Summary

Individuals use firearms legally for a variety of activities, including recreation, self-protection, and work. However, firearms can also be used to intimidate, coerce, or carry out threats of violence. Fatal and nonfatal firearm violence1 poses a serious threat to the safety and welfare of the American public. Although violent crime rates have declined in recent years, the U.S. rate of firearm-related deaths is the highest among industrialized countries. In 2010, incidents in the United States involving firearms injured or killed more than 105,000 individuals; there were twice as many nonfatal firearm-related injuries (73,505) than deaths. Nonfatal violence often has significant physical and psychological impacts, including psychological outcomes for those in proximity to individuals who are injured or die from gun violence. The recent, highly publicized, tragic mass shootings in Newtown, Connecticut; Aurora, Colorado; Oak Creek, Wisconsin; and Tucson, Arizona, have sharpened the public’s interest in protecting our children and communities from the effects of firearm violence.

In January 2013, President Obama issued 23 executive orders directing federal agencies to improve knowledge of the causes of firearm violence, the interventions that might prevent it, and strategies to minimize its public health burden. One of these executive orders noted that “in addition to being a law enforcement challenge, firearm violence is also a serious public health issue that affects thousands of individuals, families,

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1 For the purposes of this report, the terms “firearm violence,” “gun violence,” and “firearm-related violence” refer to morbidity and mortality associated with the possession and use of firearms. Firearms use a propellant or powder charge to fire a projectile and are distinct from other guns, such as BB, pellet, and other airsoft guns.



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Summary Individuals use firearms legally for a variety of activities, including recreation, self-protection, and work. However, firearms can also be used to intimidate, coerce, or carry out threats of violence. Fatal and nonfatal firearm violence1 poses a serious threat to the safety and welfare of the American public. Although violent crime rates have declined in recent years, the U.S. rate of firearm-related deaths is the highest among indus- trialized countries. In 2010, incidents in the United States involving fire- arms injured or killed more than 105,000 individuals; there were twice as many nonfatal firearm-related injuries (73,505) than deaths. Nonfatal violence often has significant physical and psychological impacts, in- cluding psychological outcomes for those in proximity to individuals who are injured or die from gun violence. The recent, highly publicized, tragic mass shootings in Newtown, Connecticut; Aurora, Colorado; Oak Creek, Wisconsin; and Tucson, Arizona, have sharpened the public’s interest in protecting our children and communities from the effects of firearm violence. In January 2013, President Obama issued 23 executive orders direct- ing federal agencies to improve knowledge of the causes of firearm vio- lence, the interventions that might prevent it, and strategies to minimize its public health burden. One of these executive orders noted that “in ad- dition to being a law enforcement challenge, firearm violence is also a serious public health issue that affects thousands of individuals, families, 1 For the purposes of this report, the terms “firearm violence,” “gun violence,” and “firearm-related violence” refer to morbidity and mortality associated with the possession and use of firearms. Firearms use a propellant or powder charge to fire a projectile and are distinct from other guns, such as BB, pellet, and other airsoft guns. 1

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2 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE and communities across the Nation,” and directed the Centers for Dis- ease Control and Prevention (CDC), along with other relevant federal agencies, to immediately begin identifying the most pressing firearm- related violence research problems. The CDC and the CDC Foundation2 requested that the Institute of Medicine (IOM), in collaboration with the National Research Council (NRC), convene a committee of experts to develop a potential research agenda focusing on the public health aspects of firearm-related violence— its causes, approaches to interventions that could prevent it, and strate- gies to minimize its health burden. In accordance with the CDC’s charge, the committee did not focus on public health surveillance and potentially related behavioral/mental health issues, as these will be addressed sepa- rately. The research program envisioned by the committee, which is de- signed to produce impacts in 3-5 years, focuses on  the characteristics of firearm violence,  risk and protective factors,  interventions and strategies,  gun safety technology, and  the influence of video games and other media. The committee identified potential research topics by conducting a survey of previous relevant research, considering input received during the workshop, and using its expert judgment. The committee was not asked to consider funding for the research agenda, and in addition to the CDC, it is likely that other agencies and private foundations will also implement the research agenda. Consequently, the committee identified a full range of high-priority topics that could be explored with significant progress made in 3-5 years. Research on these topics will improve cur- rent knowledge of the causes of firearm violence, the interventions that prevent firearm violence, and strategies to minimize the public health burden of firearm violence. To allow the research community flexibility in designing the research protocols, the report does not specify the meth- odologies that should be used to address the research topics. The evidence generated by implementing a public health research agenda can enable the development of sound policies that support both 2 The CDC Foundation’s support originated from The Annie E. Casey Foundation, The California Endowment, The California Wellness Foundation, The Joyce Foundation, Kaiser Permanente, the Robert Wood Johnson Foundation, and one anonymous donor.

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SUMMARY 3 the rights and the responsibilities central to gun ownership in the United States. In the absence of this research, policy makers will be left to de- bate controversial policies without scientifically sound evidence about their potential effects. FIREARM-RELATED VIOLENCE AS A PUBLIC HEALTH ISSUE The public health field focuses on problems that are associated with significant levels of morbidity and mortality. The complexity and fre- quency of firearm-related violence combined with its impact on the health and safety of the nation’s residents make it a topic of considerable public health importance and suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries. A public health approach involves three elements: (1) a fo- cus on prevention, (2) a focus on scientific methodology to identify risk and patterns, and (3) multidisciplinary collaboration to address the issue. Public health strategies are designed to interrupt the connection between three essential elements: (1) the “agent” (the source of injury [weapon or perpetrator]), (2) the “host” (the injured person), and (3) the “environ- ment” (the conditions under which the injury occurred). This public health approach has produced successes in reduction of tobacco use, un- intentional poisoning, and motor vehicle fatalities. CHARACTERISTICS OF FIREARM VIOLENCE In order to develop relevant research questions and interventions in- tended to prevent firearm-related violence, it is important to understand what is and is not known about the general characteristics of both fatal and nonfatal firearm violence. Gun type and intended use vary; so do the manifestations of firearm violence. Some firearm violence results in death, but most does not. There are important disparities across socioeconomic and ethnic groups in overall mortality rates from firearm violence. Further, there is substan- tial variation within each type of violence: suicide, homicide, uninten- tional injuries, and fatalities. For example, suicides in youth may be motivated by very different factors from those for suicides in older

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4 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE adults. This kind of difference will affect the success of any prevention strategy. It is ultimately important, of course, to understand the unique charac- teristics of all types and subtypes of violence. However, resources fo- cused on three specific populations—(1) the general population, (2) the general youth population, and (3) the offender population—should yield actionable information over the short term. The exact number and distri- bution of guns and gun types in the United States are unknown, but for each of these populations it would be valuable to have counts of total guns owned, their attributes (i.e., general type, caliber, firing mecha- nism), how the guns were acquired (i.e., purchased, received as a gift, traded for, stolen, etc.), and information on the sources of the guns (i.e., licensed gun dealers, friends or relatives, gun traffickers, owners of sto- len guns, and so on). It also would be valuable to better understand both the violent and relevant nonviolent and self-protective behaviors of indi- viduals with firearms. The committee identified the following key research topics as priori- ties for research on characteristics of firearm violence.  Characterize the scope of and motivations for gun acquisi- tion, ownership, and use, and how they are distributed across subpopulations.  Characterize differences in nonfatal and fatal gun use across the United States. RISK AND PROTECTIVE FACTORS The risk posed by guns is affected by a number of modifiable and unmodifiable factors, ranging from how securely guns are stored to com- plex society-, community-, situational-, and individual-level predictors. Society-level correlates of increased rates of firearm violence include, but are not limited to, cultural norms that support violence as an accepta- ble way to resolve conflicts; attitudes that regard suicide as inevitable instead of a preventable act of violence; and health, educational, econom- ic, and social policies that maintain high levels of economic or social inequality among groups in society. At the community level, a range of factors appears to be related to high levels of gun use. These factors include high rates of poverty, illicit drug trafficking, and substance use. For example, increased firearm vio-

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SUMMARY 5 lence has been associated with drug markets. A number of situational- level factors are also associated with increased risk of violence in general and firearm violence in particular. For example, the presence of drugs or alcohol increases the risk of firearm violence. Moreover, criminals often engage in violence as a means to acquire money, goods, or other re- wards. A number of individual behaviors and susceptibilities are associated with firearm violence and injury. Impulsivity, low educational attain- ment, substance use, and prior history of aggression and abuse are con- sidered risk factors for violence (for both perpetrators and victims). Suicide is often associated with mental and physical health problems, financial strain, veteran status, and relationship problems. Some studies have tried to provide accurate estimates of the proportions of the general population and subpopulations with access to firearms. Less is known about the types of weapons obtained, the means of acquisition, the fre- quency of gun carrying in public, community-level risk and protective factors (such as the role of social norms), and degree of knowledge about and skill in firearm operation and safety, as well as how these risk and protective factors are affected by the social environment and neighbor- hood/community context. The committee identified the following key research topics as priori- ties for research on risk and protective factors.  Identify factors associated with youth having access to, pos- sessing, and carrying guns.  Evaluate the potential health risks and benefits (e.g., suicide rates, personal protection) of having a firearm in the home under a variety of circumstances (including storage prac- tices) and settings.  Improve understanding of risk factors that influence the probability of firearm violence in specific high-risk physical locations. FIREARM VIOLENCE PREVENTION AND OTHER INTERVENTIONS Research findings have been mixed on the effectiveness of interven- tions to prevent firearm violence. Successful interventions to reduce firearm-related injuries, as with many other examples in public health,

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6 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE must involve the health and public safety communities, educators, and other community groups. As part of a public health approach, interven- tions may target  the “agent,” meaning the gun or its possessor;  the “host,” or the victim(s) of firearm-related violence; and  the “environment,” including social, physical, or virtual envi- ronments that may shape gun policies, norms, and behavior. Unauthorized gun possession or use is associated with higher rates of firearm violence than legal possession of guns. Controlling access to guns through background checks or restrictions on particular types of firearms remains controversial, and the effectiveness of various types of control is in- adequately researched. Research on the impact of imposing additional penalties for firearm use in illegal activities has also produced mixed results. Studies on the impact of right-to-carry laws on firearm violence also have inconsistent results and have been debated for a decade. Interventions Focused on Potential Perpetrators and Victims of Firearm Violence In 2010, incidents involving firearms injured or killed more than 105,000 individuals in the United States, including approximately 19,000 suicides. Understanding differences among subpopulations with access to guns and targeting interventions to their particular risk factors may con- fer a public health benefit. For example, alcohol use is attributed with increased levels of firearm-related violence. However, state laws de- signed to ameliorate the risk of firearm use by those that abuse alcohol differ, and there is a lack of data on the basis for these laws or on their effectiveness. Risk stratification with respect to mental health and the use of firearms is imprecise and not well understood. Although the risk asso- ciated with some specific psychiatric diagnoses is better understood now than in the past, mental health issues that foster a propensity toward violence and risk taking are not well defined and not readily recognized by authorities.

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SUMMARY 7 Interventions Focused on Social, Physical, and Virtual Environments It is unclear whether modifications in the physical and social envi- ronment have been effective in reducing firearm violence. Community- based programs and focused policing interventions in general have been found to be effective in reducing violence in some settings (e.g., high- risk physical locations) and appear to be more effective than prosecutori- al policies, including mandatory sentences. Moreover, regulations that limit hours for on-premise alcohol sales in pubs, bars, and nightclubs have been associated with reduced violence. Firearm safety education programs are widespread in public schools, but they are inadequately studied and the few evaluations that have been conducted provide little evidence of effectiveness. No conclusive data exist about interventions intended to reduce the number and impact of mass shootings. Additionally, although communities, schools, and cam- puses have developed myriad safety plans, there is very little information available about their effectiveness. The committee identified the following key research topics as priori- ties for research on prevention and other interventions.  Improve understanding of whether interventions intended to diminish the illegal carrying of firearms reduce firearm violence.  Improve understanding of whether reducing criminal access to legally purchased guns reduces firearm violence.  Improve understanding of the effectiveness of actions directed at preventing access to firearms by violence-prone individuals.  Determine the degree to which various childhood education or prevention programs reduce firearm violence in childhood and later in life.  Do programs to alter physical environments in high-crime areas result in a decrease in firearm violence? IMPACT OF GUN SAFETY TECHNOLOGY Technologies that can reduce firearm violence offer further opportu- nities to reduce the burden of product-related injuries. Research from the injury prevention field indicates that changing products to make them safer is frequently more effective at reducing injury and death than trying

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8 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE to change personal behavior. Several objectives of these gun technolo- gies are to prevent unintentional shootings, often by very young children; the shooting of police officers by assailants using the officers’ own weapons; and suicides, especially by teenagers. In addition, these preven- tion technologies offer the prospect of reducing firearm-related crime by rendering a gun unusable to an unauthorized person. There are both active and passive technologies that may have an im- pact. Passive technologies—for example, technologies that recognize person-specific features such as voice, hand geometry, iris scans, and fingerprints—are those that confer a safety benefit without requiring any specific action by a user. Active technologies require a specific action by a user to enable the technology—for example, to activate a firearm a user has to produce an item that activates the firearm (e.g., tokens, magnetic stripe badges, or proximity cards). The development and application of these technologies to guns has been an intermittent and fragmented pro- cess complicated by the diversity in firearms themselves. Technology adoption can be facilitated or hindered by a variety of factors. To achieve a reduction of preventable deaths and injuries related to firearms, future research should examine how product safety measures are accepted and used at a population level. This includes improving understanding about factors that promote consumer adoption of gun technologies and identi- fying lessons learned from public health successes across states and countries. The committee identified the following key research topics as priori- ties for research on gun safety technology.  Identify the effects of different technological approaches to reduce firearm-related injury and death.  Examine past consumer experiences with accepting safety technologies to inform the development and uptake of new gun safety technologies.  Explore individual state and international policy approaches to gun safety technology for applicability to the United States as a whole. VIDEO GAMES AND OTHER MEDIA The vast majority of research on the effects of violence in media has focused on violence portrayed in television and the movies, although

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SUMMARY 9 more recent research has been expanded to include music, video games, social media, and the Internet. Interest in media effects is fueled by the fact that youth are spending more time engaging with media that portrays increasing amounts of violence. Although research on the effects of me- dia violence on real-life violence has been carried out for more than 50 years, none of this research has focused on firearm violence in particular as an outcome. As a result, a direct relationship between violence in me- dia and real-life firearm violence has not been established and additional research is necessary. The committee identified the following key research topic as a pri- ority for research on video games and media.  Examine the relationship between exposure to media vio- lence and real-life violence. RESEARCH DESIGN AND DATA High-quality data that are usable, credible, and accessible are funda- mental to both the advancement of research and the development of sound policies. Anonymous data are sufficient for these purposes, and in fact anonymized data should be used to protect civil liberties. Basic in- formation about gun possession, distribution, ownership, acquisition, and storage is lacking. No single database captures the number, locations, and types of firearms and firearm owners in the United States. Because different forms of firearm violence respond to different strategies, with- out good data it is virtually impossible to answer fundamental questions about occurrence and risk factors or to effectively evaluate programs in- tended to reduce violence and harm. Data about the sources of guns used in crimes are important, given that studies suggest that the mechanism by which an individual acquires a gun may predict future violent use of that gun. The National Violent Death Reporting System is a beginning, but it covers only one-third of U.S. states (CDC, 2013a). Additionally, the lack of comprehensive datasets and the wide varie- ty of sources and the fact that the data lead to contradictory conclusions call into question the reliability and validity of gun-violence data. Tech- nological opportunities and recent advances that can enhance linkages among datasets from other federal, state, and local sources may enable better predictive analytics, real-time information sharing, and reduction of data noise.

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10 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE The predominant use of research study designs that have limited ability to study causality, like case-control and ecological studies that aggregate data from sources and levels, have compounded the challenge faced by researchers and policy makers alike. Progressing to other exper- imental and quasi-experimental designs that have better ability to study causality and utilizing interdisciplinary partnerships and consultations with academics, practitioners, and community members would strength- en research. These issues related to research design and data, if not addressed, will limit the ability of researchers to perform rigorous studies, as well as the ability of policy makers to use research to inform the development and evaluation of future policies. The CDC, in collaboration with its fed- eral and state partners, can improve the reliability and accuracy of data and research about firearm-related violence. CONCLUSION The research agenda proposed in this report is intended as an initial— not a conclusive or all-encompassing—set of questions critical to devel- oping the most effective policies to reduce the occurrence and impact of firearm-related violence in the United States. No single agency or re- search strategy can provide all the answers. This report focuses on the public health aspects of firearm violence; the committee expects that this research agenda will be integrated with research conducted from criminal justice and other perspectives to provide a much fuller knowledge base to underpin our nation’s approach to dealing with this very important set of societal issues.