BMJ 2000;321:1582-1585 ( 23 December )

Three lessons for a better cycling future

   Malcolm J Wardlaw, business analyst.

   92 Drymen Road, Bearsden, Glasgow G61 2SY

   [22]A.Wardlaw@btinternet.com

   Cyclists were the only group of road users in Britain whose death rate
   increased sharply during the 1990s,[23]1 yet cycling was in decline
   throughout the decade.[24]2 How could this happen, when attention on
   casualties was the most intense in the history of the bicycle? Perhaps
   a vision of the near future will be instructive^ . . .

   Summary points
          ______________________________________________________________

          Recent safety campaigns have destroyed faith in the bicycle as
          a safe means of transport, reducing participation, compromising
          public health, increasing the risks, and decreasing road skills
          ______________________________________________________________

          Deaths of cyclists have increased since the introduction of
          helmets
          ______________________________________________________________

          Cyclists fare best when they act and are treated as drivers of
          vehicles
          ______________________________________________________________

          Promote cycling for a safer road environment

       Safe walking

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   [dot.gif] Safe walking
   [26][darrow.gif] Risks of cycling
   [27][darrow.gif] Is driving safe?
   [28][darrow.gif] Dangers of helmets
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   [30][darrow.gif] Lesson one: cyclists get...
   [31][darrow.gif] Lesson two: cyclists fare...
   [32][darrow.gif] Lesson three: promote cycling...
   [33][darrow.gif] References

   It began in America, as so many trends do, but for years no one in
   Europe took any notice. American tourists wearing helmets around the
   streets of London first drew media attention. And although public
   response to walking helmets was initially amusement, the^ appeal of
   extra safety drew some pioneers to the habit, especially academics and
   competitive^ walkers.

   The first case-control study of about 2000 injuries to pedestrians in
   Britain (180 of whom had worn helmets) concluded that the risk of
   serious head injury was reduced by 75% when a good^ walking helmet was
   worn. Safety campaigners used the slogan "walkers need helmets" to
   encourage parents to send their children to school in helmets. Several
   high profile accidents focused public attention on the dangers of
   walking. A well known television presenter was severely head injured
   by a police van answering an emergency call. Doctors concluded that
   her injuries would have been "substantially reduced" had she worn a^
   helmet.

   Walking helmets became widely available. The entire cabinet posed in
   their helmets outside Number 10, the beaming prime minister urging:
   "Let's go forward together into a new era of walking safety." Most
   children now wore a helmet walking to school, although they were
   otherwise not seen on the streets. They played at home, where^ many
   injured themselves stunt walking in mountain boots. Safety campaigners
   praised the courage of the 25% of adults who wore^ a walking helmet.

   Safety campaigner Jean Keystone read her Walkers' Helmet Bill before
   parliament: "As a society we are tired of the waste of^ lives in
   walking accidents. Every year, around a 1000 pedestrians are killed in
   walking accidents, and head injuries feature in 80% of these deaths.
   Since research has shown that 75% of head^ injuries are prevented if a
   good walking helmet is worn, legislation to compel wearing is
   justified by the saving of lives that will result."

   The bill wasn't passed, but time was on the campaigners' side. The pop
   group Toyzone promoted walking helmets in their video Take a Walk on
   the Mild Side. Safety campaigners founded the Helmet Youth. Only the
   most antediluvian public figure would appear bareheaded^ in the media.
   Compensation for injury was reduced if the pedestrian had not worn a
   helmet. Pressure was mounting against those who still valued the
   "dubious pleasure of walking with the wind in their hair."

   However, safety did have its consequences. Not only had walking
   declined, the aspiration to walk skilfully had disappeared. A
   generation was growing up incapable of crossing the road. Young
   walkers had become dependent on their helmets. Casualty rates were
   increasing. Many otherwise capable adults were afraid to walk, having
   been alarmed by the safety campaigns. As one chubby chap said from his
   car: "It's got nothing to do with helmets. Walking is dangerous ---
   why take the^ risk."

   A new breed of walker had appeared, stern and serious about safety.
   They wore 100 helmets, lighthouse jackets, eye protection, and spent
   1000 on footwear. But they were a rare breed. Gym clubs were
   expanding their car parks, and the traffic had never been so bad.

       Risks of cycling

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   [35][uarrow.gif] Safe walking
   [dot.gif] Risks of cycling
   [36][darrow.gif] Is driving safe?
   [37][darrow.gif] Dangers of helmets
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   [39][darrow.gif] Lesson one: cyclists get...
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   [42][darrow.gif] References

   You think I am being facetious? Let us examine the facts. The inherent
   risks of road cycling are trivial.[43]3 Of at least 3.5 million
   regular cyclists in Britain, only about 10 a year are killed in rider
   only accidents. This compares with about 350^ people younger than
   75 killed each year falling down steps or tripping.[44]4 Six times as
   many pedestrians as cyclists are killed^ by motor traffic, yet travel
   surveys show annual mileage walked^ is only five times that cycled; a
   mile of walking must be more^ "dangerous" than a mile of cycling. In
   both cases, of course, the activity itself is harmless --- but it's in
   the way. Although a mile of driving is ten times safer than a mile of
   cycling, a^ mile of urban driving is ten times more likely to kill a
   pedestrian than such a mile^ cycled.

       Is driving safe?

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   [47][uarrow.gif] Risks of cycling
   [dot.gif] Is driving safe?
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   [53][darrow.gif] References

   One problem with comparing the safety of driving and cycling is that
   the population that cycles differs from that which drives. The average
   driver is trained, tested, will have about two decades of experience,
   and is to a degree regulated. The average cyclist is young, male,
   untutored, unregulated, not wealthy, riding a^ badly equipped machine
   on busy urban streets, and in the minority. Nearly half of all
   cyclists ride only occasionally, and most regular cyclists will do so
   for only a few years. Clearly there are potent risk factors here that
   confound comparisons based on averages. Adults aged 17-20 in the
   United Kingdom are probably less likely to be killed per hour cycled
   than hour driven,[54]5 and the danger inflicted on others will be
   fractional. Experienced cyclists, like experienced drivers, have far
   better accident rates, suggesting that a given individual should not
   be at greater risk of death or serious injury per hour cycled than
   driven. There are not enough skilful, experienced cyclists on
   Britain's roads, however.

                            [warm4664.f3.gif]
   As the Cabinet donned walking helmets, the prime minister urged the
   nation to "go forward together into a new era of walking safety"

   Notwithstanding the above, it still takes at least 8000 years of
   average cycling to produce one clinically severe head injury and
   22 000 years for one death. A recent study in Glasgow estimated^ that
   150 000 people are admitted to hospital annually with head^ injuries
   in the United Kingdom[55]6; road cyclists account for only 1% of this
   total, yet 6% of the population are regular cyclists and a further 5%
   are occasional cyclists; 60% of admissions were^ alcohol related. Do
   we need revelling helmets?

       Dangers of helmets

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   [58][uarrow.gif] Risks of cycling
   [59][uarrow.gif] Is driving safe?
   [dot.gif] Dangers of helmets
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   [64][darrow.gif] References

   The statistical wrangle over the effectiveness of helmets is actually
   a side issue; what we need people in authority to understand^ is that
   cycle helmets inevitably damage public health. Even for cyclists on
   Britain's roads, the health benefits exceed the risks by a factor of
   20.[65]7 The health benefits of cycling are so great --- and^ the
   health injuries from driving so great[66]8 --- that not cycling is
   really dangerous. By telling people that they need helmets for an
   activity that for a century has been regarded as "safe" --- and^ in
   fact has a fine safety record --- you inevitably engender the
   impression that cycling must have become more dangerous than driving
   and^ walking. That deters cycling. That reduces cyclists' presence^ on
   the roads. That increases the risk of death. And if wild claims about
   helmets saving lives are published in the media,[67]9 helmet users are
   bound to feel overly secure, thus compromising their one vital safety
   feature --- a sense of caution. [68]10 [69]11 In addition, over time
   most people --- and especially parents --- will come to believe^ that
   it is wearing a helmet that matters, not acquiring skilful
   technique.[70]12 These effects have been noted in every country where
   helmets have come into general use, including the United^
   Kingdom.[71]13 Millions will die early because they did not cycle.

       Do helmets protect the head?

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   Experience shows helmets give only limited head protection. Studies in
   Australia show some prevention of superficial injuries (such as scalp
   lacerations) but only marginal prevention of "mild" head injuries and
   no effect on severe head injuries or death.[81]14^ When helmets were
   made compulsory in Australia, admissions from head injury fell by
   15-20%, but the level of cycling fell by 35%. [82]15 [83]16 Ten years
   later, cycling levels in western Australia are still 5-20% below the
   level they were before the introduction of the^ law[84]17 yet head
   injuries are only 11% lower than would be expected^ without
   helmets.[85]18 Incidentally, 17 times more motorists than cyclists
   died of head injuries in Australia during 1988.[86]19

   The situation in New Zealand is poorly documented, but even
   sophisticated analysis reveals either no reduction in head injury with
   increased helmet use[87]20 or a modest reduction (19%) when
   superficial injuries are included in the definition.[88]21
   Misreporting of the cause of injury among people cycling without
   helmets after the law made cycling compulsory must have influenced the
   figures. The United States and Canada have had similar experiences to
   Britain. [89]1 [90]22

   Many articles have been published claiming that a helmet will prevent
   60-90% of serious head injuries while neglecting to evaluate the risks
   of cycling versus driving.[91]23 But in 1988^ the largest survey of
   cycling casualties ever undertaken concluded^ that helmets did not
   prevent injury; indeed, increased use correlated^ with increased risk
   of death.[92]24 How could real world experience^ diverge so enormously
   from the savings promised by clinical research? The trouble was,
   researchers did not compare like with like. If^ you compare a helmeted
   minority who fell off in parks with an unhelmeted majority injured in
   collisions with motor vehicles, it is no surprise that people wearing
   helmets have much less severe^ injuries. Other studies did focus on
   road accidents but drew conclusions from a small group of helmeted
   cyclists, typically 10% of the^ sample. In the early days, those who
   wore helmets were cautious, mature, educated, life long cyclists.
   Researchers failed to consider that this group would be more likely to
   attend accident and emergency after receiving a head injury or that
   they would have better anticipation, thereby reducing the risk of an
   accident or the risk of serious injury in a given accident. In fact,
   the case-control studies confirm what experienced cyclists already
   know --- that skill and^ a sense of caution cut the risk of serious
   injury by 80-90%.

   Our tarmac world is stuck in the Dark Ages; if you get hurt, you're
   wrong. The assault on cycling has vandalised the appeal of the safest,
   cleanest, most efficient, healthy, and fun means of personal transport
   that exists --- right at the time we most need^ it. Cyclists don't
   need helmets, they need^ priority.

       Lesson one: cyclists get ahead when left alone

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   [dot.gif] Lesson one: cyclists get...
   [99][darrow.gif] Lesson two: cyclists fare...
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   [101][darrow.gif] References

   Cyclists gain more from improvements in road safety than other road
   users; hence the risk of death per mile cycled fell by 60% between
   1971 and 1994 (fig [102]1). The number of reported accidents has not
   changed much in the past 40 years (see BMJ 's website^ for details).
   The fall in the number of deaths is due to accidents getting less
   lethal rather than there being fewer accidents. The^ lethality of
   cycling accidents dropped faster than the average^ for all road users
   (fig [103]2). By 1994, the risk of death in a cycling accident was
   only 75% of what it would have been had the trend^ followed the
   average. This will surprise those who see cyclists as "vulnerable" and
   drivers as "safe." However, cycling accidents got more lethal in the
   second half of the 1990s, when helmets became generally popular.

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     Fig 1.   Indices of cycling mileage and deaths (index year
   1970)[107]1

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     Fig 2.   Index of lethality (number of deaths per number of
   accidents) of cycling accidents and all traffic accidents,
   1970-98 (index year 1970)[111]1

       Lesson two: cyclists fare best when they act and are treated as
   drivers of vehicles[112]25

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   [116][uarrow.gif] Is driving safe?
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   [119][uarrow.gif] Lesson one: cyclists get...
   [120][uarrow.gif] Lesson two: cyclists fare...
   [121][uarrow.gif] Lesson three: promote cycling...
   [122][uarrow.gif] References

   It is widely thought that cyclists should be segregated from the
   traffic for safety's sake. This appears logical, since most road
   cycling injuries are due to motor traffic. It is a naive^ conclusion.
   Segregation protects the cyclist from only a rare^ accident --- being
   hit from behind --- at the expense of increasing other risks and
   reducing convenience. International research shows that segregation
   multiplies the risks threefold to fivefold, [123]26 [124]27 even in
   countries such as the Netherlands, where it is traditional. The
   promotion of danger has scared many cyclists out of the traffic,
   merely to put them at greater risk on pavements and "safe" cycle^
   routes.

   Experienced cyclists already know that the road system is by far the
   safest national cycle network that will ever exist. Cyclists and
   drivers are not enemies; each has something to offer the other in a
   civilised road environment. Cyclists should tackle the risks just as
   in a car, by acquiring a high standard of road^ craft.

       Lesson three: promote cycling for a safer road environment

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   [131][uarrow.gif] Lesson one: cyclists get...
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   [dot.gif] Lesson three: promote cycling...
   [133][darrow.gif] References

   Increasing the number of cyclists is a straightforward way of making
   cycling much safer. It is a method we can be sure of, because it has
   already worked.

   It is worth pausing here to consider the meaning of "road safety." The
   roads can get more dangerous, yet total deaths still fall. Compulsion
   to wear a seatbelt cut deaths among drivers and^ front seat passengers
   by 25% in 1983. But in the subsequent years, the long established
   trend of declining deaths in car accidents reversed, and by 1989 death
   rates among car drivers were higher than they had been in
   1983. Evidently the driving population "risk compensated" away the
   substantial benefits of seatbelts by taking extra risks, putting
   others in more danger. This period saw a^ jump in deaths of cyclists
   (fig [134]1). Although temporary, the jump can be explained fully only
   by cyclists having adapted to a more^ dangerous road environment
   through extra caution, retreat, or giving up. Is it coincidence that
   the long decline in cycling began in 1983?

   Many drivers today surge about aggressively, accelerating and braking
   hard. They don't achieve a high average speed but touch peaks of
   50-60 mph, at which pace the vehicle is a frightening menace to the
   most experienced cyclist. That kind of behaviour is the consequence
   of, among other things, compelling seatbelts, and it is a massive
   deterrent to cycling. Difficult though it may be, it is time that
   those who control road safety legislation faced the facts; reducing
   casualties is not the same as reducing danger. Give thought to the
   real cause of danger and how it can be^ reduced.

   Between 1974 and 1982 cycling mileage in Britain increased 70%, but
   there was no increase in fatalities until the seatbelt law was
   introduced in 1983 (fig [135]1). The more cyclists there are, the more
   presence they have, the less individual danger there^ is. This truth
   is confirmed by experience in the Netherlands and^ Denmark, where
   cycling is far safer despite a tradition of segregation. All road
   users should gain. Pedestrians benefit because (skilful) cyclists are
   little threat to them and because a large increase^ in cycling should
   reduce traffic speeds and thus risks to all. Then there are the health
   benefits.

   Cycling has slipped off the political agenda. The vital need to change
   attitudes is nowhere in sight. Doctors must press for recognition that
   in a civilised society, those who create danger will be held
   responsible for the consequences. Getting hurt doesn't make you wrong.
   Promote the positive aspects of cycling: speed, fitness, pride in
   learning a new skill. Focus on getting adults to cycle a few trips
   they currently drive --- later they can teach their children. Promote
   cycling, not helmets. Get out there and^ enjoy the dubious pleasure of
   the wind in your hair.

       Footnotes

      Competing interests: None^ declared.

   [bmjcom.f1.gif] A figure giving details of accident rates is available
   on the BMJ's website

       References

   [136][uarrow.gif] Top
   [137][uarrow.gif] Safe walking
   [138][uarrow.gif] Risks of cycling
   [139][uarrow.gif] Is driving safe?
   [140][uarrow.gif] Dangers of helmets
   [141][uarrow.gif] Do helmets protect the...
   [142][uarrow.gif] Lesson one: cyclists get...
   [143][uarrow.gif] Lesson two: cyclists fare...
   [144][uarrow.gif] Lesson three: promote cycling...
   [dot.gif] References

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   accidents in Great Britain; the casualty report. London: DETR, 1998.
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     _________________________________________________________________

   [161] BMJ 2000

   This article has been cited by other articles:

   [162]Home page 
   [163]J Epidemiol Community Health Home page 
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   The challenges of evaluating environmental interventions to increase
   population levels of physical activity: the case of the UK National
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   J. Epidemiol. Community Health, February 1, 2003; 57(2): 96 - 101.
   [164][Full Text] [165][PDF]
   _________________________________________________________________

   [166]Home page 
   [167]Can Med Assoc J Home page 
   M. Wardlaw
   Butting heads over bicycle helmets
   Can. Med. Assoc. J., August 1, 2002; 167(4): 337 - 338.
   [168][Full Text] [169][PDF]
   _________________________________________________________________

Rapid responses:

   Read all [170]Rapid responses

   All helmets are not created equal
          Robert Arthurson
          bmj.com, 26 Dec 2000 [171][Full text]

   Further information from the author on reference 18
          M Wardlaw
          bmj.com, 30 Dec 2000 [172][Full text]

   Don't blame the helmet
          Ian Wacogne
          bmj.com, 1 Jan 2001 [173][Full text]

   Future for Cycling
          Andy Horton
          bmj.com, 3 Jan 2001 [174][Full text]

   Web Link Update
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          bmj.com, 3 Jan 2001 [175][Full text]

   Doctor Guthrie's Ten Essential Cycling Survival Lessons
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          bmj.com, 4 Jan 2001 [176][Full text]

   Safer drivers needed
          Edwin R van Teijlingen
          bmj.com, 4 Jan 2001 [177][Full text]

   Setbelt legislation: Additional information
          Shane Foran
          bmj.com, 8 Jan 2001 [178][Full text]

   Urban cycling and safety
          Edwin Moore
          bmj.com, 11 Jan 2001 [179][Full text]

   Author's reply
          M Wardlaw
          bmj.com, 15 Jan 2001 [180][Full text]

   A better cycling future
          A A Faraj
          bmj.com, 16 Jan 2001 [181][Full text]

   Cycle Helmets
          Michael Laverick
          bmj.com, 16 Jan 2001 [182][Full text]

   Re: Author's reply - Where did helmets come from?
          Peter James
          bmj.com, 19 Jan 2001 [183][Full text]

   from the US
          De Clarke
          bmj.com, 20 Jan 2001 [184][Full text]

   A footnote Re: from the US
          De Clarke
          bmj.com, 27 Jan 2001 [185][Full text]

   Hard vs soft shell
          Chris Bitmead
          bmj.com, 10 May 2001 [186][Full text]

   Cycling has to be as simple as it really is!
          Giselle Xavier
          bmj.com, 11 May 2001 [187][Full text]