China belting up or down? Seat belt wearing trends in Nanjing and Zhoushan

National seat belt wearing legislation became effective in China May 2004 and associated provincial and city regulations followed. Despite rapid motorisation seat belt studies in China have been scarce. Patterns and trends in urban seat belt wearing were observed for all driver, front and rear seating positions over the years 2005–2007 in two eastern cities Nanjing (Jiangsu Province) and Zhoushan (Zhejiang Province). There were 35,256 vehicles observed in Nanjing, 20,939 in Zhoushan and 95,933 occupants overall. Males dominated all seating positions, especially drivers. Seat belt wearing overall was significantly higher for drivers (49.9% Nanjing, 47.4% Zhoushan) than for front seat passengers (9.1% Nanjing, 1.0% Zhoushan) and virtually nonexistent for rear passengers (0.5% Nanjing, 0.2% Zhoushan). Generally levels declined significantly from year to year (drivers Nanjing 66.7%, 47.7%, 38.6%; Zhoushan 57.4%, 57.9%, 30.6%; front passengers Nanjing 19.2%, 6.6%, 3.2%). Zhoushan wearing did not initially decline, 2006 observations coinciding with anticipation of provincial regulations (July 2006). Observations revealed an absence of child restraints. Pretend wearing/belt tampering was observed almost exclusively in taxi drivers (14.2% of Nanjing taxi drivers, 11.3% of Zhoushan’s). Awareness of and attitudes to urban seat belt laws should be investigated, appropriate countermeasures developed and enforcement reassessed.