"I didn't know the gun was loaded": an examination of two safety devices that can reduce the risk of unintentional firearm injuries.

Some handguns contain built-in safety devices intended to prevent injuries caused by erroneously believing that a handgun is loaded. A loaded chamber indicator indicates the presence of ammunition in the gun; a magazine safety prevents the gun from being fired when the ammunition magazine is removed, even if one round remains in the firing chamber. In our patent search these devices date back to the turn of the century. But on 1998 pistol models, only 11% contained a loaded chamber indicator and 14% had a magazine safety. In our random-digit-dial telephone survey of U.S. adults, 34.8% of poll respondents (incorrectly) thought that a firearm with its ammunition magazine removed could not be shot, or said that they did not know. Some of the 1100 unintentional gun deaths in the U.S. each year might be prevented if the prevalence of these and other safety devices is increased through legislation, litigation, or voluntary manufacturer action.

Why firearm injury surveillance?

With the current progress of state firearm injury surveillance systems reported in this issue of the Journal, questions about the logical progression of these efforts are being raised. This article reviews the current state of firearm injury data, discusses the importance of firearm injury surveillance, and offers suggestions for maximizing the potential of future efforts in this area.

Support for new policies to regulate firearms. Results of two national surveys.

BACKGROUND: New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The public's opinion of these innovative gun-policy options has not been thoroughly assessed. METHODS: We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers. RESULTS: A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll. CONCLUSIONS: Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

Regulating firearm advertisements that promise home protection. A public health intervention.

Firearms are a consumer product responsible for 38500 deaths in the United States in 1994. Like other products, firearms are advertised. In the absence of rules governing the design of firearms, regulating the way guns are advertised may be a useful public health intervention. Some gun advertisements include messages suggesting that bringing a handgun into the home is generally protective for the occupants of the home. The best available scientific information contradicts this message. Given this disjunction, regulating those advertisements may be an appropriate response. Under federal law, the Federal Trade Commission (FTC) has authority to prohibit advertisements that are "deceptive" or "unfair." Under the FTC's deception analysis, the focus is on whether consumers are misled by an advertisement. For a finding of unfairness, the FTC looks for advertisements that may cause substantial injury to consumers. Under either analysis, a strong argument can be made that firearm advertisements promising home protection are unlawful. On February 14, 1996, several organizations sent separate petitions to the FTC asking it to consider the issues raised by firearm advertisements that promise home protection. The FTC is still reviewing the information presented. There are no First Amendment or Second Amendment impediments to FTC regulation of deceptive firearm advertising under the US Constitution.

Firearms and health: the right to be armed with accurate information about the Second Amendment.

An organized campaign by groups such as the National Rifle Association has sought to convince policymakers and others that the Second Amendment to the US Constitution grants an unfettered right to individuals to possess any firearm, free from federal or state regulation. Although advocates may debate the meaning that should be given to the Second Amendment, under the American legal system the meaning of any particular constitutional provision is determined by the controlling precedent of Supreme Court cases. Two cases, Presser v Illinois and United States v Miller, remain the Supreme Court's latest word on the meaning of the Second Amendment. In Presser, the Court held that the Second Amendment is applicable only to federal, not state, laws. In Miller and subsequent federal cases, any Second Amendment "right" to bear arms is closely linked to the preservation of state militias, upholding a variety of federal gun legislation. Unless the Supreme Court modifies or reverses its Presser and Miller decisions, health advocates should understand that the Second Amendment poses no obstacle to even broad gun control legislation.

Public opinion polling on gun policy.

Faced with the national epidemic of gun violence, legislators should be especially sensitive to their constituents' support for various policy options. This support is best evidenced by well-conducted public opinion polls. We review public opinion polls on gun policy since 1987. Although the public support for a number of promising interventions targeting the design and manufacture of firearms has not been meaningfully investigated, strong support is evidenced for most other gun-control options. The public also believes, contrary to Supreme Court rulings, that the Second Amendment to the Constitution protects a broad individual right to bear arms.

Policies to prevent firearm injuries.

Firearm-related injuries are a substantial public health problem. A wide array of policies designed to prevent these injuries have been discussed, but few are enacted into legislation. Even fewer have undergone scientific evaluation for their effectiveness. We offer a nosology for categorizing existing and future gun policies. A brief review of the effectiveness of existing gun policies is presented, and an argument is made for redirecting gun policy.

Epidemiology and the law: courts and confidence intervals.

Beginning with the swine flu litigation of the early 1980s, epidemiological evidence has played an increasingly prominent role in helping the nation's courts deal with alleged causal connections between plaintiffs' diseases or other harm and exposure to specific noxious agents (such as asbestos, toxic waste, radiation, and pharmaceuticals). Judicial reliance on epidemiology has high-lighted the contrast between the nature of scientific proof and of legal proof. Epidemiologists need to recognize and understand the growing involvement of their profession in complex tort litigation.

The impact of specific toy warning labels.

According to the 1980 Consumer Product Safety Commission's small parts standard, toys with small parts that pose a choking hazard cannot be marketed for children under the age of 3 years. To comply with the standard, toy manufacturers place age labels on packaging to indicate the ages for which toys with small parts are recommended. We conducted a survey of 199 toy buyers to determine the degree to which they understood such labels as warnings and whether more explicit warning labels would affect toy buyers' willingness to purchase toys with small parts for children between 2 and 3 years of age. Forty-four percent of respondents said they would buy for a child between 2 and 3 years of age a toy with the label "Recommended for 3 and up"; only 5% said they would buy for a young child a toy with the label "Not recommended for below 3--small parts." These findings indicate that a change in the small parts standard to require more specific labeling might substantially reduce potentially hazardous toy purchases.

Death resulting from motor vehicle immersions: the nature of the injuries, personal and environmental contributing factors, and potential interventions.

We present an epidemiologic characterization of deaths from motor vehicle immersions, based on 77 deaths in 63 motor vehicle immersions in Sacramento County, CA, during 1974-85. All persons were autopsied; all but one of the deaths were due to drowning. Average annual mortality rates per million person years were 12 for males, four for females, 30 for Hispanics, six for White non-Hispanics, Blacks and Asians. Seventy-one percent of drivers and 60 percent of passengers had a blood alcohol concentration greater than or equal to 22 mmol/L. Most cases (57 percent) had an Injury Severity Score of 1 (minor injury) or 0 (no injury). Alcohol use was associated with higher Injury Severity Scores. Road curvature of 20 degrees or greater was far more common at crash sites than at matched control sites one mile away (OR = 6.57, 95% CI = 2.93, 14.71). Guard rail placement along highly curved sections of roadway may be an effective preventive measure.

Alcohol and drowning: an analysis of contributing factors and a discussion of criteria for case selection.

We test the hypothesis that there are host or environmental factors that significantly affect the likelihood of alcohol involvement in drownings. Our results are based on records of 234 drownings that meet predetermined eligibility criteria designed to exclude cases with postmortem blood alcohol concentrations (BACs) that do not reflect the BAC at the time of immersion. Cases are drawn from a total of 442 drownings occurring in Sacramento County, California, from 1974 to 1985. Overall, 41% of deaths were alcohol-associated; among these only one victim was under 15 years old. Among older persons, increasing age generally suggested a higher likelihood of alcohol involvement, and particularly of a BAC greater than 200 mg/dl. Other associated factors were male gender (OR = 2.5; 95% CI = 1.6, 3.8), activity (for land motor-vehicle occupants vs. all others, OR = 3.3; 95% CI = 2.6, 4.3), and time of year (January-June vs. July-December, OR = 2.1; 95% CI = 1.6, 2.8). A lower likelihood of alcohol involvement was seen for drownings in bathtubs (OR = .16; 95% CI = .04, .57) and swimming pools (OR = .47; 95% CI = .27, .82). Race was not a factor. Differing eligibility criteria have been used in studies of alcohol and drowning. After a critical review of the experimental literature, we propose that the following be adopted in future such studies: (i) death must occur within six hours of the onset of immersion, unless an antemortem sample is available and, unless evidence to the contrary exists, death can be assumed to have occurred within a few minutes of immersion; (ii) blood must be drawn for BAC determination within 24 hours of death.

The passage of Maryland's gun law: data and advocacy for injury prevention.

In 1988 the Maryland legislature passed an innovative law designed to limit the availability of certain types of handguns within the state. Pro-gun forces opposed the law and gathered the requisite number of petitioning signatures to refer the law to a public referendum on election day. The months preceding the referendum saw intense political campaigning over the gun law, with pro-gun forces spending $6.6 million, more money than had ever been spent in a Maryland political campaign. The handgun law was recognized to be a public health issue. This article reviews the activity involved in the passage of the law and the referendum, and discusses the role played by the Johns Hopkins injury prevention faculty in providing information to decision makers.

Unintentional firearm deaths in California.

We conducted a two-part study of unintentional firearm deaths in California. First, we analyzed death certificate data for the 688 unintentional firearm deaths of California residents occurring during 1977-1983. Mortality rates were 7.5 for males, 0.9 for females, 4.8 for whites, and 5.3 for blacks, all per million persons per year. Males ages 15-24 had the highest rate (17 per million persons per year). We then investigated the 131 childhood deaths in greater detail, using coroners' or medical examiners' reports. Most of these shootings occurred at a residence. Handguns were involved more frequently than predicted by their reported availability in homes in the region. Almost two thirds of child deaths resulted from head wounds, reinforcing the importance of primary prevention. At least 40% of child deaths in this study appeared in part to be attributable to defects in firearm performance or current firearm design practices, suggesting that improvements should be sought and mandated.

The epidemiology of drowning in adulthood: implications for prevention.

Previous epidemiological studies of drowning in the United States have dealt primarily with children. The epidemiology and prevention of drowning in adulthood may be very different. To test this general hypothesis, we analyzed the 293 drownings occurring among Sacramento County residents 20 years of age and above during 1974 to 1985. Drowning rates were highest for men 20-29 years of age (11.5 per 100,000 population) and blacks (7.5 per 100,000 population). Swimmers, boaters, and motor vehicle occupants were most frequently represented. Alcohol use was involved in 48% of cases overall and 77% of those involving motor vehicle occupants. A history of seizure disorder was another contributing factor. Important differences do exist in drowning epidemiology between children and adults. Our results suggest that preventing drowning will be more problematic among adults than among children. The study was also used to test the sensitivity of two commonly used methods of case ascertainment for cases in Sacramento County. A manual review of coroner's records had a sensitivity of 96%. A computerized review of death certificate data from the state's vital statistics data base had a sensitivity of 79%. The sources and implications of these differences are discussed.