Dr James Lawson [1] seeks to summarise similarities in our findings
[2] with those of three other reports, particularly that of Baker and
McPhedran [3]. He notes that we agree that there was a “continuation” of
the pre-existing trend in falling firearm deaths following the
implementation of the Australian National Firearms Agreement (NFA) of
1996. The word we used purposefully was that there was a sta...
Dr James Lawson [1] seeks to summarise similarities in our findings
[2] with those of three other reports, particularly that of Baker and
McPhedran [3]. He notes that we agree that there was a “continuation” of
the pre-existing trend in falling firearm deaths following the
implementation of the Australian National Firearms Agreement (NFA) of
1996. The word we used purposefully was that there was a statistically
significant “acceleration” of the downward trend. He says we attribute
this to the NFA. In fact, we took care to emphasise (p370) that the
accelerated overall decline was only associated with the passage of the
NFA. We highlighted the difficulty of inferring that the downturn – being
so dominated by firearm suicides – could have been readily attributable to
the removal of semi-automatic firearms from the community.
We readily agree that the large scale effort to try and reduce
suicide in the community is relevant to any consideration of why total
suicides have fallen [4]. Browsing gun lobby websites shows that poor
policing and mental health services, violence in the media, failure of the
media to censor reports of mass killings, and failure to report people who
“act strangely” are all putative causes of gun violence which have their
enthusiasts, as do simplistic notions that people posing danger to the
community are readily identifiable in advance. But suggesting that easy
access to guns designed to kill many people quickly may be relevant is a
profanity in such circles.
Where we differ from those who 10 years on, remain angered about
their inability to own military-style weaponry such as that used to kill
35 at Port Arthur, is that we are open to the possibility that removing
such firearms from the community might have reduced the ability of people
to carry out such killings.
We described the most palpable and plausible effect of the NFA as the
cessation of mass shootings, an omission of “rhinoceros in the living
room” proportions from the Baker and McPhedran paper. A cornerstone of the
NFA was the unanimous decision of all Australia’s federal, state and
territory governments to outlaw private ownership of semi-automatic rifles
and pump-action shot guns. These are weapons of choice for those intent on
killing many people quickly. The Australian Prime Minister said at the
time: “There is no legitimate interest served in my view by the free
availability in this country of weapons of this kind… Every effort should
be made to ensure such an incident [Port Arthur] does not occur again.”
[5]
Dr Lawson and others in the gun lobby regularly seek to trivialise
mass public shootings as rare events, implying that their infrequency
somehow makes them an improper outcome of interest. Here, we would simply
point to the overwhelming degree of public support for the NFA which
occurred against a background of unparalleled public discussion and media
attention where the gun lobby had every opportunity to put alternative
views, including arguments that the buyback money could have been more
effectively spent on other strategies. The small and transitory levy on
income tax which paid for the gun buyback attracted minimal criticism.
People intent on mass murder have other options than using guns, as
the Childers backpacker arsonist/murderer showed. Our analysis however,
showed that there was no apparent net substitution effect for either
homicide nor suicide. Other than the Childers incident, we know of no
other mass killing by any method in Australia since the passage of the
NFA.
Dr Lawson wonders how the Port Arthur gunman was able to acquire his
highly effective mass killing weapons. The answer would seem rather
obvious. There were hundreds of thousands of semi-automatic rifles and
pump action shot guns in the community. Being largely unregistered, and so
difficult to trace in their movement among gun owners, they were readily
available to anyone willing to sell such a gun to any buyer with money. If
even one in 1000 of Australia’s some 800,000 licensed shooters were
prepared to sell just one such gun to criminals or unstable individuals,
in an unregistered environment 800 such untraceable guns would fall into
the hands of high risk individuals. The government saw this as
unacceptable and the community agreed.
Lawson thinks it “strange” that our paper did not mention
international comparisons in firearm deaths. Our paper concerned the
Australian situation, but we are pleased to respond to his comments about
the USA and the UK. We believe there are few lessons for nations like
Australia in the USA’s track record with firearm deaths. Currently, the
United States has 14.5 times Australia’s population, 102 times its total
firearm deaths [2,6], and 173 times its number of firearm homicides
[2,7]. Relating different periods of firearm deaths in the USA with the
implication that Australia should emulate US gun policy is like arguing
that Baghdad is safer than Bogota.
Similarly, Lawson notes that in the UK, total homicides have risen
62% and firearm homicides by 20% since the introduction of the post-
Dunblane laws [8]. He fails to note though that the UK has, by US
standards, an almost homeopathic rate of gun homicide (in 2002/03, just 80
in a population of about 60 million) [8]. On the assumption that he is
arguing that US-style gun laws rather than UK and Australian laws make
communities safer, it would appear that he has a little explaining to do.
Also, of 24,070 crimes committed with “firearms” in the UK in 2002/03,
13,822 (57%) involved airguns and 1,815, toy or imitation guns [8].
Dr Lawson’s nostalgia for a return to the days when firearms were
unregistered and his carefully qualified hints about the desirability of a
heavily armed society where armed “good guys” could dispatch violent armed
“bad guys” in public settings is not a view shared by the great majority
of Australian citizens who have now lived over 10 years free of the
regular gun mayhem that characterises news about guns coming from the
United States. Similarly, his opinion of Lott and Mustard’s paper as a
“landmark” contribution to evidence about armed deterrence is not one
shared by a wide range of critical reviews, including the US National
Academy of Sciences which found no evidence showing right-to-carry laws
have an impact, either way, on rates of violent crime [9].
Finally, Dr Lawson gives SC far too much credit for “coordinating”
gun control advocacy in Australia. SC was involved for a relatively short
period (1993-1996), typically putting no more than several hours a week
into advocacy for stronger gun control. The vast majority of Australian
citizens strongly supported the NFA. They needed little persuading that
Australia did not want to go down the US road so memorably examined by
Mike Moore in Bowling for Columbine.
2. Chapman S, Alpers P, Agho K, Jones M. Australia’s 1996 gun law
reforms: faster falls in firearm deaths, firearm suicides and a decade
without mass shootings. Injury Prevention 2006; 12; 365-372.
3. Baker J, McPhedran S. Gun laws and sudden death. Did the
Australian firearms legislation of 1996 make a difference? British Journal
of Criminology 2006; Advance access Oct 18 doi:10.1093/bjc/921084
4. Morrell S, Page AN, Taylor RJ. The decline in Australian young
male suicide. Soc Sci Med. 2007;64(3):747-54.
5. Howard J. ‘Never, Ever Again.’ Prime Ministerial Op-ed. Herald
Sun. Melbourne, 10 May 1996.
6. US Centers for Disease Control. National Center for Injury
Prevention and Control. WISQARS Injury Mortality Reports 2004.
http://webapp.cdc.gov/sasweb/ncipc/mortrate10_sy.html
7. US Department of Justice. Federal Bureau of Investigation. Murder.
Table 2.9
http://www.fbi.gov/ucr/cius_04/offenses_reported/violent_crime/murder.html
8. Povey D. (ed).Crime in England and Wales 2002/2003: Supplementary
Volume 1: Homicide and Gun Crime 01/04 January 2004. Home Office Research,
Development and Statistics Directorate (RDS).
www.homeoffice.gov.uk/rds/pdfs2/hosb0104.pdf
9. National Academy of Sciences. Committee on Law and Justice.
Firearm violence: a critical review. Washington, 2004.
Re: Australia’s 1996 gun law reforms: faster falls in firearms,
deaths firearms suicides and a decade without mass shootings. Chapman et
al. Injury Prevention: 12; 365-372. Dec 2006.
Chapman et al. use official Australian Government statistics to
demonstrate a continuing fall in firearms murder and suicide following the
implementation of the Australian National Firearms Agreement (NFA) of
1996. T...
Re: Australia’s 1996 gun law reforms: faster falls in firearms,
deaths firearms suicides and a decade without mass shootings. Chapman et
al. Injury Prevention: 12; 365-372. Dec 2006.
Chapman et al. use official Australian Government statistics to
demonstrate a continuing fall in firearms murder and suicide following the
implementation of the Australian National Firearms Agreement (NFA) of
1996. They also state that this was a continuation of a pre-existing trend
in falling firearms deaths over several years. This confirms the previous
reports of Reuter and Mouzos [1], Ozanne-Smith et al [2] and Baker and
McPhedran [3]. In all four papers, the authors agree that there had been
a steady decline in gun murder and gun suicide before the NFA [4] and that
this decline continued post NFA. Reuter and Mouzos and Ozanne-Smith et al
found no decrease in total suicide after 5 years. Reuter and Mouzos found
a marginal fall in total murder, whereas Ozanne-Smith did not. Ten years
post NFA, Baker and McPhedran and Chapman et al confirm continuing falls
in both gun murder and gun suicide and also total murder and total
suicide. Thus far, all authors are in agreement.
Controversy arises in that Baker and McPhedran report a slightly
faster fall in total and gun suicide post NFA but no significant increase
in the rate of decline in gun and total murder. They attribute the
continuing decline to general social factors, not the NFA. In contrast,
Chapman et al maintain that there are marginally faster rates of decline
in gun and total murders and suicides which are significant and due to the
NFA. While it makes sense that fewer guns would be associated with fewer
gun deaths, it is intuitively difficult to see how mass gun confiscations
would reduce suicides by hanging and car exhausts and reduce murders by
stabbing and beating.
Harrison and Steenkamp reported a marked increase in suicide by
hanging and car exhaust in the first 2 years after the NFA [5], suggesting
initial method substitution. The subsequent fall in total suicide
developed after Australia mounted a strong campaign to raise awareness of
depression as a severe and treatable illness and to remove any shame or
stigma attached to depression and other mental illness. Well known public
figures, including politicians, actors and sporting personalities have
described in the media their personal struggles with depressive illness
[6]. This may account for the observed fall in total suicides, including
the continuing decline in the subset of gun suicides.
Despite the welcome post NFA fall in murder, the current rate is
still higher than in 1950-1980, when there were virtually no long gun
controls at all [7]. Curiously, Weatherburn maintains, that for the most
populous state of New South Wales, the fall in gun crime is due to good
policing, reduced availability of heroin and the arrest of hard core
violent criminals [8]. This has apparently occurred despite a 25% increase
in legal gun ownership over 2002-5.
International comparisons are even more confusing. Despite
increasingly strict gun laws, the United Kingdom murder rate doubled since
1966 [9] and is now higher than the Australian rate. (See Povey - Table 1.01 p15). In particular, since the total handgun confiscations of 1996,
the total murder numbers have risen 62%. This includes gun murder numbers
up 20%. ( Povey - Table 1.03 p17) and handgun crime numbers up 66%. (Povey - Table 2.03 p 51.) IE Mass gun confiscations in UK have produced exactly
the opposite effect claimed for Australia.
The USA murder rate doubled during 1960-1975, from about 5/100,000
to 10/100,000per annum, remained at this level for 10 years, and has now
fallen to almost 1960 levels.[10] This drop occurred despite a 36%
increase in the number of legal US guns over 1975-1985 [11].
Paradoxically, the landmark paper of Lott and Mustard [12] reported a
marked decrease in mass gun murders in public places in those US states
which changed their laws to allow citizens to carry concealed handguns.
Curiously, new Zealand, which participated in the Australian
deliberations, but chose not to implement the NFA, experienced a
significant decline in gun murder, but no change in total murder. [13]
Strangely, Chapman et al do not mention any of the international figures.
Chapman et al claim correctly that there have been no mass gun
murders in Australia since the implementation of the NFA in 1996 and that
the NFA is therefore a “success”. Unfortunately, there was never any
generally agreed definition of “success” at the time the NFA was
implemented .However there have been a few mass murders, not involving
firearms, particularly the arson attack at Childers, Queensland, in which
15 people died. The others were domestic tragedies in which parents killed
their children and then suicided. Oddly, Chapman et al appear to define a
mass murder as an incident with 5 or more deaths [14]. They state
specifically that “this is to exclude most of the more common firearm
related spousal and family violence killings” (footnote to Table 1 p367).
In contrast, the Australian Institute of Criminology uses a definition of
4 or more deaths in a single incident [15]. Chapman’s choice of definition
would result in fewer “mass murders”. (Note: The murders in Snowtown,
South Australia, 12 deaths, were serial killings). It is puzzling that
Chapman et al quote Reuter and Mouzos [16] that mass murders are an
“appropriate evaluation outcome”, but ignore their contention in the same
article that “the frequency of those events is so low that not much can be
inferred”[17] and that mass murder shows a “statistically insignificant
lower rate than pre-1996”[18]. Fortunately, Reuter and Mouzos put the
matter in perspective, pointing out that mass murders account for only 3%
of all homicides in Australia [19].
In an earlier work, Chapman points out that the Port Arthur murderer
was receiving a pension for intellectual handicap and sociopathic
personality disorder, and had a mental age of 11[20]. The murderer had
never had a gun licence and also drove a car without a licence [21]. If we
wish to prevent further mass gun murders in public places, it seems a good
idea to find out how such a person managed to obtain a military assault
rifle illegally. This was never even investigated. It did not emerge at
the trial as the accused pleaded guilty.( Note: For the benefit of readers
outside Australia, I point out that all the Port Arthur victims were
unarmed, as local laws prohibited weapon carrying for self defence. I
state this as a matter of fact, without comment).
Chapman et al quite correctly point out that there was great public
and media support for the NFA in 1996. Most of the credit for this must go
to Chapman himself. Over several years before the Port Arthur killings,
Chapman himself co-ordinated “the planned ,strategic use of media”, and
“a sustained period of public advocacy for gun law reform” [22]. He
describes “preceding years of advocacy”[23] and recommends that “violent
gun incidents should be anticipated and planned for so “advocates exploit
to advantage the huge public and political interest these disasters
generate when they occur” [24]. The distinction between media advocacy and
propaganda is never explained.
These matters are not mere academic quibbles. The Australian federal
government has spent at least half a billion dollars of public funds on
mass confiscations of legally owned guns over 1996-2003. “Buy-back” was a
euphemism for confiscation under threat of fines and imprisonment,
although monetary compensation was paid. Further tens of millions of
dollars are spent annually on registering each individual legal firearm,
despite the lack of any clear benefit. The state of Victoria has actually
gone so far as to require registration of all antique black powder muzzle
loaders and blank-firing sports starting pistols! As 90% of Australian gun
crime is committed by unlicensed persons with unregistered guns [25] and
legal guns are involved in about 2% of Australian murders [26], even total
destruction of all legal guns in Australia would have only minimal
benefit.
Could greater cost effectiveness have been achieved by using the
resources for improving mental health services or drug rehabilitation,
preventing domestic violence, anti-smoking campaigns? No-one has examined
this, a surprising omission for a Professor of Public Health.
References
1"Australia: a Massive Buyback of Low-Risk Guns".Chapter 4. In:
"Evaluating Gun Policy- Effects on crime and violence". Eds. Ludwig J,
Cook P J. Brookings Institute Press, 2003.
2. Ozanne-Smith J et al. Firearms related deaths: the impact of
regulatory reform. Injury prevention 2004;10:280-286.
3. Baker J, McPhedran S. Gun laws and Sudden Death: Did the
Australian Firearms Legislation of 1996 Make a Difference? British
Journal of Criminology 2006- Advance Access published 18 Oct 2006.
4.Firearms Deaths-Australia 1980—1995.Australian Bureau of
Statistics 1997. cat no. 4397.0.
5. Harrison JE, Steenkamp M. Australian Injury prevention bulletin
Issue 23, 2000.
http://www.nisu.flinders.edu.au/pubs/bulletin23/bulletin23.html Accessed
22 12 2006.
6. See for example http://www.beyondblue.org.au/
7. Mouzos J. Homicidal Encounters. A study of homicide in Australia
1989-1999. Australian Institute of Criminology. 2000. p9.
8. Weatherburn D. “ Gun laws fall short in war on crime.” Quoted
in Sydney Morning Herald 29 10 2005.
9. Povey D. (ed).Crime in England and Wales 2002/2003:
Supplementary Volume 1: Homicide and Gun Crime 01/04
Editor: David Povey January 2004. Home Office Research, Development and
Statistics
Directorate (RDS). www.homeoffice.gov.uk/rds/pdfs2/hosb0104.pdf Accessed
23-12 2006.
10. Fox JA, Zawitz MW. “Homicide Trends in the US. Long term trends
and patterns.”
United States Dept. of Justice. Office of Justice Programs. Bureau of
Justice Statistics.
http://www.ojp.usdoj.gov.bjs/homicide/hmrt.htm Accessed 23-12-2006.
11. Kleck G. “Targeting guns”. Aldine de Gruyter 1997. pp96-97.
12. Lott JR, Mustard DB. “Crime, Deterrence and Right-to-Carry
Concealed Handguns.” Journal of Legal Studies 26(1). Jan 1997.
13. Reuter P, Mouzos J. op cit. p135.
14. Chapman S, Alpers P, Agho K,Jones M. “ustralia’s 1996 gun law
reforms: faster falls in firearms, deaths firearms suicides and a decade
without mass shootings” Injury Prevention: 12; 365-372. Dec 2006. p366.
15. Mouzos J. “Homicidal Encounters. A study of homicide in Australia
1989-1999”. Australian Institute of Criminology 2000.
16. Reuter P, Mouzos J. op cit. p131.
17. ibid. p122
18. ibid p141.
19. ibid p127.
20. Chapman S. Over Our dead Bodies. Port Arthur and the Fight for
Gun control. Pluto Press 1997. pp136-7.
21. ibid p73.
22. ibid. preface, 1st page
23. ibid p5.
24. ibid pp6-7.
25. Mouzos J. “The Licensing and Registration Status of Firearms used
in Homicide”. Australian Institute of Criminology May2000.Trends and
Issues Paper 151.
http://www.aic.gov.au/publications/tandi/tandi151.html Accessed 28-
12 2006
26. Mouzos J, Segrave M. Homicide in Australia. 2002-2003 National
Homicide Monitoring Program Annual Report. Australian Institute of
Criminology. 2004 p15.
http://www.aic.gov.au/publications/rpp/66/ accessed 28-12 2006.
Dr.J.B.Lawson. MB BS., B Med Sc., FRANZCR.
3 Lucas St.
Brighton Vic 3186. Australia.
Mob 0417 08 1113
lawbb@melbpc.org.au
There is a plausible case that television affects the individual road-user's attitudes to safety-related issues, so McGwin et al [1] provide a
useful survey of television content regarding the portrayal of seatbelt
and helmet use. Whether McGwin et al should make such strong assertions
about the value of these devices raises arguments which have been aired
elsewhere [2].
There is a plausible case that television affects the individual road-user's attitudes to safety-related issues, so McGwin et al [1] provide a
useful survey of television content regarding the portrayal of seatbelt
and helmet use. Whether McGwin et al should make such strong assertions
about the value of these devices raises arguments which have been aired
elsewhere [2].
Such surveys could be extended to other issues. Speed could be an
excellent example, but is difficult to assess with any accuracy from TV
material. Another issue is driver distraction, which may be more amenable
to observation. Driver distraction is depicted commonly in filmed fiction:
an example at random is Stephen Daldry's movie "The Hours", in which a
driver and her passenger partake in intense dialogue, leading to steadily
more erratic and dangerous driving.
However, the issue of distraction extends beyond the requirements of
a film's plotline: monologues and interviews while driving have become
quite a common custom in factual broadcasting. A recent BBC example
concerned historical battle sites. The presenter was filmed making an in-depth commentary while driving through locations associated with the
battle. The camera provided a side view of the presenter within the
vehicle, but views of the locations were meagre. Worryingly, but not
surprizingly, the presenter's gaze frequently shifted from the road to the
camera. One must conclude that the commentary would have been just as
effective if it had been recorded in a studio - and safety would not have
been compromised.
The issue of how far TV should convey accepted safety norms raises a
number of issues; three examples: (a) Should depiction of safe behaviour
necessarily override the plotline requirements of a piece of fiction?
(b) Would the fantastical road scenarios portrayed in the likes of James
Bond movies and Homer Simpson cartoons really influence viewers' attitudes
to safety? (c) Can the above-cited scene from "The Hours" in fact act as a
warning leading to better driving behaviour?
What can surely be accepted is that gratuitous broadcasting customs
can be curtailed with no loss to anyone; if there is a small gain in
safety-relative attitudes, then that is all to the good.
References
1. McGwin G, Modjarrad K, Reiland A, Tanner S, Rue LW. Prevalence of
transportation safety measures portrayed in primetime US television
programs and commercials. Inj Prev 2006;12:400-3.
2.Reinhardt-Rutland A H. Seat-belts and behavioural adaptation: the
loss of looming as a negative reinforcer. Safety Sci 2001;39:145-55.
In his zeal to defend bicycle helmet laws, Editor Barry Pless ignored
two important issues identified by Malcom Wardlaw and in doing so raises
one of even more vital importance.
First, child cyclist head injuries declined in Ontario while data
from Macpherson showed a declining rate of bicycle helmet use. This
suggests a factor other than helmet use and helmet laws was responsible
for the decline
in head injurie...
In his zeal to defend bicycle helmet laws, Editor Barry Pless ignored
two important issues identified by Malcom Wardlaw and in doing so raises
one of even more vital importance.
First, child cyclist head injuries declined in Ontario while data
from Macpherson showed a declining rate of bicycle helmet use. This
suggests a factor other than helmet use and helmet laws was responsible
for the decline
in head injuries. Second, the authors of the 2001 Injury Prevention study
which concluded that Ontario's helmet law had not negatively impacted
levels of cycling, however they were aware but failed to mention two
critical factors in evaluating the effect of helmet laws - (a) within four
years the law had reached a null impact on helmet use, and (b) the lack of
police enforcement.
In an editorial, Pless has admitted his own biases and sensitivities
in dealing with issues concerning bicycle helmets[1] and Macpherson
recently appeared in the Ontario Legislature[2] in support of a motion to
impose a helmet law on adults. Such activism raises questions about
whether personal biases are taking priority ahead of scientific findings
and criticisms.
Pless says that he struggles to understand why Wardlaw and others
work so consistently to oppose helmet legislation. This is an astonishing
statement given Wardlaw along with Robinson, myself and others restrict
ourselves to questioning the science upon which helmet laws are based. If
Pless doesn't understand the fundamental objection to having the state
unjustifiably impose a requirement on its citizens, then what he's really
saying is that he struggles to understand human nature.
Please, let's restrict ourselves to facts. Political activism doesn't
belong in a scientific journal.
References
1. Pless B, Are Editors free from bias? The special case of Letters
to the Editor, Inj Prev 2006 12: 353-354. doi:10.1136/ip.2006.014472
2. Hansard, Legislative Assembly of Ontario, 14 December 2006
The Editor of IP does not like the fact that a debate exists about
cycle
helmets. (1) He would like not to publish correspondence from helmet
sceptics. He describes the letters he has received as frustrating and
irritating
“repeated almost boilerplate arguments”. It is welcome and honest of the
Editor to state his willingness to publish helmet sceptic eletters despite
his
dislike for this view. It compares with the a...
The Editor of IP does not like the fact that a debate exists about
cycle
helmets. (1) He would like not to publish correspondence from helmet
sceptics. He describes the letters he has received as frustrating and
irritating
“repeated almost boilerplate arguments”. It is welcome and honest of the
Editor to state his willingness to publish helmet sceptic eletters despite
his
dislike for this view. It compares with the actions of a recent editor of
the
British Medical Journal, the flagship journal of IP’s parent company. When
criticized for publishing controversial eletters about passive smoking
Smith
spoke of the journal’s deep commitment to unfettered debate (2). He went
on to quote Milton, “Truth was never put to the worse in a free and open
encounter”.
The eletters section of IP is a great place for the cycle helmet
debate to unfold
and might attract more interest to the eletters page. A look at this page
today shows only 5 postings on 3 topics over the last 90 days, one of
which is
from the editor. In contrast the paper by Robinson (3) and critique by
Hagel
and Pless (4) in the BMJ has generated 45 rapid responses of varying
points of
view, from people all over the world. The sad thing for IP is that the
editor
does not want a debate on helmets, in part I think because he is convinced
of
the infallibility of his own personal beliefs on the issue. The debate
will just
take place elsewhere instead.
A debate exists because interpretations of the scientific evidence
differ.
Partly this is due to philosophical differences, what Adams calls
‘cultural
filters’. These make more difference when ‘the state of the evidence is
contested, ambiguous or inconclusive, a description that covers most
controversies about safety.’ (5)
Contested, ambiguous and inconclusive pretty much describes the state
of
the cycle helmet literature. We have several case control studies
comparing
head injuries in cyclists who crashed with and without helmets (6). These
are
beloved of helmet enthusiasts because they generally conclude helmets are
very effective at reducing head injuries in the event of a crash. They
are
quoted by charities and authorities that want to encourage helmet wearing
and those who want us to pass laws forbidding cycling without helmets.
Sceptics point out there is no ‘real world’ evidence that helmets actually
work
when a population of cyclists starts to wear them. The four most recent
ecological studies looking at this examined both head injuries and
fatalities in
cyclists (7-10). None of these studies provides evidence that helmets
make a
difference.
Pless says that ecological studies are weaker than case control
studies. The
Centre for Evidence Based Medicine in Oxford disagrees. It places
ecological
studies above systematic reviews of case control studies. In a table,
ranking
hierarchies of evidence ecological studies are 2c and reviews of case
control
studies with homogeneity 3a (11). The conflict between what case control
studies predict should happen and what has actually happened needs
explaining. As Pless states “The moral here is that solid research
designs
cannot be discounted just because you don’t like the answers they give.”
Indeed. The results of the ecological studies need debating and
explaining
not dismissing. The challenge for helmet enthusiasts is to explain why
helmet wearing has not resulted in lower head injury rates.
Whether this debate is allowed to unfold on IP or in other fora, I
hope it will
be conducted using temperate language in an atmosphere of mutual respect.
References
1. Pless, B. Inj Prev 2006;12:353-354
2. Smith , R. BMJ 2003;327:505
3. Robinson, R. BMJ 2006;332:722-725
4. Hagel, B Pless, B. BMJ 2006;332:725-726
5. Adams, J Risk Routledge 1995: p 81.
6. Helmets for preventing head and facial injuries in bicyclists, The
Cochrane Library, Issue 4, 2006. Thompson DC, Rivara FP, Thompson R.
7. Cycle helmets and road casualties in the UK ?
Hewson PJ. Traffic Injury Prevention, 2005;6(2):127-134.
8. Investigating population level trends in head injuries amongst
child
cyclists in the UK ?
Hewson PJ. Accident Analysis & Prevention. 2005;37(5):807-815.
9. Do enforced bicycle helmet laws improve public health? ?
Robinson DL. . BMJ, 2006;332:722.
10. Trends in helmet use and head injuries in San Diego County: the
effects
of bicycle helmet legislation, Ji M, Gilchick R, Bender S. AA&P (38) 2006,
128-134.
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.
Dear Editor
Dr James Lawson [1] seeks to summarise similarities in our findings [2] with those of three other reports, particularly that of Baker and McPhedran [3]. He notes that we agree that there was a “continuation” of the pre-existing trend in falling firearm deaths following the implementation of the Australian National Firearms Agreement (NFA) of 1996. The word we used purposefully was that there was a sta...
Editor
Re: Australia’s 1996 gun law reforms: faster falls in firearms, deaths firearms suicides and a decade without mass shootings. Chapman et al. Injury Prevention: 12; 365-372. Dec 2006.
Chapman et al. use official Australian Government statistics to demonstrate a continuing fall in firearms murder and suicide following the implementation of the Australian National Firearms Agreement (NFA) of 1996. T...
Dear Editor
There is a plausible case that television affects the individual road-user's attitudes to safety-related issues, so McGwin et al [1] provide a useful survey of television content regarding the portrayal of seatbelt and helmet use. Whether McGwin et al should make such strong assertions about the value of these devices raises arguments which have been aired elsewhere [2].
Such surveys could be...
In his zeal to defend bicycle helmet laws, Editor Barry Pless ignored two important issues identified by Malcom Wardlaw and in doing so raises one of even more vital importance.
First, child cyclist head injuries declined in Ontario while data from Macpherson showed a declining rate of bicycle helmet use. This suggests a factor other than helmet use and helmet laws was responsible for the decline in head injurie...
The Editor of IP does not like the fact that a debate exists about cycle helmets. (1) He would like not to publish correspondence from helmet sceptics. He describes the letters he has received as frustrating and irritating “repeated almost boilerplate arguments”. It is welcome and honest of the Editor to state his willingness to publish helmet sceptic eletters despite his dislike for this view. It compares with the a...
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...
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