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      Helmet use in BIXI cyclists in Toronto, Canada: an observational study

      1 , 2 , 1 , 3 , , 1 , 4 , 5 , 6

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          To investigate the use of helmets for cyclists choosing to use BIXI bikes in comparison to personal bike riders in the City of Toronto.


          Cross-sectional study design.


          Cyclists were observed in Toronto, Canada.


          Of the 6732 sample size, 306 cyclists on BIXI bikes and 6426 personal bike riders were observed.

          Outcome measure

          The outcome of interest was helmet use.


          Overall, 50.3% of cyclists wore helmets. The proportion of BIXI bike riders using helmets was significantly lower than the proportion of helmet users on personal bikes (20.9% vs 51.7%, respectively, p<0.0001).


          Although the BIXI bike programme has provided an alternate means for Torontonians to use a bicycle, cyclists using BIXI bikes are much less likely to wear a helmet. Since the prevalence of helmet use in cyclists in general is already low, helmet use should be especially promoted in BIXI bike riders in order to promote a safe and healthy environment for cyclists.

          Article summary

          Article focus
          • We investigated the use of helmets for cyclists choosing to use BIXI bikes in comparison to personal bike riders in the City of Toronto.

          • We hypothesised that the proportion of helmet users using BIXI bikes would be significantly lower than those on personal bikes.

          Key messages
          • Cyclists using BIXI bikes in Toronto are less likely to wear a helmet than cyclists riding their own bike; only 20.9% of all BIXI cyclists wear helmets compared with 51.7% of cyclists riding a personal bike.

          • More men than women ride bicycles in Toronto.

          • Women in Toronto were more likely to wear a helmet while cycling.

          Strengths and limitations of this study
          • This is the first study (to our knowledge) investigating helmet use in a bike-sharing system. Additional strengths include the prospective study design, number of observations, randomly selected observation sites and stratified analyses by sex.

          • The data were collected by one of the observer not blinded to the study hypothesis; observations were limited to presumed commuter hours in the downtown core of Toronto and we were unable to account for variables previously associated with helmet use, including income, education and age.

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          Most cited references 8

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          A case-control study of the effectiveness of bicycle safety helmets.

          Bicycling accidents cause many serious injuries and, in the United States, about 1300 deaths per year, mainly from head injuries. Safety helmets are widely recommended for cyclists, but convincing evidence of their effectiveness is lacking. Over one year we conducted a case-control study in which the case patients were 235 persons with head injuries received while bicycling, who sought emergency care at one of five hospitals. One control group consisted of 433 persons who received emergency care at the same hospitals for bicycling injuries not involving the head. A second control group consisted of 558 members of a large health maintenance organization who had had bicycling accidents during the previous year. Seven percent of the case patients were wearing helmets at the time of their head injuries, as compared with 24 percent of the emergency room controls and 23 percent of the second control group. Of the 99 cyclists with serious brain injury only 4 percent wore helmets. In regression analyses to control for age, sex, income, education, cycling experience, and the severity of the accident, we found that riders with helmets had an 85 percent reduction in their risk of head injury (odds ratio, 0.15; 95 percent confidence interval, 0.07 to 0.29) and an 88 percent reduction in their risk of brain injury (odds ratio, 0.12; 95 percent confidence interval, 0.04 to 0.40). We conclude that bicycle safety helmets are highly effective in preventing head injury. Helmets are particularly important for children, since they suffer the majority of serious head injuries from bicycling accidents.
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            Helmets for preventing head and facial injuries in bicyclists.

             Diane Thompson,  Fred Rivara (corresponding) ,  Robert Thompson (1999)
            Each year, in the United states, approximately 900 persons die from injuries due to bicycle crashes and over 500,000 persons are treated in emergency departments. Head injury is by far the greatest risk posed to bicyclists, comprising one-third of emergency department visits, two-thirds of hospital admissions, and three-fourths of deaths. Facial injuries to cyclists occur at a rate nearly identical to that of head injuries. Although it makes inherent sense that helmets would be protective against head injury, establishing the real-world effectiveness of helmets is important. A number of case-control studies have been conducted demonstrating the effectiveness of bicycle helmets. Because of the magnitude of the problem and the potential effectiveness of bicycle helmets, the objective of this review is to determine whether bicycle helmets reduce head, brain and facial injury for bicyclists of all ages involved in a bicycle crash or fall. To determine whether bicycle helmets reduce head, brain and facial injury for bicyclists of all ages involved in a bicycle crash or fall. We searched The Cochrane Controlled Trials Register, MEDLINE, EMBASE, Sport, ERIC, NTIS, Expanded Academic Index, CINAHL, PsycINFO, Occupational Safety and Health, and Dissertations Abstracts. We checked reference lists of past reviews and review articles, studies from government agencies in the United States, Europe and Australia, and contacted colleagues from the International Society for Child and Adolescent Injury Prevention, World Injury Network, CDC funded Injury Control and Research Centers, and staff in injury research agencies around the world. Controlled studies that evaluated the effect of helmet use in a population of bicyclists who had experienced a crash. We required that studies have complete outcome ascertainment, accurate exposure measurement, appropriate selection of the comparison group and elimination or control of factors such as selection bias, observation bias and confounding. Five published studies met the selection criteria. Two abstractors using a standard abstraction form independently abstracted data. Odds ratios with 95% CI were calculated for the protective effect of helmet for head and facial injuries. Study results are presented individually. Head and brain injury results were also summarized using meta-analysis techniques. No randomized controlled trials were found. This review identified five well conducted case control studies which met our selection criteria. Helmets provide a 63%-88% reduction in the risk of head, brain and severe brain injury for all ages of bicyclists. Helmets provide equal levels of protection for crashes involving motor vehicles (69%) and crashes from all other causes (68%). Injuries to the upper and mid facial areas are reduced 65%. Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes including those involving motor vehicles.
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              Publication bias and time-trend bias in meta-analysis of bicycle helmet efficacy: a re-analysis of Attewell, Glase and McFadden, 2001.

               Rune Elvik (2011)
              This paper shows that the meta-analysis of bicycle helmet efficacy reported by Attewell, Glase, and McFadden (Accident Analysis and Prevention 2001, 345-352) was influenced by publication bias and time-trend bias that was not controlled for. As a result, the analysis reported inflated estimates of the effects of bicycle helmets. This paper presents a re-analysis of the study. The re-analysis included: (1) detecting and adjusting for publication bias by means of the trim-and-fill method; (2) ensuring the inclusion of all published studies by means of continuity corrections of estimates of effect rely on zero counts; (3) detecting and trying to account for a time-trend bias in estimates of the effects of bicycle helmets; (4) updating the study by including recently published studies evaluating the effects of bicycle helmets. The re-analysis shows smaller safety benefits associated with the use of bicycle helmets than the original study. Copyright © 2011 Elsevier Ltd. All rights reserved.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                18 June 2012
                18 June 2012
                : 2
                : 3
                [1 ]Faculty of Medicine, University of Toronto, Toronto, Canada
                [2 ]Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
                [3 ]Department of Paediatrics, University of Toronto, Toronto, Canada
                [4 ]Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Canada
                [5 ]Department of Surgery, University of Toronto, Toronto, Canada
                [6 ]Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
                Author notes
                Correspondence to Dr Andrew Howard; andrew.howard@
                © 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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