Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians
Authors: Renee Butkus, Robert Doherty, Hilary Daniel
Journal: Annals of Internal Medicine (2014)

Position Papers17 June 2014Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of PhysiciansFREERenee Butkus, BA, Robert Doherty, BA, and Hilary Daniel, BS, for the Health and Public Policy Committee of the American College of Physicians*Renee Butkus, BAFrom the American College of Physicians, Washington, DC., Robert Doherty, BAFrom the American College of Physicians, Washington, DC., and Hilary Daniel, BSFrom the American College of Physicians, Washington, DC., for the Health and Public Policy Committee of the American College of Physicians*Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M14-0216 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 1995, the American College of Physicians (ACP) issued its first statement that raised concern about the epidemic of firearm violence in the United States and advocated for policies to reduce the rate of firearm injuries and deaths (1). Nineteen years later, although rates of firearm-related death, injury, and disability have decreased, firearm-related mortality rates in the United States remain the highest among industrialized countries (2).The mass shooting that occurred in December 2012 at Sandy Hook Elementary School in Newtown, Connecticut, which left 6 adults and 20 children dead, and other mass shootings have brought firearm violence to the forefront of national discussion. It is critical that strategies are developed to prevent massacres like those that occurred in Newtown; in Tucson, Arizona; at Virginia Tech University; in Aurora, Colorado; at Columbine High School; and at the Washington Navy Yard. Yet, the ACP is equally concerned about the deaths and injuries that affect our nation on a daily basis when persons are injured or killed or commit suicide with firearms. Each year, firearms kill more than 32 000 persons in the United States, or approximately 88 per day (3). These deaths include homicides, suicides, and unintentional fatalities. Firearm injury is the second leading cause of death due to injury after motor vehicle crashes (4). Homicide and suicide by firearms result in 11 000 and 19 000 deaths, respectively, each year (5). The number of nonfatal firearm injuries in the United States is more than twice the number of fatal firearm injuries, with 73 883 nonfatal firearm injuries documented in 2011 (6). The ACP believes that immediate action is necessary to reduce these unnecessary injuries and deaths.Firearm violence is not only a criminal justice issue but also a public health threat. A comprehensive, multifaceted approach is necessary to reduce the burden of firearm-related injuries and deaths on individuals, families, communities, and society in general. Strategies to reduce firearm violence will need to address culture, substance use and mental health, firearm safety, and reasonable regulation, consistent with the Second Amendment, to keep firearms out of the hands of persons who intend to use them to harm themselves and others, as well as measures to reduce mass casualties associated with certain types of firearms.As an organization representing physicians who have firsthand experience with the devastating impact firearm-related injuries and deaths have on the health of their patients, the ACP has a responsibility to participate in efforts to mitigate these needless tragedies. Because patients trust their physicians to advise them on issues that affect their health, physicians can help to educate the public on the risks of firearms and the need for firearm safety through their encounters with their patients. This Executive Summary provides a synopsis of the full position paper, which is available in Appendix 1.MethodsThe ACP's Health and Public Policy Committee, which is charged with addressing issues affecting the health care of the U.S. public and the practice of internal medicine and its subspecialties, developed these recommendations. The committee reviewed available data on the impact of access to firearms on health-related outcomes, the association of mental health conditions and firearm violence, state and federal firearm laws, and the effect of efforts to reduce firearm violence. The ACP also surveyed its members on their attitudes on firearms and firearm injury prevention (7). Draft recommendations were reviewed by ACP's Board of Governors, Board of Regents, Council of Early Career Physicians, Council of Resident/Fellow Members, Council of Student Members, and Council of Subspecialty Societies, as well as non–ACP members with expertise in mental health and firearm safety. The policy paper and related recommendations were reviewed by the ACP Board of Regents and approved on 7 April 2014.ACP Position Statements and RecommendationsThe following statements represent the official policy positions and recommendations of the ACP. The rationale for each is provided in the full position paper (see Appendix 1).1. The American College of Physicians recommends a public health approach to firearms-related violence and the prevention of firearm injuries and deaths.a. The College supports the development of coalitions that bring different perspectives together on the issues of firearm injury and death. These groups, comprising health professionals, injury prevention experts, parents, teachers, law enforcement professionals, and others should build consensus for bringing about social and legislative change.2. The medical profession has a special responsibility to speak out on prevention of firearm-related injuries and deaths, just as physicians have spoken out on other public health issues. Physicians should counsel patients on the risk of having firearms in the home, particularly when children, adolescents, people with dementia, people with mental illnesses, people with substance use disorders, or others who are at increased risk of harming themselves or others are present.a. State and federal authorities should avoid enactment of mandates that interfere with physician free speech and the patient–physician relationship.b. Physicians are encouraged to discuss with their patients the risks that may be associated with having a firearm in the home and recommend ways to mitigate such risks, including best practices to reduce injuries and deaths.c. Physicians should become informed about firearms injury prevention. Medical schools, residency programs, and continuing medical education (CME) programs should incorporate firearm violence prevention into their curricula.d. Physicians are encouraged, individually and through their professional societies, to advocate for national, state, and local efforts to enact legislation to implement evidence-based policies, including those recommended in this paper, to reduce the risk of preventable injuries and deaths from firearms, including but not limited to universal background checks.3. The American College of Physicians supports appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths. The College acknowledges that any such regulations must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.a. Sales of firearms should be subject to satisfactory completion of a criminal background check and proof of satisfactory completion of an appropriate educational program on firearms safety. The American College of Physicians supports a universal background check system to keep guns out of the hands of felons, persons with mental illnesses that put them at a greater risk of inflicting harm to themselves or others, persons with substance use disorders, and others who already are prohibited from owning guns. Clear guidance should be issued on what mental and substance use records should be submitted to the National Instant Criminal Background Check System (NICS). This should include guidance on parameters for inclusion, exclusion, removal, and appeal. States should submit mental health records and report persons with substance use disorders to the NICS. The federal government should increase incentives and penalties related to state compliance. The law requiring federal agencies to submit substance use records should be enforced.b. Although there is limited evidence on the effectiveness of waiting periods in reducing homicides, waiting periods may reduce the incidence of death by suicide, which account for nearly two thirds of firearm deaths, and should be considered as part of a comprehensive approach to reducing preventable firearms-related deaths.c. Lawmakers should carefully weigh the risks and benefits of concealed-carry legislation prior to passing laws.d. The College supports a ban on firearms that cannot be detected by metal detectors or standard security screening devices.e. The College favors strong penalties and criminal prosecution for those who sell firearms illegally and those who legally purchase firearms for those who are banned from possessing them ("straw man sales").4. The American College of Physicians recommends that guns be subject to consumer product regulations regarding access, safety, and design. In addition, the College supports law enforcement measures, including required use of tracer elements or taggants on ammunition and weapons, and identifying markings, such as serial numbers on weapons, to aid in the identification of weapons used in crimes.5. Firearm owners should adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms. They should ensure that their firearms cannot be accessed by children, adolescents, people with dementia, people with mental illnesses or substance use disorders who are at increased risk of harming themselves or others, and others who should not have access to firearms. Firearm owners should report the theft or loss of their firearm within 72 hours of becoming aware of its loss.6. The College cautions against broadly including those with mental illness in a category of dangerous individuals. Instead, the College recommends that every effort be made to reduce the risk of suicide and violence, through prevention and treatment, by the subset of individuals with mental illness who are at risk of harming themselves or others. Diagnosis, access to care, treatment, and appropriate follow-up are essential.a. Physicians and other health professionals should be trained to respond to patients with mental illness who might be at risk of injuring themselves or others.b. Ensuring access to mental health services is imperative. Mental health services should be readily available to persons in need throughout their lives or through the duration of their conditions. Ensuring an adequate availability of psychiatric beds and outpatient treatment for at-risk persons seeking immediate treatment for a condition that may pose a risk of violence to themselves or others should be a priority.c. Community understanding of mental illness should be improved to increase awareness and reduce social stigma.d. Laws that require physicians and other health professionals to report those with mental illness who they believe pose an imminent threat to themselves or others should have safeguards in place to protect confidentiality and not create a disincentive for patients to seek mental health treatment. Such laws should ensure that physicians and other health professionals are able to use their reasonable professional judgment to determine when a patient under their care should be reported and should not hold them liable for their decision to report or not report.7. The College favors enactment of legislation to ban the sale and manufacture for civilian use of firearms that have features designed to increase their rapid killing capacity (often called "assault weapons" or semiautomatic weapons) and large-capacity ammunition and retaining the current ban on automatic weapons for civilian use. Although evidence on the effectiveness of the Federal Assault Weapons Ban of 1994 is limited, the College believes that there is enough evidence to warrant appropriate legislation and regulation to limit future sales and possession of firearms that have features designed to increase their rapid killing capacity and can, along with a ban on large-capacity ammunition magazines, be effective in reducing casualties in mass shooting situations. Such legislation should be carefully designed to make it difficult for manufacturers to get a semiautomatic firearm exempted from the ban by making modifications in its design while retaining its semiautomatic functionality. Exceptions to a ban on such semiautomatic firearms for hunting and sporting purposes should be narrowly defined.8. The College supports efforts to improve and modify firearms to make them as safe as possible, including the incorporation of built-in safety devices (such as trigger locks and signals that indicate a gun is loaded). Further research is needed on the development of personalized guns.9. More research is needed on firearm violence and on intervention and prevention strategies to reduce injuries caused by firearms. The Centers for Disease Control and Prevention, National Institutes of Health, and National Institute of Justice should receive adequate funding to study the impact of gun violence on the public's health and safety. Access to data should not be restricted.ConclusionFirearm violence is a public health problem in the United States that requires the nation's immediate attention. The ACP has long advocated for policies to reduce the rate of firearm injuries and deaths in the United States and once again calls on its members, nonmember physicians, policymakers, and the public to take action on this important issue. Although there is much more to learn about the causes and prevention of firearm violence, the available data support the need for a multifaceted and comprehensive approach that addresses culture, substance use and mental health, firearm safety, and reasonable regulation, consistent with the Second Amendment, to prevent the devastating effects of needless firearm-related injuries and deaths.Appendix 1: Reducing Firearm-Related Injuries and Deaths in the United States: Recommendations From the American College of PhysiciansWhy Should Physicians Care About Firearm Injury Prevention?The ACP Ethics Manual states that "Physicians should help the community and policymakers recognize and address the social and environmental causes of disease, including human rights concerns, discrimination, poverty, and violence" (8).Whether it is a 75-year-old widower who commits suicide; a 17-year-old who accidentally shoots himself; a 20-year-old bystander killed on a city street; or a horrific mass shooting, such as the one that occurred in Newtown, Connecticut, physicians witness firsthand the devastating consequences of firearm violence for victims and their families. In a February 2013 survey of internists, 63% of respondents reported having had patients who were injured or killed by a gun. The survey is discussed in more detail later in this paper. These unnecessary injuries and deaths occur to patients and affect their families and the communities that they are a part of.Physicians play an important role in intervening with patients who risk injuring themselves or others through the use of firearms. Patients and families of those who risk firearm injury have indicated a willingness to discuss concerns and safety options with their physicians (9). Brief counseling efforts by physicians have been shown to have a significant positive effect on the firearm storage habits of their patients. In one study (10), patients who completed an enrollment questionnaire and indicated that they had guns in their household agreed to participate in a study of the effect of office counseling by family physicians. The study found that groups receiving verbal counseling only or verbal counseling and written information made safe changes in gun storage (64% and 58%, respectively) compared with those who received no office counseling (33%). Twelve percent of study participants reported removing guns from their household altogether. Physician education in the recognition and treatment of depression and restricting access to lethal methods, including firearms, has been shown to reduce suicide rates (11). Screening for and treating explosive rage and violence, such as workplace violence, domestic abuse, and road rage (12), can decrease the risk for future violence. Discussions about firearms during routine examinations were well-received and recalled more than any other preventive medicine issue discussed among young African American men (13). In fact, 81% of African American men believed that it was important for a physician to talk to them about guns. A study of families in a predominantly Hispanic pediatric clinic (14) revealed that of those who received gun safety counseling or other intervention, 61.6% either removed all guns from their homes or improved their gun storage safety practice in some way. In households that still had guns at follow-up, 50.9% of patients in the intervention group were found to have some type of improvement in safe gun storage compared with 12.3% of those in the control group.As Christine Laine, MD, Editor in Chief, and the deputy editors of Annals of Internal Medicine wrote in a March 2013 editorial, "Just as physicians worked to safeguard public health by promoting smoking bans in public places, we should draw on similar motivations and strategies to promote sensible, evidence-based laws to decrease the harms associated with gun violence. It is our responsibility to do so" (15).Attitudes of Internists on Firearms and Injury PreventionIn February 2013, ACP performed a cross-sectional survey among a large, nationally representative panel of internists in the United States about their attitudes toward firearms and firearm injury prevention. Most respondents (85%) believed that firearm injury is a public health issue.Respondents' support for policies related to firearm regulation was strong. Seventy-six percent of respondents agreed that stricter gun control legislation would help to reduce the risk for gun-related injuries or deaths. An overwhelming majority also favored mandatory background checks on all gun purchases (95%); mandatory registration of all firearms (81%); banning the possession of assault weapons (86%), high-capacity magazines (85%), and armor-piercing bullets (87%); preventing persons with mental illness from purchasing guns (85%); and requiring safety features to make guns more child-proof (86%) (Table 1).Table 1. Support by Internists for Specific Measures to Deal With Firearm ViolenceFew respondents involved in patient care were asking their patients about gun use or discussing gun safety (Table 2). Fifty-eight percent of respondents reported never discussing with patients whether they had guns in the home, and 80% reported never discussing whether their patient used guns. Most (77%) reported never discussing ways to reduce the risk for gun-related injury or death or the importance of keeping guns away from children (62%). Respondents indicating that there were gun owners in their homes more often reported asking their patients about guns (54% vs. 40%). Despite this, there is interest in educational programs to help physicians counsel their patients on firearm injury prevention. When asked the extent to which there is a need for an educational program designed to increase the knowledge and skills of physicians in how to counsel patients in firearm injury prevention, 74% indicated "somewhat/to a great extent." Non–gun owners more often reported support of such a program than did those from a home with gun owners (77% vs. 63%).Table 2. Frequency of Discussions About Gun-Related IssuesFirearm Violence Is a Public Health ProblemThe number of guns owned by civilians in the United States ranges from 270 million to 310 million (16, 17), which amounts to 101.05 firearms per 100 persons (18). The United States ranks first among 178 countries in the number of privately owned guns (16). Each year, more than 32 000 persons are killed in the United States by firearms. This includes homicides, suicides, and unintentional fatalities and amounts to 88 deaths per day (19). Homicides by firearm result in 11 000 deaths each year (19). More than 19 000 firearm deaths are suicides (20). The number of nonfatal firearm injuries is more than double the number of deaths. It is estimated that nearly 74 000 nonfatal firearm injuries occurred in the United States in 2011 (21). Since its peak in 1993, the rate of gun homicide has decreased by 49%; however, the change in the overall number of firearm deaths has not been as substantial (39 595 in 1993 vs. 31 672 in 2010) and is still a major concern.In 2010, 15 576 children aged 20 years or younger were treated in emergency departments for nonfatal firearm-related injuries. Adolescents aged 15 to 19 years had a nonfatal firearm injury rate nearly 3 times higher than the general population (22). Between 2000 and 2010, 703 children aged 14 years or younger were killed by unintentional firearm injuries (23). A 2013 analysis of available data on unintentional or accidental firearm injury and death in 5 states found that official estimates may underestimate the number of accidental firearm deaths in children by as much as half, due in part to inconsistent classification and reporting (24). Misclassification of firearm homicide, suicide, and accidents, particularly in young victims, is of concern with many of the current reporting practices. As much as 38% of true cases of unintentional firearm deaths were missed, as were 42% of cases reported as false-positives in an analysis of firearm death data from the National Violent Death Reporting System, State Vital Statistics Registry, medical examiner or coroner reports, and police Supplementary Homicide Reports (25).Firearm-related violence cost the United States $174 billion in 2010. The societal cost for each firearm assault injury amounted to $5.1 million for each fatality, $433 000 for each hospitalized patient, and $123 000 for each firearm assault that resulted in only an emergency department visit. The costs included work loss, medical or mental health care, emergency transportation, policy or criminal justice activities, insurance claims processing, employer costs, and decreased quality of life (26).Firearm Violence and Mental HealthStudies have shown that "stranger homicide" is still a relatively uncommon occurrence, and psychosis has not been shown to be an accurate predictor in the risk for such homicides (27). Additional epidemiologic research has shown that persons with mental illness are less likely to seek treatment before committing a violent act; thus, no disqualifying patient or criminal record would exist to prevent the person from purchasing a firearm (28). Certain psychiatric conditions also have a stronger association with violent behaviors than others. A survey on the frequency of violent behavior in persons with mental illness found that certain psychiatric disorders were indicators of an increased risk for violent behavior. The results of the survey showed that those with anxiety or depressive disorders were 3 to 4 times more likely to engage in violent behavior, and those with bipolar disorder or alcohol and other substance use disorders were up to 9.5 times more likely to develop violent behavior (29). A study by the National Institute of Mental Health (30) revealed that persons with serious mental illness (schizophrenia, major depression, or bipolar disorder) were 2 to 3 times more likely than those without serious mental illness to commit acts of aggression. The study also found that those with serious mental illness had a lifetime prevalence of violence of 16% compared with a 7% prevalence among those without mental illness (7%). However, because serious mental illness is rare, the attributable risk to the overall rate of violence in the general population is only 3% to 5% (30). Thus, the overwhelming majority of persons with mental illness do not pose a threat of violence to others or themselves.Studies that have looked at various types of mental illness in conjunction with substance abuse have established drug and alcohol use or abuse to be a stronger predictor of violent behavior than mental health alone. One study (31) found that persons with mental illness are no more likely to be violent unless they also have a substance use disorder or a history of violence. Fazel and colleagues (32) found that persons with substance use disorders but no mental health disorders had a risk for violence similar to that of persons with substance use disorders and some level of mental health disorder. A study of 132 persons with mental illness (33) revealed that they were 1.7 times more likely to engage in serious violence on days when they consumed alcohol and 3.4 to 7.1 times more likely to engage in serious violence when they used alcohol and other substances.Access to Firearms Increases Likelihood of Injury and DeathAlthough some studies suggest that firearms can serve a protective function (34), evidence suggests that firearm availability increases the likelihood that persons will be killed, either by homicide or suicide. A study by Kellermann and Reay (35) that examined all firearm deaths in King County, Washington, over a 6-year period found 1.3 accidental deaths, 4.5 criminal homicides, and 37 suicides involving firearms for every death associated with self-defense or protection. A study that compared the frequency with which guns in the home are used for self-defense with the number of times the weapons were involved in accidental injury, suicide attempt, or criminal assault or homicide in 3 U.S. cities (36) found that for every time a gun was used in self-defense or for a legally justifiable reason, there were 4 accidental shootings, 7 criminal assaults or homicides, and 11 attempted or completed suicides. A report on firearm injury prevention by the Firearm & Injury Center at the University of Pennsylvania (37) found several associations among ownership of a firearm, firearm availability, and presence of firearms in the home and an increased risk for homicide and suicide by firearm. Even general ownership of a gun has been associated with a net increase in the risk for death by firearm compared with a typical person (38). The association between having a firearm in the home and homicide risk is of particular relevance because persons are more likely to be killed by a family member or intimate acquaintance than a stranger (39). Although an assessment of reports from the Federal Bureau of Investigation (FBI) Uniform Crime Reporting Program showed that the rate of homicide is still higher for men than women, the risk of being killed by a firearm is high among women. More than twice as many women were shot and killed by their husband or an intimate acquaintance than by strangers using guns, knives, or other means (40).An analysis of data on homicides that occurred in the home in 3 metropolitan counties (41) showed that keeping a gun in the home increases the risk for homicide in the home independent of other factors. The same study found that a significant portion of homicides in the home (76.7%) are committed by someone known to the victim, such as a family member or intimate acquaintance. The relative risk for homicide or violent death has been shown to continue for up to several years after the initial purchase of a weapon. This long-term relative risk is also reflected in the potential for suicide among gun owners several years after purchase (42).Access to firearms in the home and general access have been shown to contribute to the increase in the risk for suicide among adolescents and adults (43–48). A 6-year study of handgun purchases among California residents aged 21 years or older (42) found that the primary cause of death in the group was suicide within the first year after the purchase and that the suicide rate among the group in the first week after the purchase was 57 times higher than in the general population. The fact that access to a firearm can increase the risk for suicide by firearm has been well-established; however, it has been shown that a decrease in household ownership of firearms is associated with a decrease in the rate of suicide. Miller and colleagues (49) explored the change in suicide rates compared with the decrease in firearm ownership from 1981 to 2002 among 4 census regions. They found a reduction in firearm ownership across all 4 regions. After adjustment for multivariate and regional factors, the study found an association with significant reductions in the rate of firearm suicides and suicides overall (4.2% and 2.5%, respectively) for each 10% decrease in household firearm ownership. Children aged 0 to 19 years were affected the most; in that population, for each 10% decrease, the rate of firearm suicide decreased by 8.3% and the rate of suicides overall decreased by 4.1%.Although the focus of most firearm safety efforts has been geared toward households with children, evidence suggests that firearms in the home may also be a danger to elderly persons. Geriatric persons are more likely to suffer self-inflicted accidental or intentional gunshot w