Bike helmets—Can we improve on a good thing?

Issue: BCMJ, Vol. 50, No. 10, December 2008, page(s) 571 Council on Health Promotion
Lloyd Oppel, MD, MHSc, FCFP(Em)

In Canada, roughly 50 children die each year from bike accidents, with 75% due to head injuries.[1] In 1996, British Columbia became the first province to implement legislation requiring children and adults to wear helmets when riding a bike. Helmets are known to reduce the chance of serious head injury by 70% or more.[2]

A survey by MacPherson in 2002 examined 9700 bicycle-related hospital admissions across Canada. Results showed that in provinces with helmet regulations, childhood head injuries fell by 45%. In those provinces with no regulations in place, there was a 27% decrease in head injuries.[3] These results are supported by a 2008 Coch­rane review of North American studies.[4] Most importantly, helmet legislation is associated with fewer deaths due to bike-related head injuries. Wesson and colleagues showed a 52% reduction in childhood deaths (one life saved every 8 weeks) in Ontario after the province implemented helmet legislation.[5]

The economics seem to make good sense, too. It is estimated that every dollar spent on bike helmets saves $30 in indirect medical costs.[6,7]

As happened with the introduction of seatbelts, the number of people wearing helmets prior to legislation was small, but increased once compliance was made mandatory. Between 1995 and 1999 (dates pre- and post-helmet legislation) the proportion of riders using bike helmets rose from between 15% and 30%.8 By 1999 roughly 75% of riders were wearing helmets.[8]

Despite the clear benefits of wearing a bike helmet, a significant gap remains between the proportion of cyclists wearing helmets (75%), and the percentage of drivers using seatbelts (92%).[9] There are also reasons to worry that without ongoing programs to encourage and enforce helmet use, the number of people wearing them will decline.[10]

Clearly there is room for improvement and other options are available to encourage helmet use. Royal and colleagues summarized the results of 13 trials that examined helmet campaigns ranging from school-based programs to community-wide efforts, including the provision of free helmets. All such efforts were associated with increased usage.[11]

Across Canada, enforcement of bike helmet laws varies. Most jurisdictions have taken an educational approach and others maintain the option of administering fines ranging from $21 to $100 for infractions. In some areas, fines are waived when a properly fitted helmet is purchased.[12] Disturbingly, some provinces and territories (Saskatchewan, Manitoba, Que­bec, Newfoundland, Yukon, North­west Territories, and Nunavut) have no bike helmet legislation.[13]

Doctors can continue to advocate for helmet use and educate their patients on the benefits of wearing a properly fitted helmet. The BCMA web site has more information for patients under the Health and Wellness section (

As a public health measure, particularly for children, bike helmet use should remain a priority issue—and one well worth the cost.

—Lloyd Oppel, MD
Chair, Council on Health Promotion

References Top

1. Leblanc JC, Beattie TL, Culligan C. Effect of legislation on the use of bicycle helmets. CMAJ 2002;166:592-595.
2. Rivara FP, Thompson DC, Patterson MQ, et al. Prevention of bicycle-related in­juries: Helmets, education, and legislation. Annu Rev Public Health 1998;19:293-318.
3. Macpherson AK, To TM, Macarthur C, et al. Impact of mandatory helmet legislation on bicycle-related head injuries in children: A population-based study. Pediatrics 2002;110:e60.
4. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database Syst Rev 2008;CD005401.
5. Wesson DE, Stephens D, Lam K, et al. Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law. Pediatrics 2008;122:605-610.
6. Administration, National Highway Traffic Safety Administration. Traffic Safety Facts, Bicycle Helmet Use Laws. 2000. National Highway Traffic Safety Admin­istration. (accessed 6 November 2008).
7. SMARTRISK. The Economic Burden of Unintentional Injury in Ontario. 1999. (accessed 6 November 2008).
8. Foss R, Bierness D. Bicycle helmet use in British Columbia: Effects of the helmet use law [report] 2000. (accessed 6 November 2008).
9. ICBC. Road Safety: Seatbelts [fact sheet] 2006. (accessed 6 November 2008).
10. Macpherson A. Does bicycle helmet legislation for children remain effective 5 years post-legislation? Presented at the 6th World Conference, Injury Prevention and Control, Montreal, 2002.
11. Royal S, Kendrick D, Coleman T. Promoting bicycle helmet wearing by children using non-legislative interventions: Systematic review and meta-analysis. Inj Prev, 2007;13:162-167.
12. Safe Kids Canada. Safe Kids Canada’s Position Statement on Bike Helmet Legislation. 2005. (accessed 6 November 2008).
13. Fewer kids died in bike accidents after law enacted. The Canadian Press/CTV 2 September 2008. (accessed 6 November 2008).