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.

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.

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.

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.

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.

"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.

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.

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.

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 epidemiology of firearm deaths among residents of California.

Firearms are a leading cause of death in the United States, yet the effort to understand their aggregate impact on the public's health has only just begun. There were 26,442 firearm deaths among California residents during the years 1977 through 1983. During this period firearms were the eighth leading cause of death for California as a whole, sixth for male Californians and first for black males aged 15 to 34 years and black females aged 15 to 24 years. A plurality of firearm deaths were suicides; unintentional deaths contributed only 3% of the total. Black men aged 25 to 34 years had the single highest firearm mortality rate; 80% of firearm deaths in that group were homicides. Men 75 years old and older had the highest firearm mortality rate when all races were considered together, however, and 93% of firearm deaths in that group were suicides. The discussion focuses on our current understanding of firearms as a medical and public health problem and suggests directions for future research and intervention.

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.

Drowning in childhood and adolescence: a population-based study.

We present the results of a residence-based study of drownings among Sacramento County, California children and adolescents ages 0-19 years for the years 1974-84. Children ages 1-3 had the highest drowning rates. The majority of drownings in this group, and one-third of all drownings in the study, occurred in residential swimming pools. Males ages 15-19 had a high drowning rate as well; at least 38 per cent of drownings in that age group were alcohol-associated. The implications for preventive efforts are discussed.

When children shoot children. 88 unintended deaths in California.

Between 1977 and 1983, eighty-eight California children 0 to 14 years of age were unintentionally shot and killed either by other children or by themselves. The majority of cases occurred while children were playing with guns they had found. Easy accessibility to guns, the resemblance of guns to toys, and gun malfunctions were all contributing factors. Handguns, particularly those of .22 caliber, were frequently involved.

The choice of weapons in firearm suicides.

We report on the firearms used in 235 suicides in Sacramento County, California, during 1983-85. Handguns were used in 69 per cent of firearm suicides--65 per cent for males, 88 per cent for females--and in all such deaths among women ages 35 and older. We tested the hypothesis that the choice of firearms by persons committing suicide at home would passively reflect the reported prevalence of firearms by type in households in the region. Handguns were used more frequently (rate ratio 2.00; 95% CI = 1.68, 2.39), and rifles and shotguns less frequently than expected.