Preventing Handgun Injury
American College of Preventive Medicine Position Statement

by

Christopher R. Armstrong, MD, MPH, FACPM
Director for Outpatient Care and Chief Medical Officer
Naval Hospital, Cherry Point, NC

Introduction

The morbidity, mortality, and economic cost attributable to handgun violence are staggering. Of the 192 million firearms in the United States, only one third are handguns.¹ Yet, it is estimated that two-thirds of the more than one million Americans killed with a firearm in the past 30 years were killed with a handgun. The risk of death from homicide is threefold higher in homes where a firearm is kept.² The risk of death by suicide is five times higher in homes with a firearm.³ More adolescents die in the United States from gunshot wounds than from all natural causes combined. In 1998, 866 people sustained fatal, unintentional, gunshot wounds.⁵ There were also 11,798 homicides and 17,424 suicides committed with a firearm in 1998.⁵ For each firearm-related death, there are more than two non-fatal firearm related injuries.

In addition, firearm-related injuries are, on average, more costly that most other types of injury because of the relatively young age of decedents and because firearm-related trauma tends to be more severe than trauma sustained by other means.⁶ By one estimate, the direct costs of hospitalization and medical care combined with the indirect costs due to disability and premature death due to handgun-related violence exceeded $20.4 billion in 1990.

The American College of Preventive Medicine is the national medical society of physicians whose primary interest and expertise are in disease prevention and health promotion. The significant morbidity and mortality caused by the improper storage, handling, and use of handguns is preventable and, therefore, represents a major public health issue of concern to the College. Because of this concern, ACPM has been an active member of Doctors Against Handgun Injury (DAHI). Doctors Against Handgun Injury is a coalition of thirteen clinical and professional medical societies, organized and sponsored by the New York Academy of Medicine. DAHI is "committed to supporting policies that have proven to be, or offer the promise of being, effective in reducing firearm injuries." After a review of the literature, the group has proposed that handgun-related morbidity and mortality be "examined from a perspective based in science and rooted in established principles of epidemiology and public health practice." Specifically, DAHI has proposed that comprehensive data be collected on firearm-related injuries, handguns be treated as a consumer product, consistent requirements regarding the sale of handguns be applied, current gun laws be aggressively enforced, and health professionals provide gun owners with preventive counseling.⁷

Statement

Clearly, handgun violence is a major cause of morbidity and mortality in the United States today. In some segments of the population, it is the major cause of morbidity and mortality. Thus, the College fully supports the interventions advocated by Doctors Against Handgun Injury. Specifically, the College:

1. Encourages the establishment of a state-based, federally funded, national database containing detailed information on all handgun-related homicides, suicides, unintentional deaths, and non-fatal injuries;

2. Favors the treatment of handguns as a consumer product;

3. Urges expansion of the Brady Act (PL 103-109) to require background checks before firearm sales at gun shows;

4. Urges the enactment of legislation that would make it unlawful for anyone to knowingly deliver a firearm to someone who has received a firearm within the last 30 days or for anyone other than a licensed gun dealer to take delivery of more than one firearm per month;

5. Supports legislation to require anyone who purchases a firearm to wait at least five days before taking delivery of the firearm;

6. Supports the aggressive enforcement of current laws against the illegal purchase, possession, and sale of handguns; and

7. Urges health care providers to counsel their patients regarding the dangers of keeping firearms—particularly handguns--in the home and on strategies to reduce the risk of accidental injury and death from firearms.

In addition, the American College of Preventive Medicine:

8. Favors expanding the Brady Act to require background checks on all firearm sales—including sales between individuals;

9. Supports redirecting revenue generated by federal and state sales taxes on handguns and ammunition to fund handgun injury prevention;

10. Urges each state to adopt a handgun licensing and registration system;

11. Supports legislation making handgun owners responsible for the safe storage of their weapons;

12. Supports legislation to prevent violent misdemeanants from purchasing handguns.

Rationale

The ACPM position statement expands the DAHI proposal for background checks on firearm sales at gun shows to all private firearm sales. This proposal is based on the recommendation of Cook and Ludwig, who note that "the effects of primary-market gun regulations may depend on the extent to which the secondary market in guns is regulated. Secondary-market sales account for about 40% of the approximately 10 million gun transfers in the United States each year and are the source for the large majority of guns obtained by juveniles and criminals. The secondary market in guns, which is currently almost completely unregulated, is thus an enormous loophole that limits the effectiveness of primary-market regulations."⁸ At present, only a few states require background checks on firearm sales between private individuals. Maryland has this provision in place for all sales involving handguns and assault weapons. In Pennsylvania, the law applies only to handgun sales. In California, every purchaser must undergo a background check.

Currently, revenue from taxes on the sale of firearms and ammunition is dedicated to hunting and sporting purposes. However, since there is a substantial societal burden in mortality, morbidity, and economic costs associated with firearms (predominantly handguns), the ACPM proposes that this revenue be used to further efforts to prevent handgun injury.

Since the Firearms Owner’s Protection Act, 18 USC §926(a)(3), restricts the federal government from creating a registration system, the 39 states that have yet to implement a licensing and registration system for handguns must do so, individually. The existence of a licensing and registration system would make it easier for authorities to track handguns used in the commission of a crime.

Most states lack any mechanism for holding handgun owners accountable for the safe use and storage of their weapons. State laws that require adults to either store loaded guns in a place that is reasonably inaccessible to children or to use gun locks have been shown to reduce unintentional, firearm-related deaths in children by an average of 23 percent.⁹ In addition, safe storage of guns in the home can be expected to decrease the diversion of handguns into the secondary market through burglary and theft.¹⁰

In most states, current law does not prevent those convicted of violent misdemeanors from purchasing handguns. Research has shown, however, that individuals with even a single prior conviction for a violent misdemeanor who purchase a handgun are at increased risk for committing firearm-related crimes.¹¹ Furthermore, experience in California since 1991 has shown that denial of handgun purchase to violent misdemeanants is associated with a decrease in the risk of future arrest for firearm-related crimes.¹²

Based on the limited, available evidence, the American College of Preventive Medicine believes the policy recommendations described above are reasonable interventions to address, at present, the problem of handgun injury in the U.S. At the same time, the College acknowledges the pressing need for expanded research into the epidemiology, economics, and policy aspects of handgun injury. In addition, enhancing efforts to develop effective, practical population-based strategies and policies to reduce handgun injury should be a public health priority at both state and federal levels.

Acknowledgements

The views expressed in this position statement are those of the American College of Preventive Medicine and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

References

1. Cook PJ, Ludwig J. Guns in America: results of a comprehensive national survey on firearm ownership and use. Washington, DC: Police Foundation; 1996.

2. Kellermann AI, Rivara FP, Rushforth NB, Banton JG, Reay DT, Francisco JT, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med. 1993;329:1084-91.

3. Kellermann AI, Rivara FP, Somes G, Reay DT, Francisco J, Banton JG, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327:467-72.

4. Ash P, Kellermann AL, Fuqua-Whitley D, Johnson A. Gun acquisition and use by juvenile offenders. JAMA. 1996;275:1754-8.

5. National Center for Injury Prevention & Control, Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System. Available at: http://webapp.cdc.gov/sasweb/ncipc/mortrate.html. Accessed 4 February 2002.

6. Rice D, MacKenzie E, and Associates. Cost of injury in the United States: a report to Congress. San Francisco, California: Institute on Aging, University of California and the Johns Hopkins University Injury Prevention Center;1989.

7. Doctors Against Handgun Injury. A medical response to a public health emergency. Available from: URL: http://www.doctorsagainsthandguninjury.org

8. Cook PJ, Ludwig J. Homicide and suicide rates associated with implementation of the Brady Handgun Violence Prevention Act. JAMA. 2000;284:585-591.

9. Cummings P, Grossman DC, Rivara FP, Koepsell TD. State gun safe storage laws and child mortality due to firearms. JAMA. 1997;278(13):1084-6.

10. Sheley JF, Wright JD, Gun acquisition and possession in selected juvenile samples. Washington, DC: US Dept of Justice; 1993. National Institute of Justice Office of Juvenile Justice and Delinquency Prevention, NCJ-145326.

11. Wintemute GJ, Drake CM, Beaumont JJ, Wright MA, Parham CA. Prior Misdemeanor convictions as a risk factor for later violent and firearm-related criminal activity among authorized purchasers of handguns. JAMA. 1998;280:2083-2087.

12. Wintemute GJ, Wright MA, Drake CM, Beaumont JJ. Subsequent criminal activity among violent misdemeanants who seek to purchase handguns: risk factors and effectiveness of denying handgun purchase. JAMA. 2001;285:1019-1026.