July 2019

Michael Jan, MD, PhD, MPH

Isabelle Sternfeld, MSPH

Andrea Welsing, MPH

Rashmi Shetgiri, MD, MSHS, MSCS

Recurrent tragedies of mass shooting incidents in the United States have brought increasing attention to the issue of firearm violence and its implications for public health and safety.^1-3 Moreover, mortality from firearm homicide and firearm suicide, which occur daily in communities throughout the nation, far exceeds mortality from mass shootings.⁴ This article provides relevant local statistics, features national medical society recommendations, and summarizes potential areas for clinician action in Los Angeles County, as well as nationally.

Key Points

• Firearm violence is a persistent problem that negatively impacts public health.
• Numerous professional medical organizations have identified health care providers as having key roles in firearm safety promotion and prevention of firearm violence.
• Periodic screening for risks potentially associated with firearm violence allows for early intervention and connections to resources that can help to prevent firearm violence.
• Research to characterize the current state of firearm violence is essential in shaping future prevention and health promotion efforts.
• As firearm violence research continues to grow, there will be a need for clinicians to stay up to date on key findings.
• There are numerous opportunities for clinicians to advocate for firearm safety.

Local Firearm Injury Trends

The Los Angeles County Department of Public Health’s Injury and Violence Prevention Program routinely collects and publishes local data on firearm violence on its Injury Data and Reports page.⁵ From 2010-2016, there were 5,206 firearm-related deaths reported in Los Angeles County; 3,102 (60%) of these were homicides, 1,976 (38%) were suicides, and 128 (2%) were from other causes.⁶ More than 90% of homicides and suicides in the county were among males (Figure 1). There was also considerable variation by race and ethnicity and type of firearm death. The rate of firearm-related homicide was 16 times higher among blacks and nearly four times higher among Latinos than among whites (Figure 2). Asians had the lowest rate. In contrast, whites had the highest firearm-related suicide rate, followed by blacks, Latinos, and Asians (Figure 3).

*Other causes were reported as law-enforcement related (89), accidental (26), and undetermined (13).⁶

National Calls to Action

For more than 25 years, professional medical organizations have issued policy statements and published position papers on firearm safety and violence prevention.⁷ In 2015, a joint call to action was made by 8 health professional organizations allied with the American Bar Association.⁸ Within 5 months, this call to action was echoed and endorsed by more than 50 health-allied organizations.⁹ These organizations have called for changes related to safer firearm design, universal background checks, firearm licensing and registration, patient screening and counseling, access to mental health services, and further research.

The table "Firearm Violence Policies and Positions of Medical-Allied Professional Organizations" summarizes recommendations from 15 organizations that have detailed their reasoning in published materials. Of the myriad roles available to clinicians in promoting firearm safety and preventing firearm violence, there are 3 areas with great potential for clinician impact: patient screening and counseling, engaging in research and early adoption of evidence-based violence prevention efforts, and advocacy.^10,11 This article describes recommendations for clinicians in each of these areas.

Screening and Counseling

Observational research studies have identified a number of risk factors for firearm violence that have informed current screening recommendations, including screening for the following:^7,12-19

• Firearm safety and storage
• Alcohol and substance abuse
• Depression and suicidality
• Exposure to violence and abuse

While a detailed discussion of substance use, mental health, and violence screenings is beyond the scope of this article, selected screening and counseling tools are included under Resources, in the Screening Tools section.

Firearm Screening and Counseling

A simple question such as “Are any firearms kept in or around your home?” is recommended to determine if there is a firearm in the home.²⁰ If there are firearms in the home, the “5 L’s” mnemonic can guide a discussion of the various aspects of safer firearm ownership.²¹

“5 L’s” Mnemonic

• Locked – Is the firearm stored in a safe or is a trigger/cable lock in place?
• Loaded – Is the firearm loaded?
• Little children – Are little children present?
• feeling Low – Is the firearm owner or other members of the household at risk for suicide?
• Learned owner – Has the firearm owner received safety training?

The following resources may be useful for education regarding safe storage and can help facilitate discussions about firearm safety:

• Seattle & King County Department of Public Health’s visual reference guide of firearm safety devices²²
• State of California Department of Justice’s Firearm Safety website, which includes sections on basic firearm safety rules, firearm owner responsibilities regarding children, rules for children, methods of childproofing firearms, firearm safety certification, as well as a tool to find safety devices that are compatible with specific firearms^23,24
• Women Against Gun Violence’s The TALK Project, which provides guidance to parents on keeping children safe from firearms inside and outside of the home.²⁵

Research

Federal restrictions on funding for firearm-related research dating back to the 1990s have limited the ability to investigate factors contributing to firearm violence and interventions to address these factors.^20,26,27 Recently, the Centers for Disease Control and Prevention (CDC) was given the authority to conduct research on the causes of firearm violence by the Secretary of Health and Human Services, although the CDC and other federal agencies are still restricted from using federal funding to research firearm control.^28,29

Physician-led initiatives like the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) and the University of California Davis Violence Prevention Research Program are beginning to structure and guide research agendas.³⁰ A consensus committee identified 59 firearm violence research questions relevant to the practice of emergency medicine alone.³¹ The aim of some of these research questions is to characterize the current situation (e.g., who is at risk and who should be screened?) before moving ahead to assessing interventions (e.g., what is effective?). Additional areas that require more research are identifying the root causes that lead to firearm violence and methods to effectively address these underlying issues.

As the findings from these and other firearm injury studies become available, it will be important for clinicians to adopt evidence-based interventions that have been found to decrease injury and death from firearms.

Advocacy

The Research and Development (RAND) Corporation is conducting an ongoing analysis of the effectiveness of U.S. firearm policies. While the evidence is relatively limited due to longstanding limitations on firearm research,^26,27,34 the findings can help clinicians prioritize possible advocacy activities. Thus far, RAND researchers have found strong evidence about the effects of laws that limit children’s access to firearms and/or impose penalties to adults whose firearms are accessed by children. Such laws are associated with decreased self-injury, suicide, and unintentional injury. There is moderate evidence to support the association between background checks and decreased suicide and homicide. Some evidence supports the association between minimum purchasing age requirements and decreased suicide among children. Finally, some evidence supports the association between concealed-carry permits and increased violent crime and unintentional injury.³⁴ It is expected that ongoing research and advocacy will build upon these findings.

Clinicians interested in addressing firearm violence at the local, state, or national levels can do so in many ways. The article in this issue, “Making Your Voice Heard: How to be an Effective Health Advocate,” features a ladder of engagement with ideas for clinician advocacy ranging from lower time commitments, such as signing a petition or posting on social media, to higher engagement efforts, such as writing an op-ed, communicating with legislators, speaking at community meetings, or joining a coalition. Clinicians can also communicate the importance of funding that is explicitly dedicated to studying firearm violence. A selection of national and local resources is included below in Resources, under Advocacy and Community Engagement.

Los Angeles County Actions to Prevent Firearm Violence

There is a growing commitment to prevent injury caused by firearm violence in LA County. In 2018, the County of Los Angeles took action to support a range of firearm violence prevention bills in the California Legislature.³⁵ The County supported legislation that was aligned with its current Board-approved legislative policies on matters related to: 1) firearm control, access and availability; 2) child safety; 3) fostering socially and emotionally healthy school environments; 4) mental health awareness; and 5) violence prevention.

More recently, the Board of Supervisors proclaimed June 2, 2019 as Gun Violence Awareness Day, joining other jurisdictions in support of research into the causes and solutions to firearm violence including policy change at the federal level.^36,37 In addition, on February 19, 2019, the Board of Supervisors expanded local infrastructure to prevent violence by approving the establishment of a County Office of Violence Prevention. The Office is situated within the Department of Public Health in recognition that violence is a significant public health issue that requires a multi-sector, prevention-oriented response. The Office is currently developing an integrated and comprehensive approach to addressing all forms of violence, for which health care providers can play a key role. Clinicians interested in this area are encouraged to visit the Countywide Office of Violence Prevention website and contact the Injury and Violence Prevention Program to discuss engagement opportunities: email ivpp@ph.lacounty.gov or call 213-351-1901.

Conclusion

Firearm violence is a preventable cause of morbidity and mortality that may be mitigated in part by focused clinician efforts. While there are myriad roles that health care providers can play, this article has focused on 3 areas with greater potential for impact. In clinical settings, screening for risk factors associated with firearm violence may lead to timely interventions. Conducting firearm research can contribute to a growing body of scientific evidence, while early adoption of evidence-based violence prevention efforts may decrease injury and death. Advocacy can help shape policies and public health messaging around firearm safety and violence prevention. Finally, clinicians can partner with other sectors, including the LA County Department of Public Health, to work to end the epidemic of violence.

Resources

Screening Tools

• Firearm Violence: Clinical Tools for Screening and Counseling on Gun Violence, American Academy of Family Practice (AAFP) https://www.aafp.org/afp/2018/1101/p560.html#afp20181101p560-t2
• Intimate Partner Violence Screening: Summary of Evidence-based IPV Screening Tools, Agency for Healthcare Research and Quality (AHRQ) https://www.ahrq.gov/professionals/prevention-chronic-care/healthier-pregnancy/preventive/partnerviolence.html
• Alcohol and Drug Use: Screening and Assessment Tools Chart, National Institute of Drug Abuse (NIDA) https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools
• Depression: Patient Health Questionnaires, 2-Question: http://cqaimh.org/pdf/tool_phq2.pdf 9-Question: https://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf

Advocacy and Community Engagement

• Louder Than Guns LA: Led by Mayor Eric Garcetti’s Youth Council to End Gun Violence, the campaign includes an advocacy toolkit. https://www.louderthanguns.org/
• Doctors for America Firearm Violence Advocacy Webpage: Provides a range of actions related to ending the ban on gun violence research including signing a petition, calling members of Congress, and joining a firearm violence prevention task force. Note: Doctors for America and National Physicians Alliance merged in 2019. http://www.drsforamerica.org/issues/gun-violence-research-ban
• Prevention Institute – Recommendations to Prevent Gun Violence: https://www.preventioninstitute.org/focus-areas/preventing-violence-and-reducing-injury/preventing-violence-advocacy
• Wear Orange: Awareness campaign with planned activities across the United States. https://wearorange.org/
• Everytown for Gun Safety: Nonprofit organization that conducts research and studies on firearm violence to promote policies to prevent firearm violence. http://everytown.wecanendgunviolence.org/
• Giffords Law Center: National public interest law center that provides legal assistance, free of charge, to lawmakers, advocates, legal professionals, law enforcement, and citizens who seek to make their communities safer from gun violence. https://giffordslawcenter.networkforgood.com/
• Hope and Heal Fund: Nonprofit organization with a public health approach to preventing firearm violence, including suicides, in California. https://hopeandhealfund.org/
• Violence Policy Center: Nonprofit organization that uses federal data to analyze the effects of firearm violence across states and among specific populations. Analyses and reports are distributed to members of the United States Congress. http://vpc.org/

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