Gun Violence, Prevention of (Position Paper)

Introduction

Gun violence is a national public health epidemic that exacts a substantial toll on the U.S. society. Gun violence includes homicide, violent crime, attempted suicide, suicide, and unintentional death and injury. According to the Centers for Disease Control and Prevention (CDC), more than 38,000 deaths from firearms (including suicides) occurred in the United States in 2016,1 and nearly 85,000 injuries from firearms occurred in 2015.2 That’s an average of 105 deaths and more than 230 injuries from firearms each day.1,2

In addition to the thousands killed or injured, myriad families must also cope with the consequences of this violence. In terms of the financial toll, although the estimates vary, it’s generally held that gun violence expenses—medical charges, loss of income, daily care/support, and criminal justice expenditures—cost the U.S. economy approximately $229 billion annually.3

Gun violence should be considered a public health issue, not a political one—an epidemic that needs to be addressed with research and evidence-based strategies that can reduce morbidity and mortality. Gun violence affects people of all ages and races. Family physicians care for victims of gun violence and their families every day. These physicians, who witness the substantial impact firearm-related violence has on the health of their patients, families, and communities, have the power to help improve the safety and wellbeing of those groups.

The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be a key strategy used to prevent future harm and injuries. This approach focuses on three elements: scientific methodology to identify risk and patterns, preventive measures, and multidisciplinary collaboration.4 The AAFP encourages this public health approach and supports research that identifies which policies and interventions effectively reduce morbidity and mortality, while also respects the Constitutional right to bear arms.

Call to Action
The American Academy of Family Physicians joined the American Academy of Pediatrics, American College of Physicians, American College of Obstetricians and Gynecologists, and the American Psychiatric Association urging the president and Congress to take the following three concrete steps to address gun violence:

  • Label violence caused by the use of guns as a national public health epidemic.
  • Fund appropriate research as part of the federal budget.
  • Establish constitutionally appropriate restrictions on the manufacturing and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.5

This call to action from physician groups emphasizes the need to treat gun violence as a public health epidemic.

Family physicians can further address gun violence in their practices and communities by following these office- and community-based steps.

Office-based:

o   Patients who screen positive should undergo additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions. Patients with depression should be treated with antidepressant medication and/or psychotherapy.

o   The presence of guns in the home increases the risk that a woman will die due to an IPV-related homicide eight-fold.9

Community-based:

  • Know the rates of gun violence in your area to better understand the impact on your community (http://www.gunviolencearchive.org/charts-and-maps(www.gunviolencearchive.org))6
  • Participate in programs that address violence in your community.
  • Communicate with your local, state, and federal officials about gun violence as a public health concern. These conversations should specifically address:

o   Funding research to identify effective measures to increase the safety of firearms;
o   Gun safety legislation;
o   Strict enforcement of current gun laws;
o   Constitutionally-appropriate restrictions on the manufacture and sale, for civilian use, of large-capacity magazines and firearms; and
o   Appropriate funding for mental health services.

Gun Violence: A Public Health Epidemic
Gun violence is a public health epidemic and should be treated accordingly. While mass shootings are horrific and capture the attention of the media, they are only part of the gun-violence picture—more than half of all suicides are firearm-related,10 and firearms are used in more than 50% of female homicides.3,11

Similarly to females, firearm-related deaths are a particular threat to children in the U.S. They are the third-leading cause of death in children overall,1 and the U.S. accounts for more than 90% of all firearm deaths among children in developed, high-income nations.12

Public health professionals are trained to create and test interventions to reduce death and injury. However, limited federal funding is available to research this leading cause of death. Introduced in 1996, the Dickey Amendment prohibits federal funding allocated to the Centers for Disease Control and Prevention (CDC) be used to advocate for or promote gun control, which essentially ended all CDC funding research on gun violence or gun control measures.13

Appropriate research funding is the first step to understand gun violence and is essential to develop programs to prevent premature death from guns. An inconsistent collection of epidemiologic data is another impediment to this research. Currently, not all U.S. states report surveillance data to the National Violent Death Reporting System.14 International Classification of Disease (ICD) codes are often used to collect data on a national scale, but do not provide the same level of detail. Creating a comprehensive data collection surveillance system will provide public health researchers with comprehensive and consistent information to study gun violence.

An example of such a system in place with data to study a public health issue is research on motor vehicle accidents. The number of deaths caused by motor vehicle accidents is comparable to gun violence, but motor vehicle deaths have declined significantly over the past decade despite more motorists on the road. Extensive research has improved motor vehicle safety with multiple evidence-based interventions contributing to decreased mortality. Implementation of vehicle safety features, stricter enforcement of traffic laws, and public awareness campaigns effectively addressed high morbidity and mortality associated with motor vehicles.

The National Highway Traffic Safety Administration (NHTSA) operates with a budget of more than $1 billion annually, and is committed to the continued improvement of the safety of motor vehicles and motorists.15 Research and development for the agency alone had a budget of nearly $146 million in 2017.15

Similarly, almost all other leading causes of death, whether accident or disease, receive substantially more funding for research than gun violence.16 One study found that, “in relation to mortality, gun violence research was the least-researched cause of death and the second-least funded cause of death after falls.”16 When a similar approach to research on motor vehicle accidents is suggested for gun violence, it is often considered political, instead of an evidence-based, data-driven approach to prevent morbidity and mortality.

As whole-person health care providers, family physicians see the effect of gun violence on their patients and in their communities. Using a public health perspective, family physicians can incorporate evidence-based strategies to treat their patients and guide their communities on this important issue. With that in mind, the AAFP:

  • Continues to oppose legislation that would prohibit the CDC and other agencies from conducting and distributing research on gun violence as a public health problem;
  • Advocates for systems to allow accurate reporting of surveillance data; and
  • Encourages the evaluation and implementation of evidence-based research and approaches that addresses gun violence to improve the health and lives of all patients.

Suicide
In 2016, almost 45,000 individuals committed suicide in the U.S.1 Suicide accounts for nearly 60% of all firearm-related deaths in the U.S., with men overwhelmingly choosing firearms as their primary method to commit suicide.1 Alarmingly, suicide was the second-leading cause of death for adolescents ages 15-19, with firearms as the leading method of suicide (50.7%) in this age group.1

Firearms are the most lethal method of attempting suicide. Between 85 to 91% of firearm suicide attempts result in death, compared to 3% or less for other common ways of attempting suicide.17 Suicide is often an impulsive decision. The majority of those who survived a suicide attempt reported that less than one hour had passed between the time they decided to commit suicide and when they took action.18 The use of a firearm to commit suicide rarely allows for intervention or reconsideration, so increased access to firearms is associated with increased rates of completed suicide.19 Evidence suggests unsafe gun storage may also pose a higher risk for committing suicide using a firearm.19 The impulsive nature of suicide, in combination with often times easy access to guns, can result in a completed suicide—one that might have been preventable if another method had been attempted.

Opportunities for Prevention
Reducing the availability of firearms is one of the most effective mechanisms for suicide prevention. Waiting periods for purchasing handguns, mandatory background checks, gun locks, and restrictions on open-carry policies are also associated with a reduction in suicide by firearm.20

Waiting periods may allow for a “cooling off” time for individuals to reconsider suicide.17 Background checks limit access by creating a second barrier at the point of purchase.20 Safely securing guns places a barrier on immediate access and open-carry regulations decreases exposure to firearms.20 These mechanisms have been shown not only to decrease suicide by firearm, but also to decrease overall rates of suicide (by any method).20

In addition to decreasing access to firearms, increased access to mental health services is associated with a decrease in overall rates of suicide.19 The majority of patients with mental health issues access the health care system through primary care physicians.21 Appropriate access to primary care and payment for mental health services are critical to care for individuals with depression, substance abuse, and other mental illnesses, and can ultimately prevent attempted suicide through firearms and other means.

Domestic Violence
Among developed nations, the U.S. has the most gun violence against women. Women are nearly 16 times more likely to die by firearm when compared to other developed nations.12 The majority of these deaths are the result of intimate partner violence (IPV). For example, in 2015, more than 3,500 women and girls were victims of homicide. More than half of those deaths were related to IPV.11 These rates are even greater in subgroups defined by race. Non-Hispanic black and American Indian/Alaskan Native women have the highest rates of IPV-related homicide.11

Compared to homes without guns, households with guns are associated with a nearly three-fold increase for the risk of homicide occurring in the home.22 There is a nearly eight-fold increased risk associated with gun ownership and homicide when the perpetrator is the intimate partner or a relative of the victim.22 If the gun owner has a history of domestic violence, the risk of homicide is 20 times higher.22 Women who are physically abused by current or former partners are seven times more likely to be murdered if the partner owned a handgun compared to women whose partner does not own a handgun.9

Opportunities for Prevention
A proven strategy to protect women from IPV-related homicides includes reducing the availability of firearms. The AAFP recommends screening all women of childbearing age for IPV, and referring women who screen positive for IPV to intervention services.8 A step that family physicians can take after a positive assessment for IPV is to refer female patients to organizations which have resources for crisis intervention and counseling, and finding safe housing, medical care, and legal advocacy.11

Intimate partner violence is higher in communities experiencing severe disadvantage, such as poverty and low-social cohesion.23 System-level changes to reinvest in communities of poverty can reduce violence of many forms, including IPV-related homicide. Legislative policy change is an essential component to the reduction of IPV-related homicide.

Restricting firearm purchases for individuals convicted of domestic violence-related crimes or under a domestic violence-related restraining order is an effective way to prevent IPV-related homicide.24 States with systems to screen for restraining orders prior to firearm purchases have an 8-19% reduction in all IPV homicides and a 9-25% reduction in the rate of IPV homicide with a firearm.25 However, these safeguards must apply to all purchases to be effective. Currently, federal law only requires background checks for firearm purchases with licensed dealers.19 Firearms purchased through unlicensed sellers and at gun shows, commonly referred to as the “gun-show loophole,” do not require a background check, allowing for individuals with a history of domestic violence unfettered access to guns. States requiring universal background checks on handgun sales from all sources experienced a 47% reduction in victims of IPV-related firearm homicide.26

Homicide and Violent Crime with a Firearm
In 2016, there were more than 14,400 homicides with a firearm, accounting for nearly three-quarters of all homicides.1 In contrast to IPV, the majority (80%) of homicide victims are men.1

In the U.S., individuals are 25 times more likely to be killed by a firearm than in other high-income nations.12 Disparities exist across racial and ethnic lines, as well. Non-white individuals are more likely to die by homicide than whites. For individuals 10-29 years, homicide is the leading cause of death in non-Hispanic blacks and Hispanics.27 This is substantially higher than non-Hispanic whites, where homicide is the fifth-leading cause of death.27

Opportunities for Prevention
Not surprising, a lack of research has resulted in a scarcity of evidence regarding prevention of homicide and violent crime. Limited evidence suggests that reducing access to illegal guns through programs that have demonstrated success can reduce homicide and violent crime rates. One program implemented in Baltimore used a system of “hot-spotting,” where detectives were placed in areas at high risk for gun violence. Between 2007 and 2012, areas of “hot spotting” experienced a 12-13% reduction in homicides and an 18-20% reduction in shootings.28

Background checks may also contribute to decreased rates of both homicide and overall violent crime.19 Moderate evidence suggests a decrease in violent crime with mental health background checks.19 However, much of this data is reported voluntarily by states and may vary depending on which conditions prohibit gun ownership.19 It is important to note that there is evidence that certain policies may actually increase violent crime. There is moderate evidence that stand your ground laws increase rates of homicide, and some evidence that states with concealed carry laws see increased rates of violent crime.19

Mass Shootings
Given no standard definition of “mass shooting,” data on the subject, as well as mass murder is inconsistent. After the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, the U.S. Congress defined “mass killing” as “3 or more killings in a single incident.”29 This definition does not include information about the weapon(s) used, the number of perpetrator(s), or the location of the shooting. Mass murder is defined by the Federal Bureau of Investigation (FBI) as a “multiple homicide in which four or more victims are murdered, within one event, and in one or more locations in close geographical proximity.”29 This does not include injuries, nor is this a formal definition used for data collection purposes. Developing standard definitions through consensus among researchers will be crucial for quality, consistent research regarding gun violence.

Mass shootings account for only a small portion of gun violence deaths, but generally garner media attention due to the public and horrific nature of the incidents. In recent years, mass shootings have, by and large, been perpetrated by men using assault-style, semi-automatic weapons, often modified to mimic fully-automatic versions via high-capacity magazines and “bump stock” technology. These shootings have occurred in public places, such as schools, nightclubs, churches, and music venues.

Opportunities for Prevention
While a lack of research hinders the development of evidence-based strategies to prevent mass shootings, even small changes—banning modification devices, such as bump stocks and high-capacity magazines—could potentially reduce the number of injuries and deaths that occur.

Congress’s 1994 assault weapons ban, which included 18 types of assault weapons, weapons with military-style features, and weapons with high-capacity magazines (10 or more bullets), lapsed in 2004. In that 10-year period, “gun massacres” (six or more gun deaths) declined compared to the decade prior.

From 2004-2014, after the assault weapons ban lapsed, the number of gun massacre deaths during the ban (89) increased more than three times (302). Also, the number of gun massacre incidents during the ban (12) nearly tripled (34) during the same 10-year period.30

Unintentional Death and Injury by Firearm
Unintentional deaths and injuries by firearms are largely preventable. In 2016, 495 people died from unintentional firearm incidents.1 Of those, 127 (25.7%) were children and adolescents (0-19 years).1 Most of those deaths were among two age groups: 15-19 years (53 deaths) followed by 0-4 years (23 deaths).1 Young adults (20-24 years) had the most deaths by age group, with 68 unintentional firearm deaths.1

Unintentional injury by firearm also disproportionately affects adolescents and young adults. Of the 17,311 unintentional injuries by firearm in 2015, nearly 8,000 (50%) occurred in individuals between 15-29 years.2 The rate of unintentional injury by firearm was the highest among individuals between 20-24 years (21.9).2

Opportunities for Prevention
Research suggests clinical interventions and public health campaigns focused on safe storage are effective at preventing unintentional injuries and deaths by firearms.19 One study found that family physicians and pediatricians who ask patients (mostly those with children) about access to firearms, and are counseled on safe storage and provided a free safe storage device, it results in increased safe storage behaviors.19 Another study, following the same protocol without a providing a free safe storage device, also found improvements in safe storage of firearms. Safe storage of firearms decreases immediate access to guns, especially for children.19 Child access prevention (CAP) laws are designed to protect children by legally prosecuting adults who intentionally or carelessly create situations in which children have unsafe and negligent access to guns.19

These laws often mandate safe storage of firearms, and some states stipulate that firearms must be unloaded when stored.19 CAP laws also prohibit providing children with unsupervised, reckless access to firearms.19 Strong evidence suggests CAP laws decrease firearm-related self-injuries (intentional and unintentional) among all ages, and decrease unintentional firearm injuries and death among children.19,31 Evidence also suggests that classifying violations of CAP law as felonies may further reduce unintentional death and injuries by firearms among children.19

Policy Strategies to Address Gun Violence
Other potential avenues to address gun violence are consistent with common prevention strategies employed in other public health interventions. Two of the most effective public health strategies employed to reduce tobacco use—price increases and taxation—have proven effective deterrents to initiating tobacco use and encouraging the decline and cessation of tobacco use.32 Applying this economic strategy to the purchase of firearms could potentially reduce gun ownership, and as a result, decrease gun violence.

For example, background checks for ammunition purchases, limits on ammunition purchases, and identification requirements for firearms, have been shown to reduce firearm deaths.33 Reinstating the 1994 federal assault weapons ban could decrease access to dangerous semi-automatic weapons. Requiring microstamping—microscopic, laser-generated engravings on guns and ballistic materials—contribute to a higher solve rate for homicides and other violent crimes.34

Call for Research
The AAFP calls for increased research funding on gun violence, and identifying key areas that must be addressed. These areas could begin to be addressed by answering the following questions:

  • What specific counseling (regarding gun safety and given by physicians) reduces the likelihood of gun violence?
  • Does gun safety training reduce gun violence?
  • What policies and interventions (including legal remedies and prevention strategies) reduce gun violence?
  • What are the most effective interventions for securing public venues to minimize the risk of mass shootings and minimize resulting casualties?

AAFP Efforts to Address Firearm Safety and Violence
Family physicians frequently find themselves on the frontlines on public health issues and discussions. This role provides them an opportunity to address and guide conversations about public health issues, such as gun violence, in both the exam room and their communities. By advancing policies that promote safety and discourage violence, family physicians are instrumental in the gun violence debate.

To assist family physicians in this effort, the AAFP has policies and advocacy efforts relating to violence to help equip family physicians as they serve the needs of their patients. The AAFP recognizes violence as a public health concern, and the impact of violence has on immediate and long-term health outcomes. The AAFP acknowledges that violence occurs in the context of a broad range of human relationships and complex interactions. These encompass social, cultural, and economic risk factors, including but not limited to, the influence of the media, substance abuse, interpersonal violence, fragmentation of family life, and the increased availability of weapons.

Moreover, the AAFP recognizes that violence disproportionately affects vulnerable populations, such as women, children, lesbian, gay, bisexual, transgender, questioning, and intersex individuals, as well as those living in poverty, among other populations. The AAFP has outlined multi-faceted issues surrounding violence in position papers, and describes both the challenges and opportunities for family physicians to address the health consequences, as well as to help prevent a continued cycle of violence.

Summary

As clinicians, family physicians can help prevent gun violence in their practice and within their communities by proper screening and treatment of depression, screening for IPV, referring patients to appropriate services, and talking with patients about the safe storage and handling of guns.

Outside of the exam room, family physicians can help prevent suicide and intentional injuries and deaths by advocating for gun violence research funding and gun control legislation at the community, state, and federal levels. To gain a better understanding of gun violence and potential solutions, it is essential that the U.S. Congress implements research funding to create evidence-based strategies to combat and prevent gun violence.

Gun violence in the U.S. is a public health epidemic. Using comprehensive, interdisciplinary approaches, and working in collaboration with other public health professionals, family physicians can play an imperative role in the reduction of gun violence.

References

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(April 2018 BOD)