COMMENTARY
Skiers, Snowboarders, and Safety Helmets Michael D. Cusimano, MD, PhD Judith Kwok, BSc
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S THE WINTER OLYMPICS FOCUS THE WORLD’S ATtention on alpine sports, opportunities will arise to promote the use of personal protective equipment while skiing or snowboarding. Of the 600 000 ski- and snowboard-related injuries each year, an estimated 15% to 20% are traumatic brain injuries,1 which are the leading cause of hospitalization and account for 50% to 88% of total deaths in skiers and snowboarders.2 The US Consumer Product Safety Commission estimates that 44% of head injuries sustained during skiing and snowboarding could be prevented by the use of helmets and that the use of helmets for children could reduce head injuries during these activities in this group by 53%.2 Furthermore, recent studies have shown that helmets are associated with up to a 60% reduction in the risk of head injuries and that their use does not appear associated with an increased incidence of cervical spine or neck injury.2 Despite compelling evidence in support of helmet wear, a recent observational study of 1472 children at a western New York ski resort found that only 37% wore a helmet while skiing and snowboarding,3 whereas other studies have reported that helmets are worn by only 12% of the general ski and snowboard population.2 Those who argue that helmets are not fashionable are correct in pointing out that helmets are not yet well integrated into the culture of skiing and snowboarding. With this in mind, what needs to be done for helmets to become a part of the ski and snowboard culture so that the slopes will be safer for everyone?
Why Legislation Alone Is Not the Full Solution Several states, including Massachusetts, Michigan, New Jersey, and New York, have considered passing compulsory helmet laws for youth. While this idea was initially seen as appealing because children are more vulnerable to head injuries,2 none of these states has yet passed compulsory helmet laws. It may be possible to garner more public support for helmet wear by exploring the use of public-private coalition campaigns bearing similarities to those that years ago successfully pressured policy makers and voters to pass laws enforcing mandatory seat belt use. However, seat belt compliance on public roads is a priority of the National High©2010 American Medical Association. All rights reserved.
way Traffic Safety Administration (NHTSA) and there is no parallel agency to advance enforcement of helmet use at private ski resorts. The experience with mountain biking at private resorts, many of the same that offer skiing and snowboarding in the winter, provides a good example that enforcement may not be necessary for widespread helmet uptake. Unlike skiing and snowboarding, helmet use for mountain bikers is nearly universal with multiple US studies reporting that 80% to 90% of these participants wear helmets.4 This success can be attributed, at least partially, to the larger campaign of increasing the use of bicycle helmets for the general population, which has shown that legislation is unlikely to dramatically change the culture unless combined with other interventions such as education and incentive programs.5 A wellrounded approach encourages participants in these activities to recognize the protective value of helmets. Toward Multifaceted Interventions For skiers and snowboarders, it may be useful to create incentives to encourage helmet wear. During the 2009 National Ski Safety Week, some ski areas in California, Colorado, and Washington offered sales and discounts on helmets through the Lids for Kids helmet safety awareness program.6 One company that owns a network of popular North American ski resorts has announced that beginning with the 2009-2010 winter season, a helmet will be included with all child and youth ski and snowboard rental packages from all of their equipment rental outlets. Some insurance premium rates have been reduced for ski resorts that implement improved safety measures such as the use of better equipment. Accordingly, insurance companies could offer reduced rates for ski resorts that have lower injury rates as a result of mandatory or recommended helmet policies. When used in conjunction with other measures, this approach could help move change in the right direction. Education can be directed toward various stakeholders including legislators, national organizations, the media, resorts, advertisers, equipment makers, professional athAuthor Affiliations: Division of Neurosurgery, St Michael’s Hospital, Toronto (Dr Cusimano); and Injury Prevention Research Office, St Michael’s Hospital and University of Toronto (Dr Cusimano and Ms Kwok), Toronto, Canada. Corresponding Author: Michael D. Cusimano, MD, PhD, Division of Neurosurgery, St Michael’s Hospital, 30 Bond St, Toronto, ON M5W 1W8, Canada (
[email protected]). (Reprinted) JAMA, February 17, 2010—Vol 303, No. 7
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letes, and the public to help improve the safety behaviors of participants in winter sports. In a prospective randomized interventional study of 763 downhill skiers, a 45minute instructional safety video yielded a 30% decline in injury risk during an 8-day ski trip.7 Collaborative partnerships between various stakeholders involved with ski injury prevention could continue producing educational safety resources such as videos that could be shown to skiers and snowboarders at ski resorts or given to schools to educate novices before embarking on ski trips. In contrast to epidemiological evidence supporting helmet use, few studies have reported on the effectiveness of multifaceted interventions to increase the use of ski and snowboard helmets. Well-designed studies are needed to evaluate the effectiveness of these multifaceted interventions and to clarify the role each component in the intervention has on the outcome of helmet use. In addition, research is needed to determine whether ski and snowboard helmets have economic benefits similar to those of bicycle helmets; for every dollar spent on a bicycle helmet, an estimated $30 are saved in direct medical care costs and other costs to society.8 All 327 National Ski Areas Association member resorts officially endorse the Responsibility Code, an initiative launched in 2000 that includes 7 ski slope safety rules such as staying in control and observing signs and warnings.6 This code should be updated and include helmet wear to reflect the evidence that has emerged since its conception supporting the protective value of helmets. The Occupational Safety and Health Administration (OSHA) recently issued an unprecedented recommendation for all employees of ski areas to consider the use of personal protective equipment following the death of an on-duty unhelmeted ski patroller last year in Wyoming.9 With some leading resorts in the ski industry recently announcing that on-duty employees are required to wear a helmet at all times, it is likely that OSHA and its respective state agencies will take on a greater role for ensuring employee safety at ski resorts in the future. Role Modeling to Change Ski Resort Culture Ski patrollers and instructors can be influential cultural change agents on the slopes. A recent study revealed that even though ski patrollers are aware that helmets lessen the
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risk of traumatic brain injury and view themselves as role models for the public, most do not wear helmets regularly.10 The recent announcement that some leading ski resorts are requiring the use of helmets by on-duty employees represents an important move in the right direction. Advertising visuals that feature skiers and snowboarders regularly wearing helmets and public service announcements by prominent national athletes, during televised winter sports such as the Olympic Games, could promote fashionable and safe behavior. Achieving safer slopes for skiers and snowboarders worldwide will require a strong synergy between different stakeholders and strategies. The 2010 Winter Olympics should mark the beginning of a new culture in skiing and snowboarding. Changing the culture of the ski slopes may depend not only on communicating the evidence of helmet effectiveness to skiers and snowboarders, but also on promoting helmet use at ski resorts and modeling helmet use by ski instructors and rescue personnel. Financial Disclosures: None reported. Disclaimer: Dr Cusimano is vice president of ThinkFirst Canada, a national nonprofit organization dedicated to the prevention of brain and spinal cord injuries. His position is voluntary. REFERENCES 1. Mueller BA, Cummings P, Rivara FP, Brooks MA, Terasaki RD. Injuries of the head, face, and neck in relation to ski helmet use. Epidemiology. 2008;19(2): 270-276. 2. Ackery A, Hagel BE, Provvidenza C, Tator CH. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Inj Prev. 2007;13 (6):368-375. 3. Lawrence L, Shaha S, Lillis K. Observational study of helmet use among children skiing and snowboarding. Pediatr Emerg Care. 2008;24(4):219-221. 4. Kronisch RL, Pfeiffer RP. Mountain biking injuries: an update. Sports Med. 2002; 32(8):523-537. 5. Rivara FP, Thompson DC, Patterson MQ, Thompson RS. Prevention of bicyclerelated injuries: helmets, education, and legislation. Annu Rev Public Health. 1998; 19:293-318. 6. National Ski Areas Association. NSAA media center: current releases, 2009/ 2010 season. http://www.nsaa.org/nsaa/press/. Accessed December 30, 2009. 7. Jłrgensen U, Fredensborg T, Haraszuk JP, Crone KL. Reduction of injuries in downhill skiing by use of an instructional ski-video: a prospective randomised intervention study. Knee Surg Sports Traumatol Arthrosc. 1998;6(3):194-200. 8. Ohio Department of Health. Ohio receives federal funding for safety programming. http://www.odh.ohio.gov/ASSETS/5D89D8865FBA4EEE9467EC70A2A3E9F6 /NR111 004.pdf. Posted November 10, 2004. Accessed December 30, 2009. 9. Occupational Safety and Health Administration. “Quick Tips” for ski resort workers to stay safe on the job. http://www.osha.gov/as/opa/quicktakes/qt12012009 .html#10. Posted December 2009. Accessed December 30, 2009. 10. Evans B, Gervais JT, Heard K, Valley M, Lowenstein SR. Ski patrollers: reluctant role models for helmet use. Int J Inj Contr Saf Promot. 2009;16(1):9-14.
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