Preventing Firearm-Related Death and Injury

Abstract

Firearm-related death and injury are significant public health problems in the United States. From 2008 to 2017 (the 10 most recent years for which data are available), there were 342439 firearm-related deaths in the United Statesmore civilian deaths from gunshot wounds than from U.S. combat fatalities in World War IIand another estimated 870000 nonfatal firearm-related injuries. In 2015, for the first time in U.S. history, the age-adjusted firearm-related mortality rate surpassed that related to motor vehicle traffic events (1). The firearm-related suicide rate has increased each year since 2006; firearm-related homicide trended downward from 2006 to 2014 but has since increased (1). Among industrialized nations, the United States has uniquely high rates of firearm violence. The firearm homicide rate is more than 25 times that of comparable countries, and the firearm suicide rate is 8 times higher (2). The annual total cost of firearm-related death and injury in the United States was estimated at $229 billion for 2012; this includes direct costs of health care and emergency services and indirect costs, such as lost income from victims and caregivers (3). The case-fatality rate for firearm-related injuries has not declined since the early 2000s, and lengths of stay and hospitalization costs have increased (4). Public mass shootings command the nation s attention and are changing the character of American public life. However, they account for no more than 1% to 2% of firearm-related deaths and for less than half of all mass shootings. Clinicians have unique opportunities to prevent all types of firearm-related death and injurysuicide, homicide, unintentional injury, mass violencethrough their relationships and interactions with patients. The primary purpose of this article is to aid clinicians in assessing a patient s risk for firearm injury or death, counseling on firearm safety when appropriate, and intervening in emergency situations. These activities generally involve a patient who already owns or has access to firearms, but much of what we present is applicable to counseling a patient who does not have a firearm and is considering whether to acquire one. The effort to impede research on firearm violence and prevention has been sustained and often successful (5); as a result, the recommendations made here may not rest on the substantial foundation of scientific evidence that underlies other In the Clinic contributions. Interpretations and recommendations that rely on expert opinion are clearly indicated. Epidemiology Risk for firearm-related homicide is highest for adolescents and young adults and decreases thereafter. Overall, suicide risk increases with age (Figure 1). Firearm-related homicide and suicide rank among the 10 leading causes of death for Americans for most of the lifespan (Figure 2). However, there are profound differences in rates of firearm mortality by sex and race/ethnicity. Homicide risk is concentrated among young African American men: Nearly 90% of firearm deaths among African American men are homicides. Suicide risk is highest among middle-aged and older white non-Hispanic men: Nearly 90% of firearm deaths among white men are suicides (Figure 3). Figure 1. Firearm suicide and homicide rates, by age, 2017. Data from reference 1. Figure 2. Ranking for firearm-related suicide and homicide among all causes of death, by age, 2017. From reference 1. Causes of death were calculated by separating homicides by firearm from homicides by all other mechanisms and suicides by firearm from suicides by all other mechanisms. Figure 3. Firearm mortality rate in males, by type and race, 2017. Data from reference 1. Firearm death rates for women are approximately 10% of those for men, and suicide rates for women decrease with age. About half of homicides in the United States that involve a female victim (3986 in 2017) are committed by intimate partners, and about half of female intimate partner homicides are committed with a firearm (1, 6). Approximately 60% of all firearm-related deaths are suicides; conversely, firearms are the means of death for approximately half of all suicides nationwide (51% in 2017), with higher rates of firearm suicide death in some states (1). Among veterans, who are at increased risk for suicide, more than 75% involve firearms (7). As many as 90% of suicide attempts with a firearm result in death (8). Approximately one third of all firearm-related deaths are homicides, and most homicides are due to firearm injury (75% in 2017) (1). Firearm mortality in the United States varies geographically. Homicide rates are highest in the South, and suicide rates are highest in the Intermountain West (Figure 4). Death rates also differ between urban and rural areas within states. Urban areas have higher rates of firearm homicide, whereas rural areas have higher rates of firearm suicide (9). Figure 4. Age-adjusted firearm suicide and homicide rates, by state, 2017. Data from reference 1. Hawaii, New Hampshire, North Dakota, Vermont, and Wyoming have suppressed firearm homicide rates. * Unstable value for rate of firearm homicide. There are an estimated 265 million civilian-owned firearms in the United States (10). Approximately 22% of U.S. adults own firearms, and the median state-level prevalence of firearms in the home is 40.8% (10, 11). Firearm owners are disproportionately male, white, middle-aged or older, and residents of nonurban areas (10). Eight percent of owners own 10 or more firearms; this accounts for nearly 40% of the firearms in the United States (10). At the population level, the prevalence of ownership is strongly associated with rates of firearm-related homicide, suicide, and unintentional death (1214). Health Benefits, Harms, and Risk Groups Why do people own firearms? Americans own firearms for several reasons, chiefly to protect themselves from other people (63%) and for hunting (40%) and other sporting uses (28%) (10). Veteran populations cite similar reasons (15). Larger proportions of women (73%), Southerners (69%), and persons who own only handguns (78% of those who own 1 and 83% of those who own>1) report owning firearms for protection against people (10). An estimated 8% of Americans own firearms for their jobs (16). What are the risks associated with access? Most households with firearms do not experience injury or death in a given year. However, a firearm in the home is an independent risk factor for injury or death, and risk remains elevated, although to a lesser degree, even when they are stored safely. When a firearm is in the home, all members of the household are at increased risk for homicide, suicide, and unintentional injury. A 2014 meta-analysis calculated pooled odds ratios of 3.24 for suicide and 2.00 for homicide victimization for persons with firearms in the home (17). Several casecontrol studies have examined risk for firearm-related death associated with the presence of a firearm in the home (Appendix Figure and Appendix Table 1) (17). Appendix Figure. Odds of suicide and homicide in the context of firearm access. From reference 17. Appendix Table 1. Characteristics of Studies of Suicide and Homicide Victimization One large-scale cohort study focused on risk to handgun purchasers (18). In the first week of possession, suicide risk increased more than 50-fold; it remained elevated, although progressively less so, through 5 years of follow-up. For women who purchased handguns, the leading cause of death in the ensuing year was firearm suicide. Risk for homicide victimization was increased among women, but not men, who purchased handguns. Risk for unintentional death by firearm is also elevated in households with firearms. The magnitude of increase is related to the number of firearms in the home (19). What are safer storage practices? Do they reduce risk? Following Grossman and colleagues (20), we define safer storage to mean that firearms are stored unloaded and locked (either fitted with a locking device or secured in a locked container) and that ammunition is stored separately and also locked. In the 2015 National Firearms Survey, 46% of firearm owners reported safely storing all guns. However, 30% of firearm owners store at least 1 firearm loaded and unlocked, 25% store all weapons unloaded and locked, and 46% store their firearms either locked and loaded or unlocked and unloaded (unpublished data provided by the authors) (10). Approximately 20% of homes with children have guns stored in the least safe manner and 30% have guns stored in the safest manner, suggesting that safer storage is slightly more common among households with children than those without (21). Nonetheless, 6% to 8% of children (approximately 4.6 million) in the United States live in homes with firearms stored unlocked and loaded (21). Persons who own 5 or more firearms, those whose storage is influenced by concerns about home security, and those who are older might be less likely to store their firearms safely (22). Unsafe storage is associated with other risk factors for firearm-related death and injury, such as frequent and heavy alcohol use (23). Not surprisingly, unsafe firearm storage practices are associated with adverse outcomes. Risk for suicide among persons living in homes with firearms is higher if the weapons are stored loaded and unlocked (24, 25). A casecontrol study found that firearms used in suicide attempts or those causing unintentional injury were less likely than others to be stored safely (20). Hazards associated with unsupervised access by children and adolescents, presumably a result of unsafe storage, have been well documented. A review of school shootings from 1990 through 2017 in which 3 or more people were killed found that, in cases where information about the source of the firearms used was known, 85% of the shooters obtained them from home (26). In a series of 44 adolescent suicides with a known firearm source, 82% of the weapons were owned b