In 1992, the British Medical Association (BMA) undertook a wide-ranging analysis of cycling (BMA, 1992), which looked at the health and environmental benefits of the activity, the dangers faced by cyclists in using the roads and what might be done to make cycling safer. Many of its findings were new and influential, such as that the risks in cycling are greatly outweighed by the health benefits.
The analysis included consideration of cycle helmets and recognised that this was a complex issue. The BMA noted that head injuries were a common form of death among pedestrians and motorists as well as cyclists and remained so among motorcyclists who wore helmets. Although there was research that appeared to demonstrate clear advantages in the use of cycle helmets, this research had shortcomings that made it unsuitable as a basis for authoritative recommendations. In particular, the sample size of the studies was small and they did not distinguish the cycling behaviour of people wearing helmets from those who did not.
The BMA also noted that there were disbenefits from wearing helmets. At a personal level, helmets could be uncomfortable and hard-shell helmets diminish head ventilation and increase head surface temperature. Helmets were an inconvenience to carry around off the bike. Although helmets might be more beneficial for children, there was the danger of parents viewing the purchase of a helmet as a panacea, feeling that they had fulfilled their responsibility for the child's safety. Such an attitude might encourage a feeling of false complacency and therefore a greater risk of accidents.
In considering the mandatory wearing of helmets, the BMA stressed that the debate on the use of cycle helmets must not obscure more important areas of road safety, which involve action on behalf of motorists, road planners and policy makers. As head injuries are also a common cause of death and morbidity among car drivers and pedestrians, it was questionable why cyclists should be singled-out to wear helmets rather than other non-helmeted road users who have higher risks that result in an even greater cost to society.
The BMA noted that helmet laws shift responsibility for the safety of cyclists to cyclists themselves, despite their vulnerability and inability to control many potentially dangerous situations. It was more appropriate that responsibility should be borne by those causing most serious injuries, that is the drivers of motor vehicles. The question of cycle helmets went to the heart of policy marking for cyclists. Sooner rather than later it should be realised that the route to encouraging cycling and making it safer lies in the provision of safe cycling networks, enforced lower speed limits, and in changing the attitudes and behaviour of drivers.
The BMA did not support the introduction of helmet laws.
In 1998, the BMA's Board of Science and Education revisited cycle helmets by convening a special investigation into the subject. Outside experts were included in the project so that the Board heard at first-hand about the mechanics and physical limitations of cycle helmets, research on cycling and health, psychology and other matters. A report was published in 1999 (BMA, 1999).
The BMA looked at knowledge about cycle accidents and injuries, helmet design and standards and the health benefits of cycling. While acknowledging research that helmets might reduce injuries, the potential for saving lives through helmets was 12 times greater for pedestrians and motor vehicle occupants than for cyclists. They heard from the Transport Research Laboratory that there was some evidence to suggest that wearing a helmet leads certain riders to feel safer and so ride less carefully.
The report noted that, in common with many other consumer goods, cycle helmets are frequently manufactured to the lowest level of whatever safety standard influenced sales. Tests in the UK had shown that there are often potentially misleading safety claims and that the current standards were no guarantee of safety.
Reviewing legislation for mandatory helmet use abroad, the BMA expressed concern that helmet laws had resulted in a large number of people stopping cycling. It noted that care needed to be taken to ensure that helmet safety campaigns do not inadvertently discourage cycling.
While supportive of helmet wearing, the BMA recognised that there was a downside to helmets in the way helmets could deter people from cycling, outweighing the health benefits that cycling gives. For that reason the organisation remained opposed to the introduction of a helmet law.
During the early 2000s, a small group of doctors lobbied strongly for the BMA to adopt a position in favour of a helmet law in the UK. At the same time, membership of the BMA's Board of Science and Education changed and the Board became more susceptible to this lobbying, perhaps because they were not familiar with the analyses of helmets than had gone before.
In 2004, some Accident & Emergency doctors, assisted from within the Board of Science, launched a coordinated letter writing campaign arguing for compulsory helmets. The Board then announced a change of position in support of this. Minutes of the relevant meeting suggest that formal discussion was minimal. The letters received from A&E doctors and a Canadian paper that claimed cycle use did not fall with legislation (Macpherson, Parkin and To, 2001) were cited in support of the change. This paper has been extensively criticised and is reviewed here. It contains many flaws that invalidate its conclusions.
A motion to support helmet compulsion was then approved at the BMA’s 2004 Annual Representatives’ Meeting (ARM), making this BMA policy. While previously the BMA had sought to bring balance to its analyses and to come to an objective review of the facts by involving a range of expertise and opinion, in this case the Board changed its position on the basis of lobbying and a single discredited paper.
In 2008, a briefing was commissioned to provide further justification for the Board's support for a helmet law (BHRF, 1188). Its author was someone strongly predisposed to legislation. The briefing was heavily biased and relied upon emotive, and one-sided, anecdotal quotations in a way inappropriate for any scientific paper.
The briefing relied crucially upon studies which had been shown to have serious flaws, and passed lightly over or ignored completely more sceptical, but scientifically stronger, analyses. It misrepresented statistical data by using it out of context, showed a poor understanding of basic concepts, and ignored the likelihood and consequences of reduced cycling and rotational injuries. There was no attempt to explain the totally different outcomes of pro-helmet academic papers and the experiences across whole populations in the real world.
Although those pressing for helmet laws often suggest otherwise, the medical profession has never held a single, unanimous view on the subject. While some A&E doctors and neurosurgeons argue for all cyclists to use cycle helmets, others have told the courts that they have witnessed no differences in injuries to cyclists wearing and not wearing helmets. To some extent the opinion of doctors may have reflected their wider understanding about cycling.
Subsequent motions at the BMA's Annual Representatives Meeting did not overturn the BMA's decision to support a helmet law, but the number of doctors voting in favour of an overturn was significant. At the 2005 ARM, the vote was so close that an electronic count was required. Motions that the BMA should support the encouragement of cycling have been approved by a clear majority, although such action is incompatible with support for a helmet law.
Public health doctors have been particularly concerned at the BMA's stance, and the more so as they have become familiar with the growing evidence that existing laws have not reduced the risk of injury faced by cyclists. Pressure on their part probably explains why, in due course, the BMA modified the emphasis of its policies such that it would not campaign for a helmet law until such time as many more cyclists wore helmets voluntarily.
In 2010, the Health & Transport Study Group (not part of the BMA but closely associated with its Board of Public Health) updated its policy paper Health on the Move (THSG, 2011). This strongly supports more cycling, seeks to be realistic about risk and declines to support helmet promotion, let alone laws.
Cycling towards health and safety. British Medical Association ISBN 0-19-286151-4.1992.
Cycle Helmets. BMA Board of Science and Education ISBN 0-7279-1430-8.1999.
Macpherson AK, Parkin PC, To TM, 2001. Mandatory helmet legislation and children's exposure to cycling. Injury Prevention Inj Prev 2001;7:228-230.
Mindell JS, Watkins SJ, Cohen JM, 2011. Health on the move 2. Policies for health promoting transport. Transport & Health Study Group .