Firearm Injury in the United States: Time to Confront It as the Epidemic It Has Become
Authors: Christine Laine, Sue S. Bornstein
Journal: Annals of Internal Medicine (2022)

EditorialsJune 2022Firearm Injury in the United States: Time to Confront It as the Epidemic It Has BecomeFREEChristine Laine, MD, MPH and Sue S. Bornstein, MDChristine Laine, MD, MPHEditor in Chief, Annals of Internal Medicine Search for more papers by this author and Sue S. Bornstein, MDTexas Medical Home Initiative, Dallas, TexasSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-0865 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Americans have a complicated relationship with firearms. A 2021 survey found that 48% of Americans see gun violence as a very big problem in the country today, yet 4 in 10 adults live in a household with a gun, including 30% who say they personally own one (1). Household personal protection is a common reason Americans cite for gun ownership. Given the current divided and tense state of our nation with rising crime rates in some locales, one can see why people feel vulnerable and are seeking ways to protect that which is near and dear to them. An estimated 2.9% of U.S. adults became new gun owners between January 2019 and April 2021, corresponding to about 7.5 million people, of whom about 5.4 million had previously lived in a home with no guns (2). However, increasing evidence documents that gun ownership is not an effective strategy for protecting the well-being of oneself and one's household members.In their article, Studdert and colleagues (3) report a study that included more than 17.6 million California adults and found a substantial increased risk for death by homicide among the 595 448 adults who did not own a gun but started living with a handgun owner during the study period. Rates of homicide were more than twice as high among these adults than among those who did not live with a handgun owner (adjusted hazard ratio, 2.33 [95% CI, 1.78 to 3.05]). Further, cohabitants of handgun owners had a sevenfold higher rate of being fatally shot by a spouse or intimate partner, and 84% of such victims were women. These findings suggest that living with a handgun owner does not seem to offer protection from homicide for adults. The study had limitations. It included only 1 state, examined only lawful handgun ownership, did not have access to data on children living with handgun owners, and did not examine homicide rates in the handgun owners themselves. Further, it did not examine such outcomes as suicide and nonfatal firearm injury. However, the study was large, it was methodologically rigorous, and the homicide risk identified was in line with prior studies, including a 2014 meta-analysis that pooled data from 16 observational studies (4).That markedly increased risk Studdert and colleagues identified for cohabitants of handgun owners being fatally shot by a spouse or intimate partner is worth particular attention. Intimate partner violence culminating in homicide by firearm increased during the COVID-19 pandemic. During 2020 in Texas, 228 people were killed by an intimate partner, with 67% killed in their home with a firearm (Bornstein SS. Personal communication.), adding to the evidence that living with a gun owner does not seem to offer much protection.Homicide is not the only harm that has been associated with household access to guns. The same meta-analysis mentioned earlier found that access to a firearm increased the odds of suicide more than threefold (4). In a prior study that also used California data, handgun owners had a markedly elevated risk for suicide compared with nonowners (hazard ratio, 3.34 [CI, 3.13 to 3.56] for men and 7.16 [CI, 6.22 to 8.24] for women) (5). A recent analysis of National Vital Statistics Reports data from 2009 to 2018 from the Centers for Disease Control and Prevention found that the years of potential life lost in 2018 were higher for firearm injuries (1.42 million) than for motor vehicle crashes (1.34 million) (6). Although homicide and suicide are the firearm-related harms that receive the most attention, there are other harms to health, including nonfatal injury, mental health sequelae after gun-related assaults, adverse effects on loved ones of those killed or injured, and negative effects on community well-being. In addition, the financial burden of firearm injury is substantial (7).The risks posed by firearms are by no means limited to the home. School shootings shake us to our core. Each year, people lose their life and well-being to guns in movie theaters, concert venues, shopping malls, places of worship, academic institutions, and grocery stores and on neighborhood streets. Even the clinical ward of a hospital can become the site of firearm-related fatality (8). The presence of guns can turn common, everyday locales into dangerous places. The marked increase in firearm ownership in the United States is likely to exacerbate the problem.That firearm-related injury has surpassed motor vehicle injury as a cause of years of life lost in the United States is striking proof that firearm-related injury is a significant public health problem (6). Unfortunately, despite periodic waves of interest among legislators and the public after a school shooting or other horrific firearm-related event, effective and durable remedies to the epidemic of firearm-related harm have been elusive. Like in other public health crises, we and others have argued that physicians can play their part by talking to patients about firearm safety (9). Yet, just as physicians alone cannot tackle the COVID-19 pandemic, tackling the epidemic of firearm injury and death in the United States will require consistent focus and multiple levels of intervention.The use of a multifaceted approach is essential (10). In addition to screening and counseling in clinical settings to mitigate risk, legislation is a vital tool. Reauthorization of the Violence Against Women Act and nationwide adoption of reforms to the National Instant Criminal Background Check System are examples. The United States needs laws that enable extreme risk protection orders to remove guns from those presenting risk to self or others and universal background checks to ensure that those who obtain guns do not have contraindications to ownership. Interventions to make the firearms that Americans own safer are sorely needed, such as gun locks, other safety features, and sensible regulation of the types of guns and ammunition available for civilian use. Programs to address social factors, such as lack of economic opportunity and exposure to violence, can promote safer default decisions about guns. In addition, adverse consequences for companies and individuals who facilitate misuse of firearms send strong messages. Examples include Remington's $73 million settlement with the families of the victims at Sandy Hook Elementary School and involuntary manslaughter charges for the parents of the Michigan 15-year-old who shot 4 classmates. Hopefully, these high-profile cases are signals that the tide regarding accountability is turning.The United States should not tolerate the loss of life and health due to guns any more than we should be complacent with loss of life and health due to COVID-19 or the opioid misuse epidemic. We are meeting these other health threats head-on with resolve. We must do the same with firearm injury.References1. Schaeffer K. Key facts about Americans and guns. Pew Research Center. 13 September 2021. Accessed at www.pewresearch.org/fact-tank/2021/09/13/key-facts-about-americans-and-guns on 17 March 2022. Google Scholar2. Miller M, Zhang W, Azrael D. Firearm purchasing during the COVID-19 pandemic: results from the 2021 National Firearms Survey. Ann Intern Med. 2022;175:219-225. [PMID: 34928699] doi:10.7326/M21-3423 LinkGoogle Scholar3. Studdert DM, Zhang Y, Holsinger EE, et al. Homicide deaths among adult cohabitants of handgun owners in California, 2004 to 2016. A cohort study. Ann Intern Med. 2022;175:804-11. doi:10.7326/M21-3762 LinkGoogle Scholar4. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members. A systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] LinkGoogle Scholar5. Studdert DM, Zhang Y, Swanson SA, et al. Handgun ownership and suicide in California. N Engl J Med. 2020;382:2220-2229. [PMID: 32492303] doi:10.1056/NEJMsa1916744 CrossrefMedlineGoogle Scholar6. Klein J, Prabhakaran K, Latifi R, et al. Firearms: the leading cause of years of potential life lost. Trauma Surg Acute Care Open. 2022;7:e000766. [PMID: 35141422] doi:10.1136/tsaco-2021-000766 CrossrefMedlineGoogle Scholar7. Ranney ML, Herges C, Metcalfe L, et al. Increases in actual health care costs and claims after firearm injury. Ann Intern Med. 2020;173:949-955. [PMID: 32986488] doi:10.7326/M20-0323 LinkGoogle Scholar8. Naro G. The shooting. Ann Intern Med. 2022;175:454. [PMID: 35286830] doi:10.7326/M21-4391 LinkGoogle Scholar9. Taichman D, Bornstein SS, Laine C. Firearm injury prevention: AFFIRMing that doctors are in our lane [Editorial]. Ann Intern Med. 2018;169:885-886. [PMID: 30458522] doi:10.7326/M18-3207 LinkGoogle Scholar10. Butkus R, Doherty R, Bornstein SS, et al; Health and Public Policy Committee of the American College of Physicians. Reducing firearm injuries and deaths in the United States: a position paper from the American College of Physicians. Ann Intern Med. 2018;169:704-707. [PMID: 30383132] doi:10.7326/M18-1530 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Christine Laine, MD, MPH; Sue S. Bornstein, MDAffiliations: Editor in Chief, Annals of Internal Medicine Texas Medical Home Initiative, Dallas, TexasNote: Drs. Laine and Bornstein contributed equally to this work.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-0865.Corresponding Author: Sue S. Bornstein, MD, 3111 Beverly Drive, Dallas, TX 75205.This article was published at Annals.org on 5 April 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoHomicide Deaths Among Adult Cohabitants of Handgun Owners in California, 2004 to 2016 David M. Studdert , Yifan Zhang , Erin E. Holsinger , Lea Prince , Alexander F. Holsinger , Jonathan A. Rodden , Garen J. Wintemute , and Matthew Miller Annals On Call - Firearm Safety Robert M. Centor , and Sue S. Bornstein Metrics June 2022Volume 175, Issue 6Page: 897-898KeywordsFirearm injuriesHomicidePrevention, policy, and public healthSuicide ePublished: 5 April 2022 Issue Published: June 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...