Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians

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 a owners more often reported support of such a program than those from a home with gun owners vs. of Discussions About a Public Health number of guns by in the United States from to which to firearms per persons The United States first among countries in the number of guns Each year, more than 32 000 persons are killed in the United States by firearms. This homicides, suicides, and unintentional and to 88 deaths per day by firearm result in 11 000 deaths each year More than 19 000 firearm deaths are The number of nonfatal firearm injuries is more than the number of deaths. It is that nearly 000 nonfatal firearm injuries occurred in the United States in 2011 its in the rate of gun has by the in the number of firearm deaths has not been as in vs. in and is still a children 20 years or were in for nonfatal firearm-related to 19 years had a nonfatal firearm injury rate nearly than the and children years or were killed by unintentional firearm injuries A 2013 of available data on unintentional or accidental firearm injury and death in states found that official may the number of accidental firearm deaths in children by as much as due in part to and of firearm suicide, and particularly in young is of concern with of the current much as of of unintentional firearm deaths were as were of reported as in an of firearm death data from the National State medical or and Homicide violence the United States in The for each firearm assault injury to for each 000 for each and 000 for each firearm assault that in only an The medical or mental health care, policy or criminal justice and of and Mental have shown that is still a and has not been shown to be an in the risk for such research has shown that persons with mental illness are to seek treatment a no patient or criminal would to prevent the from purchasing a firearm psychiatric conditions also have a association with than others. A survey on the of in persons with mental illness found that certain psychiatric disorders were of an increased risk for The of the survey that those with or disorders were to more to in and those with or and other substance use disorders were to more to A study by the National Institute of Mental Health revealed that persons with mental illness or were to more than those mental illness to commit of The study also found that those with mental illness had a of violence of compared with a among those mental illness mental illness is the risk to the rate of violence in the is only to the overwhelming majority of persons with mental illness do not pose a threat of violence to others or that have at types of mental illness in with substance have and use or to be a of than mental health study found that persons with mental illness are no more to be they also have a substance use or a of violence. and 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 of mental health A study of persons with mental illness revealed that they were more to in violence on when they and to more to in violence when they used and other to Firearms of Injury and some that firearms can a evidence that firearm availability the that persons will be either by or A study by and that all firearm deaths in Washington, a found accidental deaths, criminal homicides, and firearms for every death associated with or A study that compared the with which guns in the home are used for with the number of the weapons were involved in accidental injury, suicide or criminal assault or in U.S. found that for every a gun was used in or for a legally there were accidental 7 criminal or homicides, and 11 or completed A report on firearm injury prevention by the Firearm Injury at the of found among ownership of a firearm and of firearms in the home and an increased risk for and suicide by ownership of a gun has been associated with a increase in the risk for death by firearm compared with a The association having a firearm in the home and risk is of persons are more to be killed by a family or than a Although an of from the Federal of that the rate of is still for men than the risk of killed by a firearm is among More than twice as were and killed by their or an than by or other of data on that occurred in the home in that keeping a gun in the home the risk for in the home of other The study found that a significant of in the home are by to the such as a family or The risk for or death has been shown to for to years after the purchase of a This risk is also in the for suicide among gun owners years after purchase to firearms in the home and access have been shown to to the increase in the risk for suicide among and adults A study of purchases among years or found that the 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 after the purchase was than in the The that access to a firearm can increase the risk for suicide by firearm has been it has been shown that a decrease in household ownership of firearms is associated with a decrease in the rate of and the in suicide rates compared with the decrease in firearm ownership from to among They found a in firearm ownership all for and the study found an association with significant in the rate of firearm and and respectively) for each decrease in household firearm to 19 years were the in that for each the rate of firearm suicide by and the rate of by the of firearm safety efforts has been toward households with children, evidence that firearms in the home may also be a to persons are more to accidental or intentional