Missing the forest for the bicycle helmets

The author breaking the law while making a quick bike share trip on the Burke-Gilman Trail.

This week, the authors of a disputed study promoting bicycle helmet laws with bike share systems penned an op-ed for Crosscut arguing that Seattle’s bike share companies should be forced to provide helmets with their bikes.

Aside from the ick factor of sharing helmets with strangers, the hyper-focus on helmets is dangerous because such a requirement would certainly harm and possible kill bike share business in Seattle. The helmet costs (purchasing, collecting, inspecting, cleaning, and redistributing them) were already a factor in the financial demise of Pronto. We cannot repeat that mistake.

And even the authors’ own research could just as easily be seen to demonstrate the public health and bike safety benefits of bike share systems without helmet use. They just draw a questionable conclusion from their data.

Essentially, a before-and-after study of hospital admissions for bicycle-related injuries in five U.S. that launched bike share systems found that all types of injuries decreased by 28 percent once the bike share systems launched. But head injuries only dropped 14 percent. In fact, their data showed that head injuries dropped more significantly in bike share cities than in control cities.

That sounds like a big step in the right direction to me (and bicycle researcher Kay Teschke). But to authors Fred Rivara and Janessa Graves, the data shows an increase in the proportion of those (fewer) injuries that are head injuries. So they conclude that bike share systems need to require helmets.

They are missing the forest for the trees. By hyper-focusing on helmets, the op-ed authors have failed to balance all the other public health benefits of bike share or the damage to public health that would occur if a helmet requirement shut down or limited bike share company operations.

They have also drawn conclusions without convincing support that bike share helmet use is the reason for the discrepancy in injury rates in their data.

A 2016 Mineta Transportation Institute study (sponsored by the California DOT and USDOT) backed up previous studies finding the injury rate on bike share bikes to be significantly lower than the injury rate for people riding their own bikes. The Rivara/Graves data does not specify whether the people getting head injuries were riding bike share bikes or personal bikes. So how can they conclude that bike share users not wearing helmets is the cause? That leap of logic is simply not supported by their data (UPDATE: This and other concerns were highlighted in a 2014 letter Teschke and Meghan Winters wrote to the American Journal of Public Health. UPDATE 2: The American Journal of Public Health also published this response from NE Seattle Greenways leader Andres Salomon, Gray Kimbrough, and Anna Bershteyn. The journal also published this response from Graves, et al.).

In fact, their data also cannot conclude that the changes in injury rates was due to bike share at all. The change could be due to a huge number of variables, such as the building of new bike lanes in study cities with bike share. The MTI study was unable to find a clear tie between bike share use and overall bike injury rates (though the authors acknowledge that a lack of quality bicycle trip data makes such an analysis very difficult).

But the worst part about focusing on helmets is that such a requirement puts the viability of bike share at risk. This is not a hypothetical statement. It already happened once in this town.

Here’s some data: 100 percent of U.S. bike share systems required to provide helmets with every bike and operating in counties with all-ages helmet laws have lost money and closed down. Because Pronto was the only one.

(Helmets were not the only cause of Pronto’s demise, but they contributed to the budget crisis that sunk the system both in terms of helmet costs and in terms of decreased ridership.)

Bike share could be a big part of a transportation shift in our city that leads to big public health benefits not only for the users of the bikes but for others around them. As the population grows and congestion gets worse, Seattle and King County must provide new options for people trying to get around. Transportation is our region’s biggest creator of air pollution (which causes all kinds of serious localized health issues) and greenhouse gas emissions (a public health problem on a global scale). And physical inactivity is a major contributor of all kinds of debilitating and fatal health issues.

Bike share will not solve any of these issues alone, of course. But it is a part of the solution.

Ewwwwwwwwwwwww

There’s also a simple practical barrier to requiring helmets on bike share bikes. Even if Rivara and Graves were right about their conclusion, nobody is going to wear a helmet that has been worn by unknown numbers of people and has been sitting in the open on Seattle streets and in Seattle weather for an unknown amount of time. That is disgusting and unsanitary. And it’s not even particularly safe to wear a helmet that has not been inspected for cracks and wear.

Their op-ed is titled, “Bike share and helmets: Let’s be realistic,” but their proposed solution is completely unrealistic.

King County should repeal the all-ages helmet law

King County passed its all-ages helmet law in the 90s based in large part on a disputed 1989 study that Rivara helped author. That study is the source of that factoid you see on all kinds of bicycle helmet outreach saying that helmets can prevent up to 88 percent of brain injuries from bike crashes.

But the National Highway Traffic Safety Administration no longer backs that study, and follow-up studies have not been able to replicate its results to the same extent. Studies consistently determine helmets do decrease brain injuries in the case of a collision, but some also found increases in serious neck injuries. Ultimately, a helmet clearly absorbs impact, but it’s important to know that the actual benefit is murkier than the disputed 88 percent figure would have you believe. A helmet isn’t an invincibility cloak, and it’s dangerous to think of them that way.

But even acknowledging that a bicycle helmet could help prevent a brain injury in the case of a collision, focusing on helmets ignores the biggest cause of bicycle head injuries: The collisions themselves. It is far more important to prevent collisions from happening in the first place than to require that people biking wear a helmet. Public health agencies should focus on the causes of collisions, not crash victims’ choice of headwear.

Head injuries are also the leading causes of death for people walking and people in cars, yet nobody talks about motoring helmet laws. Well, almost nobody.

The safest cities in the world for cycling have very low helmet use rates but great bike infrastructure and a ton of people biking. We should focus bicycle safety efforts on best practices in the places with the best safety records. Adult helmet laws are not among them.

The enforcement problem

The other problem with all-ages helmet laws is enforcement. As the law exists now, police officers can stop, question and ticket someone simply for riding a bike without wearing a helmet. Not only is that a very questionable use of police time, but it is also not good police policy to create cause for stops that are not of significant public safety benefit. An adult riding a bicycle without wearing a helmet just does not rise to the level of public safety menace justifying a police interaction.

Seattle Police seem to understand this, and bicycle helmet tickets are way down in recent years, the Seattle Times reports. Before that, a huge percentage of helmet tickets were given by a single officer (and many of those went to one particular bike messenger). County-wide, tickets are given disproportionately depending on where you are, MyNorthwest reports.

The solution to bike safety is definitely not to have police step up their helmet law enforcement. So why have the law at all? The King County Board of Health should repeal the helmet law, at least for adults, and focus instead on bike encouragement and safer street designs.

Unlike some more adamant opponents to helmet laws, Seattle Bike Blog is not against bicycle helmets. If you want to wear a bike helmet, please do. Whatever makes you more comfortable and gets you biking is great in our book. The use of helmets while biking is a huge gray area, which is why the debate gets so heated and divided. Human beings are not great at dealing with gray areas, preferring instead to declare something absolutely mandatory or not needed at all. There’s a clear difference between cruising a half mile to the grocery store and going on a training ride on busy roads. But King County’s helmet law clumsily lumps these activities together.

I don’t think Rivara and Graves are out to make bicycling less safe. Certainly, there are a lot of people who want more people to wear bike helmets because they genuinely want them to stay safe. And traumatic brain injury is no joke. I also want people to be safe and healthy. I want as few people getting hurt as possible.

Ultimately, focusing on helmets is a huge distraction from all the other issues that could have a much bigger effect bike safety and bike use. I really wish I didn’t have to keep writing stories about it, because it is a waste of everyone’s time to keep arguing. But as long as the law is on the books, it’s going to keep coming up and keep distracting us all. With Seattle’s bike network slowly coming together and bike share companies flourishing, we need to focus on how to support and build on those efforts.

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34 Responses to Missing the forest for the bicycle helmets

  1. Jon K. says:

    Amen! Rivara’s 1989 study is piss pour research and should never have been published. Everything is wrong, from cherry picking control and study groups (kids riding in Magnolia parks wearing helmets vs. kids in the Rainier Valley riding in the street with no helmets), to the small study size, to the self reporting problem, to it’s sensational and unsubstantiated conclusions. It’s no wonder the USDOT doesn’t reference that study any more. i cant believe he’s still out there spewing misinformation.

    • Tom Payne, MD says:

      Bike helmets save lives. Kudos to Fred Rivara, Tommy and Diane Thompson for their research published in the New England Journal of Medicine in 1989. It was a sound case-control study which was a practical approach to the question given the incidence of bike-related head injuries. I encourage more research–no single study can provide a definitive answer, yet that does not detract from the contribution by each study. That is how science works.

      I take care of people with head injuries and it is a far more serious problem than head lice, a reversible condition. My family members and friends have been in bike accidents in which bike helmets saved them from serious or fatal head injury. I’ve taken care of patients with head injury sustained while bicycling slowly on the Burke-Gilman trail. They did nothing wrong, just fell off their bikes and struck their heads on pavement. Caring for victims of head injuries who survive goes on for a very long time and society has a shared interest in reducing the number of such victims. Bicycling is healthy and should be encouraged. Please wear a helmet and ask your loved ones to do so. I would not vote to repeal our law requiring bike helmets based on my reading of the literature (only briefly summarized in this thread) and my own professional and life experience.

      • jay says:

        Oh good! somebody with a degree to help support my idea!

        People say they don’t want to carry a helmet around all day just incase they decide to use a share bike, but what if helmets were required to walk on public property? Then every one would already have their helmet.
        You have no doubt treated people with head injuries who were not riding bikes. I suspect there are more head injuries from being hit by a car (supposing one isn’t killed outright by massive trauma) than from bicycling. Then there are a not insignificant number from falling down stairs, tripping over a curb etc.
        Of course there is also falling in a bath tub, but I think privacy concerns are going to make mandatory helmet use inside private residences a hard sell, but public spaces should be a no-brainer.

        Another couple of advantages; the increased demand for helmets will spur innovation in comfortable, fashionable helmets. and most important, discouraging walking will mean less people in the way of divers who really don’t want to yield. Discouraging those G.D. cyclists quite likely being a motivation for helmet laws.
        Yet another plus, there will be more demand for private parking adjacent to drivers destinations so they don’t have to put on a helmet, therefore there should be less objection to taking on street parking for bike lanes! win win!

      • Fredster says:

        So the average semi-in shape human can run, what maybe 5-10 miles an hour tops? Then put a shmuck on a bike-share with limited saddle time and experience. That same person can easily go 25 mph down a hill. What if they get the unrecoverable wobble going. I’m not trying to sound all ‘Nanny-state’ but come on- soft crushible head vs. pavement- really? where’s the common sense?

      • Josh says:

        If it’s such a sound study, why have multiple Federal agencies repudiated it under the Data Quality Act?

  2. Gary Yngve says:

    If it is legal to ride without a helmet a boosted board that can go 20 mph , it should be legal to ride a bicycle without a helmet.

  3. ronp says:

    Great summary of the issues. Really hope the politicians can change the law to be only for kids.

    I bike commute every work day and would never not wear a helmet, but can’t see how to do bike share with a law requiring helmets.

    Lets get some great protected bike lanes set up and see how it goes.

  4. Andrew Squirrel says:

    While I 100% agree with you and think we should change the law I will say it is a little horrifying coming across a inexperienced cyclists operating the Share very unsteadily. Of all the people in the cycling community that would most benefit from a helmet its probably them. The logistics of sharing helmets is absurd and I’m not sure they would even get used as much as abused. It’s an unfortunate conundrum even though its very obvious that the law needs to be repealed.

  5. Peri Hartman says:

    While I agree that this is a “nanny law” and should be dropped, I think it’s wise to ride with a helmet.

    The solution is simple: encourage convenience stores and other shops to carry inexpensive low-use helmets. There are several available and several more that could be available, e.g. ecohelmet. Below are a few I found with a quick search.

    https://www.ecohelmet.com/

    http://www.prorider.com/cns/Economy-Bike-Helmets?gclid=CJqz58qFhdYCFUlNfgod-2kO7A

    https://www.bikefriday.com/folding-bikes/blog/webnews/review-the-morpher-folding-helmet/

    https://www.kickstarter.com/projects/fendhelmet/fend-the-collapsible-bicycle-helmet

    I don’t know what is the best way to “encourage” stores to carry these. Maybe the bikeshare companies could offer a small rebate to the stores in exchange for being allowed to have a permit here? Maybe the bikeshare companies should be required to sell them through various stores on sort-of a consignment basis? What ideas do you have?

    Frankly, I won’t ride without a helmet and I’m sure there are many like me. Again, I don’t think the law is appropriate but that doesn’t mean we should ignore the situation.

    • Al Dimond says:

      Seattle ain’t New York with a bodega on every corner. Our convenience-store density, even downtown, is less than the density of Pronto stations was! By the time you’ve managed to find and buy a helmet you’d have been better off riding the bus.

      So my idea is that people that truly insist on helmets all the time can plan ahead around their own preferences.

  6. Lee Bruch says:

    A bike is not a bike is not a bike
    Different bikes, and different riders, are different, have different dangers, and shouldn’t all be treated the same.
    Without evidence other than gut instinct (ouch, that sounds like Trump), it seems to me:

    1. helmets mainly protect when going head first over the handlebars such as when hitting an obstruction or when something catches in the spokes. It is far less likely for them to be significant protection in a crash with another vehicle.

    2. one is far more likely to go head over handlebars when clipped into pedals, or when hunched over dropped handlebars, or when riding hard than when riding more sedately sitting upright in a “cruiser” type bike like those used for rideshare.

    It’s vaguely analogous to football or hockey or baseballg. Few would use a helmet in a pick-up game between friends. But in a team game with protection of various body parts in high school, college, or the pros one would be foolish not to wear protection, including head protection.

    There are plenty of situations where it would be foolish not to wear protection on one or another of the body’s parts. But there are plenty of situations where it’s not needed.

    The variety of potential situations is so great it would be a fool’s errand to legislate all of them; it’s a decision best left to the informed individual evaluating their own risks.

    However, the answer may be different for kids, who don’t yet have the judgement to make informed decisions.

    • Clark in Vancouver says:

      This is something that I’ve thought of as well. Instead of attempting to repeal the law entirely (which while completely valid would be difficult right now) they can try to modify the law to require a helmet only for certain activities and for certain types of bikes. Here’s an example.
      Bike frame geometry types. Require helmets only for ones where it’s possible to tip forward: Road bikes, mountain bikes.
      Not require them for ones that it’s not possible to tip forward: Cruisers, roadsters, tricycles, recumbents, semi-recumbents, typical bike share styles, etc.
      Not scientific but would be easy for potential opponents to understand.
      Of the frame types that would require it it would still only be required for activities such as racing, mountain biking. Not for casual riding, commuting, shopping, etc.

      A larger question that needs to be asked is how any new law gets made based on lobbying of an interest group as opposed to evidence. Should government’s let themselves be snowed into creating more legislation just because somebody sold them a package.
      It could be an opportunity to investigate just how the law came to be and to reconsider it since it was originally passed based on a bogus study.

      It’s sad to see this shyster Rivera still out there lying.

    • asdf2 says:

      Yet another situation to consider is terrain and speed – you’re much more likely to go over the handlebars when bombing down a hill than when going slowly on flat ground. When I ride the bikeshare bikes, I normally do so without a helmet, but I also don’t do it if the trip is going to involve a steep descent. Sometimes, you just have to trust people to use common sense, as you can’t legislate every possible case in law.

  7. William says:

    Since the current bikeshare trials are working well, people are using them without helmets, and the police seem to have little interest in handing out warnings or citations for riding without a helmet, it seems to me that the status quo is perfectly satisfactory.

    • asdf2 says:

      Situations like these make it all to easy for racial bias to creep into policing. I’m not aware of any data as to whether the helmet law is being disproportionately enforced depending on skin color, but given what I’ve heard about our police’s handling of jaywalking, I would not be at all surprised if that were the case.

      That said, as much as the mandatory helmet law should be repealed, I’m not expecting it anytime soon, as the helmet law is wildly misunderstood by voters, and no politician wants to appear on the side of encouraging head injuries. Maybe after 20 years of helmetless bikeshare riding being ubiquitous on the streets, it will be possible, but not now.

  8. asdf2 says:

    Occasionally, I’ve seen people give the analogy of mandatory seat belt use for cars to justify mandatory helmet use for bicycles. But, there’s a big difference, in that the seat belt is permanently attached to the car, while a helmet is not and cannot be permanently attached to a bike.

    Imagine a world where cars didn’t come equipped with belts attached, and if you wanted one, you had to carry your own (e.g. a world where seat belts belong to the person wearing it, not the car). Under those conditions, would you carry a seat belt around with you every day on your bus (or walking) trip to work, just in case you spontaneously decide to hop in an Uber or Car2Go? Or, would you just take your chances violate the law (maybe drive slower in the Car2Go case!), and hope you don’t get a ticket.

  9. Fred says:

    Great essay, Bike Blog. Keep up the good fight.

    To all the rest of you, screw helmets on bike share. It’s virtually impossible to reach 15mph on one of those rented beasts. You’ll be fine.

    Jump on one, it’s good fun.

  10. ChamoisDavisJR. says:

    A nicely written, balanced article Tom.
    Kudos, and I agree that hopefully you won’t have to write more on this subject.

  11. LARRY C JONES says:

    The only times that I have ever had my head hit the ground in over 50 years of cycling were in side falls when my drivetrain locked up or l fell on a super steep climb.

  12. Dean R Robertson says:

    I have mountain biked for close to 30 years and have cracked at least 3 helmets in accidents during that time. The high likelihood is that had I not been wearing helmets during those crashes, I would not be able to put these words down here today.

    You may not think there’s any correlation between mountainbiking and road riding, but a crash is a crash, and road riders impact a significantly harder surface, typically, than do mountainbikers.

    Requiring helmets for 16 yrs of age and under should be mandatory, IMHO, adults should be left to make their own decisions on the matter; but, I can speak from experience when I say it may save your life, or at the very least prevent catastrophic injury. So, if you ride a bike anywhere, you really ought to wear a helmet.

    That said, requiring the bike share program to provide sharable helmets is prima facia stupid, and will not work; I don’t care what data you think you have derived from some half-assed study.

    • Kirk says:

      I’ve cracked many a helmet over the years too. But I wouldn’t say if you ride anywhere you need a helmet. Cruising to the corner coffee shop on my vintage Schwinn Racer isn’t risky and I don’t feel I need a helmet; riding my road bike in traffic is risky and I would never do it without a helmet.

      • Fred says:

        I still say accidents are just that, and they can happen at low speed or any speed. My wife has gone down when her front tire got caught on a curb cut on thr Burke-Gilman. Personal responsibility and all that, I just maintain Its always better to wear a helmet. I would in the Netherlands, where most folks do not, and I would in Seattle.

  13. Fred says:

    Dean’s comment is closest to my experience. I’ve gone over the bars and crashed sideways on a road bike bike commuting at LOW Speed. I’ve had my head hit the pavement FIRST – not my elbow, not my knee, not my hand, not my foot. I would have been dead if I hadn’t had a helmet on at that time.

    Accidents are just that – there is no way to predict when they will happen, or to ride cautiously enough to prevent them.

    When my wife and I used Citibike in NYC a couple summers back the first thing we did was go into a bike shop and buy a couple of cheap helmets.

    Perhaps the mandatory helmet law could be modified to advisory status, or not enforced. The bike share companies could be required to provide Public Service Announcements recommending people ride with a helmet (just like cigarettes cause cancer warnings) when their reservations app is started.

  14. Dave says:

    it might not seem fair and it might not be constitutionally or politically possible but one solution would be to allow bike share riders to ride without helmets and to continue requiring them for everyone else. Helmets help in a crash but having more people on bikes helps more

    • RossB says:

      That seems like the way to go. I don’t see any reason why the law can’t be changed, and apply only to bike share bikes. Bike share bikes have special regulations, and one of those should be that those that rent them don’t have to wear helmets.

      What is clear is that such a change in the law will actually make other riders safer. That is one of the key arguments for this change. In the photo above, Tom is breaking the law, but he is making those who ride with a helmet (like me) safer. He is a hero, really, and not be arrested for making other cyclists safer.

  15. Bryan Willman says:

    A possible legal angle – how is it the Health Board, for whom I don’t recall ever getting an opportunity to vote, gets to pass such laws?
    If the city council or county council or state legislature does that, I can vote them out.
    I do I vote out the Health board?

    (I think another very bad aspect is the law is very widely ignored with no consequence, which will encourage people to ignore other laws…)

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  17. Ballard Resident says:

    I rarely see discussion about concussion.

    Here’s an interesting TED talk about it.

    https://www.ted.com/talks/david_camarillo_why_helmets_don_t_prevent_concussions_and_what_might/transcript?language=en

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  19. Phill in Chicago says:

    Thanks for including the link to the article on motoring helmets: that really made my day! And generally, thanks for the great summary of this exasperating debate.

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  21. Michael Altman says:

    I agree that with bike share mandatory helmet requirements are burdensome and unnecessary. Whenever you ride you roll the dice, but if you saw the outcome of an accident on Stone Way Sept 12th by Bastyr’s clinic with a guy almost unresponsive on the street, possibly with a C Spine and internal injury, and the car he crashed into clearly at high speed considering the dent and possibly broken window his head went through, you’d wear one…

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