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Headphone use and pedestrian injury and death in the
United States: 2004e2011
Richard Lichenstein,
1
Daniel Clarence Smith,
2
Jordan Lynne Ambrose,
2
Laurel Anne Moody
3
ABSTRACT
Background The association between distraction caused
by cell phone use while driving and driver/passenger
fatalities has been documented, but the safety risks
associated with headphone use by pedestrians remains
unknown.
Objective To identify and describe pedestrianevehicle
crashes in which the pedestrian was using headphones.
Methods A retrospective case series was conducted by
searching the National Electronic Injury Surveillance
System, US Consumer Product Safety Commission,
Google News Archives and Westlaw Campus Research
databases for reports published between 2004 and 2011
of pedestrian injuries or fatalities from crashes involving
trains or motor vehicles. Cases involving headphones
were extracted and summarised. The likelihood of
headphone involvement was graded on a three-tier scale
based on the information found in the article or report.
Results There were 116 reports of death or injury of
pedestrians wearing headphones. The majority of victims
were male (68%) and under the age of 30 (67%). The
majority of vehicles involved in the crashes were trains
(55%), and 89% of cases occurred in urban counties.
74% of case reports stated that the victim was wearing
headphones at the time of the crash. Many cases (29%)
mentioned that a warning was sounded before the
crash.
Conclusions The use of headphones with handheld
devices may pose a safety risk to pedestrians, especially
in environments with moving vehicles. Further research
is needed to determine if and how headphone use
compromises pedestrian safety.
INTRODUCTION
According to the National Highway Traffic Safety
Administration, 4000e5000 pedestrian deaths
result from vehicle crashes every year, constituting
10e12% of total traffic fatalities.
1
According to the
Federal Railway Administration, approximately 50
pedestrian deaths are caused by trains each year.
2
Pedestrian fatalities are associated with environ-
mental (night time, urban environment) and
human factors (alcohol use, male gender, distract-
ible personality).
13
Devices such as MP3 players
and cell phones may be risk factors in pedestrian
injuries and fatalities near roadways and railways
because they diminish the user’s ability to appre-
ciate environmental cues.
The Pew Research Center has documented
increasing popularity of auditory technologies with
headphones.
4
The most recent report highlights
widespread ownership of these devices among
young adults (figure 1). Seventy-four per cent of
teens reported owning an MP3 player in 2008.
4
Another Pew Study found cell phone use increased
from 45% in 2004 to 71% in 2008 for teens aged
12e17 years.
5
A number of studies have called for more
research into distraction and pedestrian safety.
1 6e9
These studies and local media coverage of a traine
pedestrian crash involving headphones prompted
us to investigate the role of headphone use in the
injury and death of pedestrians.
10
We summarise
116 incidents of headphone-related pedestrian
injuries and deaths. Although causal relationships
cannot be proven, we speculate on implications for
pedestrian safety.
METHODS
We searched the National Electronic Injury
Surveillance System (NEISS), the United States
Consumer Product Safety Commission, Google
News Archives and Westlaw Campus Research
Database from 1 January 2004 to 1 June 2011.
Boolean combinations (operative algorithm using
conjunctive, disjunctive and negative modifiers ‘or’,
‘and’and ‘not’) of the terms ‘headphones’,
‘earphone’,‘earbud’,‘mp3 player’,‘iPod’,‘pedes-
trian’,‘hit’,‘struck’,‘killed’,‘dead’,‘hurt’and
‘injured’were used to search for cases. Variation in
the tenses of each of the aforementioned verbs was
used as well to maximise results. For the purposes
of this article, headphones will refer to either
traditional or earphone-style (earbud) devices, both
of which insulate from outside auditory stimuli.
Cases involving cell phones, including hands-free
devices, were not included. Reports were reviewed
to determine whether the victim was wearing
headphones at the time of the injury/death and if
any auditory alarms were sounded prior to the
crash. Cases were excluded if the incident occurred
outside the United States or the case’s mention of
headphones had nothing to do with the crash. In
the remaining cases, we rated the implicating role
of headphones by a specified subjective grading
system on strength of association of headphone use
to the injury (table 1). Each grade was agreed on by
all three authors reviewing the cases (RL, DS, JA).
Unique cases were analysed by date, location,
vehicle, victim age, victim gender and non-fatal
injury description (when available). The location of
each incident was classified according to the 2006
County UrbaneRural Classification Scheme of the
CDC National Center for Health Statistics.
11
This
system grades counties on a six-point scale, with
scores of 1e4 considered urban/metropolitan and
scores of 5e6 considered rural.
<An additional appendix is
published online only. To view
this file please visit the journal
online (http://injuryprevention.
bmj.com/content/early/recent).
1
Department of Pediatrics,
University of Maryland Hospital
for Children, University of
Maryland School of Medicine,
Baltimore, Maryland, USA
2
University of Maryland Medical
Center, University of Maryland
School of Medicine, Baltimore,
Maryland, USA
3
Office of Health Services,
Baltimore County Public
Schools, Baltimore, Maryland,
USA
Correspondence to
Dr Richard Lichenstein, Director,
Pediatric Emergency Medicine
Research, University of
Maryland Hospital for Children,
22 South Greene Street,
Baltimore, MD 21201, USA;
rlichenstein@peds.umaryland.
edu
Accepted 28 November 2011
Lichenstein R, Smith DC, Ambrose JL, et al.Injury Prevention (2012). doi:10.1136/injuryprev-2011-040161 1 of 4
Original article
IP Online First, published on January 16, 2012 as 10.1136/injuryprev-2011-040161
Copyright Article author (or their employer) 2012. Produced by BMJ Publishing Group Ltd under licence.
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The study was reviewed and exempted by the University of
Maryland Institutional Review Board.
RESULTS
The Google News Archive, Westlaw Campus, Consumer
Product Safety Commission and NEISS database searches
returned 631, 38, 6, and 1396 results, respectively. The final
series included 4 cases from NEISS, 10 from Westlaw Campus
and 102 from Google News Archive database cases.
A total of 116 unique cases of pedestrian injuries or deaths
involving headphone use were identified and are summarised in
table 2 (based on the reports listed in online appendix 1).
The median age of victims was 21 years; 68% were male and
67% were under 30 years of age. Sixty-four of the 116 victims
(55%) were hit by a train. Eighty-one of the 116 collisions (70%)
resulted in death.
Crashes were distributed across all four regions of the United
States. The majority of crashes (59%) occurred in counties that
were classified as 1e2 on the National Center for Health
Statistics urban scale, indicating large metropolitan populations
of 1 million or more residents. Only 12% of cases occurred in
counties classified as ‘rural’(score 5e6).
Eighty-six of the 116 cases (74%) had an ‘A’evidence grade,
meaning that the police and/or eyewitnesses reported the victim
was wearing headphones at the time of the crash. Thirty-four of
the 116 (29%) reports specifically mention horns or sirens being
sounded prior to the victim being hit.
Figure 1 Ownership of auditory devices: (A) overall; (B) by age
(adapted from Smith
5
).
Table 1 Description of evidence grading criteria in reviewing articles
Evidence
grade Description
A Police report or witnesses indicated the victim was wearing
headphones* at the time of the incident
B One or more of the following criteria were met:
<The police report indicated the victim may have been wearing
headphones or using an MP3 player
<The article stated the victim was wearing headphones, but the
source of this information was not specified
<Headphones were found in the victim’s ears
C Headphones were found on or near the victim’s body but not covering
his/her ears
+ Added to above grades if an alarm (yelling, horn, siren) was reported to
be sounded prior to the crash
*Or earphones or earbuds. Hands-free cell phones not included.
Table 2 Headphones-related pedestrian crashes:
summary (n¼116)
Category No.
Year
2004e2005 16
2006e2007 19
2008e2009 34
2010e2011 47
Season
Spring (MareMay) 30
Summer (JuneAug) 16
Fall (SepeNov) 30
Winter (DeceFeb) 40
Age
<15 5
15e24 62
25e34 18
35e44 6
$45 13
Unknown 12
Gender
Male 79
Female 37
Outcome
Serious injury* 24
Mild injuryy7
Death 81
Unknown 4
Evidence grade
A+ 28
A58
B+ 6
B11
C+ 0
C13
Regionz
Northeast 24
South 32
Midwest 17
West 41
Urban scorez
130
239
321
413
59
65
Vehicle
Train 64
Car 32
Otherx20
*Serious injuries include those described as serious condition, critical
condition or life-threatening injuries.
yMild injuries include those described as mild injuries, lacerations or
good condition.
zTwo case locations were unavailable.
xOther vehicles include trucks, buses, tractor trailers, bikes, SUVs.
2 of 4 Lichenstein R, Smith DC, Ambrose JL, et al.Injury Prevention (2012). doi:10.1136/injuryprev-2011-040161
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DISCUSSION
We present 116 cases of pedestrianevehicle crashes with
evidence of headphone use. This series presents some important
observations. First, the pedestrians tended to be young: more
than a third were younger than 18 years and two-thirds were
younger than 30. This predominance of younger victims may be
explained by increased media reporting of incidents involving
youth as well as this group’s lower access to motor vehicles,
higher rates of headphone use, and/or less experience in traffic
navigation.
The percentage of incidents that occurred during the summer
months in school-aged pedestrians was small: 9% of cases
involving victims #18 years of age (4 of 43) occurred during
June, July or August. In older victims, 20% (12 of 61) of crashes
occurred during the summer. This may suggest that daily travel
to school increases young pedestrian risk.
The majority of cases occurred between 2008 and 2011,
possibly reflecting an increasing awareness of the issue by the
media. Moreover, as previously mentioned, the ownership of
electronic devices using headphones has increased in recent
years. Another observation that may be explained by media bias
is the large proportion of fatal crashes and crashes involving
trains. Media reports have been shown to emphasise emerging
issues as well as ‘hard news’that reports more abnormal events
with severe outcomes.
12e15
Finally, the majority of cases (89%) occurred in urban
counties, which may be due to the increased population density
necessitating more dangerous crossings. Such a correlation was
noted by Lascala et al in their spatial analysis of pedestrian
crashes in San Francisco.
16
Distraction: inattentional blindness
Two phenomena are likely contributors to the possible associa-
tion between headphone use and pedestrian injury: distraction
and sensory deprivation. Distraction caused by the use of elec-
tronic devices has been coined inattentional blindness, essentially
a divided cognitive workload that reduces mental resource allo-
cation, or attention, to outside stimuli.
17
This phenomenon,
which involves both the cognitive distraction of interpreting
auditory input as well as the tactile distraction needed to
manipulate electronic devices, has been highlighted as an
important emerging cause of motor vehicle crashes.
18
A number of pedestrian studies have examined inattentional
blindness. Bungum et al conducted a large pedestrian observa-
tional study (n¼866) that weakly correlated distraction (defined
as wearing headphones, talking on a cell phone, eating, drinking,
smoking or talking) with less cautious street-crossing behav-
iour.
19
Nasar et al observed pedestrians at three intersections
(n¼131), and found those conversing on a cell phone were more
likely to engage in risky crossing behaviour, but failed to find this
difference in those using MP3 players.
6
Hatfield and Murphy
conducted a similar observational study (n¼546), which found
that pedestrians using cell phones crossed roads more slowly,
increasing the time in which they were exposed to oncoming
traffic.
20
Finally, Stavrinos et al used a simulated crosswalk
environment to show that children on cell phones had similar
inattentional blindness.
7
Sensory deprivation: environmental isolation
The actual sensory deprivation that results from using head-
phones with electronic devices may be a unique problem in
pedestrian incidents, where auditory cues can be more impor-
tant than visual ones. This deprivation, which we call environ-
mental isolation, is the inability to hear sounds emanating from
the local surroundings.
Only one laboratory study has examined environmental
isolation in pedestrians. Neider et al used a simulated crosswalk
environment to examine the effect of the use of hands-free cell
phones and MP3 players with headphones on adult pedestrians
crossing a street.
21
They established that cell phones caused
pedestrians to take longer to cross the street, but failed to find
a similar difference in MP3 player use. However, the study size
was small (n¼36) and overall failure rate of crossing was about
15%, a rate the authors acknowledge may have compromised
the real-world applicability of the simulated environment.
Limitations
This report has several major limitations. First, it relies on media
reporting, which likely over-publishes tragic events but vastly
under-publishes non-fatal cases. Moreover, there is no method of
collecting information about ‘near misses’, in which the pedes-
trian who is wearing headphones suddenly becomes cognisant of
danger in the environment and avoids an injury. Such misses
may be captured by video cameras at specific places, but larger
studies are only practical using pedestrian injury and death as
outcomes. Our capture of the cases in this study required
headphones to be mentioned, information that may or may not
be available to reporters at the scene.
Also, since this is a retrospective case series, neither causation
nor correlation can be established between headphone use and
pedestrian risk. Such risk can be determined only in virtual
environments or large-scale pedestrian observational studies.
However, we believe our grading system shows strong circum-
stantial evidence that headphones may have played a role in
most injuries and deaths in the case series. Moreover, although
three authors agreed on each rating, it is possible that misclas-
sification of cases still occurred.
Finally, factors other than the use of headphones, such as
suicidal intentions, substance abuse or mental illness, may have
had a role in some of the pedestrian injuries and fatalities. The
most dramatic examples are the victims who were hit by trains
despite the sounding of auditory alarms. The headphones may
have had a significant role in these scenarios; but other factors,
especially intoxication or suicidal ideation, must be considered.
In cases involving vehicles other than trains, the operators may
What is already known on the subject
<Distraction caused by cell phone use while driving has been
highlighted in driver and passenger fatalities.
<Headphone use (a distracting element) is becoming increas-
ingly popular among teenagers and adults.
<Risks associated with pedestrian use of headphones are not
well described.
What this study adds
<Reports of teens and young adult pedestrians using
headphones with injuries and fatal outcomes are described
and have increased over the last 3 years.
<Many cases describe vehicle or train warnings prior to the
crash.
Lichenstein R, Smith DC, Ambrose JL, et al.Injury Prevention (2012). doi:10.1136/injuryprev-2011-040161 3 of 4
Original article
group.bmj.com on January 17, 2012 - Published by injuryprevention.bmj.comDownloaded from
have been at fault. This factor was not mentioned in any of the
articles, but its role cannot be ruled out. Fatality review teams or
complete police reports may be more helpful in determining the
combined contributions of these various factors in pedestrian
injuries and deaths.
Summary and recommendations
The use of cell phones and MP3 players is increasing. The risks
posed in use of these devices by drivers are well documented, but
little is known about the association between headphone use
and pedestrian injury. The danger in using headphones as
a pedestrian may be explained by two phenomena: auditory
masking of outside stimuli (environmental isolation) and
distraction (inattentional blindness). This series presented 116
cases of pedestrian injury involving headphones. The majority of
victims in this series were young and/or male, with more inci-
dents occurring in urban counties, during the school year, and
involving trains. These observations may be influenced by biases
in media reporting; therefore, more complete capture rates are
needed to delineate which populations are at particular risk.
Acknowledgements We would like to acknowledge Ms Jamie Friel Blanck for her
assistance with the library search methodology. The manuscript was copyedited by
Linda J Kesselring, the technical editor/writer in the Department of Emergency
Medicine at the University of Maryland School of Medicine.
Competing interests None.
Contributors All authors provided substantial contributions to the conception and
design of this report, data collection, and interpretation. Each author contributed to the
draft of the article and its multiple revisions to develop the intellectual content that
constitutes the final version.
Provenance and peer review Not commissioned; externally peer reviewed.
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doi: 10.1136/injuryprev-2011-040161
published online January 16, 2012Inj Prev
al.
Richard Lichenstein, Daniel Clarence Smith, Jordan Lynne Ambrose, et
2011−death in the United States: 2004
Headphone use and pedestrian injury and
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