Firearm violence

and its prevention

Frederick P. Rivara, MD, MPH

Seattle Children’s, Harborview Injury Prevention Research Center,University of Washington

Case presentation

Gia Soriano

Gia at 14 years old

Tragedy of guns in the US

In the last 45 years, more Americans

have died from gunfire in the US than

died in all the wars in our history: 1.4

million vs 1.2 million

In 2000-2015, 2,945 Americans died of

terrorist attacks in the US; 455,312

died from guns

Motor vehicle fatalities , 1921-2015

95%

Motor vehicle regulations

• 1965 Ralph Nader published “Unsafe at Any Speed”

• 1966 Lyndon Johnson created the NHTSA

• 1968 Front seat belts, collapsible steering wheel required

• 1979 NHTSA started doing crash tests

• 1978 First car seat law in US (Tennessee)

• 1984 First seat belt law in US (NY)

• 1989 Driver airbags required

• 1993 Side impact regulation

• 2009 Roof-crush standard

• All states have seat belt laws except New Hampshire

(state motto: “live free or die”)

Gaps in Federal Gun Policy

• No licensing of gun owners

• No registration of firearms (except some

machine guns)

• No electronic database on guns

• No national database on firearm injuries or

fatalities

• Few regulations on gun design

• Few required safety features

Firearm and Motor Vehicle Deaths

in Washington and Oregon, 1999-2015

7CDC,WISQARS

Case fatality of firearm injuries in Denver trauma center, 2000-2013

6% increase in case-fatality rates per year

Sauaia et al, JAMA 2016

Racial disparities in firearm hospital admissions, US

2004-13

Cook et al, Injury 2017

Firearm deaths US, 2015

N=36,252

Homicide by guns: important questions

• Is the US more violent than other

countries?

• How does the homicide rate vary with

gun ownership rate?

• Does access to a gun increase the risk

of violent death?

Assaults per 100,000 population reported to police

Homicides in high income countries

13

Rate of civilian firearm possession, 2012R

ate

per

100,0

00

Source: GunPolicy.org

Firearm deaths and gun ownership, international

Banglore and Messerli, Am J Med 2013

Firearm deaths and gun ownership, US states

Reasons why Americans own guns

Percent

Protection/personal safety 60

Hunting 36

Recreation/sport 13

Target shooting 8

Second Amendment right 5

Like guns 5

Family heirloom 5

Family tradition 4

Related to line of work 3

Firearm Ownership and Gun Deaths in the Home:

King County, WA 1978-1983

43

Classification Death

s

% For every case

of self-

protection

homicide, there

were….deaths

All Self-protection

Homicides

9 2.3% 1.0

Justifiable Homicide 2 0.5%

Self-Defense Homicide 7 1.8%

Unintentional Deaths 12 3.0% 1.3

Homicide (criminal) 41 10.3% 4.6

Suicide 333 83.7% 37.0

Kellermann & Reay (NEJM 1986)

Role of weapons: December 14, 2012

• Newtown, CT: Adam Lanza shot 26 people with a

Bushmaster rifle, most multiple times (156 shots),

before taking his life with a Glock pistol at Sandy

Hook elementary school. All the victims died

• Chenpeng Village primary school: Min Yongjin

stabbed 23 children and an elderly woman. None of

the victims died

• Dues received by NRA in following 12 months

increased from $108M to $175M

• 39 states passed new gun laws within a year-

but in 24, the laws were LESS restrictive

Racial disparities in firearm homicide, males 10-24 years,

1990-2015

Reasonable conclusions on homicide and gun availability

• Prevalence of gun ownership in

community has a direct effect on weapon

choice by robbers and assailants – more

guns, more gun use in crime

• Lethality of violence depends on the mix of

weapons – more guns, more murders

• Young African American males and areas

with greater income inequality are

disproportionately affected

Suicide by guns: important questions

• What proportion of suicides

are committed with guns?

• What is the risk of suicide

when guns are available?

• If guns are not available, is

there means substitution?

Mechanism of suicide in US, 2014

Age

Risk of suicide in relationship to gun ownership

Subgroup Adjusted OR

0-24 year olds 10.4

25-40 7.2

41-60 4.0

61+ 6.6

History of mental illness 3.0

No history of mental illness 32.8

Any guns kept loaded (vs no guns) 9.2

Any guns kept unlocked (vs no guns) 5.6

One or more handguns in the home 5.8

Long guns only in home (vs no guns) 3.0

Kellermann, Rivara et al, NEJM 1992

Wintemute GJ et al. N Engl J Med 1999;341:1583-1589.

Rates of Firearm Suicide after Purchase First Four Weeks and the First Year

among Persons Who Purchased Handguns in California in 1991

Suicide risk 57 times

higher in first week

Suicide, Impulsivity and guns

• 24% of attempts were

done within 5 minutes of

decision

• 70% of attempts

occurred within 1 hour of

decision

26

(Simon et al, 2001)

Methods of self harm and lethality: US, 2001

Means % Fatal

Firearms 85%

Suffocation/hanging 69%

Jump from height 31%

Poison/overdose 2%

Cutting 1%

Other 3%

Conceptual model of how reducing access might save

lives

Barber and Miller, Am J Prev Med 2014

Percent of carbon monoxide in domestic gas, UK

Krietman, Brit J Prev Soc 1976

England and Wales suicide rates by mode of death

Krietman, Brit J Prev Soc 1976

Effect of pesticide regulation on suicide rates in Sri

Lanka

Gunnell et al, In J Epid 2007

Firearms in Israeli military

• Virtually all 18-21 year-olds in Israel serve in the Israeli Defense Force (IDF).

• In the early 2000s, IDF focused on preventing suicides—most of which were by firearm, with many occurring on weekends while soldiers were on leave.

• In 2006, IDF required soldiers to leave their weapons on base during weekend leave.

• The suicide rate decreased by 40%. Weekend suicides dropped significantly. Weekday suicides did not

• Analogy for guns on college campuses?

• April 28, 1996, 35 people killed & 23 wounded by a man with assault rifle

in Port Arthur, Tasmania

• 12 days later, Australian state and Federal government agreed to enact uniform

gun control laws. 643,726 newly prohibited guns were purchased by government

from civilians at market value. Thousands others also gave up their guns

Gun control in Australia

No evidence of substitution with other lethal means

Chapman et al, JAMA 2016

Effect of gun laws on suicides, US 2013

• Waiting periods: lower rate of gun suicides but not

overall suicide rate

• Universal background checks: Lower overall

suicide rates, lower gun suicide rates

• Restricting open carrying of handguns: Lower

overall suicide rates, lower gun suicide rates

State Law change % change in suicides

CA Restrict open carry -1%

DC Extend waiting period -1.5%

OK Restrict open carry -1.7%

SD Repeal waiting period +8.9%

Anestis & Anestis, AJPH 2015

Summary on firearms and suicide

• Strong association between gun access and

risk of suicide

• Means matter

• Means restriction appears to work because

there is not complete substitution with other

lethal means

Children and unintentional firearm deaths, 16 states,

2005-12

Age of

victim

# of cases % hunting

related

% at

friend’s

house

% family

member

was shooter

0-1 7 14 0 100

2-4 42 0 0 90

5-10 69 14 1 79

11-12 51 16 31 66

13-14 60 12 43 24

0-14 229 11 19 61

Hemenway and Solnick, 2015

What do 8-12 year old boys do when they find a gun?

Jackman et al. Pediatrics 2001;107:1247-1250

38

“Rhetoric without action is froth”

-- Gladstone

Means to reduce gun violence

• Safe storage of guns

• Universal background checks

• Do a better job of preventing high-risk individuals

from owning guns (extreme risk protection orders)

• Ban sale of assault weapons

• Ban sale and possession of large capacity (greater

than 10 rounds) ammunition magazines

• Promote the development of personalized guns

• Change norms around gun possession

39

Effect of gun safe storage on deaths of

children and adolescents

Effect of safe

storage

Reduction in firearm suicide 78%

Reduction in accidental shootings 85%

Reduction in shootings with handguns 83%

Reduction in shootings with long guns 75%

40Grossman, 2005

Safe Storage in Alaska Native Villages

41Grossman et al, 2012

Adolescents 13-18 years of age, National Comorbidity

Survey

Firearm Access

Suicide Risk FactorsMultivariable

Analyses

PR (95% CI)

No suicide risk factors ref

Lifetime mental health disorder

without a history of suicidality1.13 (0.98-1.29)

Lifetime history of suicidality with or without

history of mental health disorder1.20 (0.96-1.51)

PR = prevalence ratio; CI = confidence interval

Simonetti et al, JAMA Psychiatry, 2014

30% reported a gun in the home; 41% reported easy access to it

Pediatrician asking about gun ownership in Florida

• In 2011, Florida passed law restricting physicians from

asking if patients or household members had firearms

and prohibiting providers from writing such information

into the medical record

• Florida Chapter of AAP contested the law as

unconstitutional; a judge issued a permanent injunction in

AAP’s favor

• State of Florida appealed that decision to the Eleventh

Circuit Court of Appeals, and state won in 2-1 ruling

• August 2015, appellate panel of three judges issued their

opinion, coming to the same 2-1 conclusion

• February 2017, full appeals court threw out opinion of 3

judges and said it violated First Amendment rights

Safe Gun Storage Event Snapshot

FREE Devices Distributed: 350 Lock Boxes and 50 Trigger Locks per event

Location: Retailer or sporting goods store such as Cabela’s, Bass Pro Shops, etc.

Partnership Model: Seattle Children’s Hospital, Harborview Injury Prevention &

Research Center, public health department, Safe Kids, community safety

organizations, sporting goods retailer, others…

Cost : $15,000 - $20,000 per event

Funding: Cost split between Seattle Children’s, program fundraising efforts and

event sponsorships (typically from local hospital/health care system partners or

community organizations)

Volunteers Required: 30+ volunteers

Lock Box

• Fits most handguns

• Cost: $17-$20 each

• CA Dept. of Justice

approved device

Trigger Lock

• Fits most long guns

and handguns

• CA Dept. of Justice

approved device

• $7-$9 each

Effect of the Safe Storage events

Baseline Follow-up Difference

% %% change

Household firearms locked (n=182)All of them 63.7% 77.5% +13.7% Some of them 17.6% 15.9%None of them 18.7% 6.6%

Household firearms unloaded (n=177)All of them 62.7% 71.2% +8.5%Some of them 26.6% 20.9%None of them 10.7% 7.9%

Household ammunition stored locked(n=176)

All of it 54.6% 60.8% +6.3Some of it 19.3% 12.5%None of it 26.1% 26.7%

(n=167)All firearms stored locked, none are

loaded, and ammunition is stored locked, 32.9% 45.5% +12.6%

Strength of state gun laws and firearm deaths

Gun show loophole

• More than 4000 gun shows annually in US

• Higher proportion of weapons are large caliber

rifles and assault weapons

• Have both licensed and unlicensed vendors

• Unlicensed vendors account for up to 50% of

sales at shows

• Straw purchases are common

• 22% of guns in the US sold in last two years

were without background checks

• 50% of non-store sales without a background

check47

Effect of state laws: universal background checks and

waiting periods

Universal

Background

Checks

Mandatory

Waiting

Period

Effects of background checks on intimate partner

homicides

49

Effect of repeal of background checks in Missouri

Webster et al, J Urban Health, 2014

“Smart guns”

• Technology that can limit who can fire gun:

• Magnetic ring

• Biometric sensors

• Opposition:

• Gun proponents:

• Can fail when the gun is needed for self protection

• Interferes with Second Amendment rights

• Only one on market retails for $1,800

• Gun control advocates:

• May make guns seem safer than they really are

• Will have a negligible effect on gun violence

Silencing Science

Kellermann AL, Rivara FP. Silencing the Science on Gun Research. JAMA. Dec

2012

Silencing the science on gun research

• Riders in appropriations bills in 1996 prohibited CDC and NIH from conducting any research that could be used to “advance or promote gun control.”

• CDC funding for firearm injury prevention has fallen 96% since the rider was enacted. No gun studies have been funded.

• Academic publishing on firearms fell 60% between 1996 and 2010.

• Between 1993 and 1999, the National Institute of Justice funded 32 gun-related studies. It funded five this year.

53

Funding and Publication of Research on Gun Violence

and Other Leading Causes of Death

Stark and Shah, JAMA 2017

Firearm-Related Injury and Death in the US: A Call to Action From 8

Health Professional Organizations and the American Bar Association

“We believe that multidisciplinary, interprofessional

collaboration is critical to bringing about meaningful

changes to reduce the burden of firearm-related injuries

and death on persons, families, communities, and society

in general.”

--American Academy of Family Physicians, American Academy of

Pediatrics, American College of Emergency Physicians, American

Congress of Obstetricians and Gynecologists, American College

of Physicians, American College of Surgeons, American

Psychiatric Association, American Public Health Association,

American Bar Association February 24 2015

June 17-24, 2015: A week in America

• June 17: 9 people are shot to death at a church

in Charleston

• June 18: NRA board member Charles Cottton

blames Rev. Pinckney for his own death

because he opposed loosening gun laws in SC

• June 24: Scott Walker signs Wisconsin law

repealing the state’s 48 hour waiting period for

handgun purchases

• June 24: Congress (committee vote 32-19)

keeps in place 19 year ban on CDC funding

gun research

Costs: $229 billion annually

In 2014, hospital charges for GSW at HMC were $17.2 million for 259 patients

82% were paid out of government funds

Firearm deaths among white males 15-39, US 2006-2010

Firearm deaths among African-American males 15-39,

US 2006-2010

Brady center state scorecard

Connecticut’s Permit-to-Purchase handgun law and

homicides

In 1995, CT required:

• Background check for

all handgun sales

• Raised handgun

purchase age to 21

• Required people to

apply for permit in

person at police

station

• Required 8 hours of

handgun safety

training

No change in non-gun homicides

Rudolph et al, AJPH 2015

Our science on public health and guns

• Published in NEJM with editorials

• Picked up by lay press

• Widely used by gun control advocates

• Widely used by the CDC

• Discussed by the authors

• Reaction to the studies

Comments in the American Rifleman

• “We are obligated to correct the record by

notifying the news media and those with

congressional and executive oversight over

the activities of the CDC… clearly all

scientific standards go by the wayside

whenever the CDC and the NEJM seize an

opportunity to attack firearms ownership in

America.”American Rifleman, January 1989

Office of Scientific Integrity

Review• The NRA asked the Office to review the

firearm research conducted at the University

of Washington and the University of

Tennessee and other CDC funded violence

research because of “falsification and

fabrication of research conclusions”

• The Office declined to review it.

US Senate actions

Letter to Chair of HHS appropriations committee

from 10 Senators:

“We are absolutely committed to getting the

politics out of NCIPC’s work…The NCIPC’s

enthusiasm to promote a political agenda

against gun ownership is evidence by the $1.7

mil that Dr. Kellermann and others have received

for firearms-related research. The CDC program

can be cut with no diminution of service to the

public interest.”

June 2015- GOP panel report on restricting funding of

gun research

“The restriction is to prevent activity that would

undertake activities (to include data collection) for

current or future research, including under the title

'gun violence prevention,' that could be used in

any manner to result in a future policy, guidelines,

or recommendations to limit access to guns,

ammunition, or to create a list of gun owners”

Trends in firearm fatalities, US 1981-2015

Trends in firearm and MV fatalities, US 1981-2015

Event Evaluation

• Safe storage practices increased after the event

• 76% reported using the device to lock a household firearm

• 24% said they weren’t using the device, and maybe that’s

okay in some cases? Perhaps devices were gifted to others?

• The events were extremely well received

• The type of device distributed probably matters

➢Device Preference