Injury 54 (2023) 848–856

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The burden of unhelmeted motorcycle injury: A nationwide

scoring-based analysis of helmet safety legislation
Arjun Ganga a,b, Eric J. Kim a, Oliver Y. Tang a,b, Joshua R. Feler a,b, Rahul A. Sastry a,b,
Matthew N. Anderson a,b, Sharonda E. Keith a,b, Jared S. Fridley a,b, Ziya L. Gokaslan a,b,
Deus J. Cielo a,b, Steven A. Toms a,b, Patricia Zadnik Sullivan a,b,∗
a
Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States
b
Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, United States

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Motorcycle collisions comprise a large portion of motor vehicle injuries and fatalities with
Accepted 2 January 2023 over 80,0 0 0 injuries and 5,50 0 fatalities per year in the United States. Unhelmeted riders have poor med-
ical outcomes and generate billions in costs. Despite helmet use having been shown to lower the risk of
Keywords: neurological injury and death, helmet compliance is not universal, and legislation concerning helmet use
Motorcycle injuries also varies widely across the United States.
Motorcycle head trauma Methods: In this study, we systematically reviewed helmet-related statutes from all US jurisdictions. We
Helmet laws evaluated the stringency of these statutes using a legislative scoring system termed the Helmet Safety
Head injury prevention Score (HSS) ranging from 0–7 points, with higher scores denoting more stringent statutes. Regression
modeling was used to predict unhelmeted mortality using our safety scores.
Results: The mean score across all jurisdictions was 4.73. We found jurisdictions with higher HSS’s gen-
erally had lower percentages of unhelmeted fatalities in terms of total fatalities as well as per 10 0,0 0 0
people and 10 0,0 0 0 registered motorcycles. In contrast, some lower-scoring jurisdictions had over 100
times more unhelmeted fatalities than higher-scoring jurisdictions. Our HSS significantly predicted un-
helmeted motorcycle fatalities per 10 0,0 0 0 people (β = -0.228 per 1-point increase, 95% CI: -0.288 to
-0.169, p < .0 0 01) and per 10 0,0 0 0 registered motorcycles (β = -6.17 per 1-point increase, 95% CI: -
8.37 to -3.98, p < .0 0 01) in each state. Aspects of our score concerning helmet exemptions for riders
and motorcycle-type vehicles independently predicted higher fatalities (p < .0 0 01). Higher safety scores
predicted lower unhelmeted fatalities.
Conclusion: Stringent helmet laws may be an effective mechanism for decreasing unhelmeted mortality.
Therefore, universal helmet laws may be one such mechanism to decrease motorcycle-related neurologi-
cal injury and fatality burden. In states with existing helmet laws, elimination of exemptions for certain
riders and motorcycle-type vehicles may also decrease fatalities.
© 2023 Elsevier Ltd. All rights reserved.

Introduction and subdural hematoma, intracerebral hemorrhage, cervical spine

injury, and diffuse brain injury [12,13].
Road traffic accidents are a leading cause of mortality and dis- Over the last few decades, many studies have shown that hel-
ease burden globally [1–5]. Among these, accidents related to mo- mets reduce the risk of mortality and neurological injuries asso-
torcycle carry a particularly high mortality rate [6–8]. In the United ciated with MCC, with estimated risk reductions of 70% for head
States in 2020, motorcyclists were 28 times more likely than pas- injuries and 40% for mortality [9,14-17]. Despite the demonstrated
senger vehicle occupants to be killed in a motor vehicle accident effectiveness of helmets in preventing neurological injury and mor-
[9]. In motorcycle collisions (MCC), the head is a common site of tality, their use is not universal [18–20]. Many jurisdictions in the
injury, and a large proportion of fatalities are associated with head United States and countries around the world have enacted and
injuries [10,11], such as skull fractures, brain contusions, extradural strictly enforced helmet laws for motorcycle riders and have sub-
sequently seen significantly increased helmet use, decreased bur-
dens of neurologic injury and mortality, and decreased associated
∗
Corresponding author at: Rhode Island Hospital, 593 Eddy St healthcare costs [21–23]. Helmet laws have also been shown to
E-mail address: [email protected] (P.Z. Sullivan). be cost-effective, to have short implementation times, and to have

https://doi.org/10.1016/j.injury.2023.01.013
0020-1383/© 2023 Elsevier Ltd. All rights reserved.
A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

generally broad support from many political stakeholders [24–26]. Table 1

Helmet safety scoring system.
However, legislation generally varies widely between United States
jurisdictions. Helmet laws are no exception, demonstrated by the Helmet Safety Score (0–7)
diversity in the specificity, strength, punitive consequences, and 1. Is there a law requiring helmets for motorcyclists? (0
clarity of the laws around the United States [27]. American indi- points = no, 1 point = yes)
vidualism, often characterized as the rejection of state encroach-
ment and impatience with restraints on economic and social activ- 2. Are helmets required for all motorcyclists or only certain classes
of motorcyclists (i.e., only individuals of certain ages have to
ity, may also play a role in the diversity of helmet laws across the wear a helmet)? (0 points = certain riders only, 1 point = all
country [28]. riders)
Due to the increasing injury and fatality burden caused by MCC
in many jurisdictions following the repeal of helmet laws, and the 3. How severe is the maximum fine for the first violation of the
motorcycle helmet statute? (0 points < $100, 1 point ≥ $100)
aforementioned range of helmet laws and diverse political environ-
ment, a greater understanding of US helmet legislation is needed 4. Is there a standard for the helmet (i.e., DOT standards or
to learn how such legislation affects health-related outcomes [29– standards established by the Public Safety Commissioner)? (0
31]. Therefore, in this study, we sought to comprehensively assess points = no standard, 1 point = some standard)
and synthesize motorcycle helmet legislation across all US jurisdic- 5. Does the motorcycle helmet law apply to other motorcycle-type
tions and learn if these safety standards affect fatalities. To stan- vehicles (i.e., mopeds, motorized scooters, motorized bikes,
dardize comparisons across jurisdictions and assess the rigor of minibikes, pocket bikes, etc.)? (0 points = no, 1 point = yes)
state legislation, we devised a Helmet Safety Score (HSS). Our hy-
6. Are helmets required for passengers? (0 points = no, 1
pothesis was that jurisdictions with higher HSS’s would have lower point = yes)
proportions of unhelemeted motorcycle fatalities. We focused on
unhelmeted fatalities specifically because as previously mentioned, 7. Are helmets required for all passengers (i.e., only passengers of
unhelmeted crashes tend to be the most severe and could possibly certain ages may be required to wear a helmet)? (0 points = no,
1 point = yes)
be mitigated or even prevented with helmet use in certain cases,
allowing for possible policy implications of our results. Studying
the role of helmet wearing on reducing injuries was not the pri-
mary focus of our study as previous studies have extensively ex- safer behaviors and higher rates of compliance. This assumption is
plored this topic. Rather, we chose to exclusively research the po- consistent with past research that transportation-related safety can
tential effects of legislation. To our knowledge, no such study has be improved by increasing fines [32,35,36]. For example, a report
been conducted that comprehensively reviewed the legislation of by the US Department of Transportation National Highway Traffic
all US jurisdictions and evaluated whether such helmet standards Safety Administration (NHTSA) found that increasing a state’s fine
affect fatalities. amount for seatbelt violations was associated with a significant in-
crease in seat belt use [36].
Methods Data for all jurisdictions were first independently collected by
each reviewer (EK and AG). Following the first round of data col-
Study design and scoring system lection for all jurisdictions, inter-observer reliability showed 92%
agreement between reviewers, demonstrating excellent reliability.
A nationwide search of all motorcycle helmet legislation was If there was a discrepancy between reviewers, both reviewers met
performed for all 50 states and the District of Columbia. The au- to achieve consensus. For each state, a total score was calculated
thors collated all the necessary information pertaining to state by summing individual scores across the seven, equally weighted
laws by reviewing state statutes in Nexus Uni and Justia, both of categories. Table 2 outlines the scores of all 50 states and the Dis-
which are legal research databases. Helmet laws from 2019 were trict of Columbia and includes each state’s score for each of the
used to tabulate scores, as this was the most recent year that mo- seven categories.
torcycle fatality data have been reported at the time of data col-
lection. Reviewers also examined each jurisdiction’s definition of a Data sources and analysis
motorcycle to ensure accuracy and inform exemptions to helmet
requirements. Official state department of transportation (DOT), Motorcycle injury fatality data were collected from the NHTSA,
state highway safety office, and department of public safety web- a federal agency with the primary directives of enforcing the Fed-
sites were also reviewed for each state. Reviews were conducted eral Motor Vehicle Safety Standards and reporting data on vehicle
between January 2022 and June 2022. Data were abstracted ac- safety. The most recent data available concerning motorcycle fa-
cording to our scoring system (Table 1). Our scoring system was talities was from 2019 [37]. These data were used to calculate the
conceived to evaluate the strength of state laws. To do this, the total number of unhelmeted fatalities for each jurisdiction, the per-
authors devised a seven-category scoring rubric, with one point centage of unhelmeted fatalities among helmeted, unhelmeted, and
awarded per category if satisfied. A higher HSS more clarity and unknown fatalities, as well as the two main dependent variables
stringency concerning motorcycle helmet laws while a lower score in this study: unhelmeted fatalities per 10 0,0 0 0 people and per
implies a less clear and less stringent standard. 10 0,0 0 0 registered motorcycles in each jurisdiction. Unhelmeted
Our scoring system was modeled after another legislative scor- fatalties were choses specifically as per the hypothesis of our study.
ing system devised by Bredikhina et al. [32]. Here, the authors sim- Regarding the motorcycle injury fatality data, the NHTSA defined
ilarly used a multi-category scoring system with equally weighted, motorcycles as two- and three-wheeled motorcycles, off-road mo-
binary categories to assess the stringency of laws concerning safety torcycles, mopeds, scooters, minibikes, and pocket bikes. Therefore,
standards for children using ride-sharing services. Legal scoring in evaluating legislation according to category 5, we also used this
systems are well-established in the literature as a means to com- definition.
pare legislation across different jurisdictions [32–34]. State population data were abstracted from the US Census Bu-
Our financial penalty cut-off for category 3 was set to be the reau’s 2019 annual estimates of resident population by region [38].
median of all financial penalties across all jurisdictions, with the The number of motorcycles registered in each jurisdiction was col-
assumption that harsher fines for violating helmet laws can lead to lected from the Insurance Institute for Highway Safety (IIHS), a

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A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

Table 2
Helmet Safety Scores for each jurisdiction.

Law Helmets How severe is Does the Do helmet laws Are helmets Are helmets Total Score
requiring required for the maximum helmet have to apply to other required for required for
helmets for all motor- fine for a first meet a specific motorcycle-type passengers? all
motorcy- cyclists? offense? 0 if < standard (ie vehicles (mopeds, 0 = no passengers?
clists? 0 = no $100 1 if ≥ 100 DOT scooters, motorized 1 = yes 0 = no
0 = no 1 = yes approved)? bicycles)? 0 = yes 1 = yes
1 = yes 0 = no 1 = yes 1 = no

Alabama 1 1 0 1 1 1 1 6
Alaska 1 0 1 1 1 1 1 6
Arizona 1 0 0 0 1 1 0 3
Arkansas 1 0 1 1 1 1 0 5
California 1 1 1 1 1 1 1 7
Colorado 1 0 1 1 0 1 0 4
Connecticut 1 0 0 1 1 1 0 4
Delaware 1 0 1 1 0 1 0 4
Florida 1 0 0 1 0 1 0 3
Georgia 1 1 1 1 0 1 1 6
Hawaii 1 0 0 1 0 1 0 3
Idaho 1 0 0 1 1 1 0 4
Illinois 0 0 0 0 0 0 0 0
Indiana 1 0 1 1 1 1 0 5
Iowa 0 0 0 0 0 0 0 0
Kansas 1 0 0 1 1 1 0 4
Kentucky 1 0 1 1 0 1 0 4
Louisiana 1 1 0 1 1 1 1 6
Maine 1 0 1 1 0 1 0 4
Maryland 1 1 1 1 1 1 1 7
Massachusetts 1 1 1 1 1 1 1 7
Michigan 1 0 0 1 1 1 0 4
Minnesota 1 0 0 1 1 1 0 4
Mississippi 1 1 1 1 1 1 1 7
Missouri 1 1 0 1 0 1 1 5
Montana 1 0 0 1 0 1 0 3
Nebraska 1 1 0 1 1 1 1 6
Nevada 1 1 1 1 0 1 1 6
New Hampshire 1 0 0 1 0 1 0 3
New Jersey 1 1 0 1 1 1 1 6
New Mexico 1 0 0 1 0 1 0 3
New York 1 1 1 1 1 1 1 7
North Carolina 1 1 0 1 1 1 1 6
North Dakota 1 0 0 1 1 1 0 4
Ohio 1 0 0 1 1 1 0 4
Oklahoma 1 0 0 1 0 1 0 3
Oregon 1 1 1 1 1 1 1 7
Pennsylvania 1 0 0 1 0 1 0 3
Rhode Island 1 0 0 1 1 1 1 5
South Carolina 1 0 0 1 0 1 0 3
South Dakota 1 0 1 1 1 1 0 5
Tennessee 1 1 0 1 1 1 1 6
Texas 1 0 0 1 1 1 0 4
Utah 1 0 1 1 1 1 0 5
Vermont 1 1 1 1 0 1 1 6
Virginia 1 1 1 1 1 1 1 7
Washington 1 1 1 1 1 1 1 7
Washington DC 1 1 0 1 1 1 1 6
West Virginia 1 1 1 1 1 1 1 7
Wisconsin 1 0 1 1 0 1 0 4
Wyoming 1 0 0 1 0 1 0 3
Sum 49 20 22 48 31 49 22 N/A
Mean .961 .392 .431 .941 .607 .960 .431 4.73
Prediction of unhelmeted β =−289, β =−.842, β =−.287, β =−.367, β =−.524, p=.0003 β =−.289, β =−.882, β=−.228,
fatalities /100,000 people p=.453 p<.0001 p=.051 p=.245 p=.453 p<.0001 p<.0001
Prediction of unhelmeted β =−6.78, β =−21.2, β =−11.0, β =−11.2, β =−13.4, p=.0043 β =−6.80, β =−22.9, β=−6.17,
fatalities /100,000 motorcycles p=.580 p<.0001 p=.019 p=.266 p=.580 p<.0001 p<.0001
a
DOT: Department of Transportation.

non-profit policy and safety research organization [39]. While com- sion 8.0.0 for Windows, GraphPad Software, San Diego, California
puting the proportion of unhelmeted fatalities as a fraction of mo- USA, www.graphpad.com). Simple linear regression modeling was
torcycle miles traveled or per 10 0,0 0 0 motorcyclists in each state used to determine if Helmet Safety Scores significantly predicted
may have been a superior metric, such data were not readily avail- unhelmeted fatalities and analysis of variance (ANOVA) was used
able consistently for each state nor from a reliable source such as to compare scores between different geographic regions. In our re-
the IIHS. gression model, one dependent variable, unhelmeted fatalities, and
All data analysis was performed using Microsoft Excel (version one explanatory variable, HSS, were used. To evaluate goodness
2016; Microsoft, Redmond, WA, USA) and GraphPad Prism (ver- of fit and normality of distribution, the one-sample Kolmogorov-

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A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

Fig. 1. Helmet Safety Scores of all jurisdictions.

Smirnov (KS) test was employed. Standard assumptions of simple while Michigan does not require motorcyclists to wear helmets if
linear regression modeling such as linearity, independence of they are over the age of 21, have no-fault medical coverage that
errors, normality of errors, and equal variances were confirmed amounts to a minimum of $20,0 0 0, and have passed a motorcycle
using KS testing, examining scatterplots of the data, examining safety test [41,42].
normal probability plots of the residuals, and examining scatter
plots of the residuals versus fitted values plots. P-values less than
0.05 were considered statistically significant. All data used in this Monetary penalties and severity of fines
study were de-identified and publicly available to any individual.
Therefore, the research herein does not qualify for Institutional All jurisdictions that have helmet laws specify a monetary
Review Board review. penalty for motorcyclists who are in violation (49/49, 100%). How-
ever, the severity of fines varies widely among jurisdictions. For
Results example, New Jersey may fine up to $25 for a first time offense,
while violating the helmet law in Maine is considered a traffic in-
Wide variation in helmet laws among jurisdictions fraction and can be penalized for up to $500 [43,44]. Another state,
Nevada, bases its fines based on locality [45]. Some jurisdictions
We were able to identify information pertaining to every cate- also stipulate further legal penalties and/or insurance penalties in
gory and calculate complete scores for every jurisdiction. The mean addition to the monetary penalties. For example, motorcyclists in
score across all 51 jurisdictions was 4.73 (Table 2). Our findings Georgia who are found to be not wearing a helmet can be charged
suggest that there is a wide range of helmet safety laws with many with a misdemeanor and thus incur a fine of up to $10 0 0 and/or
age-based, vehicle-based, and insurance-based exemptions to hel- one year of jail [46].
met wearing. The two outliers of our study (3.9%), Illinois and
Iowa, did not have any helmet laws in place and thus scored 0, Standards for helmet quality
while all other 49 jurisdictions (96%) had some sort of helmet law
in place for motorcyclists (Table 2). Twenty jurisdictions (39%), all Table 2 provides evidence that almost all included jurisdictions
of which scored at least a 5 on our scoring system, have univer- with helmet laws have specific standards set in place for helmet
sal helmet laws in place, which are defined as mandated helmet quality (48/49, 98%). Among the jurisdictions that do have specific
use for all motorcyclists and passengers regardless of any status standards for motorcycle helmets, the governing bodies that de-
including age. About 37% (19/51) scored a “moderate” score of a termine these standards vary widely. Some jurisdictions use stan-
4 or a 5 (Fig. 1). There may also exist a trend of motorcycle hel- dards that have been determined by federal agencies, such as the
met law stringency based on geographic area (Fig. 2). Jurisdictions US DOT’s Federal Motor Vehicle Safety Standard No. 218 (i.e., Col-
on the West Coast (California, Oregon, and Washington) demon- orado), while other jurisdictions, such as Maryland, rely on local
strated higher Helmet Safety Scores, and many jurisdictions in the governing bodies (i.e., Maryland’s Administrator of Transportation)
Northeast and South tended to have higher Helmet Safety Scores. to determine baseline helmet standards [47,48]. Arizona is the only
However, there was no statistically significant result upon ANOVA state with helmet laws but no baseline standards for motorcycle
analysis of the US Census-defined geographic regions (Northwest, helmets.
South, Midwest, and West, p=.107) [40].

Exemptions for certain motorcyclists Exceptions for motorcycle-type vehicles

A majority of jurisdictions with helmet laws that were in- Table 2 also shows that many (18/49, 41%) of the jurisdictions
cluded for analysis have exceptions to motorcyclists wearing hel- with motorcycle helmet laws in place do not have helmet laws in
mets (29/49, 59%), with all other jurisdictions with helmet laws place for other motorcycle-type vehicles such as mopeds, scooters,
categorically requiring all motorcyclists to wear helmets (20/49, three-wheeled motorcycles, and motorized bicycles. Most of these
41%) (Table 2). Jurisdictions grant motorcyclists exceptions if cer- motorcycle-type vehicles that were not included under the helmet
tain criteria are met, including but not limited to meeting a mini- laws were mopeds. We found that exemptions for motorcycle-type
mum age requirement, having particular medical coverage, having vehicles independently predicted, with statistical significance, un-
a motorcycle license for a minimum number of years, and/or pass- helmeted fatalities per 10 0,0 0 0 people and motorcycles registered
ing particular motorcycle safety tests. Jurisdictions base their ex- (p = .0 0 03, p = .0 043, Table 2). It should be noted that while
ceptions on a wide variety of criteria. For example, Kansas does Nevada was marked as a “0 in this particular category, Nevada
not require motorcyclists over the age of 18 to wear helmets, helmet laws did not include mopeds only until late 2019 [49].

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A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

Fig. 2. Heat map of Helmet Safety Scores.

Exemptions for certain passengers ple (β = −0.228 per 1-point HSS increase, 95% CI: −0.288 to
−0.169, p < .0 0 01, R2 =69.1%, Fig. 3) and 10 0,0 0 0 motorcycles regis-
It was also of interest to investigate helmet policies regarding tered (β = −6.17 per 1-point HSS increase, 95% CI: −8.37 to −3.98,
motorcycle passengers in the studied jurisdictions. All jurisdictions p < .0 0 01, R2 =50.4%, Fig. 3) in all jurisdictions. We also performed
that have helmet laws in place also describe in some detail hel- a regression on each category of our scoring system with rela-
met policies for passengers (49/49, 100%). Similar to helmet poli- tion to unhelmeted fatalities per 10 0,0 0 0 people and motorcycles
cies for motorcyclists, exceptions to helmet wearing for passengers and found that three categories independently predicted both out-
are granted in many jurisdictions (27/49, 55%) on the basis of cer- comes with statistical significance (Table 2). These categories con-
tain criteria, including but not limited to age of the passenger and cerned whether jurisdictions had exemptions for helmet use for
experience of the motorcyclist. For example, Arkansas does not re- certain motorcyclists (category two, p < .0 0 01), passengers (cat-
quire passengers over 18 years-old to wear a helmet while Penn- egory seven, p < .0 0 01), or exemptions for certain motorcycle-type
sylvania does not require passengers over 21 years-old to wear a vehicles such as mopeds (category five, p = .0043). The results of
helmet [50,51]. Like Arkansas, Ohio also does not require passen- the KS-test were insignificant (p=.096), implying normality of the
gers over 18 to wear a helmet but only if the motorcyclist riding data. All assumptions of simple linear regression modeling were
with the passenger does not carry a “novice” designation on their met.
license [52]. In our scoring system, both categories that encapsu-
lated exemptions for motorcyclists (category two) and passengers Discussion
(category seven) independently predicted unhelmet fatalities with
convincing statistical significance (p < .0 0 01, Table 2), showcasing The primary objective of this study was to assess safety stan-
that exemptions are an important factor in the efficacy of helmet dards across 51 United States jurisdictions regarding motorcycle
laws reducing fatalities. helmet laws and learn whether the stringency of laws had an effect
on unhelmeted deaths. We systematically reviewed statutes col-
Unhelmeted motorcycle fatalities by state lated from legal databases, Nexus Uni and Justia, as well as publicly
available information from official government websites and eval-
For each state, the total number of unhelmeted motorcycle fa- uated the stringency of helmet policies among the studied juris-
talities, the percentage of unhelmeted motorcycle fatalities among dictions using a legislative scoring system (0–7). Jurisdictions with
helmeted, unhelmeted, and unknown helmet use fatalities, and un- higher scores (i.e., 6 or 7) were considered to have stricter policies
helmeted fatalities per 10 0,0 0 0 people and per 10 0,0 0 0 motorcy- regarding helmet use, and all jurisdictions known to have univer-
cles were calculated from NHTSA and IIHS data (Table 3). We found sal helmet laws in place had scores of at least 5, demonstrating the
that jurisdictions with higher Helmet Safety Scores generally had validity of our scoring methods [53].
lower percentages of unhelmeted fatalities in terms of total fa- Our findings indicated that there was a statistically significant
talities as well as lower unhelmeted fatalities per 10 0,0 0 0 people association (p < .0 0 01) between stringency of helmet laws and
and motorcycles; on average, jurisdictions in the 10th percentile rates of unhelmeted fatalities, with higher scoring jurisdictions re-
of Helmet Safety Scores had 9.1 times more unhelmeted fatalities porting lower rates of unhelmeted fatalities per 10 0,0 0 0 people
per 10 0,0 0 0 people and 6.4 times more unhelmeted fatalities per and motorcycles compared to jurisdictions with lower scores. Our
10 0,0 0 0 registered motorcycles than those in the 90th percentile. data also showed that although many jurisdictions had stringent
Concerning specific jurisdictions, some lower-scoring jurisdictions and clear helmet laws, there is room for improvement across the
(e.g., South Carolina) had over 100 times more unhelmeted fatali- country and thus opportunity to lower unhelmeted deaths. In-
ties per 10 0,0 0 0 people and motorcycles than higher scoring juris- terestingly, many jurisdictions with moderate safety scores (4–5)
dictions (e.g., Washington). showed rates of unhelmeted fatalities that were comparable to
We also report that our total Helmet Safety Scores signifi- those of jurisdictions with low safety scores (< 4), indicating that
cantly predicted unhelmeted motorcycle fatalities per 10 0,0 0 0 peo- stricter, universal helmet laws are warranted, and moderately strict

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A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

Table 3
Unhelmeted Fatalities by State (2019).

State Safety Score Total number Total number Percentage of total Population Unhelmeted Motorcycles Unhelmeted
of unhelmeted of helmeted motorcycle fatalities fatalities per registered fatalities per
fatalities fatalities that were unhelmeted 10 0,0 0 0 people 10 0,0 0 0
motorcycles

CA 7 28 437 6% 39,512,223 0.070864148 957,620 2.923915541

MA 7 0 28 0% 6892,503 0 145,532 0
MD 7 7 66 10% 6045,680 0.115785156 113,109 6.188720615
MS 7 5 33 13% 2976,149 0.168002341 50,284 9.943520802
NY 7 11 122 8% 19,453,561 0.056544917 369,328 2.978382359
OR 7 8 46 15% 4217,737 0.189675174 130,942 6.109575232
VA 7 11 91 11% 8535,519 0.128873241 197,135 5.579932534
WA 7 2 89 2% 7614,893 0.026264322 246,264 0.812136569
WV 7 9 19 32% 1792,147 0.502190948 52,196 17.24270059
AK 6 2 4 33% 731,545 0.273393981 71,764 2.786912658
AL 6 15 78 16% 4903,185 0.305923599 173,652 8.637965586
DC 6 1 2 33% 705,749 0.141693435 5290 18.90359168
GA 6 15 151 9% 10,617,423 0.14127722 214,722 6.985776958
LA 6 10 69 13% 4648,794 0.215109553 84,899 11.77870175
NC 6 19 186 9% 10,488,084 0.181157969 237,055 8.015017612
NE 6 1 21 5% 1934,408 0.051695402 53,998 1.851920441
NJ 6 14 68 17% 8882,190 0.157618786 161,241 8.682655156
NV 6 3 38 7% 3080,156 0.097397664 77,629 3.864535161
TN 6 20 130 13% 6829,174 0.292861186 81,071 24.66973394
VT 6 1 6 14% 623,989 0.160259235 24,108 4.148000664
AR 5 32 27 54% 3017,804 1.060373702 212,951 15.02693108
IN 5 89 32 74% 6732,219 1.322000963 229,343 38.8065038
MO 5 12 106 10% 6137,428 0.195521642 135,917 8.828917648
RI 5 3 9 25% 1059,361 0.283189583 28,194 10.64056182
SD 5 6 6 50% 884,659 0.67822743 51,121 11.73685961
UT 5 16 16 50% 3205,958 0.499070793 89,646 17.84797983
CO 4 54 48 53% 5758,736 0.937705774 189,449 28.5037134
CT 4 28 15 65% 3565,287 0.78535052 91,296 30.66947073
DE 4 8 10 44% 973,764 0.821554299 26,571 30.10801249
ID 4 10 32 40% 1787,065 0.559576736 66,797 14.97073222
KS 4 28 13 68% 2913,314 0.961104776 103,165 27.14098774
KY 4 68 24 74% 4467,673 1.522045145 115,832 58.70571172
ME 4 20 7 74% 1344,212 1.487860546 61,392 32.57753453
MI 4 61 62 50% 9986,857 0.610802778 248,058 24.59102307
MN 4 33 13 72% 2976,149 1.108815452 209,731 15.73444078
ND 4 7 4 64% 762,062 0.918560432 37,422 18.70557426
OH 4 116 45 72% 11,689,100 0.992377514 392,782 29.53292157
TX 4 187 207 47% 28,995,881 0.644919187 377,120 49.58633857
WI 4 54 31 64% 5822,434 0.927447181 324,126 16.6601877
AZ 3 84 77 52% 7278,717 1.154049539 212,951 39.44569408
FL 3 303 280 52% 21,477,737 1.410763154 601,849 50.34485394
HI 3 14 5 74% 1415,872 0.988789947 59,614 23.48441641
MT 3 14 9 61% 1068,778 1.309907202 62,645 22.34815229
NH 3 14 15 48% 1359,711 1.029630561 82,637 16.94156371
NM 3 32 17 65% 2096,829 1.526113956 63,722 50.21813502
OK 3 42 23 65% 3956,971 1.061417938 118,018 35.58779169
PA 3 87 85 51% 12,801,989 0.679581899 398,363 21.83937765
SC 3 115 35 77% 5148,714 2.23356745 140,702 81.73302441
WY 3 8 6 57% 578,759 1.382267922 25,600 31.25
IA 0 35 9 80% 3155,070 1.109325625 164,643 21.25811605
IL 0 100 37 73% 12,671,821 0.789152561 299,528 33.38586042

helmet laws may not be efficacious in lowering unhelmeted deaths. Carolina had markedly higher unhelmeted fatalities per 10 0,0 0 0
The present study’s HSS may not only serve as a general gage of people and motorcycles, a trend that persisted into 2022 [54]. The
the rigor of a state’s motorcycle helmet laws, but also highlight ex- reason for this is not well understood, but local law enforcement
isting areas of improvement that jurisdictions may strive to rectify leaders point to distracted driving as a possible cause [54,55].
via legislation. South Carolina has also experienced historic increases in overall
Regarding individual components of our score, three categories traffic fatalities in recent years [56,57]. Additionally, one state in
independently predicted unhelmeted fatalities. These categories our analysis, Missouri, updated its helmet legislation after the
concerned helmet-wearing exemptions for certain types of motor- year 2019. In 2019, Missouri had a universal helmet law in place.
cyclists, passengers, and motorcycle-type vehicles. This finding in- However, in August of 2020, this law was repealed and the state
dicated that despite having laws in place, exemptions to such laws began allowing riders over 25 to not wear a helmet if they had
are still associated with unhelmeted fatalities. Modifying existing health insurance and proof of financial responsibility [58]. To
helmet laws to encompass all riders and all types of motor-cycle mirror fatality data, our Helmet Safety Score was calculated in
type vehicles may thus lower unhelmeted fatalities. 2019, before this new law took effect.
Our analysis produced one outlier to our general trend: South The United States Highway Safety Act of 1966 led to the intro-
Carolina. South Carolina had a Helmet Safety Score of 3, how- duction of universal motorcycle helmet laws in almost all United
ever, compared to other jurisdictions with the same score, South States jurisdictions, with many receiving federal penalties for not

853
A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

riders accumulated over $30 million more in healthcare costs com-

pared to helmeted patients over a ten-year period, a number that
closely mirrors a similar finding using the National Trauma Data
Bank over a six year period [20,66]. Regarding overall costs, the
CDC reports that in 2017 alone, over $10 billion could have been
saved if all motorcyclists wore helmets [67].

Limitations

There were several limitations to this study. Firstly, our scoring

system did not capture non-monetary penalties specified by partic-
ular jurisdictions (i.e., potential jail time), perhaps underestimating
the stringency of helmet laws in jurisdictions with stricter helmet
laws. Secondly, intensity and quality of policing may differ in juris-
dictions, leading to varying enforcement that may independently
influence compliance with helmet laws and thus unhelmeted fa-
talities. Thirdly, we did not control for the overall hazard levels of
roads in each jurisdiction as some jurisdictions may have roads of
poorer quality, higher speed limits, hazardous weather conditions,
and/or more road congestion which may all increase the probabil-
ity of collisions. Rider level characteristics may have influenced our
results as well as possibly unhelmeted riders may have been more
prone to engage in riskier behaviors such as alcohol use while rid-
ing. Including rider knowledge and experience about helmet use
may have influenced our results as well. However, rider-level char-
acteristics were unavailable in the data provided by the NHTSA.
Also unavailable were data on motorcycle-related, non-fatal in-
juries by helmet status. Exploring non-fatal injuries would have
augmented our results to include the effects of legislation on both
injuries and fatalities. However, due to constraints of the data, we
were only able to include fatalities.
Additionally, rates of unhelmeted fatalities were calculated for
the year 2019 because it was the most up-to-date data available.
Because of this, only legislation from 2019 was evaluated. There-
fore, information in this study may not be readily extrapolated
to the current year, as helmet laws and standards can potentially
change, and the research reported herein did not consider vari-
ations in legislation over time. Additionally, our scoring system
Fig. 3. Simple regression analysis of Helmet Safety Scores and unhelmeted fatali- was not validated on a separate set of data which would have
ties.
augmented our results. Finally, another potential limitation of the
present study is that there is inherent bias in reviewing laws,
which are subject to individual interpretation.
adopting stricter motorcycle helmet laws [59]. However, due to Although there were confounders in our regression model that
increasing legal pressure from various motorcycle rights organiza- were unable to be controlled for, it was notable that the variance
tions, a shifting political tide, and the 1976 Federal-Aid Highway of unhelmeted fatalities per 10 0,0 0 0 motorcycles registered in ju-
Act—which effectively terminated these federal penalties—many risdictions with high Helmet Safety Scores of 6–7 (standard devi-
jurisdictions began loosening their helmet laws to only include ation: 6.39) was roughly half that of jurisdictions with moderate
younger motorcyclists (either under 18 or 21 years-old) [59]. safety scores of 4–5 (standard deviation: 13.3) and roughly third
Unfortunately, jurisdictions that repealed the universal helmet of low safety scores of <4 (standard deviation: 18.2). For exam-
laws saw dramatic increases in motorcycle related fatalities [59]. ple, jurisdictions such as Massachusetts, Georgia, and Louisiana, all
More recently, Michigan in 2012 repealed its universal helmet law, of which had high Helmet Safety Scores and have universal helmet
leading to significantly higher rates of unhelmeted fatalities as laws, are presumably different in terms of climate, population den-
well as traumatic brain injuries and neurosurgical interventions sity, and overall road conditions. Despite these differences, they all
[60–62]. Moreover, when Missouri loosened its motorcycle helmet had low rates of unhelmeted fatalities with low variation. We in-
law in 2020, unhelmeted deaths rose a jarring 800% [63]. On the terpret this finding to show that universal helmet laws can signif-
other hand, Massachusetts has one of the strictest helmet laws icantly reduce unhelmeted fatalities even in the presence of other
in the United States based on the present study and reported no external factors that make operating motorcycles more dangerous.
unhelmeted fatalities in 2019. These pseudo-experimental results While other studies have reported on the association of hel-
further support the notion that helmet laws may indeed lower met legislation on adverse outcomes many of these studies did not
preventable fatalities. evaluate all US jurisdictions, did not use data from the last five
Reduced helmet utilization also places substantial financial bur- years, did not assess legislation with the level of granularity that
dens on involved hospitals and providers and can lead to signif- the present study uses and merely described laws as partial or uni-
icant increases in healthcare costs, with some authors estimating versal, used traumatic brain injury as an outcome which has been
that unhelmeted riders require around $13,0 0 0 more in hospital shown to be underdiagnosed and may be subject to underreporting
costs compared to helmeted counterparts [30,64,65]. Furthermore, as patients with the condition may forego ED presentation, and/or
in Connecticut, a state with incomplete helmet laws, unhelmeted only focused on mopeds [24,27,68-72]. Therefore, we believe this

854
A. Ganga, E.J. Kim, O.Y. Tang et al. Injury 54 (2023) 848–856

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