Chapter 17
Reducing the Misuse of Firearms
Frederick P. Rivara and Arthur L. Kellermann
17.1 INTRODUCTION
Firearm injuries, by virtue of the number of deaths, years of life lost, and cost to society, represent an important and persistent public health problem. It is also a problem that crosses several disciplines, particularly public health, clinical medi- cine, mental health, criminology, and criminal justice. Approaches to controlling injuries due to guns involve all of these disciplines and include many strategies that have been effective for other injury control problems. In 2005, the U.S. Task Force on Community Preventive Services published a systematic review of gun laws and effects on homicide and suicide (Hahn et al., 2005). That review contains detailed tables about the effect of a variety of laws. The National Academies was recently asked to assess “the strengths and limitations of the existing research and data on gun violence.” Their report (National Research Council, 2005) provides another comprehensive review, with detailed tables, weighing the evidence for various inter- ventions. Due to space constraints, neither document can be summarized here.
The intended audience and the goals of these two reports differ from those of this chapter. The National Research Council (NRC) report was targeted at researchers, and its recommendations were directed at stimulating a stronger evidence base for gun policy through rigorous research. The Task Force report was narrowly focused on legislative approaches and, similar to the NRC report, was directed at assessing the quality of the current research evidence on gun policy. This chapter, on the other hand, is directed at public health practitioners and policy makers—individu- als who must base their actions and decisions on the evidence that is available now.
Although the total fluctuates from year to year, firearms consistently rank second only to motor vehicle crashes as a cause of fatal injury in the United States.
More than 95% of fatal firearm injuries are the result of self-directed or interper- sonal violence (Figs. 17.1 and 17.2). Data on deaths and injuries from firearms can be obtained from a number of sources. Deaths are almost completely captured by the vital statistics systems. While complete, these data provide no information
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on the identity or characteristics of the perpetrator, make or model of gun, or circumstances of the shooting. The Uniform Crime Reports have more detailed information on the circumstances of firearm homicides but are part of a voluntary system, often incomplete, and provide no information about suicides or uninten- tional shootings.
A more promising source of data is the National Violent Death Reporting System (NVDRS) established by the Centers for Disease Control and Prevention (CDC) in 2002 (Paulozzi, Mercy, Frazier, & Annest, 2004). Modeled after the Fatal- ity Analysis Reporting System of the National Highway Traffic Safety Administra- tion (NHTSA) for motor-vehicle crash-related injuries, this data set is intended to provide more detailed, uniform information on all violent deaths, regardless of method, including suicides and unintentional shootings. Nonfatal injuries are most often treated in hospital emergency departments; however, few states have any sys- tematic data on nonadmitted patients. Local surveillance systems can be developed
0 2 4 6 8 10 12 14 16
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001
Rates per 100,000
All
Unintentional Homicide Suicide
Figure 17.1.Changing rates of firearm-related fatality rates by intent, 1981–2002.
3%
40%
57%
Unintentional Homicide Suicide
Figure 17.2. Percentage of deaths caused by gun suicides, homicides, and unintentional injuries in 2002.
and can be used to guide intervention efforts (Kellermann, Bartolomeos, Fuqua- Whitley, Sampson, & Parramore, 2001). Hospitalized injuries can be captured by statewide hospital discharge databases, many of which are available through the Agency for Healthcare Research and Quality (2005) in its Healthcare Cost and Utilization Project (HCUP).
The available data demonstrate that firearm injuries continue to be a major cause of mortality in the United States, producing approximately 30,000 deaths per year. In 2002, more than half of these deaths were suicides, a fact that has been neglected by much of the public health community and largely outside the scope of criminal justice efforts to decrease firearm misuse. Firearm deaths from suicide have decreased by only 17% since 1981, whereas homicide deaths have decreased by 35% and unintentional deaths by 65%. Thus interventions to reduce firearm-related mortality must consider suicides as well as homicides and unintentional deaths.
Gun injuries have a very high case-fatality ratio, especially self-inflicted gunshot wounds. In a large population-based study, self-inflicted gunshot wounds had a case fatality ratio of 0.86 and assault-related firearm injuries had a case fatality ratio of 0.16 (Kellermann et al., 1996). Many of these individuals were pronounced dead on the scene or died before or shortly after reaching a hospital. Because the case-fatal- ity ratio for firearm injuries is so high, they are not as great a cause of hospitaliza- tions (relative to their contribution to deaths) as are falls or motor-vehicle crashes (Wadman, Muelleman, Coto, & Kellermann, 2003) (Figs. 17.3 and 17.4).
Figure 17.3. The pyramid of injury for all causes of injury—Missouri and Nebraska, 1996–1998. The base represents emergency department visits (ED), the middle third represents hospitalizations (Hosp), and the apex represents fatalities (Death).
The long-term consequences of firearm injury can be substantial. In one study of hospitalized gunshot victims, health status (measured by the Short-Form (SF)-36) 6–12 months after injury was significantly worse than before the event. In addition to physical disabilities, more than one third of individuals studied reported symp- toms of posttraumatic stress disorder (Greenspan & Kellermann, 2002).
Another measure of the magnitude of the gun problem and its importance for society are the costs of gun violence. Recently, Cook and Ludwig (2000) conducted an extensive analysis of these costs. Their approach considered not only the costs stemming from gunshot injuries but also “the costs of all the efforts to deter shoot- ings or protect against them” (p. 49). They estimate that the costs of gun violence in the United States are on the order of $116 billion per year (in 2004 dollars).
17.2. HISTORY OF PUBLIC HEALTH PREVENTION EFFORTS
Public health efforts to prevent firearm injuries have been relatively limited.
Most have consisted of educational efforts, which, as reviewed below, have not proven to be very effective. Some efforts have been made to promote safe storage
Figure 17.4. The pyramid of injury for firearm injuries—Missouri and Nebraska, 1996–1998. The base represents emergency department visits (ED), the middle third represents hospitalizations (Hosp), and the apex represents fatalities (Death).
of guns, an intervention now resting on firmer ground with the publication of recent data.
In contrast to the limited efforts of public health, police and the criminal justice community have made extensive efforts to combat the gun violence problem.
Concern about gun violence intensified during the crack cocaine–induced homi- cide epidemic of the mid-1980s to early 1990s, a surge driven almost entirely by gun homicides (Blumstein, Rivara, & Rosenfeld, 2000). Some of the efforts imple- mented in response to this challenge appear to have been successful, although not without controversy (NRC, 2005).
No injury control problem in America is more politically contentious than injuries resulting from the use or misuse of firearms. The political passions that surround any discussion of “gun control” have seriously hindered efforts to adopt broad-based, public health approaches to firearm injury (Kellermann, 1997).
17.3. REVIEW OF INTERVENTIONS (TABLE 17.1)
17.3.1. Educational Interventions
The vast majority of educational efforts specifically designed to prevent firearm injuries are focused on youth and the prevention of unintentional shootings. Some interventions are directed at parents, some at youth, and some at both. This litera- ture was extensively reviewed by the NRC (2005). Of the more than 80 programs disseminated in the United States, the NRC identified formal evaluations for 11.
No evidence of effects on real-life behavior or on shootings was found. The experi- ence of the two decades since the publication of Injury in America (NRC, 1985) has taught us that evaluation of educational interventions must extend beyond measur- ing changes in knowledge, attitudes, and self-reported behaviors or even observed behavior in laboratory settings. It has been repeatedly shown that such measures correlate poorly with actual behavior in the real world, much less reductions in the incidence or severity of injuries.
Despite numerous studies and stories of firearm injuries involving children, many gun-owning parents still have an unrealistic notion of how responsibly their child would behave around a loaded firearm (Farah, Simon, & Kellermann, 1999).
In one study, covert observation of 8- to 12-year-old boys playing in a room where a specially instrumented firearm was placed revealed that boys this age cannot be trusted to behave safely around firearms if no adult is present. This was true even among boys previously taught about firearm safety ( Jackman, Farah, Kellermann,
& Simon, 2001). No education intervention program has yet been shown to change this pattern of behavior. In the absence of such studies, there is no evidence to support the effectiveness (or lack of effectiveness) of educational programs aimed at reducing firearm injuries. When educational programs directed at young chil- dren have been implemented to prevent other kinds of injuries, results have been mixed (NRC, 2005). In light of these facts, we cannot endorse large-scale implemen- tation of child gun safety programs, unless they are done as part of a well-designed prospective study.
Although little is known about how to teach children to behave safely around guns, even less is known about how to prevent mishaps at the other end of the age spectrum, when cognitive decline can pose significant danger to gun owners (Green & Kellerman, 1996). Suicide among individuals with declining health
status is another concern. As America’s population ages, these issues will grow in importance.
The vast majority of educational interventions implemented to date are mostly focused on unintentional injuries, which account for a relatively small fraction of the firearm-injury problem in the United States (Fig. 17.2). Several educational programs have been implemented to prevent suicides, but none has specifically focused on suicides with guns. Some states mandate school-based suicide- prevention programs (Metha, Weber, & Webb, 1998) in hopes of increasing aware- ness; promoting identification of students at high risk of suicide attempts and suicide; enhancing the coping abilities of teenagers; and providing information to students, teachers, and parents on the availability of mental health resources for
Table 17.1. Potential Interventions to Prevent Injuries and Deaths from Firearms Educational interventions
• Educational interventions for youth and their parents
• School-based suicide-prevention programs
• Educational programs to help families of depressed individuals
• Education to promote safe storage of guns in the home Youth violence prevention programs
• Nurse home visiting
• Early childhood education
• Multisystemic therapy
• Therapeutic foster parents Engineering interventions
• Gun locks, lock boxes, and other safe storage technology
• Redesigning guns to reduce the risk of unintended discharge
Grip safeties
Loaded chamber indicators
Magazine disconnect devices
Drop safeties
Child-resistant designs
Personalized guns
• Nonlethal adjuncts for self-defense and law enforcement
• Designing environments to reduce the potential for gun violence
Metal detector technology
Bulletproof partitions in cabs, all-night gas stations, and convenience stores
Crime prevention through environmental design
Surveillance cameras
Enforcement of laws to reduce illegal carrying and/or use of firearms
• Right-to-carry laws
• Enhanced sentences for crimes committed with a firearm
• Increasing legal sanctions for unlawful carrying of a firearm
• Problem-oriented policing
• Directed patrols to identify and arrest illegal firearm carriers Decreasing the supply of firearms
• Regulating firearm sales
• Restrictive licensing of would-be purchasers
• Banning the sale of all firearms in a jurisdiction
• Firearm buyback programs
• Background checks of firearm purchasers
• Restrict access by perpetrators of intimate partner violence
• Increased oversight of firearm dealers
• Systematic tracing of firearms seized from criminals to identify scofflaw dealers and/or straw purchasers
those who need them. Evaluations of these programs indicate potentially beneficial effects but all use weak study designs (Kalaft, 1997; Metha et al., 1998; Zenere &
Lazarus, 1997).
Conversely, educational interventions to encourage family members or next- of-kin to remove guns from the homes of depressed people have not proven to be successful. In one study involving parents of depressed adolescents, 26.9% of families heeded the advice of their physicians to remove guns from the home.
Unfortunately, another 17.1% actually acquired one or more guns during the 2-year follow-up period (Brent, Baugher, Birmaher, Kolko, & Bridge, 2000).
17.3.2. Engineering Measures 17.3.2.1. Safe Storage
Families that are unwilling to consider removing guns from the home are generally more receptive to the idea of safe storage, using a variety of technologies, reviewed below. The idea of safe storage appears to be particularly acceptable to gun owners with small children in their homes. Most organizations, regardless of their position in the larger gun control debate, endorse the idea that guns and ammunition in the home should be stored safely.
There are good reasons to adopt this strategy. A population-based study of shootings in three United States cities found that 73% of unintentional shootings and 87% of firearm suicides occurred in a home, most often the home of the victim (Kellermann et al., 1996). Safe storage of firearms by a variety of means—
including use of gun locks, lock boxes, or a gun safe—has the potential to reduce unintentional shootings; some gun suicides; and, by preventing thefts, perhaps some homicides as well. Studies of the relationship between readily accessible firearms and the risk of unintentional shootings or suicide in the home have found vary- ing degrees of association (Brent et al., 1991, 1988, 1993; Conwell et al., 2002;
Kellermann et al., 1992; Shah, Hoffman, Wake, & Marine, 2000). A recent case- control study demonstrated that locking guns up is associated with a 73% decrease in the risk of a youth gun suicide or unintentional gun death (Grossman et al., 2005). Another recent case-control study examined the effect of safe storage on suicide risk, stratifying by the degree of the individual’s intent to die (Shenassa, Rogers, Spalding, & Roberts, 2004). Safe storage appeared to prevent suicide among those with low or medium intention to die but was not protective for those with a high intent to die.
Despite the potential benefits of this strategy, it is unclear whether programs that promote safe storage of guns are effective. A systematic review of seven evalu- ations of efforts to promote safe storage yielded mixed results (McGee, Coyne- Beasley, & Johnson, 2003). Only one of these studies was a randomized controlled trial; it showed no effect (Grossman et al., 2000).
Another argument marshaled in support of safe storage of guns is prevention of theft—an important source of guns used in crime. Cook, Molliconi, & Cole (1995) estimate that as many as 500,000 guns are stolen each year in the United States. As many as 10% of guns that are not acquired legally from federally licensed dealers are stolen (Alcohol, Tobacco, and Firearms [ATF], 2000). In theory, there could be adverse effects from promoting gun locks, if this impaired access to a gun when urgently needed for self-defense. Estimates of the annual incidence of defensive gun use vary widely, from 100,000 per year (McDowall & Wiersema, 1994) to 2.5 million or more per year (Kleck & Gertz, 1995). However, at least one study
suggests that firearms are infrequently used to resist home invasion crime. In a study of 198 such incidents, the victim used a gun to successfully resist the intruder in only 3 (1.5%). However, six victims lost their firearm to the intruder(s) (Kellermann, Westphal, Fischer, & Harvard, 1995). Unfortunately, the gun that is kept loaded and within easy reach for protection may also be reached by a curious child, an angry spouse, or a depressed grandparent. The odds that the firearm kept in the home will be involved in the death or injury of a member of the household substantially outweigh the odds that it will be used to injure or kill an intruder (Kellermann, Somes, Rivara, Lee, & Banton, 1998).
One compromise that provides a measure of safety yet allows quick access is use of a lockbox or safe with a push-button lock or user-specific sensor. These devices allow almost instantaneous access to the gun. Unfortunately, there are no data on whether safe storage of guns with these devices increases or decreases important outcomes, such as the rate of home invasions, burglary, or firearm theft.
17.3.2.2. Safer Firearms
The science of injury control has repeatedly demonstrated that one of the most effective methods to prevent unintentional injuries or decrease their severity is by building safety into the device itself. The number of motor-vehicle crash deaths per million miles driven has steadily declined over the last four decades due in great part to changes in the vehicle itself: collapsible steering wheels, side-impact protec- tion, padded dashes, laminated windshields, antilock brakes, and other changes.
Conversely, most changes made to guns over the same time period, such as chang- ing the most prevalent design from low-capacity revolvers with a relatively slow rate of fire to high-capacity pistols with faster rates of fire, have increased their lethality (Wintemute, 1996).
Meanwhile, manufacturers have done little to make their products less prone to inadvertent or unauthorized discharge. As many as one third of fatal and non- fatal firearm shootings may be attributed to lack of basic safety features and other shortcomings in gun design (Ismach et al., 2003). A number of simple and readily available devices can reduce unintentional shootings; these include grip safeties, loaded chamber indicators, and magazine-disconnect devices. Grip safeties require that the firearm be held properly and with a certain amount of strength, thereby preventing careless users and young children from inadvertently discharging the firearm. Loaded chamber indicators show the user that the gun has a bullet in the chamber, even if the magazine has been removed. A magazine disconnect device can prevent the firearm from being discharged once the magazine is removed. This is important because one third of U.S. adults believe that a firearm cannot be shot if the magazine is removed (Vernick, Meisel, Teret, Milne, & Hargarten, 1999).
More technologically sophisticated options could be easily adopted as well (Teret & Culross, 2002; Teret, DeFransecco, Hargarten, & Robinson, 1998). One idea that has been insufficiently explored is to design firearms to meet a certain standard of child resistance. Although this approach was employed to great effect to develop child-resistant containers for pharmaceuticals and other posions, it has not been attempted to decrease child injuries from firearms. Polls show that the idea has strong public support, even among gun owners. (Ismach et al., 2003;
Karlson & Hargarten, 1997; Teret et al., 1998). Yet another option is the idea of personalizing guns to prevent an unauthorized user, be it a child or another adult, from using the gun. Personalization of guns could involve requiring the
owner to wear a programmable electronic or magnetic ring on the hand that grips the gun or equipping the firearm with a device that recognizes the fingerprints of the authorized user. Use of personalizing technology could have a major effect on the 500,000 stolen guns entering the secondary market each year because stolen guns with this feature would be useless to criminals (Cook & Ludwig, 2000).
Currently, imported handguns must meet AFT (AFT, 1983) designer and per- formance criteria; domestically manufactured guns do not. These criteria provide importers with a modest incentive to include certain gun safety features in their products, but they aren’t required to do so. An examination of 755 different handgun models made or imported into the United States revealed that all of the imported handguns but only 66% of the domestic models met the ATF’s criteria However, no handgun, whether imported or domestically manufactured, contained all four desirable safety devices: a loaded chamber indicator, grip safety, magazine safety, and a firing pin block. Many did not include even one of these (Milne, Hargarten, Kellermann, & Wintemute, 2003).
Unfortunately, none of these technological options has been evaluated in large-scale studies to determine if they reduce unintended shootings. Although there are strong theoretical reasons to support the adoption of engineering coun- termeasures to reduce unintended shootings, there are no empirical studies to prove the validity of this approach. The NRC (2005, p. 215) report concluded that in the absence of such data, arguments on both sides of the issue of gun technol- ogy “are largely speculative.”
17.3.3. Enforcement Measures 17.3.3.1. Child Access Prevention Laws
Sometimes, individuals can be persuaded to adopt a desired injury prevention behavior under the force of law. In response to public concern about unintended shootings of children, several states adopted child access prevention (CAP) laws that make it a crime if a child is shot with an adult’s gun. The goal of CAP laws is to promote the safe storage of guns.
Evaluations of CAP laws have produced conflicting results. Lott and Whitley (2002) found no effect of CAP laws on unintentional injuries or suicides among youth but reported a net increase in violent crime. In contrast, Cummings, Gross- man, Rivara, and Koepsell (1997) found that CAP laws were associated with a 23%
reduction in unintentional shooting deaths among children under the age of 15 years. State-level declines in homicide and suicide rates were noted as well, but these differences were not statistically significant. Webster, Vernick, Zeoli, and Mangan- ello (2004) evaluated CAP laws and found that their enactment was associated with an 11% decrease in firearm suicides and no compensatory increase in nonfirearm suicides among 14- to 17-year-olds. They found a similar effect on both gun and nongun suicides for 18- to 20-year-olds as well. Thus CAP laws may represent an important intervention for prevention of youth suicides, especially suicides with a firearm.
17.3.3.2. Increased Likelihood of Arrest and Punishment
Illegal acquisition and illegal carrying of guns can be reduced by increasing the likelihood of arrest and the legal consequences of proscribed possession. Fire- arms, even illegally acquired firearms, can be approached as a commodity using
the economic principles of supply and demand. Decreasing illegal demand for firearms among criminals or reducing illegal supply and/or the illegal carrying of firearms could potentially break the chain of events that leads to gun violence and thereby reduce the incidence of gun assaults and homicides (Fig. 17.5). Most of the research on the effectiveness of various strategies to reduce illegal acquisi- tion, use, or carrying of firearms has been conducted by researchers in criminal justice and criminology and thus may be unfamiliar to public health professionals.
Because legislation and enforcement are important components of injury control, it is important to examine the evidence of potential benefit from efforts directed at decreasing illegal use of guns.
17.3.3.3. Right-to-Carry Laws
According to the NRC (2005), 34 states have current laws (also known as shall issue laws) allowing individuals who do not meet certain disqualifying criteria (primarily criminal record, mental illness, or domestic violence offender) to carry concealed handguns. The effect of these laws on crime and murder has been hotly debated in the literature. Some analyses indicate that these laws reduce crime and violence (Lott, 2000; Lott & Mustard, 1997). However, other analyses have reached the opposite conclusion (Ayres & Donohue, 2003a, 2003b) Still other evaluations have found no significant effect one way or the other (Duggan, 2001). The most recent study indicates that right-to-carry laws are associated with an 8% increase in homi- cide (Relative Risk (RR): 1.08; 95% confidence interval [CI]: 0.99–1.17) (Rosengart et al., 2005). What is clear is that the results are very sensitive to the analytic model employed and the variables used. The NRC (2005, p. 121) concluded (although not without dissent) that “it is impossible to draw strong conclusions from the existing literature on the causal impact of these laws.”
Figure 17.5.The chain of events leading to firearm violence.
Illegal Demand
Illegal Supply
Illegal Carrying
Illegal Use
Firearm Violence
*“Lie and buy”
*Straw purchasers
*Firearm trafficking
*Fear of victimization
*Low likelihood of arrest
*“Hot-spot” neighborhoods
*Crimes of opportunity
*Drugs–guns connection
*Serial shooters
*Overcrowded jails
*Limited consequences
17.3.3.4. Enhanced Sentences for Firearm Crimes
Judicial interventions to decrease demand for criminal use of guns have cen- tered on stiffening sentences for crimes committed with guns and on incarcerat- ing individuals, especially juveniles, for unlawfully carrying a gun. Perhaps the most well known of the sentence-enhancement efforts for firearm-related crimes is Richmond’s Project Exile, begun in 1997. The core of the program was transferring prosecution for selected felonies committed while in possession of a gun from state to federal courts, which do not allow parole and therefore result in much longer sentences.
Project Exile was widely touted as a great success, but subsequent analyses suggest that its effect may have been less than originally thought (Raphael &
Ludwig, 2003). Project Exile was implemented at a time when firearm homicide and overall homicide rates were dropping substantially in many cities across the country.
In addition, because Richmond experienced a surge in firearm crime immediately before implementing Project Exile, the subsequent decline may be due at least in part to regression to the mean. Once these factors are taken into consideration, the effect of Project Exile appears to be modest at best.
17.3.3.5. Unlawful Carrying
Another strategy to reduce criminal use of guns is to directly target the unlawful carrying or use of firearms. The best-known example of this strategy is the Bartley- Fox law, which was implemented in Massachusetts in 1975. This law mandated a minimum 1 year of incarceration for unlawful carrying of a firearm. Actual imple- mentation of the law was marked by the use of lesser possession charges, and poten- tially fewer gun arrests. Analyses of the Bartley-Fox law produced mixed results, suggesting unclear effects (Beha, 1977; Deutsch & Alt, 1977; Pierce & Bowers, 1981). Other countries have attempted to discourage illegal carrying in their own way. Responding to skyrocketing rates of firearm homicide, the mayors of Cali and Bogotá, Colombia, established a ban on the carrying of firearms on weekends after a payday and on holidays, times of particularly high homicide rates. Under this ordinance, police had authority to stop and search any citizen on the street. Even in a country as violent as Colombia, enforcement of the ban was associated with a 13–14% lower rate of homicide during these periods compared to times when gun carrying was allowed (Villaveces et al., 2000).
17.3.3.6. Effect of Policing Policies
Although such an indiscriminant policing strategy as used in Colombia could not pass constitutional muster in the United States, other tactics can be legally employed to break the chain of illegal acts before a violent crime occurs (Fig. 17.5).
Policing strategies can take a number of different forms, but most fall under the rubric of “problem-oriented policing” in which police focus on areas of the com- munity or individuals associated with high rates of gun crime (NRC, 2005). These policies are based on a large body of data that have consistently found that a small proportion of the population is responsible for a large portion of violent crime in a community (Farrington, 1996; Farrington, Langan, & Tonry, 2004; Loeber et al., 1999; Moffitt, 2003).
Several problem-oriented policing strategies have been subjected to rigorous examination for their effect on homicide. The most well known of these programs is the Kansas City Gun Project, in which extra proactive police patrols were used to target illegal gun carrying in a small area of Kansas City with a homicide rate 20 times the national average. These patrols increased the detection of gun carrying though car checks, pedestrian checks, searches associated with other arrests, and car stops for traffic violations. Although the effort produced a modest increase in the number of guns seized, the results were dramatic—the intervention area showed a 49% decrease in gun crimes compared to the control area, which had no decrease (Sherman & Rogan, 1995).
This program was subsequently replicated in Indianapolis. There, police focused on detecting illegal gun carrying by searching the cars of suspicious indi- viduals during traffic stops. The effort resulted in a 50% increase in the number of illegal guns seized and significantly decreased the gun homicide rate in the target area (McGarrell, Chermak, Weiss, & Wilson, 2001).
In 1998, Pittsburgh implemented stepped-up police patrols to detect illegal gun carrying by suspicious persons in two areas of the city with historically high rates of gun crime. To maximize its effect, the operation was focused on particu- larly dangerous days of the week (“high risk places at high risk times”) (Cohen &
Ludwig, 2003). A rigorous analysis of the program found that it produced a 71%
reduction in gunshot injuries from assault in the intervention areas on patrol days compared to control areas (Cohen & Ludwig, 2003).
Could similar strategies be employed to reduce illegal gun carrying by juve- niles? One study of incarcerated juvenile offenders in Fulton County, Georgia, revealed that more than 80% of gun carriers acquired their first gun before the age of 15 years. A total of 40% of those who carried a gun reported that they did so to feel safer; another 40% felt more “energized” or excited by carrying a gun.
However, 34% reported anxiety, mainly due to fear of being caught. Almost all of the respondents reported that guns were widely available from a variety of sources (Ash, Kellermann, Fuqua-Whitley, & Johnson, 1996). Findings like these suggest that interventions designed to reduce juveniles’ fear of crime, and therefore their perceived need to carry a gun for protection, and measures that increase fear of arrest could reduce levels of juvenile gun carrying (Ash et al., 1996).
A somewhat different approach was used by the Boston Gun Project to combat the high juvenile murder rate in that city during the late 1980s and early 1990s.
Working together, an interdisciplinary group of police agencies, prosecutors, com- munity groups, and academics implemented Operation Ceasefire—an highly coor- dinated effort to reduce gang violence by telling gangs that violence would not be tolerated and that violent acts by a gang would result in an immediate, severe, and sustained response. Gangs that challenged the prohibition quickly learned that the threat was real. Unlike the other programs described earlier, evaluation was built into the planning process. After implementation of Operation Ceasefire, the monthly total of homicides declined 63%, a trend significantly different from that in other cities during the same time frame (Braga, Kennedy, Piehl, & Waring, 2001a, 2001b; NRC, 2005).
17.3.4. Reducing Firearm Availability
It may also be possible, through a variety of tactics, to reduce gun violence by decreasing the illegal supply of firearms and/or reducing diversion of firearms from legal to illegal markets.
17.3.4.1. Regulating Firearm Sales
Only federally licensed dealers can legally receive interstate shipments of guns, and these guns can be legally sold only after a background check on the purchaser. The requirement for a background check and a 5-day waiting period was mandated by Congress in the Brady Bill of 1994. In 1998, the law was modified to allow “instant”
background checks, and it was extended from handguns to cover the purchase of long guns as well. Despite the intuitive appeal of this strategy, and the political struggle that surrounded its enactment, evaluations showed that the law had no overall effect on homicide or suicide rates (Ludwig & Cook, 2000). However, in the subset of states that instituted and maintained a waiting period, the rate of firearm suicides involving people ages 55 years of age and older substantially declined.
The value of a background check is supported by a study from California, which revealed that during the first week after purchase of a handgun, purchasers have a firearm suicide rate 57-fold higher than the general population (Wintemute, Parham, Beaumont, Wright, & Drake, 1999)
There are other data supporting the practice of conducting background checks and denying proscribed individuals the right to purchase a handgun may decrease firearm injuries and fatalities. For example, studies by Wintemute and colleagues (Wintemute, Wright, Drake, & Beaumont, 2001; Wright, Wintemute, & Rivara, 1999) of individuals denied handgun purchase in California indicate that denial was associated with subsequent decreases in the rate of arrest for gun offences and violent crimes.
Prohibition of sales of particular types of guns have been part of the federal effort to decrease gun injuries since 1934, when Congress outlawed the sale of machine guns and sawed-off shotguns (Vernick & Hepburn, 2003). This was sub- sequently expanded to include Saturday night specials in some states, assault-type semiautomatic weapons in 1994 (Vernick & Hepburn, 2003), and a few types of ammunition (e.g., exploding bullets). A study of the Maryland law banning Sat- urday night specials found no immediate effect of the law but possibly a delayed effect, with a 6.8–11.5% lower rate of gun homicides in subsequent years (Webster, Vernick, & Hepburn, 2002). A more recent analysis of the law found no net effect on firearm homicides or suicides (Rosengart et al., 2005). Faced with conflicting accounts of its effect and the powerful political opposition to its continuation, the assault weapons ban was allowed to expire on September 13, 2004.
Another tactic to reduce illegal supply of guns involves limiting the number of guns that can be bought at a single time by any one individual. The idea behind this policy is to discourage straw purchasing—the legal acquisition of guns followed by rapid resale of the guns to legally proscribed individuals, such as felons or juve- niles. After a “one gun a month” law was implemented in Virginia, the number of crime guns that could be traced back to purchases in Virginia decreased by 36%
(Weil & Knox, 1996). There was also a 66% reduction in crime guns along the I-95 corridor to the northeast United States that could be traced back to Virginia after enactment of the law. However, another evaluation of Virginia’s law and a similar law in Maryland found no net effect on either state’s rate of gun homicides or sui- cides (Rosengart et al., 2005). This suggests that any shortfall in supply was offset by guns from states with lax gun laws, such as Georgia and Alabama.
Canada has long adopted a restrictive approach to firearms, particularly hand- guns. Two retrospective cohort studies designed to assess the effect of Canada’s approach to gun control compared rates of crime, violence, homicide, and suicide by method in Vancouver, British Columbia, to those of Seattle, Washington, a
U.S. city of similar characteristics. Although the two cities had very similar rates of criminal activity and assault during the 7-year study interval (1980–1986), the rate of homicide in Seattle was 63% higher than in Vancouver. Virtually all of this excess risk was attributable to a 4.8-fold higher rate of handgun homicide in Seattle (Sloan et al., 1988). It is interesting that when the effects of Canadian-style gun control on suicide rates in King County, Washington, and the Vancouver metro area were examined a different pattern emerged. This study revealed that firearms were used to commit suicide in King County more than twice as often as guns were used to commit suicide in Vancouver. Handguns were used more than five times more often in King County. However, the higher rate of gun suicide in King County was entirely offset by a proportionately higher rate of firearm suicides in Vancouver.
The only age group in which a higher rate of gun suicides in King County was not entirely offset by a higher rate of nongun suicides in Vancouver was among 15- to 24-year-olds, a group thought to make more impulsive suicide attempts (Sloan, Rivara, Reay, Ferris, & Kellermann, 1990).
To the best of our knowledge, there are no studies of the effect of bans of specific types of ammunition. Ammunition bans were not covered in the NRC (2005) report or in recent systematic review of firearm laws by the Task Force on Community Preventive services (Hahn et al., 2005).
17.3.4.2. Banning the Sale of All Firearms
For understandable reasons, banning the sale of all guns has rarely been tried.
In 1976, Washington, D.C., banned the purchase, sale, transfer, or possession of handguns by any civilian in the District. Loftin, McDowall, Wiersema, and Cottey (1991) compared the homicide and suicide rate in the District to that in the adjacent metropolitan areas of Maryland and Virginia over the following 9 years.
During that time interval, the authors found that the law was associated with a 25%
decrease in gun homicides, a 23% decrease in gun suicides, and with no increase in nongun homicides or suicides. Others have examined the effect of the D.C.
handgun ban and reached different conclusions. One reported that homicide rates in D.C. increased compared to Baltimore (Britt, Bordua, & Kleck, 1996). Because handgun bans are controversial, studies of their effect should be conducted in other cities that have enacted such policies. For example, Chicago banned the sale of handguns in 1982, although the prohibition does not extend to the city’s numerous (and nearby) suburbs.
17.3.4.3. Gun Buy-back Programs
One way that has been suggested to decrease the pool of available guns is to buy them back from individuals, with no questions asked. The largest such program was instituted in Australia after the massacre of 35 people at Port Arthur in 1996 by an individual wielding a semiautomatic rifle. This led to a government prohibition of self-loading rifles and self-loading and pump-action shotguns and an offer to buy back those that were already in circulation, resulting in an estimated 50–90%
of these weapons being taken out of circulation. The net result of this policy was removal of approximately 20% of all firearms in Australia (Reuter & Mouzos, 2003).
Following this gun buyback, firearm homicides and suicides sharply declined, but there was no significant change in Australia’s overall homicide and suicide rates (Reuter & Mouzos, 2003). It is important to note, however, that guns were never
the dominant means of homicide or suicide in Australia. Even a 50% reduction in long-gun homicides would decrease the overall homicide rate in the nation by only 5%. Buy-back programs in the United States are popular, but they have never been shown to be effective. (Callahan, Rivara, & Koepsell, 1994; Sherman, 2001).
The concept of gun buybacks in the United States is probably inherently flawed, because the guns turned in are almost all low-risk guns, rather than guns most likely to be used in assaults (Kuhn et al., 2002).
17.3.4.4. Preventing Access by Intimate Partner Violence Offenders
In the United States, about 11% of murder victims are killed by an intimate partner; among females, this is as high as one third of murders (Fox & Zawitz, 2001;
Kellermann & Heron, 1999). More than twice as many women are shot and killed by their spouse or an intimate acquaintance than are murdered by strangers using a gun, knife, or any other means (Kellermann & Mercy, 1992). An abusive male having access to a gun has been associated with a 7.6 fold increased risk of intimate partner femicide (Campbell et al., 2003). In one large case-control study of gun ownership as a risk factor for homicide in the home, keeping a gun in the home was associated with a 2.7-fold increased risk. Virtually all of this risk was due to homicide at the hands of a family member or intimate acquaintance (Kellermann, Rivara, &
Rushforth, 1993).
In response to the problem, federal and state laws were enacted to prevent individuals convicted of intimate partner misdemeanors, as well as those under a current protection order, from purchasing or owning a gun (Vigdor & Mercy, 2003). Convicted felons, regardless of offense, are already prohibited from legally purchasing or owning a gun. State laws directed at preventing individuals with an active protection order from owning a gun appear to be associated with a 9% reduc- tion in both overall and firearm-related intimate partner homicide. In contrast, laws prohibiting gun ownership by individuals convicted of past intimate partner violence misdemeanors have no appreciable effect. Similar results were found for federal laws; there did not appear to be an additive effect when a jurisdiction had both a federal and state law (Vigdor & Mercy, 2003).
17.3.4.5. Regulating Firearm Dealers
Just as a small proportion of individuals account for the majority of crimes, so do a small proportion of federal firearms licensees account for the majority of the sales of guns subsequently used for assault and homicide (ATF, 2000). By systematically tracing all crime guns seized within a geographical area, law-enforcement agencies can readily determine if any federally licensed gun dealers are disproportionately involved in the sale of guns that are subsequently used to commit crimes. A Califor- nia study of crime guns used by youth under 25 years identified 812 federal firearm licensed dealers who were involved with the sale of at least one traced gun. However, 13 dealers, representing only 1.6% of all dealers involved with traced guns, sold 16.6% of these crime guns in California (Wintemute, Romero, Wright, & Grassel, 2004). Tightening of licensing requirements and increasing the fees charged for a federal firearms license reduced the number of federally licensed dealers from a high of 286,000 in April 1993 to a low of 102,020 in March 2000 (ATF, 2004).
Whether this reduction contributed to the decline in gun homicide that occurred during this interval is unknown.
17.4. DISCUSSION
One of the basic premises of injury control is that specific injury problems should be addressed by specific countermeasures. Public health–based efforts to reduce firearm injuries and fatalities can be done only by considering the three basic types of firearm injuries separately: interpersonal violence (including firearm assaults and homicides), self-directed violence (attempted and completed suicides), and unintentional shootings.
Compared with suicides and homicides, the problem of unintentional firearm injuries is small but nevertheless important, especially for children. In contrast to the other two causes of firearm injury, it should be readily amenable to prevention.
Most parents overestimate their child’s ability to be safe around guns ( Jackman et al., 2001). Unfortunately, the few educational programs tested to date have not shown to be effective. Faced with extravagant claims, but no empirical evidence of benefit, many parents may falsely conclude that it is no longer necessary to store their firearms in a safe and secure manner. In light of new evidence of the impor- tance of safe storage of guns and ammunition, an effective public health effort to promote safe storage might prevent many unintentional shootings and perhaps a few suicides. Unfortunately, no public education campaign has yet been shown to increase safe storage of guns (Sidman et al., 2005). This does not mean that such efforts are futile. Well-implemented, multifaceted community campaigns have been found to be effective in promoting other safety behaviors, such as bike helmet use (Rivara et al., 1994) and car seat use (Ebel, Koepsell, Bennett, & Rivara, 2003).
Changing product design offers the greatest hope for prevention of uninten- tional gun injuries, just as they have been effective with other types of unintentional injuries, such as motor-vehicle crash-related injuries. On this point, the NRC (2005, p. 217) seriously erred when it declared that engineering approaches are ineffec- tive. This is a fruitful avenue for exploration.
There is clear evidence that the type of weapon matters in determining whether a criminal assault will end in serious injury or death. Criminologists refer to this as an “instrumentality effect.” This instrumentality of violence suggests that mea- sures aimed at reducing illegal supply, acquisition, carrying, or use of firearms could contribute to an overall decrease in gun violence, including gun homicides (Fig. 17.5).
There is no evidence to date that traditional public health approaches are effective for preventing intentional firearm injuries. However, two avenues are available that may allow public health practitioners to address this problem. One is to attack the underlying causes of violence. Recent reviews and decision models (Ebel et al., 2005) indicate that early childhood and adolescent interventions such as home visiting (Bilukha et al., 2005), early childhood education (Schweinhart, Barnes, & Weikart, 1993), multisystemic therapy (Borduin et al., 1995), and thera- peutic foster care (Hahn et al., 2004) can prevent violent behavior among youth.
Because there is strong continuity in behavior over time (Farrington, 1996) and because most murders are committed by individuals with a history of violence dating back to childhood, interventions implemented in early life may reduce gun homicides later on.
The other avenue for public health practitioners is to actively collaborate with police and criminal justice agencies in addressing firearm carrying and firearm violence. The St. Louis, Kansas City, and Boston projects indicate that targeted interventions on high-risk individuals and behaviors can potentially reduce firearm
violence in a community. Public health professionals, and particularly acute-care clinicians such as trauma surgeons, emergency physicians and emergency nurses, can play an active role in supporting law-enforcement agencies in identifying victims, collecting spent projectiles for ballistics analysis, conducting population- based firearm injury surveillance, and evaluating the impact of community-based gun violence countermeasures (Kellermann, 2004; Kellermann et al., 2001).
The evidence for instrumentality effects of guns is even stronger for suicide than for homicide (NRC, 2005). The treatment of depression is beyond the scope of our chapter and is not reviewed here. The strategies discussed here for unin- tentional injuries, including safe storage and changes in gun design, also have the potential to have an effect on rates of firearm suicide, the most common method of suicide in the United States. Strategies like these are solidly within the public health purview.
17.5. RESEARCH NEEDS
The recommendations in the NRC (2005) report addressed research needs to inform public policy around guns and are not to be repeated here. Nevertheless, there are some specific recommendations for the public health community that we can make. While randomized community intervention trials are difficult, they are necessary to understand accurately what works and what does not (Koepsell et al., 1992; Koepsell, Diehr, Cheadle, & Kristal, 1995) Because of confounding by different individual and community characteristics, observational studies cannot address many important issues of program efficacy; these can be resolved only by conducting large-sale, randomized studies.
Unfortunately, it is difficult to convince policymakers to fund evaluation research, particularly on an issue as controversial as gun control. Responding to pressure from political interest groups in the first half of the 1990s, Congress has curtailed funding for firearm injury prevention research (Kassirer, 1995, 1998;
Kellermann, 1997). The resulting lack of experimental evidence has hampered the development of sound public policies and public health interventions to decrease deaths and injuries from firearms. Notwithstanding these difficulties, it is clear that we are reaching the limits of what can be accomplished with prehospital care, trauma surgery, and rehabilitation. If we want to save more lives from firearm inju- ries, we must do a better job of prevention.
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