legislative crisis

Original Article

Motorcycle helmets and rider safety:A legislative crisis

Allison J. Derricka,* and Lee D. Faucherb

aUniversity of Wisconsin School of Medicine and Public Health, 2705 UniversityAve Apt 6, Madison, WI 53705, USA.

bDivision of General Surgery, H4/732 Clinical Science Center, 600 HighlandAvenue, Madison,WI 53792-7375, USA.

*Corresponding author.

Abstract Over the past four decades, motorcycle helmet laws within theUnited States have been in a state of flux and have been shaped by theconflicting influences of the federal governments initiatives to shape statepolicies and motorcycle advocates persistent lobbying efforts. Examination ofindividual state experiences with motorcycle helmet legislation demonstratesthat universal motorcycle helmet laws effectively promote helmet usecompliance, reduce morbidity and mortality in motorcycle crashes, and lowerthe health care costs and associated societal burdens of these crash victims.Motorcycle advocates have challenged the implementation of these lawsand directly influenced the weakening or frank repeal of these laws tonegative consequence. We offer this review as an educational resourceto encourage and facilitate health care worker participation in legislativeefforts to support implementation and maintenance of universal motorcyclehelmet laws.Journal of Public Health Policy (2009) 30, 226242. doi:10.1057/jphp.2009.11

Keywords: motorcycle; helmet; legislation; fatality; cost

Introduction

Road traffic injuries are expected to be the third leading cause ofdeath and disability worldwide by 2020. Unhelmeted motorcyclistsworldwide face an unacceptable morbidity and mortality in theevent of a crash and place an excessive economic burden on

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societies through costly medical interventions and long-termdisability.1,2

Motorcycle use has gained popularity and motorcycle crashesaccount for a high proportion of injuries sustained in high-incomeas well as low- and middle-income countries where motorcyclesare a commonly used, cheap, and accessible form of transport.3 Inthe United States, the growth rate of associated crash fatalities hasdisproportionately exceeded that of motorcycle registrations, andby 2020, road traffic injuries are expected to be the third leadingcause of death and disability worldwide, further emphasizingthe need for improved motorcycle safety.4,5 In developingeconomies, road traffic injuries amount to 12 per cent of grossdomestic product (about US$100 billion) each year, or twice thetotal development aid received worldwide by developingcountries.6

Legislation significantly influences the use of motorcyclehelmets, reduces crash-related morbidity and mortality,and decreases the societal burden of injury-related medicalcosts.2,715 In the United States, motorcycle user group lobbyistshave influenced legislation to overlook indisputable scientificevidence supporting the efficacy of motorcycle helmet use. Theyhave relentlessly challenged the implementation and maintenanceof universal helmet laws as preventive health measures.16 Throughthe examination experiences in the United States with motorcyclehelmet legislation, we show that universal motorcycle helmetlaws effectively promote helmet use compliance, reduce morbidityand mortality of motorcycle crash victims, and lower thehealth care costs and associated societal burden of these crashvictims.Over the past decade, universal helmet laws have been repealed by

six states. In each, there followed increases in both motorcycle fatalitiesand medical costs of motorcycle crash victims.11,17,18 It seemscounterintuitive that states would continue to repeal helmet lawsdespite the negative consequences seen after repeals in other states. Anorganized and concerted effort by health care organizations, directed atmotorcyclists, lawmakers, and the general public, will be required toboth increase awareness of the repercussions of unhelmeted motorcycleuse both personal and societal costs and to encourage the enactmentand maintenance of universal helmet laws.

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227r 2009 Palgrave Macmillan 0197-5897 Journal of Public Health Policy Vol. 30, 2, 226242

Recognizing the Need for Universal Motorcycle Helmet Laws

Despite a reduction in the overall number of traffic-related fatalities,the number of motorcycle crash fatalities in the United States hasincreased disproportionately to the number of registrations. Whilemotorcycle registrations increased 63 per cent between 1997 and2005, motorcycle-related fatalities more than doubled during thissame period.1,19 Motorcycles make up less than 2 per cent of allregistered vehicles in the United States, yet they accounted for 11 percent of the total traffic-related fatalities in 2006.20 Traumatic braininjury is the leading cause of death in motorcycle crashes and helmetsreduce its risk by 69 per cent, and deaths by 42 per cent.9

Unhelmeted riders are more likely to lack health insurance or havegovernmental-funded health insurance and it is estimated that theUnited States public absorbs $5 billion annually in the form of higherinsurance premiums, increased taxation, and lost taxes related to thedeath or disability of motorcyclists.2,21 Therefore, injury to anunhelmeted motorcyclist is not a victimless event, as it places aburden on society and a drain on medical resources.

Background and Current Legislative Status

The debate over motorcycle helmet legislation is waged in theshadow of conflict between traditional American interpretations ofthe rights and liberties guaranteed by the United States Constitutionand Bill of Rights, as well as the American perception that thegovernments role is to provide protection as a whole for the greatergood, perhaps in spite of individual liberties.Motorcyclists have been historically organized and politically

active, as the biker culture is one that strongly values thepreservation of personal liberties. Groups such as A BrotherhoodAgainst Totality Enactment (ABATE) and the American MotorcycleAssociations Legislative Department were actually founded on theperceived need to coordinate lobbying efforts against state andfederal legislation affecting motorcyclists.22,23 The cohesive effortsof these groups are self-sustained through private funds.The presence of motorcycle helmet laws in the United States has

varied over time, responding to the federal governments efforts toshape state policies (Figure 1). The first laws were enacted as part of

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the 1966 Highway Safety Act, which authorized the US Secretary ofTransportation to withhold up to 10 per cent of federal highway fundsfrom states that did not adopt a law mandating motorcycle helmets.25

By 1975, 47 states and the District of Columbia had adopted universalhelmet laws. This trend reversed dramatically in the later half of 1975when Congress acquiesced to the pressure exerted by groups such asABATE, and amended the Act to remove the contingency of federalhighway funds on universal helmet laws. The amendment led to therepeal of universal coverage in 27 states shortly thereafter.16

The Intermodal Surface Transportation Efficiency Act of 1991created incentives and imposed sanctions to encourage states to enactmotorcycle helmet use and safety belt use laws. States with both lawswere eligible for federal grants, but states that had not enacted themhad up to 3 per cent of their federal highway funds redirected tohighway safety programs.25

As part of the 1995 National Highway System Designation Act,Congress lifted the federal sanction against states without universalhelmet use laws. Lobbying efforts against state universal helmet lawsfollowed, resulting in the repeal of universal helmet laws in six morestates26 (Figure 1). An associated national trend of increasing

Motorcycle Helmet Legislation in the United States

Arkansas and Texas repeal universalhelmet laws for partial laws

California and Marylandadopt universal helmet law

22 states repeal universal helmetlaws for partial helmet laws and 5states repeal laws entirely followingHighway Safety Act amendment

22 states enactuniversal helmet laws

47 states and Districtof Columbia haveuniversalhelmetlaws

Intermodal Surface Transportation Efficiency Act (ISTEA)

Louisiana re-enactsuniversal helmet law

Pennsylvania repeals universalhelmet law for partial law

Florida repeals universalhelmet law for partial law

Louisiana repeals universalhelmet law for partial law

Kentucky repeals universalhelmet law for partial law

Universal Helmet Laws - 20 states and District of Columbia Partial Helmet Laws - 27 states No Helmet Law - Illinois, Iowa, and New Hampshire

Highway Safety Act of 1966

Highway Safety Act amended National Highway System Designation Act

Washington adoptsuniversal helmet

Nebraska adoptsuniversal helmet law

1960 1970 1980 1990 2000 2010

Figure 1: Motorcycle legislation in the United States. 24,25

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motorcycle crash fatalities ensued, as the percentage of ridersrequired by law to wear helmets dropped (Figure 2). In 1996, 5.6motorcyclists were killed for every 10 000 registered motorcycles onthe road, and by 2006, the rate had risen to 7.3.1

The Evidence to Support Universal Motorcycle HelmetLegislation

Motorcycle helmet policies serve two purposes, primarily to protectcitizens from the poor choice of not wearing a helmet in the setting ofa crash, and secondarily, to serve the broader interests of society byreducing the costly burden of unhelmeted riders.27 In order tomeasure the efficacy of universal helmet laws, three primaryendpoints have been analyzed: the degree to which helmet lawsinfluence the use of helmets, the effect these laws have onmotorcycle-related morbidity and mortality, and the societal costsof motorcycle crash victims compared to the cost effectiveness ofuniversal motorcycle laws.27

United States Motorcycle Fatality Trends, 1975-2006

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Figure 2: United States fatalities per 10 000 motorcycle registrations, 19752006. 1,19

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Partial Helmet Laws

Results of data analyses comparing states have demonstrated thatage-based partial helmet laws are as ineffectual as no laws, because itis difficult for law enforcement to estimate motorcycle ridersage.25,28,29 This point is further emphasized by the fact that in 2005,helmets were worn by less than 40 per cent of the fatally injuredminors in states with partial coverage laws, despite the presence of alaw.30

Since 1997, six states have repealed universal helmet laws and putin place partial laws. Data on the resultant trends in helmet usecompliance and motorcycle crash fatality have been collected 11,3133

(Table 1, Figure 3). In the first full year following the repeal of auniversal helmet law, fatalities in Arkansas and Texas increased by21 and 31 per cent, respectively.34,35Motorcycle-related fatalities perregistered motorcycle increased by over 50 per cent in Kentucky and100 per cent in Louisiana. As a result, Louisiana re-enacted itsuniversal helmet law.30,36 After Florida repealed its universal helmetlaw in favor of a partial helmet law, helmet use among fatally injuredmotorcyclists younger than 21 years declined from 72 to 55 per centand riders younger than 21 years were 97 per cent more likely to diein motorcycle crashes after the law was changed.37,38

Universal Helmet Laws

Universal helmet legislation has a strong effect on helmet use. Dataexist for the five most recent states to implement universal helmetlaws and demonstrate significant increases in helmet use followingthe implementation of a universal helmet law in each state 28,31,33,41

(Table 2). The high rate of compliance that occurs under a universal

Table 1: Helmet use compliance before and after repeals26,39,40

Percentage compliance before Percentage compliance after

Arkansas 97 52

Florida 99 53

Kentucky 96 65Louisiana 100 52

Pennsylvania 82 58

Texas 97 66

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helmet mandate, in turn, translates into reduced motorcycle ridercrash morbidity and mortality (Figure 5). California riders increasedtheir helmet use from 50 to 99 per cent within the first year aftera universal helmet mandate was passed and motorcycle crashfatalities subsequently decreased by 37 per cent.41 Other states havereported similar trends following enactment of universal helmet laws

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Fatalities one year prior tohelmet law repeal

Fatalities during year ofrepeal

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Louisiana1999

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Texas1997

Kentucky1998

Pennsylvania2003

Florida2000

Figure 3: Motorcycle fatality before and after state helmet law repeals.1,19,24

Table 2: Helmet use compliance before and after re-enactment4245

Percentage compliance before Percentage compliance after

Nebraska 15 85

Washington 41 80California 50 99

Maryland 25 81

Louisiana 60 99

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(Figure 4), with mortality rates decreasing by 32 per cent inNebraska,42 23 per cent in Texas,35 15 per cent in Washington,30 and20 per cent in Maryland 43 (Figure 4).

Societal Implications

In addition to the safety benefits of motorcycle helmets, significanteconomic savings related to motorcycle injuries have been reported.Although it is difficult to quantify the total benefits from successfulpreventive measures, especially considering the value of lost workand long-term disability, most studies have focused on expendituredifferences in the acute care setting (Figure 5).2,10,44,46,47 Eastridge etal estimated that an additional $250000000/year in medicalexpenditures can be attributed to unhelmeted motorcycle riding.10

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Figure 4: Motorcycle fatalities before and after state helmet law enactments.1,19,24

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Analyses of motorcyclists admitted to hospital have shown thatalmost half of all motorcyclists lack health care insurance or arecovered by governmental health care services (Figure 6).2,42,4750

Only those motorcyclists with sufficient insurance impose no societalburden. Many uninsured crash victims are unable to pay theirhospital bills, which results in the hospital and governmentultimately sharing these costs.18 Furthermore, studies have alsoshown that unhelmeted riders are more likely to lack insurance thanhelmeted riders.48,51 Given the effectiveness of helmet legislation onhelmet use compliance, one can infer a substantial impact on overallmedical charges.

Opposition to Universal Helmet Laws

Introduction of universal helmet legislation will likely be met withimmediate and well-organized opposition from motorcycle usergroup lobbyists who argue that helmet use is an individuals personal

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Study Results of Average Hospital Charges per Crash Victim by Helmet Status

Figure 5: Average hospital charges per crash victim by helmet status.

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choice because it is the individual who assumes the risk of personalinjury.16 This argument is shortsighted. Serious injuries sustained byan individual create direct and indirect costs for our society throughthe consumption of costly medical resources, disability payments,and lost productivity.21,49,52

In attempt to offset some of this economic burden withoutimposing upon motorcyclists personal freedoms, some states haveimplemented laws that allow motorcyclists over the age of 21 andwith a minimum $10 000 medical benefit coverage for motorcyclecrashes to ride without a helmet.24 In 2000, Florida repealed itsuniversal helmet law in favor of a partial helmet law that excludedriders of 21 years and older with at least $10 000 of medicalinsurance coverage. Significant increases in medical costs persistedafter weakening their universal law.32 Hospital admissions for headinjury related to motorcycle crashes increased by 82 per cent andless than one-quarter of the injured patients were compliant withthe $10 000 medical insurance requirement for riders who chosenot to use helmets.1,38 When Texas repealed its universal helmetmandate, the severity of traumatic brain injuries associated withmotorcycle crashes worsened and resulted in a 300 per cent

Hundley et al.

Max et al.

Muelleman et al.

Offner et al.

Orsay et al.

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Stud

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Study Results of payer Distribution forHospital-Admitted Motorcycle Crash

Private GovernmentUninsured

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Figure 6: Payer distribution for hospital admitted motorcycle crash victims.

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increase in average treatment costs per crash, from $4585 to$22 531.35

The extent to which a minimum $10000 insurance policy willoffset the financial drain is questionable given that the averagetrauma admission exceeds $40 000.10,53 Yet, legislation requiringriders to have a higher minimum insurance policy for exemptionfrom the helmet mandate could result in more opposition and lowercompliance rates. Effective means to enforce helmet use in underageriders and those not covered by sufficient insurance policies have notbeen addressed in states with this type of helmet policy.54

The coordinated efforts of antihelmet activists have beenhistorically successful, but it is important to bear in mind that thesepeople and their opinions do not represent the majority.24 TheNational Highway Traffic Safety Administration has documentedstrong support of motorcycle helmet laws through their 2000 MotorVehicle Occupant Safety Survey, with 83 per cent of non-motorcy-clists and 51 per cent of motorcyclists in favor of a universalmandate.30 Although in favor of helmet legislation, Americans fail toadequately counter the antihelmet advocates with lobbying efforts oftheir own, and legislative decisions are often skewed.

Discussion

The primary impetus to improve motorcycle safety stems from thehumanistic drive to do no harm, yet it is difficult to promulgate thismotive in a setting in which a great many motorcyclists feel thathelmet mandates are an invasion of their personal autonomy.Antihelmet law activists fail to recognize that the consequences oftheir decisions go beyond the immediate harms that they personallymay incur. As such, they argue that a motorcycle helmet lawinfringes upon their personal freedoms and it should be their decisionto risk the consequences of not wearing a helmet.16 However,because public funds underwrite 2550 per cent of the costsassociated with motorcycle crashes, these consequences are sufferedby people other than the immediate risk taker.27 Some claims havechallenged the safety advantages of helmet use, arguing that helmetsinterfere with motorcycle riders vision and hearing, and increase therisk of spinal cord injury.52 However, the scientific community haslargely refuted these assertions.55,56 To us, it seems unfathomable

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that legislators can turn a blind eye to the precarious actions of a few,especially in the setting of limited health care resources, when wehave not yet found a way to insure basic primary care for all UScitizens.57

The prospect of increased fuel efficiency associated with motor-cycle use was an attractive benefit given elevated petroleum prices,and anecdotal evidence supports an associated increase in motor-cycle purchases and registrations.58 Therefore, with motorcycleregistrations and fatalities reaching record heights, the importance ofimplementing and maintaining helmet legislation cannot be un-derstated.Although this review focuses on experiences within the United

States, the burden of traffic-related morbidity and mortality clearlyextends beyond our borders, with traffic-related death risingespecially in developing countries with increasing industrialization.5

Research findings from outside the United States corroborate theevidence to support motorcycle helmet legislation.7,1214 Taiwansimplementation of a motorcycle helmet law in 1997 was followed bya 33 per cent reduction in motorcycle-related injuries and a 14 percent reduction in crash fatalities.12,14 In Spain, motorcycle fatalitiesdecreased by 25 per cent following passage of a motorcycle helmetlaw.8 Evidence to support the global effectiveness of motorcyclehelmets and helmet legislation has also been demonstrated throughstudies in Taiwan, Indonesia, Thailand, Greece, Spain, andItaly.7,8,1215,59 A cost benefit analysis using data from Chinadetermined that an effective motorcycle helmet legislation wouldcost $467 per disability-adjusted life year averted ($2001); however,this analysis did not consider the savings from avoided medicalspending.60

Experiences in the United States make a compelling case for thetransfer of evidence supporting motorcycle legislation from a high-income country to low-and middle-income countries, especiallygiven the significantly greater burden of road traffic injuries in low-and middle-income countries.61 Issues relevant to legislation inlow- and middle-income countries include the cost of helmets andthe design of helmets so that they are comfortable at high ambienttemperatures.3 Furthermore, in some countries, enforcementcosts for the police and justice systems may also need to beconsidered.61

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Conclusion

This is a contentious issue with a history of repeated re-enactmentsand repeals among individual states, illustrating the public healthchallenges that can arise in the absence of a national approach topolicy. Legislative action is the only evidence-based and cost-effectivemeans of promoting motorcycle safety and reducing the economicburden that injured motorcyclists place on society.62 Revising currentpartial helmet laws to include a minimum insurance coveragerequirement may generate less opposition from antihelmet lawactivists, but it has not been shown to be nearly as effective as auniversal helmet mandate in promoting helmet use compliance,reducing morbidity and mortality, or easing the health careexpenditures on motorcycle crash victims.Health care providers have an obligation to acknowledge the

benefits of motorcycle helmet use and participate in legislative effortsto enact universal motorcycle helmet laws. The present tangible needto facilitate health care cost containment and to promote the safetyof motorcycle riders may also stimulate the general public to partakein lobbying efforts more at present than in the past. Together, wemust urge lawmakers to look at the facts and not to be swayed byhigh-profile campaigns of motorcycle user group lobbyists, but to actfor the benefit of all parties involved.

About the Authors

Allison J. Derrick, MPH, is completing her Doctorate of Medicine atthe University of Wisconsin School of Medicine and Public Healthand will be pursuing a surgical residency. Her interests include injuryprevention and trauma epidemiology in the context of both publichealth policy and global health initiatives.

Lee D. Faucher, MD FACS, is Associate Professor at Division ofGeneral Surgery, University of Wisconsin School of Medicine andPublic Health. He specializes in the surgical treatment of trauma andburns, and surgical critical care. His research interests includetrauma and burn epidemiology, and the clinical aspects of burn careand nonpharmacologic adjuncts for the treatment of burn pain.

Derrick and Faucher


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