Overview
The programs that are described in this chapter use a variety of strategies to promote smart and responsible choices -- about guns, about gangs, and about violence. They employ a variety of methods to get their message across, including eye-catching graphics, peer involvement, mentoring by caring adults, and broad-based community involvement. Some of these programs are being formally evaluated; others are not. All show promise for reducing gun violence.
Prevention Education -- Changing Attitudes Toward Guns and Violence
Gun violence is not only a criminal justice problem but also a public health problem.1 Firearm incidents of all kinds (suicides, homicides, and unintentional gunshot injuries) claim the lives of approximately 34,000 Americans each year. In fact, firearm injuries are the eighth leading cause of death in the United States and the fourth leading cause of years of potential life lost before age 65.2
The impact of gun violence is even more pronounced among teenagers and young adults. A teenager in the United States today is more likely to die of a gunshot wound than from all "natural" causes of disease combined.3 More than one-half of all deaths of African-American males 15 to 19 years of age are homicides. More than 80 percent of these killings involve firearms. White teens face a lower risk of firearm-related homicide than their African-American peers, but they have a higher risk of committing suicide with a gun.4
Firearms also are a major cause of nonfatal injuries. For every firearm fatality, there are 2.6 nonfatal gunshot injuries.5 The case-fatality ratio for shootings varies widely by manner -- approximately 1 in 5 victims of a firearm assault dies, but only 1 unintentional shooting out of every 16 results in death. Suicide attempts with a firearm, on the other hand, are completed approximately 85 to 90 percent of the time.6
Some nonfatal firearm injuries are minor, but others are devastating. Violence is the second leading cause of spinal cord injuries, behind motor vehicle crashes. The vast majority of these injuries are the result of gunshot wounds. It has been estimated that the annual direct and indirect costs of fatal and nonfatal firearm injuries exceed $20 billion per year.7
Health care professionals have traditionally used reactive approaches to control death and disability from gunshot wounds. Improvements in the provision of prehospital care (an ambulance), trauma center care, postoperative critical care, and rehabilitation have greatly increased the chances that a gunshot victim will survive his or her injury. There is a limit, however, to the power of medicine and surgical techniques. Recently, researchers conducted a population-based study of firearm injuries in three cities served by sophisticated emergency services and level1 trauma centers. They found that 80 percent of fatalities were pronounced dead on the scene or immediately following arrival in an emergency department. Ninety-seven percent of deaths occurred within 24 hours of injury.8 In short, greater emphasis must be placed on prevention to reduce the morbidity, mortality, and costs of gunshot wounds.
The public health approach to reducing violence includes: (1) emphasizing the prevention of violence before it occurs; (2) making science integral to identifying effective policies and programs; and (3)integrating the efforts of diverse organizations, communities, and disciplines.9 By bringing a fresh viewpoint, new allies, and different analytical methodologies to violence control, this public health approach can complement that of the criminal justice community.
Education is a mainstay of public health.10 Education to prevent gun violence can take many forms, including promotion of safe storage and other strategies to reduce access to firearms by children, youth, and other unauthorized persons; teaching safe behavior around firearms; and a variety of programs that are designed to prevent or reduce youth violence.
Safe storage of firearms
Approximately 40 percent of American households contain one or more firearms; the average gun-owning household contains several.11 The total number of firearms in private hands in America is estimated to exceed 190 million, of which one-third (65 million) are handguns. In general, firearm ownership is more common in rural areas and small towns, and less common in urban areas, but urban gun owners are more likely to own handguns.12
In up to 50 percent of gun-owning households, firearms are kept loaded at least part of the time. Roughly 30 percent of all handguns are kept loaded and unlocked, and therefore easily accessible.13 This violates a central tenet of gun safety. The National Rifle Association's (NRA's) A Parent's Guide to Gun Safety advises owners to "Store guns so that they are inaccessible to children and other unauthorized users."14 There is consensus on these points across the political and professional spectrums.
Safe storage of firearms has multiple benefits. It reduces the risk that firearms will be lost due to burglary or theft, an event that occurs more than 350,000 times each year.15 Safe storage also reduces the chances that a loaded gun will be reached by a child.16 A home where guns are kept securely stored is less likely to be the scene of a suicide than a home where one or more guns are kept loaded and unlocked.17
A number of devices are available that are capable of rendering a firearm inoperative. These include various types of triggerlocks, cable locks, lockboxes, and gun safes. The price, performance, quality, and reliability of these devices vary widely.
Placing a gun in a safe or lockbox or rendering it inoperative with an add-on safety device is an "active" countermeasure that requires the conscious cooperation of the user each and every time he or she handles the gun.18 Gun owners who are fatigued, distracted, or inattentive may forget to follow the routine from time to time. In addition, some flatly reject the idea of "safe storage." This is especially true of individuals who keep a gun primarily for protection. However, the idea of keeping a gun loaded and readily available for protection is misguided. Evidence suggests that the odds that a gun in the home will kill or injure a member of the household are substantially greater than the odds that it will be used to injure or kill in self-defense.19
Potential avenues to promote safe storage of firearms include mass media and public education campaigns, distribution of brochures or pamphlets at the point of sale, incorporation of information about safe storage in gun safety training programs, and counseling by physicians and other health care providers. At present, little is known about the relative effectiveness of these options. One study suggests that child access-prevention laws that require adults to store their firearms safely reduce unintentional shooting deaths of children.20
Educational programs
Education is a fundamental element of many injury prevention programs.21 The educational programs described below seek to encourage kids to behave responsibly around guns.
Traditional firearm safety instruction is based on sound advice such as, "always keep the gun pointed in a safe direction" and "always keep your finger off the trigger until ready to shoot." Firearm instructors also teach shooters to assume that every firearm is loaded unless they personally verify that it is not by inspecting the firing chamber. For many, promoting gun safety education is a matter of common sense. Some believe that gun safety education, like driver's education, should be included in the curriculum of public schools.
Unfortunately, there is little evidence that safety training alters behavior around guns. One team of researchers found that when young children are unsupervised, they frequently touch and play with real guns, even after receiving clear and specific instructions not to do so.22 Another survey found that gun owners who reported taking a gun safety class were no more likely to store their firearms safely than those who had not.23 On the other hand, gun owners who received instruction from the National Safety Council were more likely to store their guns unloaded and locked than individuals who took other types of gun safety training programs.24 Whether this finding reflects differences in the design of these courses or differences in the temperament of those who took them is unknown.
The optimal role of gun safety education in community-based programs to reduce gun violence has not yet been defined. Carefully controlled evaluations that examine both the content and the impact of various curriculums and public education programs are needed. When these evaluations are conducted, it will be important to assess not only the proximate outcome of the intervention (e.g., safer behavior around firearms), but any unintended consequences as well.
Notes
1. National Committee for Injury Prevention and Control, Firearm Injuries, Injury Prevention: Meeting the Challenge, New York, NY: Oxford University Press, supplement to the American Journal of Preventive Medicine 5(3), 1989; J.A. Mercy, M.L. Rosenberg, K.E. Powell, C.V. Broome, and W.L. Roper, "Public health policy for preventing violence," Health Affairs 729, Winter 1993; M.L. Rosenberg and M.A. Fenley (eds.), Violence in America: A Public Health Approach, New York: Oxford University Press, 1991; and A.L. Kellerman, R.K. Lee, J.A. Mercy, and J. Banton, "The epidemiologic basis for the prevention of firearm injuries," Annual Review of Public Health 12:1740, 1991.
2. R.M. Ikeda, R. Gorwitz, S.P. James, K.E. Powell, and J.A. Mercy, Fatal Firearm Injuries in the United States, 19621994, Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Violence Surveillance Summary Series No. 3, 1997.
3. L.A. Fingerhut, Firearm Mortality Among Children, Youth, and Young Adults 134 Years of Age, Trends and Current Status: United States, 19851990, Advance data from Vital and Health Statistics No. 231, Washington, DC: National Center for Health Statistics, 1993.
4. Fingerhut, 1993.
5. J.L. Annest, J.A. Mercy, D.R. Gibson, and G.W. Ryan, "National estimates of nonfatal firearm-related injuries: Beyond the tip of the iceberg," Journal of the American Medical Association 273:17491754, 1995.
6. P.J. Cook, "The technology of interpersonal violence," in M. Tonry (ed.), Crime and Justice: A Review of Research, Chicago: University of Chicago Press, 1991; Annest et al., 1995; and A.L. Kellerman, F.P. Rivara, R.K. Lee, J.G. Banton, P. Cummings, B.B. Hackman, and G. Somes, "Injuries due to firearms in three cities," New England Journal of Medicine 335:14381444, 1996.
7. W. Max and D.P. Rice, "Shooting in the dark: Estimating the cost of firearm injuries," Health Affairs (Winter):171185, 1993.
8. Kellerman et al., 1996.
9. K.E. Powell and D. Hawkins (eds.), Youth Violence Prevention: Descriptions and Baseline Data from 13 Evaluation Projects, New York: Oxford University Press, supplement to the American Journal of Preventive Medicine 12(5), 1996.
10. National Committee for Injury Prevention and Control, 1989.
11. P.J. Cook and J. Ludwig, Guns in America: Results of a Comprehensive National Survey on Firearms Ownership and Use, Summary Report, Washington, DC: Police Foundation, 1997.
12. Cook and Ludwig, 1997.
13. D.S. Weil and D. Hemenway, "Loaded guns in the home: Analysis of a national random survey of gun owners," Journal of the American Medical Association 267:30333037, 1992.
14. National Rifle Association, A Parent's Guide to Gun Safety, Fairfax, VA: National Rifle Association, 1995.
15. M.R. Rand, Guns and Crime: Handgun Victimization, Firearm Self-defense, and Firearm Theft, Washington, DC: U.S. Department of Justice, Crime Data Brief, 1994.
16. G.J. Wintemute, S.P. Teret, J.F. Kraus, M.A. Wright, and G. Bradfield, "When children shoot children: 88 unintended deaths in California," Journal of the American Medical Association 257:31073109, 1987.
17. A.L. Kellerman, F.P. Rivara, G. Somes, D.T. Reay, J. Francisco, J.G. Banton, J. Prodzinski, C. Flinger, and B.B. Hackman, "Suicide in the home in relation to gun ownership," New England Journal of Medicine 327:467472, 1992.
18. National Committee for Injury Prevention and Control, 1989.
19. A.L. Kellerman, F.P. Rivara, N.B. Rushforth, J.G. Banton, D.T. Reay, J.T. Francisco, A.B. Locci, B.B. Hackman, and G. Somes, "Gun ownership as a risk factor for homicide in the home," New England Journal of Medicine 329:10841091, 1993; and A.L. Kellerman, D.S. Fuqua-Whitley, F.P. Rivara, and J.A. Mercy, "Preventing youth violence: What works?" Annual Review of Public Health 19:271292, 1998.
20. P. Cummings, D.C. Grossman, F.P. Rivara, and T.D. Koepsell, "State gun safe storage laws and child mortality due to firearms," Journal of the American Medical Association 278:10411126, 1997.
21. National Committee for Injury Prevention and Control, 1989.
22. M.S. Hardy, F.D. Armstrong, B.L. Martin, and K.N. Strawn, "A firearm safety program for children: They just can't say no," Developmental and Behavioral Pediatrics 17(4):216221, 1996.
23. Weil and Hemenway, 1992.
24. Cook and Ludwig, 1997.
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