Mandatory bicycle helmet laws in the United States

The National Transport Safety Bureau has recommended all-age mandatory bicycle helmet laws be introduced across the United States. Read about the injury and participation data ignored by the NTSB.

Below is an expanded and modified study which elaborates on peer-reviewed findings published by World Transport Policy and Practice in January 2015. The data is accurate and can be used by any researcher investigating the efficacy of bicycle helmet laws in the United States.


Abstract 2015: Studies of child and teenage cyclist injury rates in the United States consistently report a downturn since mandatory bicycle helmet laws were introduced in various states and municipalities during the 1990s and progressively since. The downturn is generally attributed to improved safety through mandatory and voluntary wearing of helmets by children and teenagers. To test these conclusions against confounding factors, primarily child cycling participation, this study considers rates of cycling sourced to public and private agencies since 1995 and compares these with injury numbers sourced to the US Consumer Product Safety Commission National Electronic Injury Surveillance System and fatality numbers sourced to the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System. Participation is also compared with cyclist traumatic brain injury and concussion data each year since 1995, and with 2010/2011 cyclist fatalities in all US states with and without child helmet legislation. The study finds that 7-17yo cycling participation in the United States declined 23.1% from a 1995-2003 average of 18,593,000 to a 2004-2012 average of 14,296,889, while 7-17yo cyclist all-body injuries fell 23.7% and concussion injuries fell 2.1%. Multiple sources confirm these results as indicative of US child cycling participation and injury trends, suggesting a failure of bicycle helmet laws to improve public health and cycling safety.


Introduction
Materials and methods
Cycling participation data
Cycling injury data
Cycling head injury data
Cycling fatality data
Cycling fatality data in different states
Discussion
Limitations
Conclusion
References
Appendix charts and tables


Note: Cycling participation and injury data to 2015 can be viewed here.


Introduction

Previous studies of child cyclist injury rates in the United States have identified a significant decline since the 1990s and have generally attributed this to the introduction of mandatory bicycle helmet laws 1.

Published surveys suggest helmet wearing among 5-15yo cyclists increased from 25% in 1994 to 48% in 2001/2002 2, 27. A 1998 survey published in the Injury Prevention journal 3, 6 put average probability of riders aged less than 16 always or almost always wearing a helmet at 72.3% in helmet law states and 49.6% in states without a helmet law.

Different state and local jurisdictions mandate helmet wearing among <12, <14, <15, <16, <17 and <18 age groups, a small number of municipalities also requiring helmet use by cyclists of all-ages.

Among other sources, this study extracts <17yo cycling data 1995 to 2020 from the US Census Bureau 4, the Outdoor Industry Association 7 and from the US Consumer Product Safety Commission National Electronic Injury Surveillance System 5.

Some analysis results are categorized by states wherein child helmet laws are applied and the study assumes there is more helmet wearing among youth than adults across the United States, either by law, parental coercion or choice.

Child cycling participation, population, cyclist number, all-body injury, head injury and fatality data from public and private agencies are compared in different age groups and American states to determine whether helmet laws and increased voluntary helmet wearing have achieved better health and injury outcomes.


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Material and methods

Data for this study are sourced from:


A majority of the source agencies are government and their calculations of relevant data are considered accurate.

All calculations and charts in this study were performed and created within the Microsoft Excel and Apple Numbers spreadsheet applications. All data used is publicly accessible from the internet and all calculations are arithmetic, requiring no skills beyond knowledge of basic spreadsheet functions to verify data.


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Cycling participation data

According to An Overview of the Bicycle Study 31, a survey by the US Consumer Product Safety Commission estimated that in 1991 there were 66.9 million Americans of all ages who had cycled at least once during the previous year (39.5% in 1-14yo age bracket). An estimated 17.6% of all cyclists wore a helmet all or most of the time in 1991, with another 6% wearing a helmet sometimes (11-14yo age group 11.4%; 1-11yo age group 17.0%).

Georgia was the first American state to introduce mandatory bicycle helmet laws for children aged less than 16 years old in 1993, although child and youth helmet wearing had been mandated by various local municipalities and/or enforced by many parents and schools across the USA in previous years.

According to the National Sporting Goods Administration 8 (NSGA), an estimated 56,308,000 Americans rode bicycles in 1995 at least six times a year. However, participation dropped 17,008,000 or 30.2% by 2012 to 39,300,000. From 2000 to 2011, 7-11yo cycling fell 21% and 12-17yo cycling was down 15% 15.

Averaged 1995-1998, there were 21.2% fewer cyclists than 2009-2012 (49,576,000 / 39,084,750). Averaged 1995-2001 and 2003-2009, 7-17yo cycling fell 20.1% (9,673,286 / 7,730,571) and 18+ cycling fell 10.7% (4,462,405 / 3,983,405). On average, there were 1,942,715 fewer <17yo cyclists and 479,000 fewer cyclists aged 18+.

NSGA survey data suggest there were 17.6 million Americans aged 7-17yo who cycled at least once a year in 2000 and 10.1 million in 2014 - a 42.6% reduction - while 18y+ cycling was static at 25.5 million in 2000 and in 2014 33.

Outdoor Industry Association 7 (OIA) data below indicate the 6-17yo proportion of all cyclists on roads and paved surfaces in the US was 45.2% in 2006 (17,401,000 / 38,457,000) and 23.8% in 2020 (10,605,000 / 44,471,000).


Table 1


Youth Participation in Cycling, Ages 6 to 17

us child cycling injuries


Adult Participation in Cycling, Ages 18+

us adult cycling injuries


Participation in Cycling, All Americans Ages 6+

us all age cycling injuries


The OIA figures above show the number of 6-17yo Americans cycling on road/mountain/BMX fell by 3,908,000 or 22.4% from 2006 to 2020, and on road or paved surfaces by 6,796,000 or 39.1%. America's 6-17yo population increased 2.7% from 2006 to 2020 (49,768,249 > 51,112,000).

The number of 18yo+ Americans cycling on road/mountain/BMX increased by 16,950,000 or 76.3% from 2006 to 2020, and on road or paved surfaces by 12,810,000 or 60.8%. America's 18yo+ population increased 14.8% from 2006 to 2020 (224,622,198 > 257,939,000).

All Americans aged 6yo+ participation in cycling on road/mountain/BMX increased by 13,042,000 or 32.9% from 2006 to 2020, and on road or paved surfaces by 6,014,000 or 15.6%. America's 6yo+ population increased 12.6% from 2006 to 2020 (274,390,447 > 309,051,000).

All the reduction from 2006 to 2020 was among 6-17yo cyclists who are subject to mandatory helmet laws in half the American states (in all states if parent, school and local government coercion is taken into account). There was a strong participation boost in 2020 due to COVID-19 lockdowns, although this had no influence on 6-17yo cycling on roads and paved surfaces which saw a reduction of 497,000 from 2019 to 2020.

NSGA data below suggest the 7-17yo cycling proportion was 27.4% in 2012 (10,800,000 / 39,400,000).


Chart 1


united states cycling participation


Chart 2


united states cyclist ages


Data from the US National Household Travel Survey 10 below confirm a significant downturn in <30yo and particularly <18yo cycling from 1995 to 2009, with 5-15yo and 16-17yo bicycle trips falling 20.1% and 40.8% respectively.


Table 2


us census cyclist numbers


Census Bureau data show a 16.6% reduction in 7-17yo cycling from 2001 to 2006 (17,008,000 / 14,183,000). The OIA participation surveys tabulated above suggest a 27.9% decline in 6-17yo cycling participation from 2006 to 2015.

Most of the reduction has occurred in the <17yo age group:


Chart 3


us census cycling participation


America's 7-17yo population increased 9.0% from 1995 to 2009 (41,221,000 > 44,924,000).

These results validate findings by Pucher et al 27 of a 33% decline in youth participation per population 2001-2009:


Chart 4


pucher chart for cycling participation

Physical activity from walking and cycling for daily travel in the United States, 2001–2017: Demographic, socioeconomic, and geographic variation by Buehler, Pucher and Bauman confirms this website's estimate that youth cycling in the US declined by more than 50% from 2001 to 2017. The paper notes:

One notable change was the significant decline in walking and cycling rates of children aged 5–15. The decline in cycling by children indicated by the 2001 and 2017 NHTS is corroborated by the 48% decline in recreational cycling from 1997 to 2017 in the age group 7–17 reported by the National Sporting Goods Association (2018). The falling rates of walking and cycling by children are a continuation of a trend over previous decades, as documented by the earlier 1973–1995 NPTS surveys, which the NHTS superseded in 2001 (McDonald, 2007; Kontou et al., 2019). The long-term decline in children’s walking and cycling from 1973 to 2017 has reduced an important source of children’s regular physical activity and might be a contributor to rising child obesity rates in the United States (Ogden et al., 2016).

The modified demographic table below is based on the 2020 paper and confirms a huge decline in 5-15yo cycling:

american cycling participation 2017

Based on total US population in 2001 and 2017, the figures above for the 5yo to 15yo demographic translate as:

10 minutes

2001 : 4.5% of 285,000,000 = 12,825,000
2017 : 1.9% of 325,100,000 = 6,176,900

20 minutes

2001 : 3.2% of 285,000,000 = 9,120,000
2017 : 1.3% of 325,100,000 = 4,226,300

30 minutes

2001 : 2.4% of 285,000,000 = 6,840,000
2017 : 0.9% of 325,100,000 = 2,925,900

Averaged, these figures equate to a 53.7% reduction in US 5-15yo cycling participation from 2001 to 2017.

Alternatively, 5-15yo cycling participation can be compared with 5-15yo walking participation data contained within the paper:

Cycling

2001 : 10 minutes 4.5% + 20 minutes 3.2% + 30 minutes 2.4% = 10.1%
2017 : 10 minutes 1.9% + 20 minutes 1.3% + 30 minutes 0.9% = 4.1%

Walking

2001 : 10 minutes 17.5% + 20 minutes 11.5% + 30 minutes 7.7% = 36.7%
2017 : 10 minutes 12.8% + 20 minutes 8.5% + 30 minutes 5.9% = 27.2%

The relative reduction in 5-15yo walking was 25.9% from 2001 to 2017 and for cycling it was 59.4%, more than double the proportionate decline in walking and suggesting a greater disincentive because of bike helmet promotion and mandatory helmet laws for youth.


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Cycling injury data

Data from the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS)5 show the 1-15yo cyclist age group enjoyed a 36.3% drop in injuries from 2001-2010 to 2011-2020, while 16yo+ cyclists suffered a 24.9% increase in injuries :


Chart 5


american cycling injuries

NEISS data 5 show the 1-15yo cyclist age group enjoyed a 38.2% drop in head injuries from 2001-2010 to 2011-2020, while 16yo+ cyclists suffered a 42.1% increase in head injuries :


Chart 6

american cycling head injuries

NEISS data 5 show the 1-15yo cyclist age group enjoyed a 30.5% drop in lower extremity injuries from 2001-2010 to 2011-2020, while 16yo+ cyclists suffered a 25.1% increase in lower extremity injuries :


Chart 7

american cycling lower body injuries

Cyclist lower extremity injuries are in no way prevented or reduced by the wearing of a helmet in the event of a crash, although they may reflect crash frequency or cycling participation levels.

The 30.5% drop in 1-15yo lower extremity injuries suggests that a significant proportion of the 38.2% drop in head injuries was due to reduced cycling participation by American children and teenagers.

The 25.1% increase in 16yo+ lower extremity injuries suggests that this was roughly the increase in 16yo+ cycling participation in the US from 2001 to 2020, but the 42.1% increase in head injuries suggests a disproportionate number of such injuries despite surveys commissioned in 2014 by the PeopleForBikes group finding that 40% of 18yo+ respondents typically wore a helmet when riding a bike. Subsequent surveys suggest this had increased to 46% of US adults regularly wearing helmets when cycling.

The NEISS and the Outdoor Industry Association provide systemically consistent datasets since 2006 that allow a comparison of age group injuries with age group participation.

The following three charts compare cycling participation from 2006 to 2019 within the -17yo, 18yo+ and 6yo+ plus demographics with corresponding total injuries in the US:


Chart 8


us 6-17yo cycling participation and injuries


Chart 9


us 18yo+ cycling participation and injuries


Chart 10


us 6yo+ cycling participation and injuries

The following three charts compare cycling participation from 2006 to 2019 within the 6-17yo, 18yo+ and 6yo+ plus demographics with corresponding hospitalised injuries in the US:


Chart 11


us 6-17yo cycling participation and hospitalised injuries


Chart 12


us 18yo+ cycling participation and hospitalised injuries


Chart 13


us 6yo+ cycling participation and hospitalised injuries

The following three charts compare cycling participation from 2006 to 2019 within the 6-17yo, 18yo+ and 6yo+ plus demographics with corresponding head injuries in the US:


Chart 14


us 6-17yo cycling participation and head injuries


Chart 15


us 18yo+ cycling participation and head injuries


Chart 16


us 6yo+ cycling participation and head injuries

The following three charts compare cycling participation from 2006 to 2019 within the 6-17yo, 18yo+ and 6yo+ plus demographics with corresponding concussion injuries in the US:


Chart 17


us 6-17yo cycling participation and concussion injuries


Chart 18


us 18yo+ cycling participation and concussion injuries


Chart 19


us 6yo+ cycling participation and concussion injuries

The tables below compare different types of participation and injuries among 6-17yo cyclists, 6yo+ cyclists and 18yo+ cyclists from 2006 to 2019, with data sourced from the US Product Safety Commission's National Electronic Injury Surveillance System and from the Outdoor Industry Association.




US Census Bureau data for 7-17yo cycling participation from 1995 to 2012 can be compared annually with total 7-17yo cyclist injury data from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS):


Chart 20


us child cycling us child cyclist injury age brackets us child cyclist injury age brackets us child cyclist injury age brackets us child cyclist injury age brackets


From the chart above, 7-17yo cycling participation in the US declined from a 1995-2003 average of 18,593,000 to a 2004-2012 average of 14,296,889, or 23.1%. At the same time, 7-17yo cyclist all-body injuries in the US declined from a 1995-2003 average of 291,970 to a 2004-2012 average of 222,869, or 23.7%.

America's 7-17yo population increased 10.31% from 1995 to 2012 (41,221,000 > 45,472,409).

Department of Transportation National Highway Traffic Safety Administration (NHTSA) 20 data for 2011 show <=20yo cyclists had an injury rate of 194.4 per million population compared to a 21yo+ injury rate of 141.9 per million:


Table 3 - United States per capita cyclist injury and fatality rates and state fatality breakdown, 2011


cycling in different us states


US population <=15yo was 21% and cyclists <=15yo represented 18.75% of all cyclist injuries. Cyclists <=15yo had an injury rate of 137.7 per million population compared to a 16yo+ injury rate of 158.4 per million population.

In this NHTSA data for 2011, there were less than 500 injuries among the <5yo age group but these are included in the comparison with <=15yo population of 20,162,000. Excluding that age group entirely, 5-15yo had an injury rate of 199.1 per million population compared to a 16yo> injury rate of 158.4 per million population.

Census Bureau data 15 show 17,008,000 cyclists aged 7-17 in 2001 and 13,196,000 in 2009. CDC data 6 show 259,193 injuries for 7-17yo cyclists in 2001 and 215,947 in 2009. Participation fell 22.4% and injuries fell 16.7%.

NSGA data show 2012 participation among 7-17yo cyclists at 10,800,000, down 36.5% on 2001 participation data from the Census Bureau.

Census Bureau data show 21,996,000 cyclists aged 18yo+ in 2001 and 24,942,000 in 2009. CDC data show 192,712 all-body injuries for 18yo+ cyclists in 2001 and 247,359 in 2009. Participation rose 13.4% and injuries rose 28.4%.

NSGA data show 2012 participation at 24,640,000 cyclists aged 18+, up 12% on 2001 participation data from the Census Bureau.


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Cycling head injury data

Compared annually with the 7-17yo decline in cycling participation of 23.1%, NEISS data for 7-17yo cyclists show that 7-17yo cyclist concussion injuries in the US dropped from a 1995-2003 average of 6,555 to a 2004-2012 average of 6,420, down 2.1%:


Chart 21


us cyclist concussions us child cyclist injury age brackets us child cyclist injury age brackets us child cyclist injury age brackets us child cyclist injury age brackets


Surveillance for Traumatic Brain Injury Related Death - United States, 1997-2007 17 shows that, on average, head trauma deaths fell less for cyclists than for vehicle occupants:


Table 4


us cyclist brain injury


Traumatic Brain Injury 18 suggests riders aged 5-19 represented 49.2% of total pedal cyclist traumatic brain injury hospitalisations from 2002-2006 (750 / 1,524) and cyclists aged 5-14 represented 33% (507 / 1,524):


Table 5


us cyclist traumatic brain injury


Comparative NEISS data 19 show average annual 5yo+ cyclist injuries 2009-2019 were 7.3% less than 1998-2008 (515,220 / 477,705). Average annual total injuries aged 5-15yo in 2009-2019 were 38.1% less than 1998-2008 (287,292 / 177,750) and all head injuries in this age group were 41.3% less (90,154 / 52,931). Head only injuries in this age group were 28.2% less (35,304 / 25,331).

Average annual total injuries aged 16yo+ in 2009-2019 were 31.6% more than 1998-2008 (227,927 / 299,955) and all head injuries in this age group were 52.8% more (55,557 / 84,913). Head only injuries in the 16yo+ age group were 86.9% more in 2009-2019 than in 1998-2008 (25,444 / 47,565):


Chart 22


american cyclist concussions in different age groups

Bearing in mind that most US children and teenagers are subject to jurisdictional, school or parental helmet mandation and most adults are not, the charted data above from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System provides the following calculations for US cycling total injuries and head injuries treated in US emergency departments (whether or not admitted to hospital) comparing the periods 1998-2008 with 2009-2019:

  • 5-15yo - 31.4% of total injuries were head injuries in 1998-2008
  • 5-15yo - 29.8% of total injuries were head injuries in 2009-2019
  • 16yo+ - 24.4% of total injuries were head injuries in 1998-2008
  • 16yo+ - 28.3% of total injuries were head injuries in 2009-2019


Comparative NEISS data 19 show average 5yo+ cyclist injuries 2008-2019 were 7.1% less than 1996-2007 (515,361 / 478,544). Average total injuries aged 5-15yo in 2008-2019 were 39.6% less than 1996-2007 (299,612 / 181,099) and concussions in this age group were 24.5% less (7,053 / 5,323).

Average total injuries aged 16yo+ in 2008-2019 were 37.9% more than 1996-2007 (215,749 / 297,445) and concussions in this age group were 82.4% more (4,359 / 7,951):


Chart 23


american cyclist concussions in different age groups

The charted data above from the US Consumer Product Safety Commission’s National Electronic Injury Surveillance System provides the following calculations for US cycling total injuries and concussions treated in US emergency departments (whether or not admitted to hospital) comparing the periods 1996-2007 with 2008-2019:

  • 5-15yo - 2.35% of total injuries were concussions in 1996-2007
  • 5-15yo - 2.94% of total injuries were concussions in 2008-2019
  • 16yo+ - 2.02% of total injuries were concussions in 1996-2007
  • 16yo+ - 2.67% of total injuries were concussions in 2008-2019


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Cycling fatality data

Census Bureau data 15 show 18,089,000 cyclists aged 7-17yo in 1999 and 13,196,000 in 2009. CDC data 6 show 172 fatalities for 7-17yo cyclists in 2001 and 69 in 2009. Participation fell 27% and fatalities fell 59.9%.

NSGA data show 7-17yo participation at 10,800,000 in 2012, down 40.3% from the Census Bureau’s 1999 estimate. Fatality records for 2012 are unavailable but CDC data show 67 fatalities for 7-17yo in 2010, down 61% from 2001.

Census Bureau data show 24,316,000 cyclists aged 18yo+ in 1999 and 24,942,000 in 2009. CDC data show 425 fatalities for 18yo+ cyclists in 1999 and 451 in 2009. Participation increased 2.6% and fatalities increased 6.1%.

NSGA data show 18yo+ participation at 24,640,000 in 2012, up 1.3% on 1999 participation data from the Census Bureau. Fatality data for 2012 are not available but CDC data show 478 for 18yo+ in 2010, up 12.5% from 1999.

NHTSA Traffic Safety Facts 21 shows that pedal cyclist fatalities worsened as a proportion of all traffic deaths in the US from 2002 to 2011:


Table 6


american cycling fatalities


Out of 51 jurisdiction in the NHTSA dataset for 2011, 23 or 45.1% had some form of helmet law for child cyclists, some up to 17yo.

NHTSA Traffic Safety Facts 2011 allows comparison of cyclist and other road user death and injury rates from 2002 to 2011:


Table 7


american road user fatalities


Table 8


US road user fatalities


Police reported injuries are always less than hospitalised injuries but the NHTSA data suggest US cyclist death and injury trends are worse than for most other road users with the exception of motorcyclists.


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Cycling fatality data in different states


Table 9


cycling safety in different states Table 10 Table 10 Table 10 Table 3 Table 3 Table 9 Table 9 Table 9 Chart 23 Chart 23 Chart 24 Chart 24 Chart 25 Chart 25 Chart 25


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Discussion

Multiple data sources have been used to compare child, teenage and adult cyclist participation, all-body injuries, head injuries and fatalities from 1995 to 2019, during which time various American states introduced child helmet laws for different age groups less than 18 and concluding with 22 states and districts enacting such legislation.

Nationwide, 51.1% of Americans aged 17 and less lived in bike helmet jurisdictions in 2012 (37,457,154 / 36,270,934). Various surveys suggest that about 63% of children and 46% of adults in the US regularly wore bike helmets in 2019.

Census Bureau data show 7-17yo cycling across the US was 22,948,000 in 1995 and reliable NSGA survey data show numbers had dropped to 10,800,000 in 2012. This is a 52.9% reduction or 12,148,000 fewer cyclists aged 7-17, impacting regular recreational exercise among American youth with future public health implications.

Participation surveys by the Outdoor Industry Association show 6-17yo cyclist numbers fell 28.8% from 2006 to 2012 and survey data compiled by the NSGA suggest the reduction was 37.9% by 2012.

OIA participation data show 6-17yo cyclist numbers on roads and paved surfaces fell 38.4% from 2006 to 2018, while 6-17yo cycling on all surfaces and bike types fell 27.3%

In response to such significant falls in child and teenage cycling participation, and with more than 60% of 5-15yo cyclists wearing helmets that are claimed to reduce head injury risk by up to 85% 23, a corresponding reduction in accidents and injured cyclists should be expected at hospital emergency departments.

Census Bureau and NEISS injury data show a 23.1% decline in 7-17yo cycling participation averaged 1995-2003 to 2004-2012, a 23.7% reduction in all-body injuries and a 2.1% reduction in concussion injuries. Analysis of 5-15yo cyclist fatalities through FARS shows a lower rate per million population in non-helmet law states than in helmet law states.

Among 0-16yo cyclists and averaged 1994-2002 to 2003-2011, fatalities fell 55.2% in states without child helmet laws and 50.0% in states with such laws.

Analysis of all 1,740 bicyclists aged 0-16 years in FARS 9 who died or suffered an incapacitating injury from a motor vehicle collision between January 1999 and December 2011 allows a per million population comparison between states with child helmet laws and those without:


Chart 24


child cyclist and car injuries in america


There is no significant difference in child cyclist fatality rates per million population in states that enforce mandatory child helmet legislation. Various US local municipalities have enforced helmet laws for different ages, primarily children, regardless of state legislation and it is likely that voluntary helmet wearing also increased in states without helmet laws through parental or school coercion.

US Government data suggest that among 5-15yo cyclists the average annual total injury count fell by 38.1% from 1998-2008 to 2009-2019, while the all head injury average fell by 41.3% and the head only injury average fell by 28.2%, despite the significant increase in child and teenage mandatory/voluntary helmet wearing since 1995. These reductions were mostly due to a substantial decline in recreational cycling exercise and participation among American youth.

The data suggest that among 5-15yo cyclists the average annual total injury count fell by 39.6% from 1996-2007 to 2008-2019, while the concussion average fell by 24.5%.

The data suggest that among 16yo+ cyclists the average annual total injury count increased by 31.6% from 1998-2008 to 2009-2019, while the all head injury average increased by 52.8% and the head only injury average fell by 86.9%.

The data suggest that among 16yo+ cyclists the average annual total injury count increased by 37.9% from 1996-2007 to 2008-2019, while the concussion average increased by 82.4%.

Click here for a pop-up window with Figures 17-44 showing total US cyclist participation and head, concussion, face, upper arm, lower arm, neck, upper trunk, hand, elbow, shoulder, lower leg, upper leg, toe and foot injury trends among child and adult cyclists from 1995 to 2012.

Click here for a pop-up analysis of a September 2015 Journal of the American Medical Association research letter detailing adult cycling injuries and hospital admissions in America from 1998 to 2013.


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Limitations

This study is limited in scope by different age group parameters defined in the source datasets published by public and private agencies, at times requiring comparison between slightly different age groups (e.g. 6-17yo, 7-17yo and 5-15yo).

No attempt has been made to adjust state data according to different variables such as speed limits, drink driving laws and driver age limitations in the 51 state jurisdictions. These confounding factors are numerous and all have a debatable influence on child cyclist injury and fatality rates.

Raw participation and fatality data are compared between 29 states without helmet laws and 22 states/districts with helmet laws, each with unique and countervailing variables such as population, demographics, wealth, infrastructure and geography that create an unbiased average.

US Census Bureau data on cycling participation since 1995 is only available to 2009. This study uses survey findings from the Outdoor Industry Association for 2006 to 2019, and from the National Sporting Goods Association for 2012.

Census Bureau/NSGA data from 1995 to 2009 and NSGA data for 2012 are for cyclist ages 7-17 but the OIA data from 2006 to 2019 are for cyclist ages 6-17.

A comparison of participation surveys from the three sources in overlapping years from 2003 to 2009 shows similar annual numbers with lower NSGA figures that more accurately reflect the 7-17yo age criteria.

Albeit using different survey methods, NSGA and OIA all-age cycling participation results are similar (2006 - 38,457,000 / 35,600,000; 2007 - 38,940,000 / 37,400,000 / 2008 - 38,114,000 / 38,700,000; 2009 - 40,140,000 / 38,100,000 / 2010 - 39,320,000 / 39,800,000; 2011 - 40,348,000 / 39,300,000; 2012 - 39,232,000 / 39,300,000).

The NSGA annual numbers are generally lower than OIA surveys because they estimate 7-17yo rather than 6-17yo participation.

Some timescale calculations include data for states that were voluntary at first but have since enacted child helmet laws, with no adjustment for their early absence of law so as to maintain a consistent baseline. Due to different and at times large state populations, adjustments distort trends and normally exaggerate fatality and injury rates in states that now have child helmet laws.

Census Bureau participation data for 2008 is significantly above trend. Assuming the bureau is consistent and accurate in its survey methodology, the 2008 spike may be related to cycling interest generated by the Beijing Olympics, consecutive Tour de France victories by Lance Armstrong, above average summer temperatures across the US 24 and/or record high gasoline prices above US$4 per gallon 29.


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Conclusion

All public and private data sources confirm that child and teenage cycling participation in the United States has fallen by at least a third since the 1990s with latest surveys suggesting the decline continued in 2018.

A reduction of approximately 12,000,000 cyclists aged <17yo from 1995 to 2018, ignoring population growth over that period, signals a substantial decline in recreational exercise among American youth.

Concussion and head injury data show the significant increase in child and teenage mandatory/voluntary helmet wearing since 1995 has had little impact on these injury types per cyclist.

Although youth cycling participation rates in each state are unknown, childhood disdain for helmet wearing is a likely cause of the decline in cycling participation, coupled with increased parental safety fears.

Child cycling participation rates in all American states warrant further study to determine if the reduction is related to helmet laws. A breakdown of child cyclist fatalities per million population in states with and without laws shows little difference, which conflicts with expectations that rates should be lower in states where more children wear helmets.

The counterintuitive conclusion that accident/injury rates per child cyclist are greater in helmet law states may be explained by influences such as risk compensation 25 and safety in numbers 26, 30.

It should be noted that according to An Overview of the Bicycle Study 31, there were an estimated 66.9 million Americans of all ages cycling (at least once per year) in 1991, with about 531,000 hospital emergency department injuries (excluding bike passengers). This represents 0.79% of all cyclists in 1991 being injured (531,000/66,900,000). According to annual surveys by the Outdoor Foundation 32, in 2018 there were an estimated 47,877,000 cyclists aged 6+ who had cycled at least once in the previous year, with 401,901 emergency department injuries (0.84% of cyclists injured).

If the 1991 participation/injury percentage (0.79%) is applied instead of 0.84%, there should have been 378,228 cyclist injuries in 2018 instead of 401,901. Such data consistently suggests an increase in the ratio of overall injuries to cyclists participating over the 27 years, despite child helmet laws in half the American states, similar parental or school enforcement in other states, and about half the adult population voluntarily wearing helmets.

Consistent data from public and private agencies suggest reduced recreational cycling among children and teenagers with current and potential future health implications for the US, which has the highest obesity and overweight ratio in the world. Increased per cyclist injury rates and similar state fatality rates point to a failure in public policy for cycling safety in the United States.


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References

1) Bicycle Helmet Laws Are Associated with a Lower Fatality Rate from Bicycle–Motor Vehicle Collisions - William P. Meehan, Lois K. Lee, Christopher M. Fischer, Rebekah C. Mannix
http://www.ncbi.nlm.nih.gov/pubmed/23706604

2) Bicycle helmet use among children in the United States: the effects of legislation, personal and household factors, Dellinger, Kresnow
http://www.ncbi.nlm.nih.gov/pubmed/20846554

3) Injury Prevention
http://injuryprevention.bmj.com/content/8/1/42.full.pdf

4) US Census Bureau
http://www.census.gov/

5) US Consumer Product Safety Commission National Electronic Injury Surveillance System
https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx

6) Centers for Disease Control and Prevention web-based Injury Statistics Query and Reporting System (WISQARS) 13/7/4
http://www.cdc.gov/injury/wisqars/nonfatal.html

7) The Outdoor Industry Association
https://outdoorindustry.org/collection/participation/

8) National Sporting Goods Administration
http://www.nsga.org/i4a/pages/index.cfm?pageid=4653

9) National Highway Traffic Safety Administration’s Fatality Analysis Reporting System
http://www-fars.nhtsa.dot.gov//QueryTool/QuerySection/SelectYear.aspx

10) U.S. Department of Transportation, Federal Highway Administration, National Household Travel Survey
http://nhts.ornl.gov/det/Extraction3.aspx

11) Alliance Bicycling and Walking Benchmarking Project
http://www.peoplepoweredmovement.org/site/index.php/site/memberservices/C529

12) US single year cyclist injuries and population 2001-2011 (Excel)
http://www.cycle-helmets.com/us-yearly-injuries-2001-2011.xls

13) Bicycle Retailer and Industry News: Light at the end of the tunnel? Maybe.
http://www.bicycleretailer.com/opinion-analysis/2012/06/05/light-end-tunnel-maybe#.UdeXduDxaVg

14) Bicycle Retailer and Industry News: More women, fewer kids riding bikes
http://www.bicycleretailer.com/studies-reports/2013/06/20/nsga-more-women-fewer-kids-riding-bikes

15) US Census Bureau bike riding participation data
http://www.cycle-helmets.com/us-census-bike-riding-1995-2009.pdf

16) Centers for Disease Control and Prevention tabulated age and injury data (Excel)
http://www.cycle-helmets.com/us-cdc-age-injuries.xls

17) The Centers for Disease Control and Prevention Surveillance for Traumatic Brain Injury Related Death - United States, 1997-2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6005a1.htm

18) Traumatic Brain Injury
http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

19) US Consumer Product Safety Commission National Electronic Injury Surveillance System concussion data
http://www.cycle-helmets.com/us-neiss-concussions-1996-2012.xls

20) US Department of Transportation National Highway Traffic Safety Administration
http://www-nrd.nhtsa.dot.gov/Pubs/811743.pdf

21) US Department of Transportation National Highway Traffic Safety Administration Traffic Safety Facts 2011
http://www-nrd.nhtsa.dot.gov/Pubs/811743.pdf

22) FARS and US Census data tables (Excel)
http://www.cycle-helmets.com/us-state-fatalities-per-pop.xls

23) A case-control study of the effectiveness of bicycle safety helmets, Thompson, Rivara
http://www.ncbi.nlm.nih.gov/pubmed/2716781

24) National Oceanic and Atmospheric Administration
http://www.noaanews.noaa.gov/stories2008/20080911_ncdcsummerwrap.html

25) The Risk Compensation Theory and Bicycle Helmets; J Adams, M Hillman
http://injuryprevention.bmj.com/content/7/2/89.full

26) Safety in numbers? A new dimension to the bicycle helmet controversy
http://injuryprevention.bmj.com/content/7/4/343.2.full

27) Walking and Cycling in the United States, 2001-2009: Evidence from the National Household Travel Surveys, Pucher et al
http://bloustein.rutgers.edu/wp-content/uploads/2014/10/NHTS_TRB_25Jan2011.pdf

28) NHTSA FARS cyclist fatalities 0-16yo and all-ages in different states (Excel)
http://www.cycle-helmets.com/nhtsa-state-fatalities-1994-2011.xls

29) US Energy Information Administration: Gasoline and Diesel Fuel Update
http://www.eia.gov/petroleum/gasdiesel/gaspump_hist.cfm

30) Safety in numbers: more walkers and bicyclists, safer walking and cycling; PL Jacobsen
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1731007/pdf/v009p00205.pdf

31) An Overview of the Bicycle Study; Gregory B Rodgers
http://www.cpsc.gov/PageFiles/112701/344.pdf

32) An Overview of the Bicycle Study; Gregory B Rodgers
ParticipationStudy2013.pdf

33) Overcoming obstacles to bicycle riding
https://issuu.com/nsga1929/docs/nsga_now_janfeb2016


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Appendix charts and tables


Chart 25


american state cyclist fatalities us state cycling deaths


Chart 26


american cyclist and pedestrian fatalities american cyclist and pedestrian fatalities


Chart 27


american cyclist and car fatalities american cyclist and car fatalities american cyclist and car fatalities


Table 9


american state cycling fatalities american state cycling fatalities


Table 10


american state cycling injuries american state cycling injuries


Note: Below is extracted from the Traffic Safety Facts for 2018 published by the US National Highway Traffic Safety Administration :


Table 11


american state cycling fatalities 2018


Note: In January 2015, Health Economics published Effects of Bicycle Helmet Laws on Children's Injuries (PDF download 217K) by Sara Markowitz and Pinka Chatterji who found similar evidence to this paper that the laws discourage cycling with unintended injury consequences.


Note: In August 2015, the Centers for Disease Control and Prevention published Bicyclist Deaths Associated with Motor Vehicle Traffic — United States, 1975–2012 by Vargo et al who again found similar evidence to this paper.


Note: In September 2015, the Journal of the American Medical Association published Bicycle Trauma Injuries and Hospital Admissions in the United States, 1998-2013 by Sanford et al who again found similar evidence to this paper, with injuries among cyclists aged 18+ increasing 28%, hospital admissions increasing 120% and head injuries increasing 60%.


Note: In December 2016, Research and Practice published Trends in Walking and Cycling Safety: Recent Evidence From High-Income Countries, With a Focus on the United States and Germany by Buehler and Pucher, its cyclist injury conclusions similar to the study on this page.

The rate of serious cyclist injuries per 100 million kilometres in the United States fell from 230.5 in 2001-02 to 207.1 in 2008-09. However, the rate of severe cyclist injuries was 4.7 times higher in the US than in Germany.

The severe injury rate for cyclists in 2008–2009 in the US was much higher for children (415.7) than the national average (207.1), despite most children wearing helmets due to state laws, local regulations or school and parent demand. The severe injury rate for children rose significantly between 2001-02 and 2008-09, from 392.9 to 415.7.

Between 2001-02 and 2008-09, the severe injury rate per 100 million kilometres for 15-24yo fell from 305.2 to 176.0, increased for 25-64yo from 141.5 to 156.5, and fell for 65yo+ from 351.3 to 337.3.


Note: In 2019, Sanford et al published Trends in bicycle-related injuries, hospital admissions, and deaths in the USA 1997–2013, finding that the crude incidence of injury per cycling participant increased from 701 per 100,000 in 1997 to 1,164 per 100,000 in 2013, with hospital admissions increasing from 41 per 100,000 in 1997 to 109 per 100,000 in 2013.


Note: Published in 2019, Trends in school-age pedestrian and pedalcyclist crashes in the USA: 26 states, 2000–2014 analysed police-reported motor vehicle crash data for pedestrians and cyclists in 26 US states for the 5-19yo demographic from 2000 to 2014, finding they represented 29.0% of all age pedestrians and 44.3% of all age cyclists involved in such crashes.

These school aged children and teenagers represented 44.5% of all age cyclist injuries and 30.0% of all age pedestrian injuries; 25.4% of all age cyclist deaths and 11.3% of all age pedestrian deaths; and with 5-19yo cyclists having an average crash rate of 35.4 per 100,000 population compared to 5-19yo pedestrians with an average crash rate of 42.9 per 100,000 population.

The average cyclist crash rate per 100,000 population from 2000 to 2014 was 37.50 in the 10 states with helmet laws and 34.07 in the 16 states without helmet laws.

The authors found an overall 40% decline in 5-19yo pedestrian crashes and 53% decline in 5-19yo bicyclist crashes between 2000 and 2014. It is worth noting published research findings that from 2001 to 2017 in the US, the relative reduction in 5-15yo walking duration was 25.9% from 2001 to 2017 and for cycling duration it was 59.4%.


Note: A 2020 study based in California and titled Helmet Usage Reduces Serious Head Injury Without Decreasing Concussion After Bicycle Riders Crash.


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