Extreme risk protection orders, race/ethnicity, and equity: Evidence from California.

Extreme risk protection orders (ERPOs) provide a civil mechanism to temporarily remove firearm access from individuals at high risk of harming themselves or others. Evidence and theory suggest that ERPOs can prevent firearm-related harm, but the policy's impact on racial/ethnic equity is largely unknown. To examine potential inequities by race/ethnicity in public perceptions and use of California's ERPO law, we drew on two complementary data sources: 1) a 2020 state-representative survey of California adults, and 2) ERPO court documents for the first 3 years of policy implementation (2016-2018). Majorities (54-89%) of all racial/ethnic groups reported that ERPOs are at least sometimes appropriate, and 64-94% were willing to ask a judge for an ERPO for a family member. However, Black and Hispanic/Latinx survey participants less often perceived ERPOs as appropriate and were less willing to serve as petitioners, with Black participants citing lack of knowledge about ERPOs and not trusting the system to be fair as their top reasons for unwillingness. Similarly, review of ERPO court documents revealed that no family or household members served as petitioners for Black and Hispanic/Latinx ERPO respondents. Additionally, Black respondents were the least likely to have documented access to a firearm and legal representation in court. Racial/ethnic equity in ERPO use may be improved by reducing barriers to petitioning, incorporating non-law enforcement intervention professionals like behavioral health specialists into the ERPO process, providing legal assistance to respondents and petitioners, and investing in the social safety net.

Disproportionate sales of crime guns among licensed handgun retailers in the United States: a case-control study.

OBJECTIVE: To determine risk factors among licensed firearm retailers for disproportionate sales of handguns that are later subjected to ownership tracing, generally after use in crime. DESIGN: Case-control; the study period was 1998-2003. Cases were all eligible firearm retailers whose handguns were later traced at a rate that significantly (p<0.05) exceeded the expected value. Controls were a 4:1 random sample of the remainder. Data were obtained from sales and tracing records for 1998-2003 and site visits conducted August-December, 2004. SUBJECTS AND SETTING: 60 cases and 240 controls, from the 573 retailers in California selling >or= 50 handguns annually during the study period. MAIN OUTCOME MEASURE: Status as a case. Odds ratios were used to measure relative risk. RESULTS: In multivariate analyses, cases had larger sales volumes, sold inexpensive handguns more often, had a higher percentage of sales denied because the prospective purchasers were prohibited from owning firearms, and were more likely to be in an urban area, in or near a city with a policy of tracing all recovered crime guns. The effects of several risk factors, including status as a pawnbroker and sales to law enforcement personnel, appeared to be mediated by purchaser characteristics for which denied sales are a proxy measure. CONCLUSIONS: A number of factors-most of them characteristics of the retailers or of their handgun purchasers, and most of them available in existing data-were linked to disproportionate sales of handguns that are later used in crime.

The attitude-practice gap revisited: risk reduction beliefs and behaviors among owners of residential swimming pools.

Complete pool fencing and effective bystander resuscitation are both believed to reduce the risk of childhood drowning. The relationship between support for, and prevalence of, a complete pool barrier and current cardiopulmonary resuscitation certification was investigated among an equal probability sample of 795 owners of residential swimming pools in Sacramento County, California. Only 50% (95% confidence interval [CI] 44%, 56%) of respondents who favored a cardiopulmonary resuscitation certification requirement for pool owners represented a household with any members so certified. Only 35% (95% CI 26%, 44%) of respondents who endorsed a complete barrier requirement for all pools had a fence surrounding their own pool. Support for a cardiopulmonary resuscitation requirement was associated with a modestly higher prevalence of current cardiopulmonary resuscitation certification (46% vs 33%, difference = 13%, 95% CI for difference 2%, 24%). Endorsement of a pool barrier requirement was associated with a substantially higher prevalence of complete pool fencing (35% vs 7%, difference = 28%, 95% CI for difference 19%, 37%). The proportion of the pool-owning population endorsing these risk reduction behaviors is much larger than the proportion actually adopting them. The results suggest that an effective pool drowning-prevention program will rely primarily on legislative approaches, with health education serving as a useful adjunct.

Swimming pool owners' opinions of strategies for prevention of drowning.

Training in cardiopulmonary resuscitation for pool owners and mandatory placement of a barrier around pools, two commonly suggested strategies for prevention of drowning, will depend, in part, on the support of pool owners to be successfully implemented. To measure this support, an equal probability sample of 795 Sacramento County households with pools was surveyed. An 80% response rate was achieved. A large majority (86%) favored voluntary cardiopulmonary resuscitation training, and a plurality (40%) favored required cardiopulmonary resuscitation certification for pool owners. However, 61% opposed a universal barrier requirement, and 49% objected to a barrier requirement for new pools only. Respondents with small children at home were more likely (P = .0001) to support a required barrier. The previous occurrence of a significant immersion event had surprisingly little effect. The results suggest some specific directions for programs to prevent swimming pool drownings.

Injury mortality and socioeconomic development: an exploratory analysis.

Injury mortality is commonly viewed as a 'disease of development'--a viewpoint which may well be incorrect. This exploratory study found no relationship between reported injury mortality rates and per capita gross national product for 46 developing and industrialized countries; the highest rates reported were all from developing or transitional nations. Greater attention should be given to injuries as a cause of death and disability in developing countries.

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.

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.

From research to public policy: the prevention of motor vehicle injuries, childhood drownings, and firearm violence.

PURPOSE: The purpose of this article is to review the development of the modern sciences of injury epidemiology and injury prevention and to illustrate the use of applied research in formulating effective public policy. SEARCH METHODS: MEDLINE searches were conducted from 1966 to 1990, and bibliographies of articles thus obtained were reviewed. Fugitive sources were identified by multiple means. MAJOR FINDINGS: Motor vehicle fatality rates on a per mile driven basis have been reduced by 50% over the past 25 years, largely through attention to the road environment and design of motor vehicles. Passive restraint systems such as air bags promise further reductions. Drowning has emerged as a leading cause of death among young children. Complete pool fencing is expected to prevent many of these events. Firearm violence, particularly among young people, is rapidly increasing. Firearms are hazardous consumer products but are not addressed as such by our current regulatory structure and intervention agenda. CONCLUSIONS: Epidemiologic and other applied research can make important contributions to the development of public policies designed to prevent injury. Such policies often address the design and performance of hazardous products and environments and consider individual behavior change as only a secondary objective.

Is motor vehicle-related mortality a disease of development?

The effect of economic development on motor vehicle-related mortality was assessed using per capital GNP from 46 countries, Gini coefficients from 34 countries and mortality statistics reported to WHO. The data suggest that these commonly used indicators of economic development do not reliably predict a given country's current experience with motor vehicle-related mortality. Implications for health planners and traffic safety workers are discussed.

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.

Risk factors among handgun retailers for frequent and disproportionate sales of guns used in violent and firearm related crimes.

OBJECTIVE: To determine the retailer and community level factors associated with frequent and disproportionate sales of handguns that are later used in violent and firearm related crimes (VFC handguns). DESIGN: Cross sectional. The authors used California records to identify all handguns sold by study subjects during 1996-2000 and federal gun tracing records to determine which of these guns had been recovered by a police agency in the US or elsewhere and traced by 30 September 2003. SUBJECTS AND SETTING: The 421 licensed gun retailers in California selling at least 100 handguns annually during 1996-2000. MAIN OUTCOME MEASURE: The number of VFC handguns per 1000 gun years of exposure. Differences are expressed as incidence rate ratios (RR) with 95% confidence intervals (CI). RESULTS: Subjects accounted for 11.7% of California retailers with handgun sales, 81.5% of handgun sales, and 85.5% of VFC handguns. Among subjects, the 3426 VFC handguns accounted for 48.0% of all traced handguns and 65.0% of those linked to a specified crime. The median VFC handgun trace rate was 0.5/1000 gun years (range 0-8.8). In multivariate analysis, this rate increased substantially for each single-point increase in the percentage of proposed sales that were denied because the purchasers were prohibited from owning guns (RR 1.43; 95% CI 1.32 to 1.56), and was increased for pawnbrokers (RR 1.26; 95% CI 1.02 to 1.55). Community level crime rates and sociodemographics had little predictive value. CONCLUSIONS: Risk factors, largely determined at the retailer level, exist for frequent and disproportionate sales of handguns that are later used in violent and firearm related crimes. Screening to identify high risk retailers could be undertaken with data that are already available.

People and guns involved in denied and completed handgun sales.

OBJECTIVE: Denial of handgun purchases by prohibited people and knowledge of the structure of gun commerce have helped to deter and prevent firearm violence. The authors hypothesize that handguns involved in a denied purchase would more closely resemble those used in crime compared with handguns sold. DESIGN: Cross sectional. SETTING: Denied and completed handgun sales in California, 1998-2000. MAIN OUTCOME MEASURES: Handgun and purchaser characteristics of denied and completed sales were compared. In particular, handgun characteristics most closely associated with crime guns (type, caliber, barrel length, price) were examined. RESULTS: Compared with handguns sold, handguns in denied sales were somewhat more likely to be semiautomatic pistols (74.6% v 69.4%), to have short barrels (25.9% v 22.2%), and be of medium caliber (48.9% v 37.3%). Ten percent of the handguns in denied sales and 3.4% of handguns sold were identified as inexpensive. CONCLUSIONS: The characteristics of denied handguns are similar to those seen among crime guns. Both groups of guns may reflect the desirability for criminal purposes of pistols, which have larger ammunition capacities than other handguns, and short barrels, which increase their ability to be concealed.

Firearms as a cause of death in the United States, 1920-1982.

We present the epidemiologic history of firearms in the United States. Firearms are among the nation's ten leading causes of death. Nearly one million firearm deaths occurred in the half-century 1933-1982. Suicide is the leading type of firearm death. Teenagers, young adults, and males 75 years old and older are currently at highest risk. An individual's risk of suffering a firearm death has generally risen with age. Increased firearm availability is associated with increased rates of firearm homicide and suicide. Strategies to prevent firearm deaths and injuries should be formulated in light of these findings, and heightened efforts to design, implement, and evaluate preventive measures are urgently needed.

Childhood drowning and near-drowning in the United States.

More than 2000 children drown each year; in some states drowning is considered the leading cause of death for children under the age of 5 years. Many survivors of near-drowning have permanent neurologic disability. There are two distinct high risk groups: children under 5 years of age and boys aged 15 to 19 years. Most drownings in the former group occur in residential pools. Among survivors, the clinical course is bimodal; intact survival and survival with severe permanent disability are the most likely outcomes. The outcome of an immersion event is determined within a few minutes of the onset of immersion, mandating an emphasis on primary prevention. A requirement for pool fencing is the most promising such strategy and could be implemented soon. Training in cardiopulmonary resuscitation and (for older children) alcohol abuse prevention programs may be valuable adjuncts.

Homicide, handguns, and the crime gun hypothesis: firearms used in fatal shootings of law enforcement officers, 1980 to 1989.

OBJECTIVES: Many policies seeking to limit handgun violence rest on the largely untested "crime gun hypothesis," which holds that subclasses of handguns differ in their risk for use in violent crime. This study tests that hypothesis for handguns used in homicides of law enforcement officers and describes the population of homicide-involved handguns. METHODS: A cross-sectional study was done of civilian (criminal) handguns used in homicides of law enforcement officers from 1980 to 1989. Life tables were generated for each year's cohort of new handguns to estimate gun-years at risk, analogous to person-years, for rate and relative risk calculations. RESULTS: Four hundred thirty-five deaths involved 428 civilian handguns. Revolvers were at greater risk than pistols. For both, risk was lowest for .22-caliber handguns. Risk was greatest for .32-caliber pistols and .38-caliber revolvers. Forty-six percent of handguns had a barrel length of 3 in or less. CONCLUSIONS: Subclasses of handguns differ substantially in their risk for use in fatal shootings of law enforcement officers. Such epidemiological data may be useful in formulating efforts to prevent these and similar instances of firearm violence.

Initial and subsequent hospital costs of firearm injuries.

OBJECTIVE: To provide economic, epidemiologic, and clinical data on initial and subsequent hospitalizations for firearm injuries. DESIGN: Nonconcurrent prospective study; data obtained by medical records review. SETTING: Public university teaching hospital, designated a level I trauma center. SUBJECTS: Two hundred fifty persons first hospitalized for firearm injuries at UC Davis Medical Center, Sacramento, between January 1, 1984, and June 30, 1985, and followed by medical records review to June 30, 1989. RESULTS: The aggregate hospital charge for 250 firearm injuries, exclusive of professional fees, was $3,745,496, of which 80% was borne directly or indirectly by public funds. The charge for initial hospitalizations was $3,297,506. Mean and median initial charges per case were $13,190 and $5,996 respectively; range, $787-$494,152. The five patients with charges over $100,000 accounted for 33% of all charges; 36% of all patient days were attributable to the eight patients with hospitalizations lasting more than 30 days. Thirty-one patients were rehospitalized a total of 71 times; charges for rehospitalization totaled $447,990. Three fourths of all charges resulted from handgun injuries. CONCLUSIONS: The costs for hospital treatment of firearm injuries are substantial. Avoiding prolonged hospitalization may be helpful in controlling these costs, but will be difficult to achieve. Primary prevention of firearm injuries may be the most effective cost-control measure.

Immersion events in residential swimming pools. Evidence for an experience effect.

BACKGROUND: --Drowning and near-drowning in residential swimming pools are leading causes of morbidity and mortality for young children. We tested the hypothesis that the period immediately after a pool is acquired is a time of high risk for these events. This study was also designed to provide population-based data on swimming pool immersion events, regardless of severity. METHODS: --We conducted a mail survey of a probability sample of Sacramento County, California, households with in-ground swimming pools in January 1988; 80% of eligible subjects responded. Onset of exposure to a pool was defined as the month in which (1) the responding household had a pool installed, or (2) the responding household first occupied a residence with a pool. Exposures began in 1959 through 1987. RESULTS: --The home swimming pool immersion event rate was 11 per 1000 pool-years. The rate per 1000 pool-years was higher for the first 6 months of exposure than thereafter (0 to 6 months, 44; 7 to 24 months, 14; greater than 24 months, seven), but 77% of events occurred outside the high-risk period. For households whose exposures began in 1984 through 1987, the immersion event rate was 51 per 1000 pool-years overall and 123 per 1000 pool-years for the first 6 months of pool exposure; these increases probably represent underreporting of earlier events. In this group, 48% of events occurred outside the high-risk period. The family swimming pool accounted for 91% of immersion events at the respondents' homes. CONCLUSIONS: --The residential swimming pool is an important hazard for pool-owning households. The first 6 months of exposure constitute a high-risk period, but many immersion events occur later. Pool drowning prevention programs may focus on newly acquired swimming pools and their owners but should be as broad as possible to maximize their effectiveness.