past summer. While attending
CPHS, he joined the Air Force Junior ROTC program for four years and
served as a Wing Commander, in the rank of Cadet Lieutenant Colonel.
While at CPHS, he provided tremendous leadership and mentorship to his
fellow ROTC cadets within the program and to all other students inside and
outside of the school. He is the only cadet who has earned the most
ribbons, medals, and other decorations since the AF Junior ROTC has been
in existence at CPHS. Apichai’s dedication and devotion has inspired so
many of his friends, ROTC instructors, school staff, and people in the
community.
My son and his best friend, Nicholas Morales (who was also 18) were
killed on Monday, 14 August 2006 in the University Place located in
Tacoma, Washington. Apichai and his best friend were passengers in the
back seat of his own car. Apichai has a big heart and always allowed his
friends to drive his own car. There were four teens in the car; the
driver, Chris Smith, is 16 and another front seat passenger, John Simpson,
is 17. They were supposed to go bowling that evening until someone drove
past Chris illegally. Chris got upset with that driver and started to
chase him down. It quickly became a road race exceeding the speed of 67
miles in a 35 mile zone. Chris lost control of the vehicle when the other
driver tried to cut him off. The car spun around and the back of the
vehicle struck an oncoming vehicle. It then proceeded to hit a guard rail
and lastly a traffic pole where it finally came to a halt. Apichai and
Nick died instantly; John and Chris survived the crash.
It is a tragic lost for both my family and Ms. Morales (Nick's
mother). The students, ROTC Cadets, school staff, and other friends were
also in so much of pain with these losses. Apichai had made so much
impact for the past four years at Clover Park School District. He led the
team to win the first ever regional unarmed drill team competition. I
cannot describe all of the things that he has done for the school, ROTC
program, and his friends. The Clover Park School District would like to
keep his legacy going so they are planning to create an "Apichai Kevin
Noppakovat" Scholarship at the Clover Park High School. This scholarship
will be dedicated to a senior student at CPHS who has demonstrated the
best leadership, mentorship, and maintained the highest academic
achievement to attend a four year college.
Malcom Wardlaw asks if a serious head injury rate of 1 per 7,000
capita per year is great enough to warrant enforced use of protective
headgear. My view is that there is no magic number; even 1 per 70,000
would be too many if the injury had serious sequelae, as undoubtedly many
do. I am certain most sensible parents and most pediatricians who treat
these children would agree. The opinions of the City of Toronto Police
S...
Malcom Wardlaw asks if a serious head injury rate of 1 per 7,000
capita per year is great enough to warrant enforced use of protective
headgear. My view is that there is no magic number; even 1 per 70,000
would be too many if the injury had serious sequelae, as undoubtedly many
do. I am certain most sensible parents and most pediatricians who treat
these children would agree. The opinions of the City of Toronto Police
Service and even that of "most of Ontario society" (which, apparently
Wardlaw has knowledge of) is entirely irrelevant. Police in my city fail
to enforce speeding, red light, and stop sign violations. Why safety is
not their priority remains one of life's great mysteries. It is hardly
surprising then that the authors did not discuss other reasons for lack of
enforcement. If Wardlaw cares to speculate on what he believes these
reasons to be, he should do so.
The decline in head injury admissions noted by Wardlaw only serves to
reinforce the need to enforce helmet legislation, not, as he implies, to
abandon it. The BMA's reversal of its position indicates that it agrees
with this reasoning. Moreover, to suggest that without enforcement laws
are "at best, ineffective..." flies in the face of much evidence to the
contrary. Laws work even when unenforced; they work better when enforced.
It is as simple as that.
How it is possible for Wardlaw to know what the BMA assumed is beyond
my comprehension, as is the confused logic in the sentence in which this
assertion appears. Nonetheless, I continue to struggle to understand why
Wardlaw and others work so consistently to oppose helmet legislation. And,
by the way, I struggle to understand how or why "timely release" figures
into the argument.
Hagel and Rowe reject(1) my criticisms(2) of their study of the
impact of a child bicycle helmet law in Alberta, Canada(3). However they
appear to have missed the point.
The first issue raised in my letter concerning reduced cycling as a
result of Alberta's helmet law, Hagel and Rowe say there could have been
confounders which would discount the drawing of a conclusion from the
smaller propo...
Hagel and Rowe reject(1) my criticisms(2) of their study of the
impact of a child bicycle helmet law in Alberta, Canada(3). However they
appear to have missed the point.
The first issue raised in my letter concerning reduced cycling as a
result of Alberta's helmet law, Hagel and Rowe say there could have been
confounders which would discount the drawing of a conclusion from the
smaller proportion of children observed cycling. Actually I did not
suggest the drawing of a conclusion, but rather commented that there was a
red flag deserving of attention considering the reported negative impact
of legislation on cycling that had occurred elsewhere(4). Similar or other
confounders could equally apply to the authors' own conclusion that the
proportion of children wearing helmets increased as a result of Alberta's
law.
Hagel et al also argued that the increased proportion of children
wearing helmets was due to legislation not education or enforcement, yet
they admit there were educational programs in the Alberta area studied and
there was some police enforcement. The authors supported their view by
citing Maryland work(5) which concluded that legislation was more
effective than education. In that case however the legislation was
enforced and therefore is inconsistent with Hagel et al's conclusion.
Other evidence exists which contradicts their conclusion also. A Canadian
survey(6) found educational programs actually do account for increases in
helmet use. I had cited the Ontario evidence which showed helmet use
increases are not sustained by legislation alone anyway in my first
letter.
There were other inconsistencies. Police enforcement in Alberta may
have been more than the authors pointed out. They say 48 tickets were
issued by the Edmonton Police. Were the authors aware that persons under
the age of 16 cannot be charged in Canada? The tickets could only have
been validly issued to a subset of the age group covered in the original
study. It is probable that enforcement among the lower age group took
another form, possibly stern police lecturing. In addition, the Edmonton
Police Service does not and do not have jurisdiction over all of the areas
covered, some of the latter are outside of City boundaries. It must be
assumed that the authors did not contact the RCMP who police the remainder
of the areas to obtain a count of tickets. These two factors suggest Hagel
et al underestimated the degree of police enforcement.
Regarding the second issue concerning their errors in logic, Hagel
and Rowe say that it was their intention to illustrate the degree of
variation in helmet use depending on the helmet and age characteristics of
companions. If that were the case they should have stated so in the
report. Instead they and their colleagues chose to say, "considering that
children riding with helmeted adults are almost 10 times more likely to be
wearing a helmet than children riding with nonhelmeted child companions,
policy makers should consider extending current children-only helmet
legislation in Alberta and other locations." I stated that the relevant
comparison was with non-helmeted adults and showed that children were only
slightly more likely to wear a helmet when with adults. That information
was available from the first Alberta observations yet the authors chose to
use an irrelevant comparison from another jurisdiction, and used it to
reinforce a weak case to extend a helmet law to adults.
References
1. Brent Hagel, Brian Rowe, Emergency Medicine, University of
Alberta (5 September 2006), Re: Alberta helmet article - logic problem and
missing data. Authors reply.
http://ip.bmj.com/cgi/eletters/12/4/262 (accessed 16 December 2006)
2. Avery Burdett (5 September 2006), Alberta helmet article - logic
problem and missing data http://ip.bmj.com/cgi/eletters/12/4/262 (accessed
16 December 2006)
3. Hagel BE, Rizkallah JW, Lamy A, Belton KL, Jhangri GS, Cherry N,
et al. Bicycle helmet prevalence two years after the introduction of
mandatory use legislation for under 18 year olds in Alberta, Canada. Inj
Prev 2006;12(4):262-265
4. Robinson DL. No clear evidence from countries that have enforced
the wearing of helmets. BMJ 2006;332:722-725.
5. Cote´ TR, Sacks JJ, Lambert-Huber DA, et al. Bicycle helmet use
among Maryland Children: effect of legislation and education. Pediatrics
1992;89:1216–20.
6. Parkin PC, Spence LJ, Hu X, Kranz KE, Shortt LG and Wesson DE,
Evaluation of a promotional strategy to increase bicycle helmet use by
children. Pediatrics 1993; Vol 91, 772-777.
Macperson et al. present valuable findings [1] on rates of helmet use
by Toronto children of different income groups; and how these rates varied
across a period in which a helmet law was passed. The wearing rates rise
to a peak after the law of 1995, followed by a decline back to roughly pre-law levels by 1999. This profile occurred because the law was not
enforced. The City of Toronto Police Service c...
Macperson et al. present valuable findings [1] on rates of helmet use
by Toronto children of different income groups; and how these rates varied
across a period in which a helmet law was passed. The wearing rates rise
to a peak after the law of 1995, followed by a decline back to roughly pre-law levels by 1999. This profile occurred because the law was not
enforced. The City of Toronto Police Service confirmed in 2004 that no
child cyclist had been ticketed for not wearing a cycle helmet in that
city[2].
This history raises two issues that warrant further discussion:
1) Risk in cycling:
The principal cause of head injuries to Canadian children is falls,
followed by pedestrian road accidents[3]. There are about six million
Canadians aged 5-19, amongst which an average of 2,200 were admitted to
hospital annually between 1994 and 1998 following a cycling crash[4]. 35%
had head injuries. This is a (serious) head injury rate of 1 per 7,000
capita per year. Is this injury rate great enough to warrant enforced use
of protective headgear? The City of Toronto Police Service, and most of
Ontario society, apparently thought not.
The authors did not discuss reasons for the absence of enforcement.
Their commentary is limited to: “Finally, the role of law enforcement was
not studied; therefore its impact could not be assessed”. Their data make
it clear that enforcement is required to sustain helmet use above what is
found in voluntary jurisdictions. This is a useful piece of knowledge in
the debate on helmet legislation.
A report[5] issued by the Canadian Institute for Health Information
revealed that between 1997/98 and 2001/2, Ontario child cyclist hospital
admissions declined by 12.5%, but head injury admissions specifically
declined by 26%. This advantageous outcome occurred in a period in which,
the authors report, helmet use declined from a peak in 1996/97 to pre-law
levels by 1999. Other evidence[6] reveals that large changes in helmet use
have not noticeably improved serious head injury trends at the population
level.
2)Timely release of data is important:
In a previous paper[7] of 2001, based on the same dataset, Macpherson
et al reported that the introduction of helmet legislation in Ontario had
not deterred children from cycling. The authors reported numbers of
cyclists counted, rather than the extent of enforcement or helmet wearing
rates. However, the conclusion was cited (and still is cited) by
influential bodies in support of the introduction of enforced helmet
legislation. For instance, the British Medical Association reversed its
long opposition to helmet laws and cited the 2001 paper alone in its
change of stance[8]:
“In our 1999 report, significant emphasis was placed on the BMA's
wish not to discourage cycling by making helmets compulsory. The advice
was based on evidence from Australia indicating that cycling levels
decreased following the introduction of legislation. The evidence is now
outdated ... A study from Ontario, Canada has demonstrated that
introduction of helmet legislation did not reduce numbers of children
cycling [referenced to Macpherson et al 2001].
“As with any other legislation, enforcement is as important as the
law itself. Without compliance, the law is at best ineffective...”
The BMA assumed the research referred to an enforced law, when in
fact it referred to an unenforced law, which of course the BMA explicitly
did not wish to see. Such confusion would likely have been avoided had the
2001 paper mentioned that the helmet law was not enforced and helmet
wearing rates returned to pre-law levels by 1999.
References
1.Macpherson A, Macarthur C, To T, Chipman M, Wright J, Parkin P.
Economic disparity in bicycle helmet use by children six years after the
introduction of legislation. Injury Prevention 2006;12:231-35.
2.Personal correspondence with City of Toronto Police Service by A.
Macpherson.
3.Canadian Institute for Public Health data, presented at:
http://secure.cihi.ca/cihiweb/en/media_30aug2006_tab3_e.html
4.Macpherson A, Teresa M, Macarthur C, Chipman M, Wright J, Parkin P.
Impact of mandatory helmet legislation on bicycle-related head injuries in
children; a population-based study. Pediatrics 2002;110:60.
5.“Bicycle-related injuries among Ontario children declining”.
Canadian Institute for Health Information.
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_19mar2003_e
6.Robinson DL, No clear evidence from countries that have enforced
the wearing of helmets. BMJ 2006;332:722-25.
7.Macpherson A, Parkin P, To T. Mandatory helmet legislation and
children's exposure to cycling. Injury Prevention 2001;7:228-30.
8.“Legislation for the Compulsory Wearing of Cycle Helmets”. The
British Medical Association 2005.
http://www.bma.org.uk/ap.nsf/Content/cyclehelmetslegis
According to good public policy, all laws with potentially
detrimental effects (such as reduced cycling and reduced safety in
numbers) should be evaluated. Far from being selective, my review
examined every jurisdiction with a large increase in helmet wearing (more
than 40 percentage points within a year). If helmet laws were beneficial,
there should have been an obvious response. Yet there was no c...
According to good public policy, all laws with potentially
detrimental effects (such as reduced cycling and reduced safety in
numbers) should be evaluated. Far from being selective, my review
examined every jurisdiction with a large increase in helmet wearing (more
than 40 percentage points within a year). If helmet laws were beneficial,
there should have been an obvious response. Yet there was no clear
benefit to offset the expected harm from reduced cycling.[1]
Decisions concerning helmet legislation should, as Hagel and Rowe
suggest, be based on the best available evidence. It would be naïve to
assume that, even if voluntary wearing were beneficial, the same would be
true for helmet laws. Case-control studies cannot determine the effects
of reduced cycling, reduced safety in number or risk compensation.
Consequently, the only reliable way to determine if helmet laws are
beneficial is evaluate their effects on cycle use and head injury rates,
in comparison to the cost buying millions of helmets or introducing other
road safety measures.
It is surprising and disappointing that Hagel et al. chose not to
collect the information needed to evaluate Alberta’s helmet law. Instead,
they devoted 3.5 pages of Injury Prevention to the fact that, at 22 sites
in Edmonton, helmet use of adults remained stable. In contrast, at these
sites, in 2000, 29 children and 17 adolescents wore helmets, 37 children
and 81 adolescents did not. In 2004, 13 children and 21 adolescents wore
helmets; 0 children and 7 adolescents did not. Although the study was not
designed to measure cycle use, this undeniably represents a significant
reduction in the proportion of children and adolescents, compared to
adults who were not affected by the legislation.
The onus should be on those who advocate laws taking away freedom to
choose to prove those laws are beneficial. My systematic review found no
evidence of benefit and probable harm from reduced cycling. Hagel et al.
provide no evidence to contradict this. Most people would consider it more
sensational to argue, as Hagel et al. do, that the helmet law should
extended to adults than, with no evidence of benefit and some suggestion
of harm, that it should be repealed.
References
1 Robinson DL. No clear evidence from countries that have enforced
the wearing of helmets. BMJ 2006;332:722-725.
McEvoy et al (2006) provide empirical evidence to support the case
that distractions for the driver are an important feature of road crashes.
There should be nothing too surprising in this; after all, many
authorities recognise that an enforcible code of behaviour must be applied
to public-service drivers; bus passengers are not likely to feel at ease
with a driver whose attention deviates from the task in hand.
McEvoy et al (2006) provide empirical evidence to support the case
that distractions for the driver are an important feature of road crashes.
There should be nothing too surprising in this; after all, many
authorities recognise that an enforcible code of behaviour must be applied
to public-service drivers; bus passengers are not likely to feel at ease
with a driver whose attention deviates from the task in hand.
The real problem is of course the private automobile driver, always a
difficult creature to control. No doubt, education would help. However,
this is an uphill task: for example, I imagine few would suggest that
restrictions on mobile-phone use in jurisdictions such as the UK have been
notably successful, even when backed up by punishment (1).
Nonetheless, one practice that seems unnecessarily gratuitous is the
portrayal of driving on TV: frequently, interviews or monologues to the
camera are undertaken while the speaker is driving, perhaps in fast-moving
and heavy traffic. Often, this adds absolutely nothing to the content of
the programme; for example, I can think of a recent monologue by the
presenter of a BBC TV programme about sites of battles that predate mass
car usage by many years!
In the UK, there has been much comment about driving-related
programmes - BBC's "Top Gear" is a prime example - which seem to promote a
cavalier attitude to road safety. I argue that the problem is more
insidious. Policies to control driver distractions might be given greater
legitimacy in the eyes of the driving public, if a strict code of conduct
could be imposed on the media, with the abolishment of programme
presentation while driving as a priority.
References
(1) Walker L, Williams J, Janrozik K. Unsafe driving behaviour and
four wheel drive vehicles: observational study. BMJ 2007 333:71
In response to our article, Burdett makes two main criticisms. The
first relates to the issue of level of cycling activity in the community
post-legislation. The second relates to our interpretation of the evidence
for child cyclist helmet wearing when accompanying adults are helmeted
compared with non-helmeted children. We consider these points separately.
In response to our article, Burdett makes two main criticisms. The
first relates to the issue of level of cycling activity in the community
post-legislation. The second relates to our interpretation of the evidence
for child cyclist helmet wearing when accompanying adults are helmeted
compared with non-helmeted children. We consider these points separately.
On the issue of the level of cycling post-legislation, we commented
on this in the text. The analysis of this complex issue cannot be solved
by the rudimentary analysis provided by Burdett. For example, cycling
activity conclusions require a larger overall sample, conducted over many
more sampling sites, accounting for weather and road construction
differences, and changing demographics within a region. In Alberta, large
population influxes have changed the dynamics of both Calgary and Edmonton
since the original survey. Despite these issues and the variations in
methodology between the 2000 and 2004 surveys, Burdett concludes that “The
proportion of cyclists affected by the law dropped from over 25% of those
observed in 2000 to approximately 15% of those observed at the same sites
in 2004.” Burdett goes on to call this a “disturbing indicator” that
should have caught our attention. Clearly, this should not have caught our
attention, since the analysis performed by Burdett cannot reasonably reach
the conclusion that helmet laws are somehow responsible for decreased
cycling activity. A control for time trends in the demographic
distribution of the population studied would have been, at the very least,
an essential element of any comprehensive assessment. The aim of our
report was to examine the prevalence of helmet use and comment on the
implications of changes in this outcome. A much more comprehensive and
considered assessment of changes in levels of cycling would be required to
evaluate the helmet legislation’s influence on cycling. Moreover, drawing
the conclusion that this is somehow partly responsible for the rising
trend of childhood obesity is, quite frankly, fear mongering.
On the issue of how much more likely children are to be wearing a
helmet if accompanied by a helmeted adult vs. a non-helmeted child
companion, Burdett argues that the relevant comparison is with non-helmeted adult companions. Our intention was to illustrate the degree of
variation in helmet use depending on the helmet and age characteristics of
companions. We do, however, agree that the comparison Burdett suggests is
informative. Certainly an almost 2.5 fold increase in the likelihood of
helmet use when a child is accompanied by a helmeted compared with a non-helmeted adult in the study by Khambalia et al is noteworthy.(1) Referring
back to the original report by Nykolyshyn et al,(2) which presents the
baseline data for the present study, the results also suggest that a
significantly greater proportion of children wear helmets when accompanied
by a helmet wearing adult, compared with a non-helmeted adult. We thank
Burdett for this comment and the opportunity to point out the additional
evidence that suggests if adults wear helmets, accompanying children are
more likely to as well.
The issue of reduced cycling raised by Robinson has been addressed in
our response to Burdett. In addition, this issue and the other issues she
raises about consideration of head injury trends and the evidence on
helmet effectiveness have been previously addressed elsewhere.(3-5) Most
of the evidence cited by Robinson is not systematically collected and
suffers from selection bias. Clearly, Robinson has focused on the fatality
end of the injury spectrum and argues that helmets fail to protect riders
because of the large kinetic energy of traumatic events, especially those
involving motor vehicles. Despite this, well-accepted systematic reviews
arrive at different conclusions. We suggest the readers draw their own
conclusions. Finally, we take exception to the comment that “the
significant reduction in children's cycling relative to adults is enough
to suggest that the law should be repealed.” We firmly believe that
decisions regarding helmet legislation should be based upon the best
available evidence, a balanced assessment of the risks and harms, and
avoidance of personal opinion and rhetoric.
Respectfully,
Brent Hagel,
Brian Rowe
REFERENCES
1. Khambalia A, Macarthur C, Parkin PC. Peer and adult companion
helmet use is associated with bicycle helmet use by children. Pediatrics
2005;116:939-42.
2. Nykolyshyn K, Petruk J, Wiebe N, Cheung M, Belton K, Rowe BH. The
use of bicycle helmets in a western Canadian province without legislation.
Canadian Journal of Public Health 2003;94:144-148.
3. Cummings P, Rivara FP, Thompson DC, Thompson RS. Misconceptions
regarding case-control studies of bicycle helmets and head injury.
Accident Analysis & Prevention 2006;38:636-643.
4. Hagel B, Macpherson A, Rivara FP, Pless B. Arguments against
helmet legislation are flawed. British Medical Journal 2006;332:725-726.
5. Hagel BE, Pless IB. A critical examination of arguments against
bicycle helmet use and legislation. Accident Analysis & Prevention
2006;38:277-278.
In their report on bicycle helmet use[1], Hagel et al recommend that Alberta's child helmet law be extended to include adults. They base this on (a) an increase in the rate of helmet use among the age group affected (under 18 years of age) from two years before the introduction of helmet legislation in 2002 to two years after, and (b) children being observed riding at higher rates of helmet use when accompa...
In their report on bicycle helmet use[1], Hagel et al recommend that Alberta's child helmet law be extended to include adults. They base this on (a) an increase in the rate of helmet use among the age group affected (under 18 years of age) from two years before the introduction of helmet legislation in 2002 to two years after, and (b) children being observed riding at higher rates of helmet use when accompanied by helmeted adults.
Aside from the utility of helmets, important in any consideration of helmet legislation is the impact helmet laws may have on the level of cycling. In jurisdictions where helmet laws have been enforced, cycling has declined[2]. Although cycling may not decline in jurisdictions where laws are not enforced, immediate increases in post-law helmet use rates are unlikely to be maintained. In the Borough of East York, Toronto, Ontario's child helmet law was not enforced. There the helmet use rate among children initially increased[3] but four years later it fell to pre-law levels[4]. In respect of Alberta, Hagel et al said they could not comment on the number of cyclists seen in the 2000 and 2004 observations. That was unfortunate since a repetition in 2004 of the year 2000 count design should have been relatively straightfoward. Regardless, an analysis
of the data they did collect suggests that a post-law decline in child cycling occurred. The proportion of cyclists affected by the law dropped from over 25% of those observed in 2000 to approximatly 15% of those observed at the same sites in 2004. This is a disturbing indicator which ought to have garnered the attention of the authors. Any decline in a healthy and life-extending activity like cycling should be of serious concern to policy makers in view of the increasing trend in child obesity in Canada and elsewhere.
To further support their recommendation, data from Toronto collected principally in the 1990's of child cyclists under 15 years of age is cited[5]. They say "considering that children riding with helmeted adults
are almost 10 times more likely to be wearing a helmet than children riding with nonhelmeted child companions, policy makers should consider extending current children-only helmet legislation in Alberta and other locations". There is a problem with this logic. In considering such an
extension, the relevant helmet use comparison is not with non-helmeted child companions, after all they are already subject to Alberta's law. The correct comparison is with non-helmeted adult companions. While these data were available in the cited Toronto report and produce a figure of just under 2.5 times more likely, more recent and pertinent companion data were available to the authors from the results of the year 2000 observations in Alberta[6]. These show that the helmet wearing rate of children riding with non-helmeted adults was 84%, whereas when riding with helmeted adults it was 99%. Thus children were only 0.15 times less likely to wear helmets when riding with non-helmeted adults. Given the significant difference of this likelihood compared to the stated Toronto "10 times more likely" using a different age group, a serious oversight or an error in judgement in omitting this fact has occurred.
When it comes to issues concerning public policy, it is essential that those who are in a position to influence policy-makers do not ignore obvious indicators or omit relevant data that could have a bearing on
subsequent decisions.
Avery Burdett
References
1.Hagel BE, Rizkallah JW, Lamy A, Belton KL, Jhangri GS, Cherry N,et al. Bicycle helmet prevalence two years after the introduction of mandatory use legislation for under 18 year olds in Alberta, Canada.
Inj Prev 2006;12(4):262-265.
2. Robinson DL. No clear evidence from countries that have enforced the wearing of helmets. BMJ 2006;332:722-725.
3. Macpherson AK, Parkin PC and To TM. Mandatory helmet legislation and children's exposure to cycling. Injury Prevention 2001;7:228-230
4. Macpherson AK, Macarthur C, To TM, Chipman ML, Wright JG and Parkin PC. Economic disparity in bicycle helmet use by children six years after the introduction of legislation. Injury Prevention 2006;12:231-235.
5. Khambalia A, Macarthur C, Parkin PC. Peer and adult companion helmet use is associated with bicycle helmet use by children. Pediatrics 2005;116:939–42.
6. Alberta Centre for Injury Control and Research. Bicycle Helmets Observational Study Summary.
http://www.med.ualberta.ca/acicr/download/bikesumm.pdf [accessed August 8,
2006]
There is considerable debate about enforced helmet laws. Surveys in Australia counted several thousand cyclists before and after legislation, at the same sites, observation times and time of year. Percent helmet
wearing (%HW) increased mainly because non-helmeted cyclists were discouraged from cycling – reductions in numbers counted were 2 to 15 times greater than the increases in numbers wearing helme...
There is considerable debate about enforced helmet laws. Surveys in Australia counted several thousand cyclists before and after legislation, at the same sites, observation times and time of year. Percent helmet
wearing (%HW) increased mainly because non-helmeted cyclists were discouraged from cycling – reductions in numbers counted were 2 to 15 times greater than the increases in numbers wearing helmets.[1] Despite
the large increases in %HW, there was no obvious response in percent head injury, suggesting that helmet laws have very little benefit to counteract the drawback of discouraging this healthy exercise and environmentally-friendly transport.[2]
It is therefore surprising that Hagel et al. consider only %HW and try to draw useful conclusions from an outcome that everyone expected – all studies show enforced laws increase %HW.
Despite limitations, Alberta’s data strongly suggest that cycling was discouraged. Child cyclists fell from 10.3% to 4.8% of all cyclists, and teenagers from 15.4 to 10.3%, a very significant reduction in the proportions of children and adolescents (p=0.0015). Relative to numbers
of adults counted, the data suggest that about 50% of children and a third of teenagers were discouraged from cycling.
Post-law, remarkably few children were counted – only 13 primary school children and 28 adolescents – at all 22 observation sites. With 3 observers per site, that equates to 0.2 children and 0.4 adolescents per observer per site. Even though pedestrians were also recorded, surely the
survey could have been designed to at least count all cyclists? It would be unfortunate if this were the only information on cycle-use before and after Alberta’s helmet law. But if so, the significant reduction in children’s cycling relative to adults is enough to suggest that the law should be repealed.
Indeed, before helmet laws can be recommended, there should be
evidence of substantial reductions in head injuries that clearly outweigh
losses from discouraging cycling. Unfortunately, the authors provide no
evidence of this. Preliminary reports stated that head injuries doubled
from 5% to more than 10% of cyclist injuries.[3] Although this may have
been due partly to changes in data coding, the increase in %HI was
slightly greater for children than adults,[3] the opposite of what would
be expected if helmets are beneficial, given that %HW of children
increased, but %HW of adults did not.
Two other issues deserve comment. First, the authors state:
“Considering that children riding with helmeted adults are almost 10 times
more likely to be wearing a helmet than children riding with non-helmeted
child companions, policy makers should consider extending current children-only helmet legislation in Alberta and other locations.” In fact, the
pre-law survey in Alberta shows that 81% of children riding with non-helmeted adults wore helmets,[4] so in reality forcing adults to wear a
helmet is unlikely to make much difference.
Second the authors claim that two systematic reviews found that
helmets reduce fatal injuries by 73%. Only one review is cited, and that
simply lists a crude odds ratio, based on 47 fatalities, with no
adjustment for confounders.[5] Helmet wearers are more likely to obey
traffic laws,[6] wear fluorescent clothing and use lights at night[7] and
ride in playgrounds or bicycle paths than city streets.[8] All these
factors affect the risk of bike/motor vehicle collisions, the main cause
of cyclist fatalities. There is no way of knowing whether helmet wearers
had fewer deaths relative to the number of minor injuries (but not
necessarily population wearing rates) because of these factors, or because
of helmets.
Recent research showed that, even with adjustment for confounders,
case-control studies can produce incorrect and misleading results. For
example, a systematic review of more than 30 studies of hormone
replacement therapy (HRT) concluded that it reduced the risk of heart
disease by 50%. We now know that HRT does not decrease and probably
increases the risk of heart disease.[9] To avoid such problems,
researchers should cite only reliable evidence, and discount odds ratios
with no attempt to adjust for counfounders.
One reliable source of evidence is a detailed study of serious head
injuries to cyclists in Brisbane. Based on the type and severity of
injuries, it concluded that helmets would prevent very few fatalities. All
deaths were caused by bike/motor vehicle collisions. For 13 of the 14 non-helmeted cyclists who died, there was no indication that a helmet would
have made any difference. The authors were very concerned about brain
damage from rotational injuries and recommended developing a test to
measure sliding impact friction of helmets.[10]
Cyclist deaths were also investigated in Auckland. 16 of 19 non-helmeted cyclists died from multiple injuries, so helmets would not have
changed the outcome. Only one cyclist died of head injuries in a bike-only
crash, the most likely situation for a helmet to help. That cyclist died
despite wearing a helmet. The authors concluded: "This study indicates
that the compulsory wearing of suitable safety helmets by cyclists is
unlikely to lead to a great reduction in fatal injuries, despite their
enthusiastic advocacy."[11]
In the three years after helmets were made compulsory in New South
Wales, Australia, 80% of fatally injured cyclists wore helmets, an almost
identical proportion to population wearing rates (75% of children, 84% of
adults), again suggesting that helmets are ineffective at preventing
fatalities.[1]
Comparing Australia-wide fatalities in 1988 (before any helmet law)
with 1994 (when all states had enforced laws and about 80% helmet
wearing); cyclist, pedestrian and all road user deaths fell by 35%, 36%
and 38% respectively; head-injury deaths fell by 30%, 38% and 42%. Thus
the reductions for cyclists were less than for other road users. Factoring
in the reduction in cycling, cyclists were probably at greater risk with
compulsory helmet laws than without them.[12]
In inner London, 58% of cyclist fatalities were caused by collisions
with heavy goods vehicles, as were 30% of those in outer London. It is
implausible that a polystyrene helmet could be of significant benefit in
such circumstances. The well-known tragic case of 4 helmeted cyclists
killed by a car travelling at 50 miles/hr demonstrates that cyclists often
die in impacts too severe for a helmet to help.[13]
Thus the most reliable evidence suggests that helmets prevent few, if
any, fatalities. In Australia, implementation of other measures, such as
random breath testing, speed cameras, and fixing up accident blackspots,
resulted in large and immediate reductions in fatalities.[1]
In conclusion, the survey data for Alberta show a significant
reduction in the proportions of children and teenagers, strongly
suggesting the main effect of the law was to discourage cycling. Unless
the authors can demonstrate a large response in percent head injury
coinciding with the change in %HW that clearly outweighs the lost health
and environmental benefits from reduced cycling, perhaps in future
attention can be focussed on measures (such as those listed above) that
have been shown to reduce injuries, instead of reducing cycling.
Dr Dorothy L Robinson
References
1 Robinson DL. Head injuries and bicycle helmet laws. Accid Anal
Prevent 1996;28:463-475.
2 Robinson DL. No clear evidence from countries that have enforced
the wearing of helmets. BMJ 2006;332:722-725.
3 Sands D. Helmet law stats called surprise. Calgary Sun 2003
Saturday, July 12, 2003.
4 Alberta Centre for Injury Control & Research. Bicycle
Observational Study Summary. 2001.
5 Attewell R, Glase K, McFadden M. Bicycle helmet efficacy: a meta-
analysis. Accid Anal Prev 2001;33:345–52.
6 Farris C, Spaite DW, Criss EA, Valenzuela TD, Meislin HW.
Observational evaluation of compliance with traffic regulations among
helmeted and nonhelmeted bicyclists. Ann Emerg Med 1997;29(5):625-9.
7 McGuire L, Smith N. Cycling safety: injury prevention in Oxford
cyclists. Inj Prevent 2000;6(4):285-7.
8 DiGuisseppi CG, Rivara FP, Koepsell TD. Bicycle helmet use by
children. Evaluation of a community-wide helmet campaign. JAMA
1989;262:2256-61.
9 Petitti D. Commentary: hormone replacement therapy and coronary
heart disease: four lessons. Int J Epidemiol 2004;33(3):461-3.
10 Corner JP, Whitney CW, O'Rourke N, Morgan DE. Motorcycle and
bicycle protective helmets: requirements resulting from a post crash study
and experimental research. Federal Office of Road Safety, Report CR 55.,
1987.
11 Sage M, Cairns F, Koelmeyer T, Smeeton W. Fatal injuries to
bicycle riders in Auckland. N Z Med J. 1985;98:1073-4.
12 Curnow WJ. The Cochrane collaboration and bicycle helmets. Acc
Anal Prevent 2005;37(3):569-73.
13 Gilbert K, McCarthy M. Deaths of cyclists in London 1985-92: the
hazards of road traffic. BMJ 1994;308(6943):1534-7.
Cummings et al. assume that bike helmets prevent 65% of deaths.[1] Yet a study of cyclist crashes in Brisbane concluded that helmets would prevent very few fatalities. All deaths were caused by bike/motor vehicle collisions. For 13 of the 14 non-helmeted cyclists who died, there was no indication that a helmet would have made any difference. The authors were very concerned about brain da...
Cummings et al. assume that bike helmets prevent 65% of deaths.[1] Yet a study of cyclist crashes in Brisbane concluded that helmets would prevent very few fatalities. All deaths were caused by bike/motor vehicle collisions. For 13 of the 14 non-helmeted cyclists who died, there was no indication that a helmet would have made any difference. The authors were very concerned about brain damage from rotational injuries and recommended developing a test to measure sliding impact friction of helmets.[2]
Cyclist deaths were also investigated in Auckland. 16 of 19 non-helmeted cyclists died from multiple injuries, so helmets would not have changed the outcome. Only one cyclist died of head injuries in a bike-only crash, the most likely situation for a helmet to help. That cyclist died despite wearing a helmet. The authors concluded: "This study indicates that the compulsory wearing of suitable safety helmets by cyclists is unlikely to lead to a great reduction in fatal injuries, despite their enthusiastic advocacy."[3]
In the three years after helmets were made compulsory in New South Wales, Australia, 80% of fatally injured cyclists wore helmets, an almost identical proportion to population wearing rates (75% of children, 84% of adults), again suggesting that helmets are ineffective at preventing fatalities.[4]
Comparing Australia-wide fatalities in 1988 (before any helmet law) with 1994 (when all states had enforced laws and about 80% helmet wearing); cyclist, pedestrian and all road user deaths fell by 35%, 36% and 38% respectively; head-injury deaths fell by 30%, 38% and 42%. Thus the reductions for cyclists were less than for other road users. Factoring in the reduction in cycling, cyclists were probably at greater risk with compulsory helmet laws than without them.[5]
In inner London, 58% of cyclist fatalities were caused by collisions with heavy goods vehicles, as were 30% of those in outer London.[6] The idea that a polystyrene helmet could be of significant benefit in such circumstances borders on the absurd. The well-known tragic case of 4 helmeted cyclists killed by a car travelling at 50 miles/hr demonstrates that cyclists often die in impacts too severe for a helmet to help.[7]
Riley Geary explained that helmet-wearing status in the FARS database grossly underestimates the true value – many state agencies do not have a check-box for helmet use on their forms and unknowns seem to have been incorrectly recorded as non-wearers.[8] The claims of Cummings et al.[1], based on incorrect helmet wearing rates, and an assumption of the ability of helmets to prevent mortality that bears no relationship whatsoever to information from fatality data, might be dismissed as "enthusiastic advocacy", a classic case of GIGO (garbage in, garbage out).
But in a world of limited resources, there is a sinister side to unrealistic and exaggerated claims – they divert funding away from measures that really could save lives. The only cycling fatality of which I have personal knowledge happened where an off-road cycleway intersects a minor road. It was a difficult crossing; cyclists had to ride carefully through a line of parked cars. By the time cross-traffic was visible, cyclists were almost in front of it, a problem that had been drawn to the attention of the local council. Despite his helmet, a teenager died of head injury after an emergency operation failed to stop the swelling in his skull.
The evidence cited above indicates that forcing cyclists to wear helmets saves very few lives. Other measures, such as guidelines to prevent car parking in places where it obscures sightlines, exploring ways of reducing the disproportionate numbers of circulating cyclists hit by motorists entering roundabouts,[9] random breath testing, speed cameras, and fixing up accident blackspots[10] could save many more.
Perhaps the authors of this article would like to estimate how many more lives might be saved if the considerable efforts currently spent exhorting cyclists to wear helmets were instead spent on making the roads safer for cyclists?
References
1. Cummings P, Rivara FP, Olson CM, Smith KM. Changes in traffic crash mortality rates attributed to use of alcohol, or lack of a seat belt, air bag, motorcycle helmet, or bicycle helmet, United States, 1982-2001. Inj Prev 2006;12(3):148-154.
2. Corner JP, Whitney CW, O'Rourke N, Morgan DE. Motorcycle and bicycle protective helmets: requirements resulting from a post crash study and experimental research. Federal Office of Road Safety, Report CR 55., 1987.
3. Sage M, Cairns F, Koelmeyer T, Smeeton W. Fatal injuries to bicycle riders in Auckland. N Z Med J. 1985;98:1073-4.
4. Robinson DL. Head injuries and bicycle helmet laws. Accid Anal Prevent 1996;28:463-475.
5. Curnow WJ. The Cochrane collaboration and bicycle helmets. Acc Anal Prevent 2005;37(3):569-73.
6. Gilbert K, McCarthy M. Deaths of cyclists in London 1985-92: the hazards of road traffic. BMJ 1994;308:1534-1537.
Dear Editor,
My name is Master Sergeant Chairat Noppakovat and I am stationed at the Madigan Army Medical Center located at Fort Lewis, Washington. I am in the United States Army and have served proudly for nearly 22 years. The reason I am writing this letter is to share with you the story of my son. His name is Apichai Kevin Noppakovat. He was just 18 years old and passed away on 14 August 2006. He had just g...
Malcom Wardlaw asks if a serious head injury rate of 1 per 7,000 capita per year is great enough to warrant enforced use of protective headgear. My view is that there is no magic number; even 1 per 70,000 would be too many if the injury had serious sequelae, as undoubtedly many do. I am certain most sensible parents and most pediatricians who treat these children would agree. The opinions of the City of Toronto Police S...
Dear Editor
Hagel and Rowe reject(1) my criticisms(2) of their study of the impact of a child bicycle helmet law in Alberta, Canada(3). However they appear to have missed the point.
The first issue raised in my letter concerning reduced cycling as a result of Alberta's helmet law, Hagel and Rowe say there could have been confounders which would discount the drawing of a conclusion from the smaller propo...
Dear Editor
Macperson et al. present valuable findings [1] on rates of helmet use by Toronto children of different income groups; and how these rates varied across a period in which a helmet law was passed. The wearing rates rise to a peak after the law of 1995, followed by a decline back to roughly pre-law levels by 1999. This profile occurred because the law was not enforced. The City of Toronto Police Service c...
Dear Editor
According to good public policy, all laws with potentially detrimental effects (such as reduced cycling and reduced safety in numbers) should be evaluated. Far from being selective, my review examined every jurisdiction with a large increase in helmet wearing (more than 40 percentage points within a year). If helmet laws were beneficial, there should have been an obvious response. Yet there was no c...
McEvoy et al (2006) provide empirical evidence to support the case that distractions for the driver are an important feature of road crashes. There should be nothing too surprising in this; after all, many authorities recognise that an enforcible code of behaviour must be applied to public-service drivers; bus passengers are not likely to feel at ease with a driver whose attention deviates from the task in hand.
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Dear Editor,
In response to our article, Burdett makes two main criticisms. The first relates to the issue of level of cycling activity in the community post-legislation. The second relates to our interpretation of the evidence for child cyclist helmet wearing when accompanying adults are helmeted compared with non-helmeted children. We consider these points separately.
On the issue of the level of cycl...
Dear Editor,
In their report on bicycle helmet use[1], Hagel et al recommend that Alberta's child helmet law be extended to include adults. They base this on (a) an increase in the rate of helmet use among the age group affected (under 18 years of age) from two years before the introduction of helmet legislation in 2002 to two years after, and (b) children being observed riding at higher rates of helmet use when accompa...
Dear Editor,
There is considerable debate about enforced helmet laws. Surveys in Australia counted several thousand cyclists before and after legislation, at the same sites, observation times and time of year. Percent helmet wearing (%HW) increased mainly because non-helmeted cyclists were discouraged from cycling – reductions in numbers counted were 2 to 15 times greater than the increases in numbers wearing helme...
Dear Editor,
Cummings et al. assume that bike helmets prevent 65% of deaths.[1] Yet a study of cyclist crashes in Brisbane concluded that helmets would prevent very few fatalities. All deaths were caused by bike/motor vehicle collisions. For 13 of the 14 non-helmeted cyclists who died, there was no indication that a helmet would have made any difference. The authors were very concerned about brain da...
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