Introduction: Hello and welcome. My presentation today examines the impact that bicycle helmet policy has had in Australia. I will review the history and background of the legislation, efficacy on head injury rates in Australia, Impact on Cycling rates and public health.
The use of Bicycles provide an important recreational activity and physical activity for many people, it is also used as a transportation source (Cummings, Rivara, Thompson, Thompson 2006). The issues surrounding bicycle helmets have been discussed for around 20 years, some of these issues concern, health, safety, environment, civil liberties, injury compensation, law enforcement, fines and court costs (Clarke 2008).The enactment of helmet laws in Australia had a major impact on helmet use in terms of being the cause of some groups of people discontinuing cycling when required to wear helmets by law (Bicycle Helmet Research Foundation 2012). There are not many countries where cyclists are required to wear helmets. Australia was the first country to do so and was closely followed by New Zealand (Walter et al 2011).
Light relief: There are many alternative names for bicycle helmets, not all flattering!
Cyclists were first legally compelled to wear helmets in Australia in the early 1990’s. A federal parliamentary enquiry into the advantages of wearing helmets was initially held in 1978 and it was argued by the Royal Australasian College of Surgeons that in order to assist in preventing brain injury and fatal injuries to the brain that cyclists should be wearing bicycle helmets at all times (McDermott 1992). In the early part of the 1980’s there was a move to have children wear helmets and this was backed by the Australian Medical Association and the National Health and Medical Research Council (NHMRC) The Royal Australasian College of Surgeons was also pushing for bicycle helmets to be mandatory following the introduction of legislation regarding mandatory seat belts in cars and motorcycle helmets. The official reasoning behind compulsory bicycle helmet wearing from a policy point of view was to minimise the medical and other public costs of bicycle accidents to cyclists with the critical efficacy of preventing head injury that is fatal or disabling (Curnow 2008).
Efficacy of compulsory Bicycle Helmet legislation on head injuries Serious and fatal injuries in relation to bicycling include those involving the head and associated acquired brain injuries. The term head injury is used to provide a description of injuries to the scalp, skull and brain. Brain Injury refers in greater detail to the injuries that have been the cause of some degree of brain dysfunction, including concussion, intracranial haemorrhage and diffuse axonal injury (Cummings, Rivara, Thompson and Thompson 2006). The main causes of brain injury are a blow that damages the skull and angular acceleration of the head. In the case of the skull or an external object damaging the brain focal injury such as laceration and contusion may occur. In the case of the angular acceleration of the head the rotation of the head may cause bone to strike the brain causing diffuse injury to small blood vessels and neurons, including diffuse axonal injury (Curnow 2008). It is suggested that the effect of helmets on rotational injuries requires further study due to the lack of evidence for significant reductions in serious head injury following helmet legislation (Robinson 2007).
A fundamental question is whether or not helmets really do offer protection against head injury. This is an issue that has been heavily discussed (Sheikh, Cook, Ashcroft 2004). Reviews into the effect of helmet wearing on individuals however noted significant reductions in terms of brain, head and facial injury. The reviews were conducted mainly using case control studies in Australia, however it has been argued that observational studies into this issue may not have taken into account or accurately reflect occurrences at a population level due to unmeasured levels in the data such as risk compensation, improper helmet wearing and reduced safety in numbers (Walter, Olivier, Churches, Grzebieta 2011). Curnow (2008) also criticises the Cochrane review Helmets for preventing head and facial injuries in bicyclists, saying that the review takes no account of the scientific knowledge of types and mechanisms of brain injury, the best evidence arising from the review is that hard-shell helmets protect the brain from injury consequent upon damage to the skull. Curnow (2008) concludes in his report that the Cochrane review is not a reliable guide to the efficacy of helmets.
A retrospective study conducted by the Royal Prince Alfred Hospital in NSW into the long term trends in cyclist head injuries at an inner-city major trauma centre to determine the odds of any skull fracture or intracranial bleed associated with not wearing a helmet was conducted looking at the time period from 2001 to 2010. The measures examined included, mechanism of injury, anatomical injury (skull fracture or intracranial bleed), helmet use, and the type of road where the incident occurred. The study found that there was an increase in admissions for bicycle injury, but this was in line with population trends. The number of cyclists with severe head injuries has been consistently low over the long term, along with a decline in the rate of severe head injuries in admitted patients since 2005. It was also discussed that the benefits of helmet use need to be placed in the context of lifetime costs of severe traumatic brain injury which is estimated to be around $4.8 million per incident case and that based on findings from this study that mandatory bicycle helmet laws be maintained as part of an overall road safety strategy (Dinh, Roncal, Green, Leonard, Stack, Byrne, Petchell 2010).It has been noted however that an ideal assessment of the impact of helmet legislation with regards to head injuries requires individual level population wide data on cycling exposure and helmet wearing. There is currently a lack of information in the generation of accurate population level rates of cycles head injuries in relation to compulsory helmet legislation (Walter, Olivier, Churches, and Grzebieta 2011). There is ongoing debate centering around bicycle helmet legislation, supporters of the legislation argue that wearing helmets demonstrates a reduction in head injuries (Robinson 2007) and case control studies have provided evidence for a protective effect of helmets in terms of the prevention of injuries to the brain, head and face amongst bicycle riders who have accidents (Cummings, Rivara, Thompson, Thompson 2006). It has been noted however that an ideal assessment of the impact of helmet legislation with regards to head injuries requires individual level population wide data on cycling exposure and helmet wearing. There is currently a lack of information in the generation of accurate population level rates of cycles head injuries in relation to compulsory helmet legislation (Walter, Olivier, Churches, and Grzebieta 2011). Cost benefit analyses can determine whether or not the intervention of compulsory bicycle helmet wearing is worthwhile. Published cost-benefit analyses of helmet law data discovered that the cost of buying helmets to satisfy legislation have most likely exceeded any savings arising from reduced head injuries. Other studies of road safety measures such as reductions in speeding or drink driving have often shown that benefits are significantly greater than costs (Robinson 2007).
Prior to helmet legislation from 1986-1989 it was found that the number of people proportionality who were cycling was increasing by 10-12% per year (Clarke 2008). Enforced helmet wearing has been found to actually result in a decreased number of people riding bicycles resulting in increased indirect costs to society such as increased obesity rates, reduced exercise levels and a decrease in safety to cyclists through the reduction in the number of other cyclists around (Robinson 2007). Cycling to work throughout Australia declined in 2006 to 1.24% compared to a previous rate in 1991 of 1.56% of people riding to work based on census data (ABS 2007) (as shown in the table). Following the introduction of mandatory bicycle helmet legislation in Australia in 1991 it was found that there was a reduction of 25-38% in people cycling in Western Australia, a reduction of 47% of NSW students riding to school and 29% fewer adult and 42% fewer child cyclists in Melbourne. New Zealand also experienced a negative effect on cycling levels after the introduction of mandatory bicycle helmet laws; this was a 51% drop in the number of trips by bicycle (Rissel and Wen 2011).
Surveys in Australia have shown also that younger people and those who only ride occasionally would be more likely to cycle if they did not have to wear a helmet. The figures indicated that the greatest increases would be among occasional cyclists who represent almost two-thirds of the adult population and this would result in a significant increase in cycling levels. The findings are also consistent with other studies which have noted that legislation requiring bicycle helmets discourages cycling (Rissel and Wen 2011). Cost benefit analysis studies conducted in Australia in relation to compulsory helmet legislation have not included the loss of health benefits from reduced cycling (Curnow 2008, Robinson 2006).
Cycling has been found to be effective in preventing such diseases as, coronary heart disease, stroke, diabetes, colon cancer and obesity (Clarke 2008). In 1989 36% of Australians aged 15 years and over were overweight or obese, in 2001 44% of people were overweight or obese, in 2000-2001 cardiovascular disease was estimated at costing the Australian health system $5.4 Billion (ABS 2005) and in 2006/07 the direct cost of physical inactivity was quoted as being $1.49 billion for Australia (Clarke 2008). Enforced helmet wearing has been found to actually result in a decreased number of people riding bicycles resulting in increased indirect costs to society such as increased obesity rates, reduced exercise levels and a decrease in safety to cyclists through the reduction in the number of other cyclists around (Robinson 2007).
It has been further discussed that the compulsory wearing of helmets has resulted in cycling being discouraged to the point that the increased burden of disease associated with reduced physical activity outweighs any reduction in the burden of cyclist head injuries (Walter et al 2011, Clarke 2008, Robinson 1996) and although case control studies have suggested that cyclists who choose to wear helmets have fewer head injuries than non-wearers that helmet laws would be counterproductive if they increased car use and discouraged people from taking up cycling. It has also been discussed that the wearing of helmets may encourage risk taking amongst both cyclists and motorists (Robinson 2006). In order to evaluate a program, certain questions need to be asked such as, is the goal of the program good? Does the program achieve the goal effectively? Does it do so in a manner consistent with the values and liberties of the population? So within the context of the introduction of mandatory laws around the wearing of bicycle helmets and the prevention of potential head injury it is beneficial. However the goal of health prevention is to also review the benefits for the entire population and while some people will gain as a result of not being head injured for example, will the rest of the population be disadvantaged due to trading off riding a bicycle for a moderate inconvenience that includes some expense against a reduced risk of an unlikely event? (Sheikh, Cook, Ashcroft 2004).
The impact on head injuries following the introduction of the legislation was somewhat inconclusive. Further study which takes into account other bias also needs to be looked at (Robinson 2006). In conclusion, the impact of the compulsory wearing of bicycle helmets legislation would appear to be negative in light of reduced rates of cycling, especially the fact that 40% fewer young people are cycling due to the fact that helmet wearing for bicycles is compulsory (Curnow 2008). As the costs of physical activity increase in Australia, as well as other health issues such as increased obesity levels then it may be time for the Australian Government to review the legislation or for further cost benefit analysis to be conducted into this area. From research undertaken I feel that the impact of the introduction of compulsory bicycle helmet legislation has not been successful in terms of the discouragement of the population from riding bicycles. Thank you for listening.
History and Background ◦
First laws to have cyclists wear helmets enacted in Australia in the 1990’s. ◦ A federal parliamentary enquiry occurred as far back as 1978. ◦ Based on evidence submitted by the Royal Australasian College of Surgeons around the fact that cyclists should wear helmets in order to prevent fatal and disabling injury to the brain.
The efficacy of compulsory
bicycle legislation on head injury rates in Australia. ◦ Do helmets really offer protection? ◦ Other issues that need to be looked at: Risk taking Helmet type Improper helmet wearing
Trends in bicycle helmet use
and severe head injury as a percentage of totalcyclist trauma admissions, RPAH, Sydney, New South Wales 1991-2009
Cycling rates and the impact
on Public Health.Cycling rates in Australia 1991-2006 Year Census % cycling to work % Drop from 1991 value 1991 1.56 - 1996 1.24 32 2001 1.21 35 2006 1.24 32
Cycling rates and the
impact on public health ◦ Following legislation: Decrease of 47% NSW students riding to school. Reduction of 25-38% of people cycling in WA. 29% Fewer adults cycling in Australia. 40% Fewer children cycling in Australia.
Cycling rates and the
impact on public health ◦ 1989-36% of Australians over 15 were overweight or obese. ◦ 2001- 44% of Australians were overweight or obese. ◦ 2006/07-Physical inactivity $1.4 billion in cost to Australia.
Cycling rates and the impact
on Public HealthQuestions: Is the goal of the program good? Does the program achieve the goal effectively? Does it do so in a manner consistent with the values and liberties of the population?
Australian Bureau of Statistics.
2005. Cardiovascular disease in Australia: A snapshot. 2004-2005. Clarke, C. 2008. Assessment of Australia’s Bicycle Helmet Laws. Cummings,P. Rivara, F. Thompson, D. Thompson, S. 2005. Misconceptions regarding case-control studies of bicycle helmets and head injury. Accident Analysis and Prevention. 38. 636-643. Curnow, W.2008. Bicycle helmets and public health in Australia. Health Promotion Journal of Australia, 19(1). 10-15. Dinh, M. Roncal, S. Green, T. Leonard, E. Stack, A. Byrne, C. Petchell, J. 2010. Trends in head injuries and helmet use in cyclists at an inner-city major trauma centre-1991-2010. Medical Journal of Australia. 193 (10) 619-620. Karkhaneh, M., Rowe, Brian H,M.D., M.Sc, Saunders, L. D., Voaklander, D., & Hagel, B. (2011). Bicycle helmet use after the introduction of all ages helmet legislation in an urban community in alberta, canada. Canadian Journal of Public Health, 102(2), 134-8. McDermott, F.T. 1992. Helmet efficacy in the prevention of bicyclist head injuries: Royal Australasian College of Surgeons Initiatives in the introduction of compulsory safety helmet wearing in Victoria, Australia. World Journal of Surgery. 16. 379-383.
Mozer, D. 2012. Do
you need a bike helmet? Available at: http://www.ibike.org/education/helmet.htm Rissel, C. Wen, L.M. 2011. The possible effects on frequency of cycling if mandatory bicycle helmet legislation was repealed in Sydney, Australia: a cross sectional survey. Health Promotion Journal of Australia. 22 (3). 178-183. Robinson, D. 1996. Head Injuries and Bicycle Helmet Laws. Accident Analysis and Prevention. 28. 463-475. Robinson, D. 2006. No clear evidence from countries that have enforced the wearing of helmets. BMJ. 332 (7543). 722-725. Robinson, D. 2007. Bicycle helmet legislation: Can we reach a consensus? Accident Analysis and Prevention. 39. 86-93. Sheikh,A. Cook, A. Ashcroft, A. 2004. Making cycle helmets compulsory: ethical arguments for legislation. Journal of the Royal Society of Medicine. 97. 262-264. Walter, S. Olivier, J. Churches, T. Grzebieta, R. 2011. The impact of compulsory cycle helmet legislation on cyclist head injuries in New South Wales, Australia. Accident Analysis and Prevention. (43). 2064-2071.