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SECTION V--DESCRIPTION OF STRATEGIES EXHIBIT V-46 (Continued) Strategy Attributes for Identifying and Promoting Visibility-Enhancement Methods and Technology Training and Other Identifying and promoting visibility-enhancement methods and technology does not Personnel Needs necessarily require training or additional agency personnel, but it does require awareness of the conspicuity issues, knowledge of visibility-enhancement methods and technology, a priority to address conspicuity issues, and a willingness to partner with key stakeholders to begin the process of effecting change. Legislative Needs Some states prohibit the use of pulsing auxiliary brake lights. Products that serve to improve visibility and reduce the likelihood of crashes should be evaluated. When appropriate, laws should be revised to promote these safety measures. Other Key Attributes Public education and information activities complement this strategy. Educational materials may be required to inform those implementing this strategy of effective treatment methods. Information on Agencies or Organizations Currently Implementing This Strategy An Oregon law enforcement agency installed auxiliary LED brake light bars on their fleet of police enforcement motorcycles. The LED lights flash to draw attention to the stopping motorcycle. However, the state's Attorney General ruled that state law prohibits flashing red lights for use in any circumstance other than on emergency vehicles where allowed. The LED devices were removed. The state law was subsequently changed to allow such devices. Objective 11.1 E--Reduce the Severity of Motorcycle Crashes Strategy 11.1 E1--Increase the Use of FMVSS 218 Compliant Helmets (P) General Description The objective of this strategy is to reduce the severity of motorcycle crashes by increasing the use of FMVSS 218 compliant helmets among motorcycle riders.1 When worn, helmets are estimated to be 37 percent effective in preventing fatalities in crashes. Enactments of universal helmet laws have consistently been associated with a 90- to 100-percent increase in helmet usage, a 20- to 40-percent decrease in fatalities and fatality rates, and approximately a 67-percent decrease in serious head and brain injuries. Universal helmet laws are the only proven way to increase the use of FMVSS 218 compliant helmets. On the other hand, the repeal or weakening of such laws has been associated with a 40- to 50-percent decline in usage and a 20- to 100-percent increase in fatalities and serious injuries, particularly head and brain injuries. These findings have been replicated over several cycles of legislative activity, including two periods of law enactments (19661975 and 19901995) and two periods of repeals (19771981 and 1996present). 1 The National Highway Traffic Safety Administration (NHTSA) has developed and enforces Federal Motor Vehicle Safety Standard 218 (FMVSS 218) which provides minimum performance requirements for helmets designed for use by motorcyclists. V-74

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SECTION V--DESCRIPTION OF STRATEGIES Recently, there has been a decline in nationwide helmet usage, particularly from 2000 to 2006, when compliant usage declined from 71 to 51 percent. Coupled with this decline, there has been a dramatic increase in rider fatalities, which have more than doubled since 1995. While factors other than declining helmet use have contributed to the increase in fatalities, state- specific studies consistently show large and significant reductions in helmet use and increases in fatalities and injuries associated with recently repealed or weakened universal helmet laws. Thus, the potential for helmet use to ameliorate the negative impact of the other factors contributing to the increase in motorcycle fatalities has not been realized during this recent period of repeals and declining usage. With regard to strategies for increasing helmet usage, there is compelling evidence regarding the impact of universal helmet use laws but little or no evidence to suggest that partial laws or other approaches have the potential to achieve high use rates. In addition to declining helmet use, it appears that FMVSS 218 non-compliant helmets are being worn with greater frequency in recent years. Because such helmets provide no protection in a crash, they do not have fatality-reduction potential.2 Nationwide non-compliant helmet use was observed to be between 13 and 15 percent in 2006, and there is evidence that non-compliant use is higher in some universal helmet law states. Thus, a second important objective of this strategy is to eliminate the use of non-compliant helmets. Helmet Effectiveness Fact: Motorcycle helmets are effective in reducing fatalities and injuries, particularly serious head injuries. A 1991 study, conducted by the U.S. General Accounting Office (U.S. GAO, 1991)3 found that: Helmets were 28- to 29-percent effective in reducing fatalities. Helmeted riders suffered fewer serious and critical injuries because of a lower incidence of head injuries. Fatality rates among helmeted riders involved in crashes were 32- to 73-percent lower than among non-helmeted riders (median: 55 percent). More recent studies based on CODES data4 reported that: Helmets are 35-percent effective in reducing fatalities and 26-percent effective in reducing serious injuries (Johnson and Walker, 1996). Helmets are about 65-percent effective in preventing brain injuries (NHTSA, 1998). Unhelmeted riders are three times more likely to have head injuries requiring EMS trans- port or hospitalization or resulting in death (Finison, 2001). 2 In 2006, the last year for which such data were available, there was no significant difference in non-compliant helmet usage between states with universal helmet laws and those with partial or repealed laws. 3 More recently called the U.S. General Accountability Office. 4 The Crash Outcome Data Evaluation System (CODES) links data from police crash reports, emergency medical services, hospital emergency departments, hospital discharge files, claims and other sources. States are funded by NHTSA to link statewide crash and injury data. The purpose of the linkage is to find out who is injured in motor vehicle crashes, what types of injuries occur, and how much it cost to treat these injuries over time. V-75

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SECTION V--DESCRIPTION OF STRATEGIES Most recently, a 2004 study of FARS data (Deutermann, 2004)5 concluded that: The effectiveness of helmets against fatalities was 37 percent, an increase from 29 percent in the late 1980s, likely associated with improvements in helmet design and materials.6 Myth: Motorcycle helmets increase the incidence of neck injuries. Fact: Research has refuted these claims. Studies that have examined this issue have found fewer head and neck injuries among helmeted riders than among non-helmeted riders.7 Myth: Motorcycle helmets cause crashes by restricting the operator's field of vision or by inhibiting a rider's ability to hear warning signals Fact: Research has consistently found such claims to be untrue.8 The most recent in a series of studies concluded that wearing motorcycles helmets does not restrict a rider's ability to hear auditory signals or see a vehicle in an adjacent lane (McKnight and McKnight, 1994). As a result of the compelling evidence of the safety benefits of helmet use, the National Agenda for Motorcycle Safety (NAMS) concluded that: In the event of a crash, no existing strategy or safety equipment offers protection comparable to a FMVSS 218 compliant helmet (NHTSA, 2000). Strategies to Increase Helmet Usage Conceptually, strategies to increase helmet usage can be dichotomized into mandatory and educational approaches. Within the mandatory approach, there have been universal helmet laws, which require use among all age groups and under all conditions; and there have been partial helmet laws, which generally require use only among riders under age 21 or under age 18.9 Effectiveness of Universal Helmet Laws Fact: Observed usage among riders in universal helmet law states is 60- to 100-percent greater than in other states. Examples include: Thirteen years of observations in 19 U.S. cities documented that motorcycle operator usage averaged about 96 percent in states with universal helmet laws and 45 percent in all other states.10 5 FARS refers to the National Highway Traffic Safety Administration's Fatality Analysis Reporting System, a census of all crash-related fatalities occurring on public roadways. 6 According to the 2004 report, one of the more significant improvements in helmet material has been the use of Kevlar, expanded polypropylene, and carbon fiber in helmet shells and linings. 7 These studies included Newman (1974), Nebraska Dept. of Public Roads (1975), Carr, Brandt and Swanson (1981), Hurt et al. (1981), Kelley et al. (1989), Sakar, Peek, and Kraus (1995), and Rowland et al. (1996). 8 Early research included studies by Gordon and Prince (1975), Henderson (1975), Van Moorhem et al. (1977), Lummis and Dugger (1980), and by Hurt et al. (1981). 9 Some states also have other provisions or contingencies, such as having a minimum of $10,000 in medical insurance. 10 Data collected in 1979, 1980, 1981, and 1982 were from surveys conducted by Opinion Research Corp. and reported by Phillips (1980 and 1983). Data collected from 1983 through 1991 were from surveys conducted by Goodell Grivas Inc. They included the following years of data and reports: 1983 use rates (Perkins, Cynecki, and Goryl, 1984); 1984 use rates (Goryl and Cynecki, 1985); 1985 use rates (Goryl, 1986); 1986 use rates (Goryl and Bowman, 1987); 198788 use rates (Bowman and Rounds, 1988 and 1989); and 198991 use rates (Datta and Guzek, 1990, 1991, and 1992). V-76

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SECTION V--DESCRIPTION OF STRATEGIES The 2006 National Occupant Protection Use Survey (NOPUS) found 83-percent helmet use overall in states with universal helmet laws and 50-percent use in all other states.11 In addition to these survey results, at least 19 studies conducted in individual states have shown this large difference in observed usage between states with universal helmet laws and other states, leading the U.S. General Accounting Office to conclude that helmet use is consistently higher under universal helmet laws (U.S. GAO, 1991). Fact: Helmet usage among crash-involved riders in states with universal helmet laws is generally twice the rate of usage among such high-risk riders in states with partial helmet laws and no helmet laws. Results from the GAO review show usage among crash-involved riders in universal helmet law states to be more than twice the usage among such riders in partial helmet law states. Median usage rates were 95 and 42 percent, respectively. Fact: When a universal helmet law is enacted (or re-enacted), observed usage generally doubles and fatalities decline by 20 to 40 percent. Examples include: In Louisiana, following a 1982 re-enactment, observed usage increased from 50 to 96 percent (McSwain, and Willey, 1984).12 Following a subsequent downgrade in 1999, usage again declined to 50 percent (Ulmer and Preusser, 2003). Texas twice enacted and twice repealed its universal helmet law. Usage increased from 50 to 95 percent with its initial law in 1968, then declined to below 45 percent following a repeal in 1977 (Lund et al., 1991). Usage increased for a second time, to near 100 percent following a 1989 universal helmet law re-enactment, then fell to 66 percent following a 1997 repeal (Preusser, Hedlund, and Ulmer, 2000). Two studies suggested that the 1989 re-enactment was associated with a 55-percent reduction in serious head-related injuries (Mounce et al., 1992, Fleming and Becker, 1992). In California, usage increased from 50 to 99 percent following enactment of a universal helmet law in 1992. Fatalities declined by 37 percent and the fatality rate (per registered motorcycle) declined by 26 percent (Kraus et al., 1994; 1995b). Another study found that the average annual number of rider fatalities was 54 percent lower in the 5 years after the law than in the 5 years prior to the law (Ulmer and Preusser, 2003), providing evidence of a long-term impact of the law. In Maryland, a 1992 re-enactment was followed by a 42-percent decline in average annual fatalities (5 years before the law versus 5 years after the law), based on autopsy reports (Mitchell et al., 2001).13 Fact: Partial helmet laws, resulting from downgrades of universal helmet laws, are associated with large declines in observed usage (by as much as 50 percent), declines in usage among crash-involved riders (of about 40 percent), and by increases in fatalities. Examples include: The 1980 Report to Congress, which reviewed all studies prior to 1980, reported that repeals or downgrades were followed by 50-percent declines in observed usage14 and 11 Usage rates include 15 percent non-compliant use in universal law states and 13 percent non-compliant use in other states. 12 Note that the Louisiana law was again repealed in 1999 resulting in another decline from near 100 percent usage to about 50 percent usage (Ulmer and Preusser, 2003). 13 After the 5-year post-law period, fatalities increased in Maryland, as they did nationwide (Ulmer and Preusser, 2003). 14 These results are identical to those of the 19-cities surveys conducted throughout the 1980s. V-77

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SECTION V--DESCRIPTION OF STRATEGIES declines of more than 40 percent in usage among crash-involved riders (from near 90 to 50 percent).15 More recently, universal helmet laws have been repealed in Arkansas and Texas (1997), Kentucky (1998), Louisiana (1999), Florida (2000), and Pennsylvania (2003). Evaluations have been conducted in nearly all of these states. These evaluations found:16 Significant declines in observed usage, from pre-repeal levels of 95 to 100 percent to post-repeal levels of 50 to 60 percent.17 A 35-percent median decline in usage among crash-involved riders in Arkansas, Texas, Kentucky, Louisiana, and Florida, from 60- to 93-percent usage under universal helmet laws to 30- to 60-percent usage after repeals. More importantly, a median 50-percent increase in fatalities (range: 20 to 100 percent). Fatalities per registered motorcycle increased as well. Fact: Usage among young riders covered by partial helmet laws is substantially lower under such laws than under universal helmet laws. Examples include: In Texas, only 29 percent of injured riders under age 18 were found to be helmeted under a partial helmet law (U.S. GAO, 1991). In North Dakota, only 44 percent of young riders involved in crashes were helmeted under a partial helmet law (Heilman et al., 1982). A 2000 downgrade in Florida was associated with a 26-percent decline in usage among young riders killed, along with nearly a 200-percent increase in fatalities among such riders (Ulmer and Shabanova-Northrup, 2005). Myth: Changes in fatalities associated with universal helmet law enactments or repeals are the result of changes in motorcycle registrations, rather than a result of the law changes. Facts: During some time periods, such as when there are large changes in registrations, some of the changes in fatalities have been associated with increases or decreases in motorcycle registrations. Many studies have controlled for such changes by reporting impact in terms of fatalities per registered motorcycle and by comparing changes in state rates (post-law versus pre-law and/or state versus national changes in rates). These studies show substantial increases in usage associated with universal helmet law enactments, despite downward trends nationwide, and they show large and significant reductions in fatality rates, compared with national trends. Examples include: Eight GAO-reviewed studies showed a median 33-percent reduction in fatalities per reg- istered motorcycle under universal helmet laws, compared with pre-enactment periods (range: 20 percent to 58 percent). 15 These early studies included Krane and Winterfield (1980) and Struckman-Johnson and Ellingstad (1979). 16 These studies included: Preusser et al. (2000); Ulmer and Preusser (2003); Muller (2004); and Ulmer and Shabanova- Northrup (2005). 17 The high rate of use in Florida, prior to repeal, included a substantial percent of riders wearing non-compliant helmets. V-78

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SECTION V--DESCRIPTION OF STRATEGIES Twelve GAO-reviewed studies showed a median 35-percent lower rate of fatalities per registered motorcycle under universal helmet laws, compared with subsequent repeal or downgrade periods (range: 12 to 62 percent). It should be noted that, as a result of these findings, the GAO reviewers concluded that "Congress may wish to consider encouraging states to enact and retain universal helmet laws; and that . . . this could be accomplished via the use of penalties, incentives, or a combination of the two" (U.S. GAO, 1991, page 31). More recent studies of enactments have also controlled for changes in registrations. For example: Following the California enactment, fatalities declined by 37 percent and the rate of fatalities per registered motorcycle declined by 26 percent (Kraus et al., 1994). The 1989 universal helmet law re-enactment in Nebraska was accompanied by a sharp decline in the number and rate of injuries per registered motorcycle (Muelleman et al., 1991). Similarly, recent studies of repeals or downgrades have found that:18 The 1998 repeal in Kentucky was followed by a 38-percent increase in fatalities per registered motorcycle. The 1999 repeal in Louisiana was followed by a 75-percent increase in fatalities per registered motorcycle. The 2000 repeal in Florida was followed by a 21-percent increase in fatalities per registered motorcycle. Thus, while some change in fatalities (and injuries) can be explained by changes in registrations, large and significant changes are also associated with law changes. Nationwide Changes in Fatalities, Registrations, and Fatality Rates Since 1975 The number of registered motorcycles has generally increased over time. As indicated, these changes are important when considering the impact on fatalities and injuries associated with helmet legislation. Following are trends in rider fatalities, motorcycle registrations, and fatalities per registered motorcycle since 1975 (when initial repeals began): 19751980 (26 repeals): Registered motorcycles increased by 20 percent, fatalities increased by 55 percent, and fatalities per registered motorcycle increased by about 35 percent. 19811990 (little change in laws). Registrations declined by 20 percent, fatalities declined by 25 percent, and fatalities per registered motorcycle declined by about 5 percent. 19901994 (modest number of enactments). Registrations declined by 20 percent, rider fatalities declined by 26 percent, and fatalities per registered motorcycle declined by 12 percent. 1995 to 2005 (modest number of repeals): Registered motorcycles increased by 60 percent, fatalities doubled, and fatalities per registered motorcycle increased by 28 percent. 18 These data come from studies conducted by Ulmer and Preusser (2003). V-79

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SECTION V--DESCRIPTION OF STRATEGIES EXHIBIT V-47 Motorcycle Rider Fatality Rates by Legislative Phase EXHIBIT V-48 Motorcycle Fatalities, Registrations, Mileage, and Fatality Rates (2-Year Intervals) Number of MC Number of Registered Number of Fatalities Legislative Phase Year Rider Fatalities Motorcycles (1,000s) Per 100K MCs Initial Repeals 1976 3,312 4,933 67.1 1978 4,577 4,868 94.0 1980 5,144 5,694 90.3 Little Activity 1982 4,453 5,754 77.4 1984 4,608 5,480 84.1 1986 4,566 5,262 86.7 1988 3,662 4,584 79.9 Re-Enact 1990 3,244 4,259 76.2 1992 2,395 4,065 58.9 1994 2,320 3,757 62.4 Repeals And Downgrades 1996 2,161 3,872 55.8 1998 2,294 3,879 59.1 2000 2,897 4,346 66.7 2002 3,270 5,004 65.4 2004 4,028 5,781 69.7 2005 4,553 6,227 73.1 Summary of Effectiveness: Universal and Partial Helmet Laws There is strong evidence of the effectiveness of universal helmet laws in that they are associated with large and significant increases in usage and declines in fatalities, fatality rates, injuries (particularly head and brain injuries), and reduced medical costs. Partial helmet laws have been shown to be ineffective in maintaining high usage rates; these repeals or downgrades to universal helmet laws have been associated with substantial declines in usage (observed and among crash-involved riders) and with increases in fatalities and injuries. V-80

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SECTION V--DESCRIPTION OF STRATEGIES As a result of these facts, in September 2007, the National Transportation Safety Board (NTSB) has recently issued a recommendation that all states with partial or no helmet laws enact a universal helmet law to increase helmet use and decrease fatalities and serious injuries. Costs Associated with Helmet Non-Use Fact: Repeals of universal laws have consistently been followed by substantial declines in usage (observed and among crash-involved riders) and increases in serious head and brain injuries. As such, these law changes have also been followed by increased costs associated with such injuries. The most common finding is that crashes involving non-helmeted riders result in more serious head and brain injuries and that these injuries are generally the most expensive to treat. The costs associated with brain injuries range from $42,000 to more than $1.4 million per injured rider, depending upon the seriousness of the injury and the range of costs included (Zaloshnja et al., 2004). The 1998 CODES study found helmets to be 65 percent effective in reducing brain injuries (NHTSA, 1998). Fact: Studies that have looked at the impact of universal helmet laws on costs have generally concluded that enactment (or re-enactment) of such a law significantly reduces head and brain injuries and total costs incurred by riders involved or injured in crashes. For example, a critical review of this literature entitled, Costs of Injuries Resulting from Motorcycle Crashes found that: Helmet use reduced the fatality rate, the probability and severity of head injuries, the cost of medical treatment, the length of hospital stay, the necessity for special medical treatments (including ventilation, intubation, and follow-up care), and the probability of long-term disability (Lawrence et al., 2003). In addition, this review found that: Slightly more than one-half of motorcycle crash victims had private health insurance coverage. For patients without private insurance, a majority of medical costs were paid by govern- ment sources. Costs and Barriers Associated with Universal Helmet Laws The actual costs associated with enacting universal helmet laws are minimal, particularly in comparison with the cost-savings associated with reductions in fatalities and injuries. However, while the effectiveness and benefits associated with universal helmet laws are large and consistent, the barriers to enacting such laws have become formidable as well. Some motorcycle rider groups oppose such laws on the grounds that they violate personal freedoms. These groups have, in the past, mounted organized campaigns for the elimination of such laws. V-81

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SECTION V--DESCRIPTION OF STRATEGIES If a state proposes a universal helmet law, it can be expected that some rider groups will work hard to oppose it. In addition to the issue of personal freedom, it is likely that such groups will again raise issues regarding helmet causation of neck injuries, restricted vision, and diminished ability to hear warning sounds, issues that have not been supported in the research literature.19 On the other hand, public support for universal helmet laws is strong. The 2000 Motor Vehicle Occupant Safety Survey (MVOSS), the last MVOSS that surveyed this issue, found that just over 80 percent of the public supported a universal helmet law. Support was lower (51 percent) among current or recent riders of motorcycles (NHTSA, 2006a). In spite of objections by some riders, it is clear that helmet use and universal helmet laws have been proven to reduce motorcycle head injuries, fatalities, and associated costs. From an evidence-based perspective, a recent review of Countermeasures That Work found universal helmet laws to be the only proven effective strategy for increasing helmet use (GHSA, 2007). Elements of a Strategy to Enact Universal Helmet Laws Work with Motorcycle Rider Organizations. Enacting or re-enacting a universal helmet law will likely face stiff opposition from some rider organizations. It is important to work with such organizations, to the extent possible, to convince them of the proven life-saving and injury- prevention potential of such laws. That will likely be a difficult task but every effort should be made. Form Broad-based Coalitions. Nearly all successful efforts to enact universal helmet laws have involved broad-based coalitions that have included law enforcement, insurance, medical, public health, advocacy and safety organizations. Hire Someone to Coordinate Your Campaign. Opposition to universal helmet laws is strong and very well-organized. In order to present your case and convince a sufficient number of legislators to vote for your bill, you must also be well-organized and have someone to spear- head the activity. This will require the coordination of support and resources from many potential allies and advocates. Gain Bipartisan Support in the State Legislature. Many successful coalitions have been able to gain sponsors from both parties. Use Paid Lobbyists. It is important to enlist the services of paid lobbyists. They understand the dynamics of the legislature and they have existing relationships, usually among both parties. Gain the Support of the Governor and His/Her Staff. This is a critical element in efforts to obtain a universal helmet law. There have been cases where such legislation has been enacted but the Governor failed to sign it and there have been examples where such laws have been repealed but the repeal was vetoed by the Governor. Work with the Governor's staff early to make sure they understand the strength of the evidence in support of such a law, public opinion with regard to such laws, the costs associated with helmet non-use and the cost- savings associated with helmet use. 19 At the end of this section there are links to websites representing some of the groups and arguments in support of and oppo- sition to universal helmet laws. V-82

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SECTION V--DESCRIPTION OF STRATEGIES Conduct Public Opinion Polls. Measure the support for a universal helmet law. This may help to convince legislators that the vast majority of the public supports universal helmet laws. Conduct Evaluations and Cost-Savings Analyses. It is important to understand and be able to communicate the current status of usage rates (observed and among crash-involved and injured motorcycle riders), fatalities, injuries (particularly severe head injuries), and costs associated with existing law and to predict likely changes if a universal helmet law is enacted. Make Use of Existing Resources. Many organizations have conducted research and developed materials to aid advocates of universal helmet laws. Make use of these organizations, their websites, and the materials that they have developed. Increasing Helmet Use Through Education Conceptually, an alternative strategy for increasing motorcycle helmet usage is to communicate the benefits of helmet use to riders and rider groups and to promote use of FMVSS 218 compliant helmets. The National Agenda for Motorcycle Safety (NHTSA, 2000) for example, states that, "All motorcyclists should choose to wear protective apparel because they understand that such apparel can reduce injuries in a crash. All motorcyclists should want to wear FMVSS 218 compliant helmets while riding to reduce head trauma resulting from a crash." Effectiveness of Strategies to Increase Helmet Use Through Education Evidence to Support the Potential for Impact. We found no research to suggest that riders will voluntarily choose to use safety helmets, regardless of the frequency or type of messages communicated to them, particularly messages regarding safety benefits. Such benefits have been known for more than 60 years and they have been communicated to motorcycle riders. Efforts to Increase Seat Belt Use Through Education. Experience with safety belt usage provides some interesting parallels. Prior to 1984, when the first safety belt use law was enacted, more than 20 years of efforts to promote safety belt usage had little or no impact.20 Usage remained well below 30 percent in any community that implemented a comprehensive communications effort. The most publicized examples were: In Oakland County, Michigan, where a campaign consisting of print, radio, and televi- sion ads increased usage (temporarily) from 18 to 21 percent (Oakland County Traffic Improvement Association, 1969) In Southeast Michigan, where a $900,000 media campaign was associated with an increase in usage from 12 to 17 percent (Motorists Information Inc., 1978) 20 This was also the case in more than 20 foreign nations, including Australia, Canada, and several European nations, including France, Germany, Great Britain, etc. In several of these countries extensive multi-year public information and education efforts were mounted, sometimes with expensive paid media campaigns and incentive programs. None of these nations was able to attain a usage rate greater than 40 percent until a mandatory safety belt use law was enacted. After such enactment, usage immediately increased to 7090 percent in nearly every case (Nichols, 2002). V-83

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SECTION V--DESCRIPTION OF STRATEGIES In California, public service campaigns in three moderate-size towns resulted in no sig- nificant increase in safety belt usage (Fleischer, 1973) Another controlled evaluation of an extensive cable television campaign in New York resulted in no measured impact on safety belt usage (Robertson et al., 1974) At the national level, an intensive, 5-year program to promote safety belt usage was implemented by NHTSA in 1980. This effort included a multi-million dollar outreach and education effort, involving scores of national organizations, to educate targeted constituencies about the benefits of safety belt use. It also included one of the most popular and widely known public-service media campaigns ever implemented in the United States, the "Vince and Larry" crash dummy campaign. Outreach efforts, media campaigns, and incentive programs were implemented in many states and communities as well. As a result of these efforts, national safety belt usage increased by three percentage points (from 11 percent in 1979 to 14 percent in 1984), as measured by NHTSA's 19-city surveys (Nichols, 2002). At the time, these same surveys were documenting decreases in motorcycle helmet usage associated with law repeals and they were finding the large and significant differences in usage in states with universal helmet laws, compared to states with partial helmet laws and states with no helmet laws. The single greatest benefit from the 19801984 media and outreach campaign may have been that it facilitated the enactment of safety belt laws. Whether or not that was the case, extensive nationwide lobbying for such laws began in 1985, and by 1992, 43 states and the District of Columbia had enacted a safety belt law. National usage increased rapidly and did not return to pre-law levels. In fact, subsequent media and high visibility enforcement campaigns have resulted in sustained increases in national usage to over 80 percent, with some states exceeding 90 percent. Costs and Barriers to Increasing Helmet Use through Education The primary barrier to promoting helmet use through education is the fact that there is no research-based evidence, domestically or internationally, that such a strategy is effective. In fact, based on research and experience in other areas of safety, there are consistent indications that a public education campaign, based on some combination of media, education, and incentives, would not significantly increase helmet usage. Another barrier is cost. Any comprehensive media campaign would likely involve repeated waves of media, education, and outreach with (per wave) costs of about 3 to 6 cents per capita for paid advertising alone (based on current Click It or Ticket campaigns in various states). That would translate to $10 to 20 million per wave and, unless such a campaign was designed to support enforcement of a universal helmet law, existing evidence suggests that it would not have a significant impact on usage. Should a public education campaign be undertaken, the following elements should be included: Safety organizations and agencies could partner with the motorcycle community to promote knowledge of helmet effectiveness (and of universal helmet law effectiveness). It is important that all motorcyclists understand how FMVSS 218 helmets perform to protect them from injury. V-84

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SECTION V--DESCRIPTION OF STRATEGIES Additionally, it may be important to convey that helmets provide comfort from exposure to the elements (e.g., sun, wind, rain, temperature extremes, wind-borne insects and debris, etc.), thus allowing riders to concentrate more on the task of riding than on discomforts or distractions. A public information effort should also address common myths regarding the dangers of FMVSS 218 helmet use (i.e., helmets cause neck injury, restrict vision and hearing), and inform riders about the lack of protection afforded by non-compliant helmets. In the end, however, unless such a campaign increases support for enactment of universal helmet laws, it is unlikely that it will have any significant impact on the use of safety helmets, particularly among riders most likely to be involved in a potentially fatal crash. Improve Effectiveness of Enforcing Helmet Standard FMVSS 218 Fact: Surveys suggest that there has been an increase in the use of helmets that are not compliant with the current FMVSS 218 helmet standard (Peek-Asa et al., 1999; Turner and Hagelin, 2000). Non-compliant helmets, sometimes referred to as novelty or `beanie-style' helmets, are intended to give the appearance that the rider is wearing a compliant helmet, thereby minimizing the chances of being stopped for a universal helmet law violation. Many non-compliant helmets carry a fake DOT label, but they do not comply with the FMVSS 218 standard due to minimal coverage area, lack of impact-absorbing material, and inadequate retention systems. At the present time, it is not clear how prevalent such helmets are among crash- involved riders. Fact: Non-compliant helmets make enforcement of universal helmet laws more complicated. While some resources have been provided to help law enforcement officers identify non-compliant helmets, more needs to be done. Because of difficulties in such identification and in the interpretation of FMVSS 218, which is an engineering standard, some law enforcement agencies have reduced their level of enforce- ment of universal helmet laws. While non-compliant helmets may be obvious to the trained eye, providing proof that a helmet is non-compliant in court can be difficult. Possible Strategy Components NHTSA is currently working with appropriate national, state, and local law enforcement organizations to train law enforcement officers to identify noncompliant helmets while also developing training for judges and prosecutors to adjudicate universal helmet law violations. NHTSA is currently preparing a proposed revision to the FMVSS labeling requirement to strengthen the enforceability of the standard. The objective is to enable officers to distinguish and provide evidence of non-compliance more readily. V-85

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SECTION V--DESCRIPTION OF STRATEGIES All stakeholders should work with the U.S. Department of Transportation to develop strategies to ensure that all helmets offered for sale meet the FMVSS 218 standard. Another strategy component would be for interested stakeholders, in cooperation with NHTSA and motorcycle helmet manufacturers, to develop a comprehensive and regularly updated list of FMVSS 218 compliant motorcycle helmets. This list could be available through the Internet as a tool for enforcement, consumers, training providers, and other groups seeking information on compliant helmets. EXHIBIT V-49 Strategy Attributes for Increasing the Use of FMVSS 218 Compliant Helmets Technical Attributes Target The targets of this strategy include all stakeholders in efforts to increase motorcycle helmet use and thus reduce fatalities, injuries, and costs associated with motorcycle crashes. These targets include, but are not limited to, state agencies; public and private sector organizations; medical, public health, and safety advocacy groups; insurance companies; enforcement entities; motorcycle operators and their passengers; the motorcycle industry; and the motorcycle safety and rider training community. Expected Effectiveness The effectiveness of FMVSS 218 compliant helmets in reducing head injuries is proven and the implementation of a universal helmet law has consistently been shown to increase helmet usage to nearly 100 percent and to reduce fatalities by 20-40 percent (U.S. GAO, 1991). Enforceable legislation requiring the use of FMVSS 218 Compliant Helmets is the only proven means of increasing use of such helmets. Legislation and its effects on usage have been proven to reduce motorcycle fatalities when enacted, and to increase fatalities when such legislation in place is repealed. Specifically, recent universal helmet laws enacted or re-enacted in California, Maryland, Nebraska, and Washington have provided evidence of the impact of such laws. Recent repeals in Arkansas, Kentucky, Louisiana, Texas, and Florida have again shown that repeal or downgrading of such laws results in significant reductions in usage among motorcyclists on the road and in crashes and a significant increase in fatalities. There is no comparable body of research evidence of the potential for educational strategies to increase helmet use or therefore to reduce fatalities and injuries associated with increased helmet use. Such strategies have been tried but are unproven. Keys to Success Success should be viewed as the increased usage of FMVSS 218 compliant helmets by riders of all ages and skill levels and associated reductions in fatalities, injuries, and costs. One important factor that could contribute to success in this area is to involve the motorcycle rider and safety community in the development and implementation of this strategy and to make riders aware of the positive benefits of wearing a FMVSS 218 compliant helmet and of the evidence supporting the effectiveness of universal helmet laws. Other important components include: formation of a broad-based coalition including the enforcement community; hiring someone to coordinate the campaign; obtaining bipartisan support in the legislature; enlisting the aid of a paid lobbyist; working with the Governor and his/her staff to obtain their support; conducting public opinion polls, evaluations, and cost analyses; and making maximum use of existing resources. V-86

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SECTION V--DESCRIPTION OF STRATEGIES EXHIBIT V-49 (Continued) Strategy Attributes for Increasing the Use of FMVSS 218 Compliant Helmets Potential Difficulties Universal helmet laws are unpopular with some segments of the motorcycle riding community and these segments have made such laws very divisive and contentious issues. Where universal helmet laws exist, some motorcycle rider groups can be expected to campaign for their elimination. Similarly, when a state proposes a universal helmet law, opposition to such a law by these groups is immediate and well coordinated. In spite of their opposition, efforts should be made to work with the motorcycling community in any universal helmet law initiative. Although working relationships may be difficult in states where current universal helmet laws exist and where the rider groups are actively engaged in repeal or downgrade legislation, efforts should continue to gain the respect, understanding, and support from as broad a segment of that community as is possible. An apparently emerging problem involves the difficulty of enforcing the use of FMVSS 218 compliant helmets. Law enforcement officers often cannot determine if a helmet is indeed non-compliant and courts are sometimes unable to conclude whether a helmet complies with the standard. When this occurs, violations are frequently dismissed. Appropriate Measures There are several important measures of effectiveness of any program intended and Data to increase FMVSS 218 compliant helmet usage. The first is the percent of riders using such helmets, the second is the frequency and severity of head injuries among motorcycle riders and passengers involved in crashes, and the third is the number and rate of fatalities (per licensed motorcycle and/or per vehicle miles traveled). As with other occupant protection strategies, the "bottom-line" objective is a reduction in fatalities and injuries. Efforts to promote helmet usage should be held to the same standards and measures as those described above. The bottom-line is the same for any strategy or approach. Associated Needs NHTSA is currently working with appropriate national, state, and local law enforcement organizations to train law enforcement officers to identify non- compliant helmets while also developing training for judges and prosecutors to adjudicate universal helmet law violations. However, this task will prove challenging. Enforcing universal helmet laws that reference or incorporate FMVSS 218 has been difficult for local and state law enforcement officers. Law enforcement officers find it challenging to prove a helmet is non-compliant under state law due to the accessibility of counterfeit DOT stickers. NHTSA will continue to provide technical assistance to states, when requested, with regard to legislation and laws relating to compliant helmet use. NHTSA is also considering amending FMVSS 218 to address the falsification of helmet certifications resulting from the non-specific labeling requirements of the motorcycle helmet standard. NHTSA is also planning to implement an outreach program directed at motorcycle helmet manufacturers. Organizational and Institutional Attributes Organizational, To the extent possible, all key stakeholders should be involved in any universal Institutional and helmet law initiative. This includes motorcycle rider groups; law enforcement; Policy Issues insurance; the motorcycle and helmet industries; and medical, public health, advocacy, employer, youth, and safety organizations. V-87

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SECTION V--DESCRIPTION OF STRATEGIES EXHIBIT V-49 (Continued) Strategy Attributes for Increasing the Use of FMVSS 218 Compliant Helmets Issues Affecting Depending on the magnitude of opposition, the time required to enact universal Implementation Time helmet legislation can be extensive. When such legislation is enacted, however, benefits are immediate and substantial. There is no known timetable for implementing a successful program to promote helmet usage because there is no documented history of success with such efforts. Based on efforts with safety belts, acceptably high usage will not be obtained until strong and unambiguous laws are enacted and enforced. Costs Involved The costs associated with enacting a universal helmet law include lobbying, whether paid or donated by stakeholders, law enforcement training, and costs for evaluating the impact of the law change. Other potential costs could include a public information campaign to inform riders about the new law. A public information campaign, implemented to publicize a law or its enforcement, or to make the public aware of the benefits of helmet use, can be implemented at different levels, using different combinations of broadcast, cable, print, or outdoor advertising and/or coupled with other actions. Campaigns have generally not resulted in significant behavioral change unless they have been coupled with legislation, enforcement, or sanctions. Even in these cases, costs should be anticipated for message and materials development, for the purchase of media time, and for evaluation. Training and Other With regard to universal helmet laws, training is necessary for law enforcement Personnel Needs personnel to identify compliant and non-compliant helmets and to properly enforce such laws. NHTSA has created a video and training sheet, "Fake Helmets, Unsafe On Any Head," for law enforcement. This 12 and 1/2 minute instructional video, suitable for roll-call training, teaches law enforcement officers how to identify non-compliant motorcycle helmets. It also shows examples of non-compliant helmets. A link is available in the following section. Legislative Needs Universal helmet laws require legislative action. Information on Agencies or Organizations Currently Implementing This Strategy NHTSA has created a training video and brochure, "Fake Helmets, Unsafe On Any Head" (http://www.nhtsa.dot.gov/people/outreach/safesobr/21qp/html/program_ pubs/moto_safety.html). This 12 and 1/2 minute instructional video teaches law enforcement officers how to identify non-compliant motorcycle helmets. It also shows some examples of non-compliant helmets. Police agencies and the military are currently using this video. Current status of motorcycle helmet legislation is summarized by the National Conference of State Legislatures. For more information, visit http://www.ncsl.org/. The Wisconsin Motorcycle Safety Program promoted protective apparel in this promotional piece targeting riders--http://www.dot.wisconsin.gov/safety/vehicle/motorcycle/. V-88

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SECTION V--DESCRIPTION OF STRATEGIES The Motorcycle Safety Foundation (MSF) has EXHIBIT V-50 developed PSAs promoting helmet usage and MSF Helmet Usage PSAs web applications in a variety of sizes and formats and will provide them at no cost. Contact the MSF for more information--http://www. msf-usa.org/. There have been cases of motorcycle dealer- ships instituting a "beanie buy-back" program, where discounts are given to riders who turn in non-compliant helmets and purchase a helmet that meets FMVSS 218. Washington State Police have developed a brochure which describes some of the differences between non-compliant helmets and FMVSS 218 compliant helmets. They have developed public awareness campaigns to promote usage of FMVSS 218 compliant motorcycle helmets: http://www.wsp.wa.gov/traveler/helmets.htm. Additional information is available from the FHWA Motorcyclist Advisory Council: http://safety.fhwa.dot.gov/mac/index.htm. Websites The following websites are listed to provide information on the arguments in support of and opposition to universal helmet laws. Organizations That Support Universal Helmet Laws Advocates for Highway and Auto Safety: http://www.saferoads.org/issues/fs-helmets.htm American College of Emergency Physicians: http://www.acep.org/ American College of Surgeons: http://www.facs.org/fellows_info/statements/st-35.html Trauma Foundation: http://www.traumaf.org/featured/7-28-04motorcycle%20helmet%20laws.html Governor's Highway Safety Association (GHSA): http://www.statehighwaysafety.org/ National Highway Traffic Safety Administration: http://www.nhtsa.dot.gov/people/injury/pedbimot/motorcycle/safebike/helmet.html http://ntl.bts.gov/lib/6000/6200/6285/fs_mcycl.pdf National Transportation Safety Board (NTSB): www.ntsb.gov V-89

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SECTION V--DESCRIPTION OF STRATEGIES Organizations That Oppose Universal Helmet Laws American Motorcyclist Association position paper in support of promoting helmet use: http://www.amadirectlink.com/legisltn/positions/helmet.asp Motorcycle Rider Foundation White Papers on Helmets: http://www.mrf.org/whitepapers.php Strategy 11.1 E2--Increase the Use of Protective Clothing (T) General Description Constant exposure to the elements is physically dangerous, but wind, weather conditions, and temperature extremes can also affect a rider's concentration. Furthermore, dehydration, overheating, and hypothermia can compromise a rider's judgment and cause decreased vision, light-headedness, and impaired coordination. Safety is the main reason to wear protective apparel, but comfort is important also. Motorcycle riding gear is designed specifically for this activity. Arm and leg lengths are cut longer to provide comfort in the seated position. Sleeves can be zipped tight and collars can be either closed (with Velcro), to block cold wind, or opened, for ventilation. Most riding gear is constructed of leather or ballistic nylon--tough material for tough conditions. It has to be able to resist abrasion and stay affixed while sliding along the roadway or roadside surface. Body padding or body armor built into the gear dissipates impact forces and provides greater protection. The European Union has devised testing standards: CE EN1621-1&2 for elbow, shoulder, knee and spinal armor. No such armor standards exist in the United States. Typical protective riding gear includes: FMVSS 218 compliant helmet Helmets come in three basic styles--full face, three-quarter shell, and half-shell. The full face provides the most protection and includes a face shield to protect the face and eyes and a chinbar to protect the jaw and teeth. Eye protection Face shields or goggles provide the most protection from wind, insects and flying debris. Jacket and long pants Fabricated out of abrasion-resistant materials such as leather or ballistic nylon, motorcycle gear provides ventilation and closures and often comes with body padding or body armor. Gloves Motorcycle gloves are usually made of leather. Winter gloves with gauntlets keep cold wind from going up the sleeve. V-90

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SECTION V--DESCRIPTION OF STRATEGIES Boots Boots provide solid ankle support at a stop and better protection than low-cut shoes. Boots should also provide a good grip with the road when stopped. Raingear Raingear has to stand up to the wind and seal out driving rain to keep the rider warm and dry. The National Agenda for Motorcycle Safety identified several ways to increase use of protective apparel (NHTSA, 2000): Educate motorcyclists about the value of protective apparel by providing an informa- tion source on related research and a forum for the exchange of information. Conduct research regarding protective apparel and its effectiveness, and consider development or adoption of existing standards, if research justifies. The objective of this strategy is to convince riders to wear clothing that provides protection and comfort from the elements as well as from the dangers of a fall from the motorcycle. Wearing protective clothing can make the difference between an uncomfortable slide and severe injury along with months of rehabilitation. The motorcycle safety and rider training communities should be involved in this strategy to assist in the development of public information and education resources for motorcyclists to understand the benefits of helmets and protective gear. EXHIBIT V-51 Strategy Attributes for Increasing the Awareness of the Benefit of Protective Clothing Technical Attributes Target The target of this strategy is motorcycle riders and passengers, as well as the motorcycle safety and rider training community. Expected Effectiveness The effectiveness of increasing the awareness of the benefits of protective clothing has not been satisfactorily quantified. Keys to Success The key to success is to involve the motorcycle rider and safety community in the development and distribution of the materials resulting from this strategy. Potential Difficulties A potential difficulty with this strategy is accurately targeting the appropriate group of motorcyclists. That is, it may be difficult for highway agencies, and the group of stakeholders with which they are working, to identify where motorcyclists congregate and can be expected to view the public information material. Motorcyclists may be effectively reached at rallies and similar events. Another potential difficulty is effecting change in a long-established culture. Riders may be very reluctant to put aside the traditional attire in favor of protective clothing. Appropriate Measures Depending on the scope of effort, process measures could include the existence and Data of a coordinated system, number of meetings held, number and type of materials produced, number of postings, and contacts made. Roadside evaluations can be conducted before and after the campaign to measure effectiveness in increased use of protective apparel. V-91

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SECTION V--DESCRIPTION OF STRATEGIES EXHIBIT V-51 (Continued) Strategy Attributes for Increasing the Awareness of the Benefit of Protective Clothing An advanced level of analysis could include an evaluation of motorcycle crashes and the effect of protective clothing on injury outcome. Such a study would require data linkage between crash records and hospital records as well as follow-up activities to determine what type of protective clothing was worn at the time of the crash. Associated Needs None identified. Organizational and Institutional Attributes Organizational, Central to the success of any motorcycle safety initiative is to form alliances with Institutional and key stakeholders in transportation and motorcycle safety, licensing, enforcement Policy Issues and the motorcycle community. Many state governments support a Motorcycle Safety Advisory Committee (MSAC) through statute or rule. Often, these committees comprise motorcycle leaders, authorities and activists from across the state, and include representatives from state police, DMV, transportation safety and the state's motorcycle safety program. Partnering with MSAC groups is essential to begin to (a) understand the problems motorcyclists face and (b) provide a mechanism to convey information between researchers, policy makers and the state leaders and activists within the motorcycling community. Broadening organizational involvement to include the private sector, such as those that produce motorcycles and motorcycle-rider wear may add a needed dimension to the effectiveness of the strategy, through effective marketing. Issues Affecting A public awareness campaign aimed at motorcyclists should be targeted around the Implementation Time prime riding season, when motorcyclists are most likely to be congregating where the public awareness material is distributed (e.g., riding events, etc.). The timing of the campaigns is most effective when it coincides with the riding season. This will entail highway agencies beginning to work on information programs well in advance of the prime riding season in order to have the public awareness campaign ready. Costs Involved Costs vary depending on the scope of effort. Training and Other Increasing the awareness of the benefit of protective clothing does not necessarily Personnel Needs require training or additional agency personnel, but it does require knowledge of how clothing can protect motorcycle riders and a willingness to partner with key stakeholders. Legislative Needs None identified. Other Key Attributes None identified. V-92