The Effect of an All-Ages Bicycle Helmet Law on Bicycle-Related Trauma

In 2003, Seattle implemented an all-ages bicycle helmet law; King County outside of Seattle had implemented a similar law since 1994. For the period 2000–2010, the effect of the helmet legislation on helmet use, helmet-preventable injuries, and bicycle-related fatalities was examined, comparing Seattle to the rest of King County. Data was retrieved from the Washington State Trauma Registry and the King County Medical Examiner. Results comparing the proportions of bicycle related head injuries before (2000–2002) and after (2004–2010) the law show no significant change in the proportion of bicyclists admitted to the hospital and treated for head injuries in either Seattle (37.9 vs 40.2 % p = 0.75) nor in the rest of King County (30.7 vs 31.4 %, p = 0.84) with the extension of the helmet law to Seattle in 2003. However, bicycle-related major head trauma as a proportion of all bicycle-related head trauma did decrease significantly in Seattle (83.9 vs 64.9 %, p = 0.04), while there was no significant change in King County (64.4 vs 57.6 %, p = 0.41). While the results do not show an overall decrease in head injuries, they do reveal a decrease in the severity of head injuries, as well as bicycle-related fatalities, suggesting that the helmet legislation was effective in reducing severe disability and death, contributing to injury prevention in Seattle and King County. The promotion of helmet use through an all ages helmet law is a vital preventative strategy for reducing major bicycle-related head trauma.     

Influence of socioeconomic status on the effectiveness of bicycle helmet legislation for children: a prospective observational study

Objective To evaluate the influence of average family income in a geographical area on the effectiveness of helmet legislation on observed helmet use by children (5–14 years). Methods The study was conducted in East York, a health district of Metropolitan Toronto, in collaboration with the East York Health Unit. In 1996, the total population was 107 822, 11 340 of which were children aged 5–14 years. Census data were used to group the 21 census tracts in East York into seven geographically distinct areas. The boundaries of these areas are natural barriers to travel, such as expressways, ravines, railway tracks and hydroelectric power lines. The areas were also ranked according to average family income (based on Statistics Canada data). For analytical purposes, areas were defined as low‐, mid‐, and high‐income areas. Census data profiles of the areas have been previously described. For each consecutive year from 1990 to 1997 inclusive, direct observations of children riding bicycles in East York during the months of April through October were made. In 1995, observations were completed before the introduction of the law on 1 October 1995. Only children who were between 5 and 14 years of age and riding a two‐wheeled bicycle were included in the study. In total, 111 sites across all seven areas were selected for observation. Observational sites included school yards of all elementary and middle schools (kindergarten to grade 8) and all parks in East York. In addition, five major intersections and five residential streets from each area were randomly selected. Observers were trained and used a standardized data collection form. A pilot study showed that the data collected by observers were reliable and valid. Observers remained at each site for 1 h and collected data on helmet use and sex. Ethical approval for the study was obtained from the Hospital for Sick Children Research Ethics Board, the East York Board of Education and the Metropolitan Separate School Board. The proportion of children who were wearing a bicycle helmet was estimated by year (1990–97, inclusive), sex (male, female), location (school, park, major intersection, residential street) and income area (low‐, mid‐, high‐income). For estimating the effect of legislation on helmet use, data from the year immediately after legislation (1996) were compared with data from the year preceding legislation (1995). The relative risk (RR) of helmet use (after vs. before legislation) was calculated along with a 95% confidence interval (CI). Logistic regression analysis was used to adjust for potential confounding variables (sex and location). Results During the 8‐year study period, 9768 observations were made (range 914–1879 observations per year). The proportion of child cyclists who wore a bicycle helmet increased steadily during the first 4 years of the study period, from 4% in 1990 (34 of 914), to 16% in 1991 (303 of 1879), to 25% in 1992 (383 of 1563), and to 45% in 1993 (438 of 984). During 1994 (460 of 1083) and 1995 (568 of 1227), helmet use remained relatively stable at approximately 44%. Helmet use rose markedly in 1996 (the first year after helmet legislation was introduced) to 68% (818 of 1202) and remained stable at 66% (609 of 916) in 1997. Throughout the study period, girls were consistently more likely to wear helmets than were boys. In total, 47% (1420 of 3047) of girls wore helmets, compared with 33% (2193 of 6721) of boys (RR 1.43; 95% CI 1.36–1.50). In addition, children who were riding to school were more likely to use helmets, compared with children who were riding on residential streets, major intersections and parks. Overall, 48% (1497 of 3129) of children who were riding to school wore bicycle helmets, compared with 32% (2116 of 6639) of children who were riding at other locations (RR 1.50; 95% CI 1.43–1.58). Children in the high‐income areas were consistently more likely to wear helmets, compared with children in the mid‐ and low‐income areas. Helmet legislation was associated with a significant increase in helmet use by children in East York. In 1995, 46% (568 of 1227) of children wore bicycle helmets, compared with 68% (818 of 1202) of children in 1996 (RR 1.47; 95% CI 1.37–1.58). The effect of legislation, however, varied by income area. In low‐income areas, helmet use increased by 28% after legislation, from 33% (213 of 646) in 1995 to 61% (442 of 721) in 1996 (RR 1.86; 95% CI 1.64–2.11). In mid‐income areas, helmet use increased by 29% after legislation, from 50% (150 of 300) in 1995 to 79% (185 of 234) in 1996 (RR 1.58; 95% CI 1.39–1.80). In high‐income areas, helmet use increased by only 4%, from 73% (205 of 281) in 1995 to 77% (191 of 247) in 1996 (RR 1.06; 95% CI 0.96–1.17). This finding of a significant increase in helmet use after legislation in low‐ and mid‐income areas but not in high‐income areas remained even after logistic regression analysis adjusted for sex and location. Conclusions This study showed that bicycle helmet use by children increased significantly after helmet legislation. In this urban area with socioeconomic diversity and in the context of pre‐legislation promotion and educational activities, the legislative effect was most powerful among children who resided in low‐income areas.     

Helmet use by drivers and passengers of motorcycles in Pamplona (Spain), 1992

In 1992 a new Traffic Rules Code was enacted in Spain. This Code included a helmet law that came into force on 1 September 1992. Since then, helmet use is compulsory for motorcycles in urban areas. Previously, helmet use had been obligatory only for motorcycle in highways. To evaluate driver and passenger compliance with the helmet law, an observational prevalence survey of helmet use in Pamplona (a city of 183,539 inhabitants in the north of Spain) was performed. The utilization of helmet by motorcycle drivers and their passengers was recorded three months before and three after the helmet law took effect. Helmet use increased from 19.7% in the first period to 94,8% in the second period. After the law took effect helmet use was higher among drivers 97.5% than among passengers 77.5%. Passengers used helmet more frequently when the driver was also using helmet. The prevalence ratio of helmet use, in those passengers whose driver used helmet versus those who didn't, was 9.91 (95% CI=1.52, 64.83). Health education and law enforcement efforts should be targeted to drivers to prevent them from giving a ride to passengers without helmet.     

A comparison of the effect of different bicycle helmet laws in 3 New York City suburbs.

OBJECTIVES: This study was conducted to evaluate the effectiveness of 3 different bicycle helmet laws. METHODS: A direct observational study of nearly 1000 cyclists at 20 matched sites in each of 3 contiguous counties--Rockland and Westchester in New York and Fairfield in Connecticut--was carried out. Rockland's bicycle helmet law requires approved helmets for all cyclists regardless of age; Westchester's, by state law, requires cyclists younger than 14 years to wear helmets; and Fairfield's, also by state law, requires cyclists younger than 12 years to wear helmets when riding on highways. RESULTS: Rockland cyclists had the highest helmet use rate (35%), followed by Westchester (24%) and Fairfield (14%) cyclists. As a subgroup, teenagers used helmets least, a trend that was seen in all 3 counties. CONCLUSIONS: Our study suggests a positive effect of bicycle helmet legislation with no age limitation.     

Head injury resulting from scooter accidents in Rome: differences before and after implementing a universal helmet law

OBJECTIVES: To estimate the incidence rates and related determinants of head injuries before and after the implementation of a new universal helmet law in Italy. METHODS: The investigation took place in the Emergency Room of the Accident and Emergency Department, Teaching Hospital 'Umberto I', Rome, in 1999 (before the new law), and 2000 (two periods after the new law). Personal data, injury circumstances, helmet use, others involved in injury and health data, were collected. Incidence rates by time period were calculated and differences between groups were analysed. Logistic regression models were conducted to assess the association between head trauma and potential determinants. RESULTS: The incidence rate of all injury among scooter riders rose from 64.36/10,000 person-years before the new law (1999) to 98.05/10,000 person years afterwards. The incidence rate of head trauma among scooter riders showed an opposite trend, i.e. a decrease from 26.65/10,000 person-years (1999) to 8.88/10,000 person-years in the second post-legislation period. Helmet use among injured scooter riders rose from 5% before the new law to 90% afterwards. Helmet use is a protective factor for being a patient with head trauma, in all the periods considered (OR 0.24-0.44). After implementation of the new law, age (18+) showed a protective effect as well (OR 0.42-0.44). CONCLUSION: Helmet use has a protective effect on head trauma among scooter riders. One year after implementing a universal law, helmet use has increased substantially and a sharp reduction in head trauma among persons older than 18 years could be observed.     

Effectiveness of a state law mandating use of bicycle helmets among children: an observational evaluation.

In spring 1999, the authors evaluated the effectiveness of a 1997 Florida law requiring helmet use by all bicyclists younger than age 16 years. Sixty-four counties in Florida had enacted the bicycle helmet-use law, while the other three counties had opted out. Using a cross-sectional study design, the authors conducted unobtrusive observations at bicycle racks at public elementary schools statewide. Florida children riding bicycles in counties where the state helmet-use law was in place were twice as likely to wear helmets as children in counties without the law. In counties where the state law was in place, 16,907 (79%) of 21,313 riders observed wore a helmet, compared with only 148 (33%) of 450 riders in counties where no such law was in place (crude prevalence ratio = 2.4, 95% confidence interval: 2.1, 2.8). Helmet use by children of all racial groups exceeded 60% under the law. No significant difference in use by gender was found. These data support the positive influence of a law on bicycle helmet use among children. The data reinforce the Healthy People 2010 objective that all 50 states adopt such a law for children in order to increase helmet use and consequently reduce brain injury.     

Helmet Use Among Cyclists in New York City

Lack of helmet use while bicycling can have deleterious effects on health. Despite evidence that helmets can greatly reduce the risk of head injury, the prevalence of helmet use among riders, including those in urban bicycle-share programs, has been shown to be very low. Building upon the authors’ previous work, this study’s aim was to assess prevalence of helmet use among cyclists riding on widely used New York City (NYC) bike lanes. Across a 2-month period, cyclists were filmed in five NYC locations with bike lanes. Filming took place at two separate time periods (recreation and commute) at each location. Helmet use was coded for each cyclist. A total of 1,921 riders were observed across 10 h. Overall, half (50.0 %) of all riders were observed wearing a helmet. Rates of using a helmet were consistent across all five locations. In addition, only 21.7 % of Citi Bike users and 15.3 % of other bicycle rentals were observed wearing helmets while cycling. The prevalence of helmet use was significantly higher among males than females (z = 4.48, p < .001). Cyclists observed during the recreational time period were also less likely than those observed during the commuting time period to be wearing a helmet (z = 7.17, p < .001). The results of this study contribute to the growing literature about cyclist helmet use in urban areas.     

Exploring the economics of motorcycle helmet laws--implications for low and middle-income countries

This paper reviews economic evaluations of motorcycle helmet interventions in preventing injuries. A comprehensive literature review focusing on the effectiveness of motorcycle helmet use, and on mandatory helmet laws and their enforcement was done. When helmet laws were lifted between 1976-80, 48 states within the U.S.A. experienced a cost of $342,047 per excess fatality of annual net savings. Helmet laws in the USA had a benefit-cost ratio of 1.33 to 5.07. Taiwan witnessed a 14% decline in motorcycle fatalities and a 22% reduction of head injury fatalities with the introduction of a helmet law. In Thailand, where 70-90% of all crashes involve motorcycle, after enforcement of a helmet law, helmet-use increased five-fold, the number of injured motorcyclists decreased by 33.5%, head injuries decreased by 41.4%, and deaths decreased by 20.8%. There is considerable evidence that mandatory helmet laws with enforcement alleviate the burden of traffic injuries greatly. For low and middle-income countries with high rates of motorcycle injuries, enforced, mandatory motorcycle helmet laws are potentially one of the most cost-effective interventions available.     

EFFECTS OF BICYCLE HELMET LAWS ON CHILDREN'S INJURIES

In recent years, many states and localities in the USA have enacted bicycle helmet laws. We estimate the effects of these laws on injuries requiring emergency department treatment. Using hospital‐level panel data and triple difference models, we find helmet laws are associated with reductions in bicycle‐related head injuries among children. However, laws also are associated with decreases in non‐head cycling injuries, as well as increases in head injuries from other wheeled sports. Thus, the observed reduction in bicycle‐related head injuries may be due to reductions in bicycle riding induced by the laws. Copyright © 2013 John Wiley & Sons, Ltd.     

Bicycle helmet-wearing variation and associated factors in Ontario teenagers and adults

BACKGROUND: The incidence of bicycle helmet use and the factors associated with helmet use in Ontario are presented in this study. The Ontario Health Survey (1996), a population-based survey of Ontario residents, was used as the data source. METHODS: As the factors associated with helmet use were found to differ between adults and teens, a separate analysis was performed for each age grouping. A logistic regression model (with Bootstrap confidence intervals--95%) was used and adjusted odds ratios (OR) are reported. RESULTS: Of the 7,693 respondents, 41.1% reported wearing their helmets on a regular basis when riding a bicycle. Helmet use was greatest among 12-14 year olds (71.7%) and lowest among those 15-18 years old (33.3%). In teenagers, drinking alcohol (OR: 2.8) and smoking (OR: 4.4) were strongly associated with helmet non-use. In the adult group, female gender (OR: 1.26), higher income (OR: 1.43), higher education (OR: 1.68), nonsmoking status (OR: 2.0) and abstinence from alcohol (1.27) were associated with helmet use. Living in a rural area was also associated with helmet use in the multi-variable analysis. CONCLUSION: This study indicates that bicycle helmet non-use is a multifaceted problem and thus any strategy for increasing helmet-wearing rates requires multi-dimensional interventions. The results of this study are discussed within the context of other studies and related to their public health implications.     

A decrease in both mild and severe bicycle-related head injuries in helmet wearing ages--trend analyses in Sweden

Several international studies point at the efficacy of bicycle helmets in reducing head injuries. In Sweden, observational studies show that from 1988 to 1996 helmet use increased in all categories of cyclists. The objectives of this study were to analyse the trends of bicycle-related head injuries based on their main diagnosis and external cause of injury by different age groups. Our study area was the whole population of Sweden from 1987 to 1996. Outcome evaluation was based on data from the Swedish National Hospital Discharge Register concerning all bicycle-related injuries from 1987 to 1996, which presented 49 758 reported in-patient care. The trends in incidence rates (IRs) were studied with regression analyses. The results show that children under 15 years had the highest IRs. For these children, the IR decreased by 46%. The head injuries in children decreased both in collisions with motor vehicles and in other accidents. Similarly, the IR of concussion and skull fracture decreased. For non-head injuries, there were no significant changes for children. On the other hand, the incidence of both head and other injuries for adults aged 16-50 years increased. Ages above that showed no significant changes. Our conclusions are that the decrease in IR for bicycle-related head injuries refers to children in ages for whom bicycle helmet use during the period increased. This could not be explained by any general decrease in bicycle-related accidents or by any changes in the distribution of injuries after collision with motor vehicles. The increasing helmet use among younger schoolchildren probably contributed to the decrease in head injuries.     

Injury Control Recommendations for Bicycle Helmets

ABSTRACT: These guidelines were developed by the Centers for Disease Control and Prevention for state and local agencies and organizations planning programs to prevent head injuries among bicyclists through use of bicycle helmets. The guidelines contain information on the magnitude and extent of the problem of bicycle-related head injuries and potential impact of increased helmet use; characteristics of helmets, including biomechanical characteristics, helmet standards, and performance in actual crash conditions; barriers that impede increased helmet use; and approaches to increasing use of bicycle helmets within the community. In addition, bicycle helmet legislation and community educational campaigns are evaluated. (J Sch Health. 1995;65(4):133–139)     

Bicycle helmet laws and educational campaigns: an evaluation of strategies to increase children's helmet use.

OBJECTIVES. The passage of a mandatory bicycle helmet law for children in Howard County, Maryland, provided an opportunity to compare legislation and education as strategies to increase helmet use. METHODS. In 1991, a survey was mailed to fourth-, seventh-, and ninth-grade students attending a stratified sample of public schools in Howard County and in two similar suburban/rural counties without helmet laws. RESULTS. Of 7217 students surveyed, 3494 responded (48.4%). Self-reported helmet use in Howard County rose from 11% to 37% after the law and accompanying educational campaign went into effect. Helmet use changed from 8% to 13% in Montgomery County, where educational efforts were undertaken, and from 7% to 11% in Baltimore County, where helmet promotion activities were minimal. Predictors of helmet use included having friends who wore helmets, believing helmet laws are good, being in fourth grade, living in Howard County, and using seatbelts regularly. CONCLUSIONS. Legislation combined with education appears to increase bicycle helmet use substantially more than does education alone. The Howard County law may be considered a successful model of a strategy to increase children's helmet use.     

Bicycle helmet use in Sweden during the 1990s and in the future

This paper describes how the use of bicycle helmets in Swedenhas changed for different categories of cyclists from 1988 to2002, and it also estimates future trends in voluntary wearingof bicycle helmets up to the year 2010. Observational studiesof the use of bicycle helmets were conducted once a year from1988 to 2002 at 157 sites in 21 cities. The subjects observedwere children cycling to school (average n = 5471/year) andin their free time (average n = 2191/year), and adults cyclingto workplaces and on public bike paths (average n = 29 368/year).The general trend in helmet use from 1988 to 2002 was determinedby linear regression analysis, and the results were also employedto estimate future helmet wearing for the period 2003–2010.Differences in helmet use according to gender and size of citywere analysed by chi-square tests. From 1988 to 2002, all categoriesof cyclists showed an upward trend in helmet use (p < 0.01,p < 0.001). Helmet wearing increased from about 20 to 35%among children (10 years) cycling during free time, from approximately5 to 33% among school children, and from around 2 to 14% inadults. Total average helmet use rose from about 4 to 17%. However,during the last 5 years of the study period (1998–2002),none of the categories of cyclists studied showed an upwardtrend in helmet wearing. It is estimated that 30% of cyclistswill wear helmets voluntarily by the year 2010, if helmet promotionactivities are continued at the same level as previously. Theresults suggest that Sweden will probably not reach its officialgoal of 80% helmet use unless a national bicycle helmet lawis passed.     

Helmet Use Among Users of the Citi Bike Bicycle-Sharing Program: A Pilot Study in New York City

The use of bicycle helmets to prevent or reduce serious head injuries is well established. However, it is unclear how to effectively promote helmet use, particularly in the context of bicycle-sharing programs. The need to determine rates of helmet use specifically among users of bicycle-sharing programs and understand if certain characteristics, such as time of day, affect helmet use, is imperative if effective promotion and/or legislative efforts addressing helmet use are to be developed. We estimated the prevalence of helmet use among a sample of Citi Bike program users in New York City. A total of 1,054 cyclists were observed over 44 h and across the 22 busiest Citi Bike locations. Overall, 85.3 % (95 % CI 82.2, 88.4 %) of the cyclists observed did not wear a helmet. Rates of helmet non-use were also consistent whether cyclists were entering or leaving the docking station, among cyclists using the Citi Bikes earlier versus later in the day, and among cyclists using the Citi Bikes on weekends versus weekdays. Improved understanding about factors that facilitate and hinder helmet use is needed to help reduce head injury risk among users of bicycle sharing programs.     

Bicycle injuries: road trauma is not the only concern

Data on bicycle injury presentations at a public hospital emergency department for 1991–95 inclusive were analysed to determine the nature and extent of bicycle injuries in the community. There were 599 bicycle injury presentations during the study period, representing more than 2.0% of all injury-related presentations to the emergency department. The main outcome measures were severity and type of injury. Distribution by gender, age, helmet use (1991 and 1992 only), location and mechanism was examined. Rider-only injuries (falls or collisions with stationary objects) accounted for 79.3% of all presentations with only 5.2% due to collisions on a public road or footpath with other moving traffic. Of all injuries where a location was determined, 61.6% occurred in off-road locations. There was little difference in the overall proportions of hospital admissions from injuries on-road (12.4%) and off-road (9.0%). Cyclists injured in on-road collisions with traffic had a higher proportion of hospital admissions (40.0%) than those injured on-road by other mechanisms (7.6%). Children under 10 years of age who had been riding without a helmet suffered a much higher proportion of injuries to the head (53.2% of all injuries) than older cyclists riding without a helmet (19.4%). The majority (83.1%) of head injuries in children under 10 years of age occurred off-road and helmet use was lowest in this group (28.6%). Given previous evidence that helmet use can prevent head injuries, strategies to increase helmet use among cyclists, particularly young children, while riding both on and off-road, should be given a high priority. Rider-only injuries are also an important public health issue.     

Prevention of bicycle-related head injuries

Each year in the United States, bicycling accidents cause approximately 1,300 deaths and 60,000 injuries. The death and injury rates are particularly high among children. The death rate from bicycle injuries in children exceeds the death rate from accidental poisonings, falls, firearm injuries, and many major illnesses. Head trauma is the most frequent cause of death and serious injury among bicyclists. Bicycle helmets have the potential to decrease the frequency and severity of bicycle-related head injury. Unfortunately, however, most bicyclists do not use a helmet. The helmet-use rate is extremely low among children. The failure of bicyclists, particularly children, to use bicycle helmets presents an opportunity for prevention of thousands of the traumatic head injuries that occur annually in the United States. Helmet use could be encouraged by schools, community safety programs, and office-based education by physicians.     

A proposal for the mandatory inclusion of helmets with new children's bicycles.

To reduce bicycle-related head injuries in children, we propose new regulations be established that mandate the inclusion of approved helmets with the sale of all new children's bicycles. Currently, purchasing a helmet is a separate economic decision that acts as a barrier to helmet ownership and use. The inclusion of a helmet with the bicycle would markedly increase helmet ownership. The increased demand would reduce the manufacturing cost per helmet, so the cost of the bicycle with the helmet would be lower than the current retail price of the two separately. This proposal could potentially be implemented by federal or state legislation, a Consumer Product Safety Commission regulation, or voluntary adoption of a practice or standard by bicycle manufacturers. Increased helmet ownership is necessary but not sufficient to raise helmet use rates. The increased ownership generated by this proposal, complemented by enhanced educational, promotional, and legal interventions, is probably the most practical and cost-effective public health strategy available to increase helmet usage and prevent bicycle-related head injuries in children.     

Changes in motorcycle-related head injury deaths, hospitalizations, and hospital charges following repeal of Pennsylvania's mandatory motorcycle helmet law

To evaluate the 2003 repeal of Pennsylvania's motorcycle helmet law, we assessed changes in helmet use and compared motorcycle-related head injuries with non-head injuries from 2001-2002 to 2004-2005. Helmet use among riders in crashes decreased from 82% to 58%. Head injury deaths increased 66%; nonhead injury deaths increased 25%. Motorcycle-related head injury hospitalizations increased 78% compared with 28% for nonhead injury hospitalizations. Helmet law repeals jeopardize motorcycle riders. Until repeals are reversed, states need voluntary strategies to increase helmet use.     

The effects of a 4-year program promoting bicycle helmet use among children in Quebec.

OBJECTIVES. This study assessed the effectiveness of a 4-year program of bicycle helmet promotion that targeted elementary school children in one region of Quebec. The program revolved primarily around persuasive communication and community organization, combining standard educational activities and activities to facilitate helmet acquisition and use. METHODS. Helmet use was compared between more than 8000 young cyclists in municipalities exposed or not exposed to the program. Factors influencing helmet use were controlled through the use of multivariate analyses. RESULTS. Helmet use increased from 1.3% before program implementation to 33% in 1993. The program was clearly effective in most cycling circumstances and for various groups of children. However, the benefits of the program were unequally distributed; the program was one third as effective in poorer municipalities as in "average-rich" ones. CONCLUSIONS. This community-based program that combined various types of activities appeared to be effective. New intervention models are needed to ensure an equitable distribution of benefits.