Handgun regulations, crime, assaults, and homicide. A tale of two cities

Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018

INTRODUCTION

The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers.

METHODS

Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018.

RESULTS

A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico.

CONCLUSION

States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Challenges, Successes, and the Future of Firearm Injury Prevention

Policy Points Firearm injury is a leading cause of death in the United States, with fatality rates increasing 34.9% over the past decade (2010-2020). Firearm injury is preventable through multifaceted evidence-based approaches. Reviewing past challenges and successes in the field of firearm injury prevention can highlight the future directions needed in the field. Adequate funding, rigorous and comprehensive data availability and access, larger pools of diverse and scientifically trained researchers and practitioners, robust evidence-based programming and policy implementation, and a reduction in stigma, polarization, and politicization of the science are all needed to move the field forward.

Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80

Firearms are a leading cause of injury mortality across the lifespan, with elevated risks for older adult populations. To inform prevention efforts, we conducted a probability-based web survey (12/1/2019-12/23/2019) of 2048 older adults (age 50-80) to characterize national estimates of firearm ownership, safety practices, and attitudes about health screening, counseling, and policy initiatives. Among older U.S. adults, 26.7% [95%CI = 24.8%-28.8%] report owning one or more firearms. The primary motivation for ownership was protection (69.5%), with 90.4% highlighting a fear of criminal assault. 39.4% of firearm owners reported regularly storing firearm(s) unloaded and locked, with 24.2% regularly storing at least one loaded and unlocked. While most firearm owners found healthcare screening (69.2% [95%CI: 64.9-73.1]) and safety counseling (63.2% [95%CI = 58.8-67.3]) acceptable, only 3.7% of older adults reported being asked about firearm safety by a healthcare provider in the past year. Among firearm owners, there was support for state-level policy interventions, including allowing family/police to petition courts to restrict access when someone is a danger to self/others (78.9% [95%CI = 75.1-82.3]), comprehensive background checks (85.0% [95%CI = 81.5-87.9]), restricting access/ownership under domestic violence restraining orders (88.1%; 95%CI = 84.9-90.7], and removing firearms from older adults with dementia/confusion (80.6%; 95%CI = 76.8-84.0]. Healthcare and policy-level interventions maintained higher support among non-owners than owners (p's < 0.001). Overall, data highlights opportunities exist for more robust firearm safety prevention efforts among older adults, particularly healthcare-based counseling and state/federal policies that focus on addressing lethal means access among at-risk individuals.

Violent trauma as an indirect impact of the COVID-19 pandemic: A systematic review of hospital reported trauma

INTRODUCTION

The COVID-19 pandemic has exacerbated many social conditions associated with violence. The objective of this systematic review was to examine trends in hospital reported violent trauma associated with the pandemic.

METHODS

Databases were searched in using terms "trauma" or "violence" and "COVID-19," yielding 4,473 records (2,194 de-duplicated). Exclusion criteria included non-hospital based studies and studies not reporting on violent trauma. 44 studies were included in the final review.

RESULTS

Most studies reported no change in violent trauma incidence. Studies predominately assessed trends with violent trauma as a proportion of all trauma. All studies demonstrating an increase in violent trauma were located in the United States.

CONCLUSIONS

A disproportionate rise in violence has been reported within the US. However, most studies examined violent trauma as a proportion of all trauma; results may reflect relative changes from lockdowns. Future studies should examine rates of violent trauma to provide additional context.

Barriers to Firearm Injury Research

INTRODUCTION

Firearm injuries and motor vehicle injuries are 2 leading causes of fatal injury in the U.S., each accounting for approximately 35,000 deaths annually. Research on firearm injuries is under-represented compared with research on motor vehicle collisions. This study seeks to identify perceived barriers to firearm injury research versus motor vehicle injury research.

METHODS

This was a mixed-methods survey of corresponding authors of a minimum of 1 study, archived in PubMed, related to firearm injury or motor vehicle injury between 2014 and 2018. Analyses were performed in 2019. Electronic surveys included both closed- and open-ended questions to assess barriers to research. Bivariable and multivariable logistic regression was performed to identify differences in perceptions to barriers between the 2 groups. Qualitative analysis of free-text responses was performed through inductive derivation of themes.

RESULTS

Surveys were distributed to 113 firearm injury researchers (42% response rate) and 241 motor vehicle injury researchers (31.5% response rate). After adjustment, firearm injury researchers were less likely to cite institutional support (AOR=0.3, 95% CI=0.1, 0.8) as a factor contributing to their success, than motor vehicle injury researchers. Firearm injury researchers were more likely to report fear of personal threats (AOR=10.4, 95% CI=2.4, 44.4) and experiencing personal threats (AOR=16.1, 95% CI=1.6, 165.4). Thematic analysis revealed 4 themes: career, political, funding, and harassment.

CONCLUSIONS

When compared with motor vehicle injury researchers, firearm injury researchers are significantly more likely to report limited support and threats to personal safety as barriers to research. Further research to understand the impact of these barriers and methods to overcome them is needed.

Trauma Surgeons' Perspective on Gun Violence and a Review of the Literature

Background

In the United States, there is a constant debate between the proponents of the right to bear arms and those desiring to reduce the epidemic of gun violence. We sought to capture the trauma surgeons' perspective on gun control.

Methods

We presented an on-line based survey to the members of the American Association for the Surgery of Trauma (AAST). Survey questions were chosen to reflect the popular media poll questions as well as trauma-specific perspectives. We compared the trauma surgeons' perspectives to that of the general populace from a poll conducted by the New York Times (NYT).

Results

A total of 120 trauma surgeons responded to the survey. The age group ranged from 34 to 82 years, and the median age was 51. Most respondents were male (64%, n = 67) and worked at a Level I trauma center (80%, n = 96) in an academic setting (67%, n = 80). About half of the responding surgeons owned a household firearm (40%; n = 48 of the AAST members vs. 47%; n = 521 of the general populace). Sixty-one percent of the trauma surgeons (n = 73) and 53% (n = 588) of the NYT respondents favor stricter gun control laws. While 80% (n = 888) of the NYT respondents felt that mental health screening and treatment would decrease gun violence, only 56% (n = 67) of surgeons felt that mental health screening would be beneficial. The majority (90%, n = 999) of the NYT poll respondents favor a law restricting the sale of guns only by licensed dealers. Only (66%, n = 79) of the trauma surgeons were in agreement with the stricter gun sale legislation by licensed dealers.

Conclusion

Trauma surgeons appear to share similar views with the general American populace regarding gun violence and injury control.

State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County

IMPORTANCE

Firearm laws in one state may be associated with increased firearm death rates from homicide and suicide in neighboring states.

OBJECTIVE

To determine whether counties located closer to states with lenient firearm policies have higher firearm death rates.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of firearm death rates by county for January 2010 to December 2014 examined data from the US Centers for Disease Control and Prevention for firearm suicide and homicide decedents for 3108 counties in the 48 contiguous states of the United States.

EXPOSURES

Each county was assigned 2 scores, a state policy score (range, 0-12) based on the strength of its state firearm laws, and an interstate policy score (range, -1.33 to 8.31) based on the sum of population-weighted and distance-decayed policy scores for all other states. Counties were divided into those with low, medium, and high home state and interstate policy scores.

MAIN OUTCOMES AND MEASURES

County-level rates of firearm, nonfirearm, and total homicide and suicide. With multilevel Bayesian spatial Poisson models, we generated incidence rate ratios (IRR) comparing incidence rates between each group of counties and the reference group, counties with high home state and high interstate policy scores.

RESULTS

Stronger firearm laws in a state were associated with lower firearm suicide rates and lower overall suicide rates regardless of the strength of the other states' laws. Counties with low state scores had the highest rates of firearm suicide. Rates were similar across levels of interstate policy score (low: IRR, 1.34; 95% credible interval [CI], 1.11-1.65; medium: IRR, 1.36, (95% CI, 1.15-1.65; and high: IRR, 1.43; 95% CI, 1.20-1.73). Counties with low state and low or medium interstate policy scores had the highest rates of firearm homicide. Counties with low home state and interstate scores had higher firearm homicide rates (IRR, 1.38; 95% CI, 1.02-1.88) and overall homicide rates (IRR, 1.32; 95% CI, 1.03-1.67). Counties in states with low firearm policy scores had lower rates of firearm homicide only if the interstate firearm policy score was high.

CONCLUSIONS AND RELEVANCE

Strong state firearm policies were associated with lower suicide rates regardless of other states' laws. Strong policies were associated with lower homicide rates, and strong interstate policies were also associated with lower homicide rates, where home state policies were permissive. Strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that may extend beyond state lines.

A longitudinal ecological study of household firearm ownership and firearm-related deaths in the United States from 1999 through 2014: A specific focus on gender, race, and geographic variables

Firearms have a longstanding tradition in the United States (US) and are viewed by many with iconic stature with regards to safety and personal freedom. Unfortunately, from a public health point of view, firearm-related deaths (FRDs) in the US have reached a crisis point with an estimated > 31,000 deaths and 74,000 nonfatal injuries resulting from firearms each year. This longitudinal ecological study analyzed variations in FRDs following firearm assaults (FAs) and law enforcement incidents involving a firearm (LEIF) in comparison to variations in household firearm ownership (HFO) among different geographic and demographic groups in the US from 1999 to 2014. The Underlying Cause of Death database was examined on the CDC Wonder online interface. Records coded with ICD-10 codes: FA (X93 – assault by handgun discharge, X94 – assault by rifle, shotgun, and larger firearm discharge, or X95 – assault by other and unspecified firearm discharge) and LEIF (Y35.0) were examined, and the prevalence of HFO was determined using the well-established proxy of the percentage of suicides committed with a firearm. Gender, ethnicity, Census Division, and urbanization significantly impacted the death rates from FA and LEIF. Significant direct correlations between variations in HFO and death rates from FAs and LEIF were observed. Understanding the significant impacts of gender, race, Census Division, and urbanization status may help shape future public health policy to promote increased firearm safety.

What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries?

Firearms account for a substantial proportion of external causes of death, injury, and disability across the world. Legislation to regulate firearms has often been passed with the intent of reducing problems related to their use. However, lack of clarity around which interventions are effective remains a major challenge for policy development. Aiming to meet this challenge, we systematically reviewed studies exploring the associations between firearm-related laws and firearm homicides, suicides, and unintentional injuries/deaths. We restricted our search to studies published from 1950 to 2014. Evidence from 130 studies in 10 countries suggests that in certain nations the simultaneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of (e.g., background checks) and access to (e.g., safer storage) firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children, respectively. Limitations of studies include challenges inherent to their ecological design, their execution, and the lack of robustness of findings to model specifications. High quality research on the association between the implementation or repeal of firearm legislation (rather than the evaluation of existing laws) and firearm injuries would lead to a better understanding of what interventions are likely to work given local contexts. This information is key to move this field forward and for the development of effective policies that may counteract the burden that firearm injuries pose on populations.

Public Mass Shooters and Firearms: A Cross-National Study of 171 Countries

OBJECTIVE

Model the global distribution of public mass shooters around the world.

METHOD

Negative binomial regression is used to test the effects of homicide rates, suicide rates, firearm ownership rates, and several control variables on public mass shooters per country from 1966 to 2012.

RESULTS

The global distribution of public mass shooters appears partially attributable to cross-national differences in firearms availability but not associated with cross-national homicide or suicide rates.

CONCLUSION

The United States and other nations with high firearm ownership rates may be particularly susceptible to future public mass shootings, even if they are relatively peaceful or mentally healthy according to other national indicators.

Alcohol misuse, firearm violence perpetration, and public policy in the United States

OBJECTIVE

Firearm violence is a significant public health problem in the United States, and alcohol is frequently involved. This article reviews existing research on the relationships between alcohol misuse; ownership, access to, and use of firearms; and the commission of firearm violence, and discusses the policy implications of these findings.

METHOD

Narrative review augmented by new tabulations of publicly-available data.

RESULTS

Acute and chronic alcohol misuse is positively associated with firearm ownership, risk behaviors involving firearms, and risk for perpetrating both interpersonal and self-directed firearm violence. In an average month, an estimated 8.9 to 11.7 million firearm owners binge drink. For men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. Enforceable policies restricting access to firearms for persons who misuse alcohol are uncommon. Policies that restrict access on the basis of other risk factors have been shown to reduce risk for subsequent violence.

CONCLUSION

The evidence suggests that restricting access to firearms for persons with a documented history of alcohol misuse would be an effective violence prevention measure. Restrictions should rely on unambiguous definitions of alcohol misuse to facilitate enforcement and should be rigorously evaluated.

State Firearm Legislation and Nonfatal Firearm Injuries

OBJECTIVES

We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries.

METHODS

We estimated discharge rates for hospitalized and emergency department-treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates.

RESULTS

We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3-36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department-treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries.

CONCLUSIONS

There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.

Bring a gun to a gunfight: armed adversaries and violence across nations

We use homicide data and the International Crime Victimization Survey to examine the role of firearms in explaining cross-national variation in violence. We suggest that while gun violence begets gun violence, it inhibits the tendency to engage in violence without guns. We attribute the patterns to adversary effects-i.e., the tendency of offenders to take into account the threat posed by their adversaries. Multi-level analyses of victimization data support the hypothesis that living in countries with high rates of gun violence lowers an individual's risk of an unarmed assault and assaults with less lethal weapons. Analyses of aggregate data show that homicide rates and gun violence rates load on a separate underlying factor than other types of violence. The results suggest that a country's homicide rate reflects, to a large extent, the tendency of its offenders to use firearms.

Effects of Causes and Causes of Effects: Some Remarks From the Sociological Side

Sociology is pluralist in subject matter, theory, and method, and thus a good place to entertain ideas about causation associated with their use under the law. I focus on two themes of their article: (1) the legal lens on causation that "considers populations in order to make statements about individuals" and (2) the importance of distinguishing between effects of causes and causes of effects.

The relationship between gun ownership and firearm homicide rates in the United States, 1981-2010

OBJECTIVES

We examined the relationship between levels of household firearm ownership, as measured directly and by a proxy-the percentage of suicides committed with a firearm-and age-adjusted firearm homicide rates at the state level.

METHODS

We conducted a negative binomial regression analysis of panel data from the Centers for Disease Control and Prevention's Web-Based Injury Statistics Query and Reporting Systems database on gun ownership and firearm homicide rates across all 50 states during 1981 to 2010. We determined fixed effects for year, accounted for clustering within states with generalized estimating equations, and controlled for potential state-level confounders.

RESULTS

Gun ownership was a significant predictor of firearm homicide rates (incidence rate ratio = 1.009; 95% confidence interval = 1.004, 1.014). This model indicated that for each percentage point increase in gun ownership, the firearm homicide rate increased by 0.9%.

CONCLUSIONS

We observed a robust correlation between higher levels of gun ownership and higher firearm homicide rates. Although we could not determine causation, we found that states with higher rates of gun ownership had disproportionately large numbers of deaths from firearm-related homicides.

The Burden of Bad Metaphors: Putting Blinders on how we Think about Gun Violence

There have been many calls for physicians to enter the political discourse on gun control by viewing “gun violence” as a “disease.” The medical metaphor for social problems is seductive, but has many pitfalls. Studies have shown that metaphors create significant cognitive bias regarding both the perception of the problem and can dictate the solutions that are considered. It creates an authoritarian approach to social problems that can have severe negative consequences. These problems have appeared in the use of the metaphor of “gun violence as disease.” Adherence to this metaphor has resulted in the substitution of advocacy for academic integrity and has damaged the credibility of the medical community.

Evaluating the effect of an injury prevention intervention in a population

The evaluation of injury prevention interventions is important before the widespread dissemination of these interventions. One level of evaluation is at the population level, to determine the effect of the intervention on the incidence of injury. The size and nature of the study population depend on the study design, the nature of the intervention, and the outcome measures of interest. Possible designs are randomized controlled trials; nonrandomized controlled trials; and observational studies, including cohort, case-control, and ecologic designs. These strategies have been successfully applied to evaluate a wide variety of interventions for intentional and unintentional injury prevention, the results of which have been used to guide public policy. These same strategies can be successfully used to evaluate methods for the prevention of injury due to child abuse.

Evidence for Interventions for Young Offenders

Young offenders are an issue of global concern. Despite a greater understanding of the aetiology of conduct disorder and juvenile delinquency, the research on treatments and the use of evidence-based methods of interventions has not kept pace. This review critically and selectively examined interventions for young offenders, and organises them based on levels of care. The challenge is to intervene using empirical strategies that are implemented based on our emerging understanding of aggression.

Penetrating trauma in Ontario emergency departments: a population-based study

BACKGROUND

There is a paucity of population-based research on health service utilization related to penetrating trauma in Canada, even though such trauma can result in serious injury or death, and gunshot wounds have been labelled the "the new public health issue." Complete epidemiologic data, including emergency department (ED) visits and hospitalizations, for penetrating trauma is not available. The objective of this paper is to describe the epidemiology of ED visits for firearm-related and knife-related penetrating trauma in one Canadian province.

METHODS

All EDs in the province of Ontario (pop. approx. 12 400 000 at the time of the study) submit data on ED visits to the National Ambulatory Care Reporting System. This database includes patients' demographic information (i.e., age, sex and geographic area of residence), the reason for the visit, disposition (i.e., admitted to hospital or sent home), and other diagnostic information. For visits related to injuries, the cause of injury is also reported (e-codes according to the Canadian Enhancement to the International Statistical Classification of Diseases and Related Health Problems, 10th rev [ICD-10-CA]). All patients seen in Ontario EDs for an injury related to a firearm, knife, or sharp object, were included in our study.

RESULTS

Of the 1.2 million ED visits in 2002-03 for trauma in Ontario, 40 240 (3.4%) patients were treated for injuries relating to penetrating trauma. Most patients were male, and most were 15-24 years of age. Penetrating trauma was frequently a result of knives or sharp objects (39 654 visits or 98.5%); only 1.5% (n = 586) of these injuries were caused by firearms. Of those hospitalized, 151 were related to firearms and 1455 were related to knives/ sharp objects.

CONCLUSIONS

Analyzing administrative data provides an estimate of the impact of penetrating trauma on a population, thereby providing prevention programs with data upon which to design their strategies. Evidence-based prevention strategies are needed to reduce the burden of penetrating trauma. Monitoring ED and hospitalization data over time will help to assess trends and provide evidence for the effectiveness of such strategies.

Cross-national study of fighting and weapon carrying as determinants of adolescent injury

OBJECTIVES

We sought to (1) compare estimates of the prevalence of fighting and weapon carrying among adolescent boys and girls in North American and European countries and (2) assess in adolescents from a subgroup of these countries comparative rates of weapon carrying and characteristics of fighting and injury outcomes, with a determination of the association between these indicators of violence and the occurrence of medically treated injury.

DESIGN AND SETTING

Cross-sectional self-report surveys using 120 questions were obtained from nationally representative samples of 161082 students in 35 countries. In addition, optional factors were assessed within individual countries: characteristics of fighting (9 countries); characteristics of weapon carrying (7 countries); and medically treated injury (8 countries).

PARTICIPANTS

Participants included all consenting students in sampled classrooms (average age: 11-15 years).

MEASURES

The primary measures assessed included involvement in physical fights and the types of people involved; frequency and types of weapon carrying; and frequency and types of medically treated injury.

RESULTS

Involvement in fighting varied across countries, ranging from 37% to 69% of the boys and 13% to 32% of the girls. Adolescents most often reported fighting with friends or relatives. Among adolescents reporting fights, fighting with total strangers varied from 16% to 53% of the boys and 5% to 16% of the girls. Involvement in weapon carrying ranged from 10% to 21% of the boys and 2% to 5% of the girls. Among youth reporting weapon carrying, those carrying handguns or other firearms ranged from 7% to 22% of the boys and 3% to 11% of the girls. In nearly all reporting countries, both physical fighting and weapon carrying were significantly associated with elevated risks for medically treated, multiple, and hospitalized injury events.

CONCLUSIONS

Fighting and weapon carrying are 2 common indicators of physical violence that are experienced by young people. Associations of fighting and weapon carrying with injury-related health outcomes are remarkably similar across countries. Violence is an important issue affecting the health of adolescents internationally.

From gunstore to smoking gun: tracking guns that kill children in North Carolina

PURPOSE

This study reviews the epidemiology of pediatric firearm deaths in North Carolina and estimates the time from the retail sale of guns to their involvement in pediatric firearm deaths.

METHODS

The authors reviewed autopsy reports for all children 0 to 14 years of age that died of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained included demographic information, firearm type, and manner of death. Data from the Bureau of Alcohol, Tobacco and Firearms, which traced guns involved in crimes and determined the time elapsed from purchase to their involvement in a crime (ie, time-to-crime were also reviewed).

RESULTS

During the study period, 40 children died of firearm injuries. Mean age was 7.6 years. Handguns were responsible for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and undetermined cause (10%). Most deaths were homicides (67%) followed by unintentional death (18%), suicide (13%), and undetermined cause (2%). Most crime guns (76%) were purchased legally, and many (40%) had a time-to-crime of less than 3 years.

CONCLUSIONS

Legally purchased firearms pose a significant threat to children in North Carolina. A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States.

Urban-rural shifts in intentional firearm death: different causes, same results

OBJECTIVES

We analyzed urban-rural differences in intentional firearm death.

METHODS

We analyzed 584629 deaths from 1989 to 1999 assigned to 3141 US counties, using negative binomial regressions and an 11-category urban-rural variable.

RESULTS

The most urban counties had 1.03 (95% confidence interval [CI]=0.87, 1.20) times the adjusted firearm death rate of the most rural counties. The most rural counties experienced 1.54 (95% CI=1.29, 1.83) times the adjusted firearm suicide rate of the most urban. The most urban counties experienced 1.90 (95% CI=1.50, 2.40) times the adjusted firearm homicide rate of the most rural. Similar opposing trends were not found for nonfirearm suicide or homicide.

CONCLUSIONS

Firearm suicide in rural counties is as important a public health problem as firearm homicide in urban counties. Policymakers should become aware that intentional firearm deaths affect all types of communities in the United States.

Impact of police and legislative initiatives on urban gunshot wound admissions

BACKGROUND

This study aimed to assess the effects of local and state anti-crime initiatives on the number of gunshot wound admissions to a level 1 trauma center.

METHODS

A retrospective time series analysis of gunshot wound admissions from July 1, 1990 to July 30, 1999 was performed at a level 1 trauma center. The gunshot wound admissions were divided into four subgroups: assault, suicide, accident, and police-involved gunshot wounds. The effects of the following three initiatives were studied: (1) the Three Strikes law; (2) a local police initiative, the Violent Crime Suppression Unit; and (3) the Use a Gun and You're Done law. The periods that corresponded with each intervention were defined, and the rates of gunshot wound-related admissions for all causes after each intervention were compared.

RESULTS

During the study, 1,499 patients were admitted with gunshot wounds. These admissions involved 1,220 assaults, 196 suicide attempts, 52 accidents, and 31 police-involved cases. Over the defined periods, an average of 13.7 gunshot wound admissions (range, 7.9-15.5) occurred, most of which were assaults (mean, 10.8; range, 5.5-13). There were no differences across the periods for gunshot wound admissions among three of the subgroups: suicide, accidental, and police-related gunshot wounds. However, the assault subgroup showed a significant decrease across all the periods and a statistically significant decrease after enactment of the Use a Gun and You're Done law (p < 0.005). When control was used for an increasing number of police officers, however, the association was no longer statistically significant.

CONCLUSIONS

Gunshot wound admissions attributable to assault at a level 1 trauma center decreased during a period when several local and state initiatives focused on decreasing violent crime were enacted. The causes likely were multifunctional, and included increasing the number of police officers as well as the enactment of new laws.

Mechanisms of Pediatric Trauma Deaths in Canada and the United States: The Role of Firearms

BACKGROUND

This study aimed to determine whether firearms are a more prevalent cause of pediatric death in the United States than in Canada.

METHODS

All pediatric trauma deaths from 1991 to 1996 in Ontario and Missouri were reviewed. Socioeconomic data were compiled for the two jurisdictions.

RESULTS

During the period reviewed, there were 1,146 pediatric trauma deaths in Ontario (10.4 per 100,000 population) and 1,782 in Missouri (32.4 per 100,000 population). Firearm injuries accounted for 19% of the trauma deaths in Missouri and 0.5% of such deaths in Ontario. Overall, a child was 100 times more likely to die of firearm injury in Missouri (6 per 100,000 population) than in Ontario (0.06 per 100,000 population). The incidences of violent acts unrelated to firearms were similar between the two groups. Both populations were similar in terms of socioeconomic and education parameters, but differed in their rates for guns carried.

CONCLUSION

The significantly higher death rate from firearm injuries in Missouri likely reflects differing gun control attitudes and legislation, and provides a rationale for prevention and future investigation.

Homicide and suicide risks associated with firearms in the home: a national case-control study

STUDY OBJECTIVE

I test the hypothesis that having a gun in the home is a risk factor for adults to be killed (homicide) or to commit suicide.

METHODS

Two case-control analyses were based on national samples of subjects 18 years of age or older. Homicide and suicide case subjects were drawn from the 1993 National Mortality Followback Survey. Living control subjects were drawn from the 1994 National Health Interview Survey. Ten control subjects matched by sex, race, and age group were sought for each case subject.

RESULTS

The homicide sample consisted of 1,720 case subjects and 8,084 control subjects. Compared with adults in homes with no guns, the adjusted odds ratio (OR) for homicide was 1.41 (95% confidence interval [CI] 1.20 to 1.65) for adults with a gun at home and was particularly high among women (adjusted OR 2.72; 95% CI 1.89 to 3.90) compared with men (adjusted OR 1.23; 95% CI 1.01 to 1.49) and among nonwhite subjects (adjusted OR 1.74; 95% CI 1.37 to 2.21) compared with white subjects (adjusted OR 1.27; 95% CI 1.03 to 1.56). Further analyses revealed that a gun in the home was a risk factor for homicide by firearm means (adjusted OR 1.72; 95% CI 1.40 to 2.12) but not by nonfirearm means (OR 0.83; 95% CI 0.62 to 1.11). The suicide sample consisted of 1,959 case subjects and 13,535 control subjects. The adjusted OR for suicide was 3.44 (95% CI 3.06 to 3.86) for persons with a gun at home. However, further analysis revealed that having a firearm in the home was a risk factor for suicide by firearm (adjusted OR 16.89; 95% CI 13.26 to 21.52) but was inversely associated with suicide by other means (adjusted OR 0.68; 95% CI 0.55 to 0.84).

CONCLUSION

Having a gun at home is a risk factor for adults to be shot fatally (gun homicide) or commit suicide with a firearm. Physicians should continue to discuss with patients the implications of keeping guns at home. Additional studies are warranted to address study limitations and to better understand the implications of firearm ownership.

Epidemiology and prevention of childhood injuries

Traumatic injury is the leading cause of death in children after infancy. The leading causes of childhood injury deaths are motor vehicle crashes, submersion injury, homicide, suicide, and fires. Injuries are not random events. Factors associated with injuries allow identification of high-risk populations and targeted interventions. Injury research includes development of conceptual models to include preinjury, event, and postevent features that can be modified to prevent or limit injuries. Successful prevention strategies often include multifaceted approaches such as education, incentives for safe human behavior, legislation/enforcement, and environmental changes. Preventive programs must weigh both societal and economic values and costs. Careful evaluation for effectiveness of injury prevention programs to decrease or limit injury continues to be a challenge. Generally, passive measure such as improved engineering are more effective than measures that require modification of human behaviors. Childhood injury prevention programs have reduced deaths from some causes such as motor vehicle crashes, but deaths from gun-related homicide and suicide remain high. Critical care providers can actively engage in both prevention efforts and improved acute care of the severely injured child.

More guns, more deaths

It is contended that easier access to small arms increases the likelihood of misuse, on the basis of evidence comparing rates of firearm mortality and availability both between comparably developed countries, contrasting particularly the United States and others, and in different regions of individual countries. For example, firearm mortality is often greater in rural areas than urban. Possible inaccuracies in data collection are considered, but felt not sufficient to account for the finding. Measures to restrict availability such as stricter licensing, regulations governing storage and legally-imposed 'gun-free zones' may all reduce the death toll. In conflict zones, measures to remove arms post-conflict reduce subsequent mortality. Breaking the supply chain is also important and the link between supply, demand and the values of a society must be kept in mind.

Firearm availability and suicide, homicide, and unintentional firearm deaths among women

CONTEXT

In the United States, more than 45,000 women died from gun violence over the last decade.

OBJECTIVE

To determine whether measures of firearm availability are related to rates of suicide, homicide, and unintentional firearm deaths among women in the United States.

DESIGN

Pooled cross-sectional time series data on suicide, homicide, and unintentional firearm deaths (1988-1997) were used to estimate the association between the rate of violent death among women and four proxies of firearm availability. Two proxies came from survey reports of household firearm ownership rates; two were derived from mortality statistics.

SETTING

United States, 1988-1997.

RESULTS

The increased rate of suicide and homicide in states with high gun levels was accounted for primarily by significantly elevated firearm suicide and firearm homicide rates. Unintentional firearm death rates were also increased in states with more guns. At the regional level, qualitatively similar results were obtained.

CONCLUSION

Between 1988 and 1997, the suicide, homicide, and unintentional firearm death rates among women were disproportionately higher in states where guns were more prevalent. The elevated rates of violent death in states with more guns was not entirely explained by a state's poverty or urbanization and was driven primarily by lethal firearm violence, not by lethal nonfirearm violence.

Firearm availability and unintentional firearm deaths, suicide, and homicide among 5-14 year olds

BACKGROUND

In the United States, only motor vehicle crashes and cancer claim more lives among children than do firearms. This national study attempts to determine whether firearm prevalence is related to rates of unintentional firearm deaths, suicides, and homicides among children.

METHODS

Pooled cross-sectional time-series data (1988-1997) were used to estimate the association between the rate of violent death among 5-14 year olds and four proxies of firearm availability, across states and regions.

RESULTS

A statistically significant association exists between gun availability and the rates of unintentional firearm deaths, homicides, and suicides. The elevated rates of suicide and homicide among children living in states with more guns is not entirely explained by a state's poverty, education, or urbanization and is driven by lethal firearm violence, not by lethal non-firearm violence.

CONCLUSION

A disproportionately high number of 5-14 year olds died from suicide, homicide, and unintentional firearm deaths in states and regions where guns were more prevalent.

Criminal deterrence as a public health strategy

Deterrence is an established theme in criminal justice, but its role in prevention of assault has been treated with ambivalence and even hostility in medicine. The extent to which offenders can be persuaded, through knowledge of criminal and health risks, not to injure others is emerging from studies of the health effects of firearm and other crime legislation, and from macro-level studies and controlled experiments of police interventions. There is convincing evidence that motorists can be deterred from alcohol-impaired driving, and recognition that specific, targeted, and visible police work and increasing certainty of punishment are effective interventions. By contrast, duration of imprisonment and generic police initiatives such as blanket increases in police numbers seem to have little effect on deterrence, at least in the context of the decline in US homicide rates since 1991, to which demographic and economic factors seem to have contributed little. Together with established and cost-effective preschool education and early family support, targeted policing and increasing rates of conviction should be integrated into strategies for injury prevention.

Community firearms, community fear

To examine how perceptions of safety are influenced as more people in a community acquire firearms, we conducted a nationally representative random-digit-dial survey of 2,500 adults and asked whether respondents would feel more safe, less safe, or equally safe if more people in their community were to acquire guns. We used multivariable logistic regression to explore correlates of perceived safety while taking into account various confounders. Fifty percent of respondents reported that they would feel less safe if more people in their community were to own guns; 14% reported they would feel more safe. Women and minorities were more likely than were men and Whites to feel less safe as others acquire guns, with Odds ratios of 1.7 and 1.5, respectively. Our findings suggest that most Americans are not impervious to the psychological effects of guns in their community, and that, by a margin or more than 3 to 1, more guns make others in the community feel less safe rather than more safe.

Assessing and managing violence risk in outpatient settings

Psychologists and other mental health professionals practicing in essentially all clinical settings are called on to assess and manage clients who may pose a risk of violence to third parties. Over the past 25 years much has been learned about the relationship between violence and mental disorder, and about assessing violence risk. In this article risk factors for violence among persons with mental disorder are reviewed, clinical assessment strategies are discussed, and a model for thinking about treatment and other types of interventions designed to minimize violence risk is offered.

Recent weapon carrying and substance use among United States Virgin Islands youth

The objective of the present study was to estimate the strength of the associations between recent weapon carrying and alcohol, cigarette, and illicit drug use among US Virgin Islands (USVI) youth. Data from 1,124 students in Grades 7-12 were analyzed using the conditional form of multiple logistic regression. Compared with youth who did not carry a weapon. youth who carried a weapon were more likely to be male and recent cigarette, alcohol, and illicit drug users. After matching on school and controlling for age, sex, race, neigborhood characteristics, and affiliation with friends who use alcohol and illegal drugs, the associations with cigarette smoking and illicit drug use remained both moderate and statistically significant (odds ratio [OR] = 4.31, p < .001; OR = 2.99, p < .001, respectively). These findings identify a potentially high-risk population that could be targeted for interventions to reduce weapon carrying among youth.

Firearm-related injuries affecting the pediatric population. Committee on Injury and Poison Prevention. American Academy of Pediatrics

This statement reaffirms the 1992 position of the American Academy of Pediatrics that the absence of guns from children's homes and communities is the most reliable and effective measure to prevent firearm-related injuries in children and adolescents. A number of specific measures are supported to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban on handguns and semiautomatic assault weapons; and expanded regulations of handguns for civilian use. In addition, this statement reviews recent data, trends, prevention, and intervention strategies of the past 5 years.

A structural model of health behavior: a pragmatic approach to explain and influence health behaviors at the population level

BACKGROUND

Behavior is influenced by individual-level attributes as well as by the conditions under which people live. Altering policies, practices, and the conditions of life can directly and indirectly influence individual behavior. This paper builds on existing ecological theories of health behavior by specifying structural mechanisms by which population-level factors effect change in individual health behaviors.

METHODS

This paper moves ecological theory from model building to a pragmatic characterization of structural interventions. We examined social and environmental factors beyond individual control and mechanisms as to how they influence behavior.

RESULTS

Four categories of structural factors are identified: (1) availability of protective or harmful consumer products, (2) physical structures (or physical characteristics of products), (3) social structures and policies, and (4) media and cultural messages. The first three can directly influence individuals through facilitating or constraining behavior. The fourth, media, operates by changing individual-level attitudes, beliefs, and cognitions, as well as group norms.

CONCLUSION

Interventions that target the four identified structural factors are a means to provide conditions that not only reduce high-risk behavior but also prevent the adoption of high-risk behaviors. Structural interventions are important and underutilized approaches for improving our nation's health.

Firearms and family violence

Firearms contribute significantly to morbidity and mortality in family violence. This article discusses the debate on gun use for protection and guns in the home. Weapons-related risks in the setting of intimate partner violence are closely reviewed. Recommendations for physicians are discussed in the context of firearms and family violence.