1. Cycling Seminar, University College London, 26 th September 2011 Cycling: health and safety study for HotM2 Presenters:DrJenniferMindel MalcolmWardlaw JohnFranklin

2. Cycling Seminar, University College London, 26 th September 2011 Topics  Health & Safety basics – the Hierarchy of Controls  Risk in cycling and other modes of travel  Cycling and health  Review of cycle helmet research and experience  HotM2 conclusions on cycling – what should be done?  Q&A  Discussion– “achieving a cycling revolution”

3. Cycling Seminar, University College London, 26 th September 2011 HSE fundamentals - The Hierarchy of Controls Most effective Least effective  Reduce hazard at source – reduce and enforce speed limits, increase cyclist numbers, reduce traffic, reduce vehicle size, strict liability law, enforce existing manslaughter law, “friendly” vehicle design, raise driving age to 21yo  Contain the hazard – restrict motor traffic access, limit HGV access to major roads  Reduce exposure to hazard – traffic calming, off- highway cycle routes, cycle paths on trunk roads  Training and supervision – National Cycling Proficiency, parental supervision  Personal protective equipment – helmets and high-viz jackets Risk

4. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 1 “Traditionalist” risk assessment creates confusion….. 22 KSI per billion KM travelled 530 KSI/Bn KM based on police-reported casualties 24 x driver risk 1,850 KSI/Bn KM based on hospital admission data (HES) 84 x driver risk 370 KSI/Bn KM based on police reported casualties 17 x driver risk 430 KSI/Bn KM based on hospital admission data 20 x driver risk 6,500 KSI/Bn KM if admissions due to falls* are included 295 x driver risk! ….so cycling is really dangerous? NO! Pedestrian falls don’t count as “transport accidents” in HES… 99% of road safety researchers do not grasp this point…. 2006 UK data from Road Casualties Great Britain 2007 * Falls “in highway “and “in unspecified location”.

5. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 2 Subtleties of STATS19 & ICD-10 (HES) have led to confusion….. ….. Popular wisdom has it that serious cyclist injuries are under-reported by the police…………..or.. = “non-traffic transport accident” (HES) (“unspecified transport accident” actually) c. 5,000 admissions in 2006..or.. = “fall” (HES) c.120,000 admissions in 2006 not coded as transport accident in ICD-10 not reported by police in STATS19 In HES, ALL cycling injuries are coded as “transport accidents” irrespective…. …… popular wisdom is wrong…. ……..in reality, pedestrian transport injuries are mis-coded as falls in HES (ICD-10).

6. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 3 Time is the most important basis in transport risk…. 5 km/hr 13 km/hr 40 km/hr + 40-50 km/hr

7. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 4 …indeed, riding motorbikes is relatively dangerous… …averages reveal and yet conceal… …cycling risk within range of drivers’ risks. Figures based on 2006-2008 data

8. Cycling Seminar, University College London, 26 th September 2011 Risk in UK cycling and driving across the decades… Risk in cycling and other modes of travel - 5  Best years for cyclists’ safety 1973-1981, with fast growth in cycle use;  Cyclist and driver safety have run parallel for >40 years.

9. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 6 Does it matter if risk is exaggerated? YES. Conditioned promotion of cycling: Contributory negligence: Risk compensation: “Negative” infrastructure: Contributory negligence:

10. Cycling Seminar, University College London, 26 th September 2011 Risk in cycling and other modes of travel - 7 Conclusions regarding the risks of cycling and other modes of transport: 1.Risk per hour is the most meaningful basis of comparison; 2.Risks of motorcycling are clearly much higher than other modes; 3.Risks of cycling vary by place and by time; 1.Over time, the risks fall in line with road safety improvements; 2.Risks vary from place to place in similar range to drivers’ risks; 3.More cyclists mean safer cycling (of which, more later); 4.Young drivers face higher risks than young cyclists; Conclusions regarding the risks of cycling and other modes of transport: 1.Risk per hour is the most meaningful basis of comparison; 2.Risks of motorcycling are clearly much higher than other modes; 3.Risks of cycling vary by place and by time; 1.Over time, the risks fall in line with road safety improvements; 2.Risks vary from place to place in similar range to drivers’ risks; 3.More cyclists mean safer cycling (of which, more later); 4.Young drivers face higher risks than young cyclists; Current safety policies for cycling do not match actual risks. The correction of flawed policies will be the fundamental task…..

11. Cycling Seminar, University College London, 26 th September 2011 Cycle helmet research and experience - 1 A confrontation of views lasting decades…… Clinical evidence of effectiveness (60+% reduction in head injury); Reinforced by meta analysis; Widely supported by emergency medicine community; Clinical evidence of effectiveness (60+% reduction in head injury); Reinforced by meta analysis; Widely supported by emergency medicine community; Health benefits of cycling greatly exceed the risks of an accident; Cycling is benign; Helmet laws and promotion deter people from cycling; Health benefits of cycling greatly exceed the risks of an accident; Cycling is benign; Helmet laws and promotion deter people from cycling; Both sides missed the point: no risk assessment!

12. Cycling Seminar, University College London, 26 th September 2011 Cycle helmet research and experience - 2 The problem is the chaos of evidence….. …and the paucity of proof………… Case-control studies show that helmets prevent 60- 88% of brain injuries. Helmets increase the risk of diffuse brain injury due to rotation. Risk compensation leads to more serious crashes. Helmets reduced child cyclists fatalities by 50% in Ontario. Ahem! Helmet use did not change in those years….. Observational studies are not reliable – look at cannabis smoking and schizophrenia… Helmets must have a hard outer shell to be effective. Biomechanical evidence shows that helmets can save lives.

13. Cycling Seminar, University College London, 26 th September 2011 Cycle helmet research and experience - 3 This is a population- level result. These are not. Effect of New South Wales (AU) helmet law Effect of New Zealand helmet law

14. Cycling Seminar, University College London, 26 th September 2011 Cycle helmet research and experience - 4 Three “bridges” link the contradictory evidence: Meta-analyses of case-control studies did not account for publication bias or time-trends bias; Inclusion of neck and facial injuries reduced (corrected) net protective effect to zero in recent studies; Meta-analyses of case-control studies did not account for publication bias or time-trends bias; Inclusion of neck and facial injuries reduced (corrected) net protective effect to zero in recent studies; Selective recruitment – those who choose to wear a helmet tend to be from social groups the least likely to suffer death or severe injury in accidents (i.e. mid to upper income and educational attainment). Biomechanical tests do not replicate real-world accidents. Plastic yielding of helmets is rarely, if ever, seen outside the laboratory. Helmets crack and break up in practice.

15. Cycling Seminar, University College London, 26 th September 2011 Cycle helmet research and experience - 5 Effects of (enforced) helmet legislation on cycle use: New Zealand, 75% drop in children cycling 1989-2008 (helmet law from 1/1/94) “Only” 30% drop in children walking… Utility cycling in Australia is almost nothing and is going nowhere. Beware...Helmet laws not enforced won’t deter cycling! (not too much…) Ontario Under-18’s helmet law 1995; California Under-18’s helmet law 1994; Many other US state child helmet laws; Beware...Helmet laws not enforced won’t deter cycling! (not too much…) Ontario Under-18’s helmet law 1995; California Under-18’s helmet law 1994; Many other US state child helmet laws;

16. Cycling Seminar, University College London, 26 th September 2011 The health benefits of cycling are very large – as great as cessation of cigarette smoking… HotM2 principal conclusions on cycling - 1 The risk in cycling is very low – in the range of driving or walking – helmet promotion not indicated; Cyclists rarely harm 3 rd parties; More cyclists mean safer cycling – and safer roads; Health and Safety policies must reflect these facts! At present they do not……….

17. Cycling Seminar, University College London, 26 th September 2011 Respect the safety case for cycling: *Cycling is low risk; *Safety in numbers; *Cycling is a source of safety. *Change Highway Code; *Change BMA policy; *Stop contributory negligence. HotM2 principal conclusions on cycling - 2 What should be done? “Myth shall prevail if the wise remain silent….” + & More “positive” infrastructure (i.e. Hierarchy of Provision) Parking & “bike docks” Training Priority Quality Network Bike Combined with public transport

18. Cycling Seminar, University College London, 26 th September 2011 Beware… myths die hard….. “In the Netherlands, 45% of those seriously injured on the roads are injured while cycling with no motor vehicle involved….” (from European Transport Safety Council 5th Road safety PING Report 2011). “Pedal cyclist casualties account for 17 per cent of HES road traffic accident casualties in England…” (from Road Casualties Great Britain (2006)). “A specialist biomechanical assessment of over 100 police forensic cyclist fatality reports predicted that between 10 and 16% could have been prevented if they had worn an appropriate cycle helmet.” (from p1 of DfT summary of Report PPR446 (2009). “…it was not possible to quantify the amount of benefit offered by modern cycle helmets in the UK from the literature review alone.” (from p3 of same summary report). … and finally: my helmet saved my life.

19. Cycling Seminar, University College London, 26 th September 2011