Is ski helmet legislation more effective than education?
- Correspondence to Dr Gerhard Ruedl, Deptartment of Sport Science, University of Innsbruck, Fürstenweg 185, 6020 Innsbruck, Austria;
- Accepted 23 July 2012
- Published Online First 17 August 2012
Annually, several hundred million people worldwide enjoy alpine skiing and snowboarding.1 Besides the well-known beneficial effects related to exercise, these snow sports are also associated with a certain risk of injury. Head injuries account for 9–19% of all winter sport injuries reported by ski patrols and emergency departments.1 ,2 However, the use of ski helmets has been shown to reduce the head injury risk up to 60% among children and adults.1 ,2 While in recent years ski helmet use has become mandatory for children in Italy and in most Austrian provinces,3 ,4 the worldwide first mandatory ski helmets for all ages was introduced in Nova Scotia (East Canada) in 2011.5 Although over the last 10 years ski helmet use has steadily increased worldwide, for example, up to 70% in Canada, Austria and Switzerland in 2010,4 ,5 there is an ongoing debate in various countries about the introduction of mandatory ski helmets.4 ,6 Therefore, question arises as to whether ski helmet legislation is more effective regarding an increasing helmet use than education.
How effective is ski helmet legislation?
To our knowledge, only one study has investigated the impact of mandatory ski helmets on helmet usage.4 Ruedl et al4 compared helmet use in people aged <16 and ≥16 years of Austrian provinces with and without mandatory helmets between 2008/2009 (n=16 342) and 2009/2010 (n=32 011) winter seasons. Helmet use in people aged <16 years in the 2009/2010 season increased by 16.2% in provinces with mandatory helmets and decreased by 2.1% in provinces without mandatory helmets (all p<0.001), respectively.4 However, provinces with and without mandatory helmets did not differ regarding mean helmet use in people aged <16 years (92.2% vs 92.8%, p=.506) in the 2009/2010 season.4 These results suggest that mandatory helmets for children aged <16 years may increase helmet use only when helmet use is still relatively low at baseline.
Interestingly, helmet use in skiers aged ≥16 years was lower in provinces with mandatory helmets compared to provinces without (63.1% vs 68.1%, p<0.001) in the 2009/2010 season4, thus not supporting the expected effectiveness of mandatory helmets in this age group.
Is a non-legislative helmet promotion campaign an alternative?
In Switzerland, a country without mandatory helmets, overall helmet use significantly increased from 63% in 2008/2009 to 75% in 2009/2010.4 This large increase has been attributed to a national prevention campaign ‘Protect yourself with a helmet’.7 Interestingly, the evaluation of this campaign identified only a small correlation between campaign recognition and helmet use making the impact of the helmet campaign on increased helmet rate unclear.7
Impact of public awareness after fatal skiing injuries involving celebrities on helmet use
In addition to the increase in helmet use in Switzerland, awareness of head injury risk and consciousness of vulnerability during skiing and snowboarding increased considerably in the same period among targeted groups of the Swiss preventive campaign.7 This might also be due the wide media coverage after few fatal ski injuries in the Alps involving celebrities in the 2008/2009 winter season.2 ,8 ,9 In Austria for example, helmet use increased from 44% in December 2008 to 57% in April 2009 in injured skiers and snowboarders probably due to the impact of the media coverage on helmet use after the fatal injury involving a German politician on the New years day 2009.2 Similarly, Jung et al9 reported that after the increased media coverage between January and April 2009 15% of interviewed neurosurgeons and 13% of a control group consisting of non-traumatic-brain-injury-educated persons bought a ski helmet while 26% of neurosurgeons and 16% of the control group planned to buy and use a helmet.
Impact of parental role modelling on ski helmet use
The high ski helmet rate in children up to 90% in various countries4 is very likely due to the fact that parents make their children wear a helmet because parents may place greater emphasis on the safety of their children than on their own safety when skiing or snowboarding.6 In addition, Jung et al9 reported that children whose parents used ski helmets themselves wore significantly more frequently ski helmets than children whose parents did not. In addition, Provance et al10 recently showed that parent's helmet-wearing behaviour was strongly associated with the child/adolescent's helmet-wearing behaviour. About 96% of the children wearing a helmet indicated that their parents also wear a ski helmet.10 Adults using ski helmets seem to be important role models for their children.
Is there a need for ski helmet legislation?
In a recently published commentary11 we concluded that there is not really a need for mandatory ski helmets for children aged <16 years when taking into account the lower head injury rate and the highest helmet rate in younger children compared with adolescents and adults. If a country, however, decides to require mandatory helmet wearing, it seems more meaningful that all ages will be covered as done in Nova Scotia/Canada. However, bicycle helmet legislation for all ages in Alberta/Canada failed to achieve higher general helmet usage compared to that among skiers and snowboarders.5 ,12
A recent study of the acceptance for mandatory helmet wearing for people of all ages showed a significant lower acceptance for mandatory helmets compared to recommendations for helmet use irrespective of helmet use or gender.13 Thus, one might assume that preventive helmet campaigns attain a higher acceptance leading to a higher helmet use compared to mandatory helmets.13 It has been proposed that autonomous decisions lead to enhanced motivation to change behaviour.14 ,15 Providing people with information regarding protective effects of helmets might cause higher acceptance for wearing helmets than mandatory regulations.
To date, there is no evidence that ski helmet legislation is likely to be more effective for increasing helmet wearing than education alone, as public awareness and education efforts have strongly increased ski helmet use worldwide in recent years. In conclusion, non-legislative helmet promotion campaigns, especially including the parental role model for helmet use in children, may even reach a higher acceptance compared to a helmet law.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.