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Medicine and Public Issues |

Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar AssociationFirearm-Related Injury and Death in the United States FREE

Steven E. Weinberger, MD; David B. Hoyt, MD; Hal C. Lawrence III, MD; Saul Levin, MD, MPA; Douglas E. Henley, MD; Errol R. Alden, MD; Dean Wilkerson, JD, MBA; Georges C. Benjamin, MD; and William C. Hubbard, JD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 24 February 2015.


From American College of Physicians, Philadelphia, Pennsylvania; American College of Surgeons and American Bar Association, Chicago, Illinois; American Congress of Obstetricians and Gynecologists and American Public Health Association, Washington, DC; American Psychiatric Association, Arlington, Virginia; American Academy of Family Physicians, Leawood, Kansas; American Academy of Pediatrics, Elk Grove Village, Illinois; and American College of Emergency Physicians, Irving, Texas.

Acknowledgment: The authors thank Renee Butkus for her invaluable role in developing the document. They also thank the persons who reviewed and provided input about the document for their professional organization, including Robert Doherty, David W. Clark, Kate Connors, Judith C. Dolins, Kristin Kroeger Ptakowski, Dr. Debra A. Pinals, Dr. Marco Coppola, Dr. Alex Rosenau, and Dr. Sandra Schneider.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0337.

Requests for Single Reprints: Steven E. Weinberger, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, sweinberger@acponline.org.

Current Author Addresses: Dr. Weinberger: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Hoyt: American College of Surgeons, 633 North Saint Clair Street, Chicago, IL 60611.

Dr. Lawrence: American Congress of Obstetricians and Gynecologists, 409 12th Street SW, Washington, DC 20024.

Dr. Levin: American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209.

Dr. Henley: American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211.

Dr. Alden: American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, IL 60007.

Mr. Wilkerson: American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038.

Dr. Benjamin: American Public Health Association, 8001 I Street NW, Washington, DC 20001.

Mr. Hubbard: American Bar Association, 321 North Clark Street, Chicago, IL 60654.

Author Contributions: Conception and design: S.E. Weinberger, H.C. Lawrence, E.R. Alden.

Analysis and interpretation of the data: H.C. Lawrence, D. Wilkerson.

Drafting of the article: S.E. Weinberger, H.C. Lawrence, D.E. Henley, D. Wilkerson, G.C. Benjamin.

Critical revision of the article for important intellectual content: S.E. Weinberger, D.B. Hoyt, H.C. Lawrence, S. Levin, E.R. Alden, D. Wilkerson, W.C. Hubbard.

Final approval of the article: S.E. Weinberger, D.B. Hoyt, H.C. Lawrence, S. Levin, D. Henley, E.R. Alden, D. Wilkerson, G.C. Benjamin, W.C. Hubbard.

Administrative, technical, or logistic support: S.E. Weinberger, H.C. Lawrence.

Collection and assembly of data: H.C. Lawrence, E.R. Alden.


Ann Intern Med. 2015;162(7):513-516. doi:10.7326/M15-0337
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Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician “gag laws,” restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.


Across the United States, physicians have first hand experience with the effects of firearm-related injuries and deaths and the impact of such events on the lives of their patients. Many physicians and other health professionals recognize that this is not just a criminal violence issue but also a major public health problem (12).

Because of this, we, the executive staff leadership of 7 physician professional societies (whose members include most U.S. physicians), renew our organizations' call for policies to reduce the rate of firearm injuries and deaths in the United States and reiterate our commitment to be a part of the solution in mitigating these events. We represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, and the American Bar Association (ABA), which is committed to helping lawyers and the public understand that the Second Amendment does not impede reasonable measures to limit firearm violence, join the physician organizations in articulating the principles and consensus-based recommendations summarized herein.

The recommendations presented here are based substantially on the various positions approved and adopted by our organizations (312).

In the United States, firearm-related deaths and injuries are a major public health problem that requires diligent and persistent attention. Each year, more than 32 000 persons die as a result of firearm-related violence, suicides, and accidents in the United States; this rate is by far the highest among industrialized countries (1314). Firearms are the second-leading cause of death due to injury after motor vehicle crashes for adults and adolescents (15). What's more, the number of nonfatal firearm injuries is more than double the number of deaths (16). Although much attention has been given to the mass shootings that have occurred in the United States in recent years, the 88 deaths per day due to firearm-related homicides, suicides, and unintentional deaths are equally concerning (17).

Approximately 300 million guns are owned by U.S. civilians, ranking the United States first among 178 countries in terms of the number of privately owned guns (1820). Although some persons suggest that firearms provide protection, substantial evidence indicates that firearms increase the likelihood of homicide or, even more commonly, suicide. Access in the home and general access to firearms have also been shown to increase risk for suicide among adolescents and adults (21). This violence comes at a substantial price to our nation, with a total societal cost of $174 billion in 2010 (22).

Our organizations support a public health approach to firearm-related violence and prevention of firearm injuries and deaths. Similar approaches have produced major achievements in the reduction of tobacco use, motor vehicle deaths (seat belts), and unintentional poisoning and can serve as models going forward. Along with our colleagues in law and public health, those of us who represent the nation's physicians are aware of the significant political and philosophical differences about firearm ownership and regulation in the United States, but we are committed to reaching out to bridge these differences, with the goal of improving the health and safety of our patients and their families. We strongly support a multifaceted public health approach.

To reduce firearm-related injuries and deaths, it is essential to address culture, firearm safety, and regulation that maximizes safety while being consistent with the Second Amendment. In addition, improving the diagnosis and treatment of persons with mental and substance use disorders is critical, especially because of the risk for firearm-related suicides in persons with these conditions. However, we believe that efforts to address firearm-related violence should focus on reducing availability to persons who may pose a threat to themselves or others and not simply single out persons with any mental or substance use disorder.

On the basis of this background and our organizational policies, we believe that the following recommendations appropriately integrate the multidisciplinary perspectives of medical, public health, and legal professionals.

Our organizations strongly support requiring criminal background checks for all firearm purchases, including sales by gun dealers, sales at gun shows, and private sales between individuals. Although current laws require background checks at gun stores, purchases at gun shows do not require such checks. This loophole must be closed. In 2010, of the 14 million persons who submitted to a background check to purchase or transfer possession of a firearm, 153 000 were prohibited purchasers and were blocked from making a purchase (23). Background checks clearly help to keep firearms out of the hands of persons at risk for using them to harm themselves or others. However, 40% of firearm transfers take place through means other than a licensed dealer; as a result, an estimated 6.6 million firearms are sold annually with no background checks (24). The only way to ensure that all prohibited purchasers are prevented from acquiring firearms is to make background checks a universal requirement for all gun purchases or transfers of ownership.

Patients trust their physicians to advise them on issues that affect their health, and physicians can answer questions and educate the public on the risks of firearm ownership and the need for firearm safety. Often, these confidential conversations occur during regular examinations and are a natural part of the patient–physician relationship. Because of this, our organizations oppose state and federal mandates that interfere with physician free speech and the patient–physician relationship, including laws that forbid physicians to discuss a patient's gun ownership (25).

When appropriate, physicians can intervene with patients who are at risk for injuring themselves or others due to firearm access. To do so, physicians must be allowed to speak freely to their patients in a nonjudgmental manner about firearms, provide patients with factual information about firearms relevant to their health and the health of those around them, fully answer their patients' questions, and advise them on the course of behaviors that promote health and safety without fear of liability or penalty. Physicians must also be able to document these conversations in the medical record as they are able and required to do with discussion of other behaviors that can affect health.

Although mental and substance use disorders in and of themselves are only a small factor in societal violence, they can be a significant factor in firearm-related suicide. Access to mental health care is critical for all persons who have a mental or substance use disorder. The health professional organizations represented in this article support improved access to mental health care and caution against broadly including all persons with any mental or substance use disorder in a category of persons prohibited from purchasing firearms. We also support adequate resources to facilitate coordination among physicians and state, local, and community-based behavioral health systems so they can provide care to patients, raise awareness, and reduce social stigma.

Early identification, intervention, and treatment of mental and substance use disorders would reduce the consequences of firearm-related injury and death (9). The overall proportion of violent acts committed by persons with mental or substance use disorders is relatively low, and those who receive adequate treatment from health professionals are less likely to commit acts of violence (2627). Reducing firearm-related violence and suicide requires keeping firearms out of the hands of persons who may harm themselves or others, but it is important that restrictions be applied appropriately by limiting access to such individuals rather than limiting access solely on the basis of a mental or substance use disorder (28).

Blanket reporting laws that compel physicians and other health professionals to report patients who are displaying signs that they might cause serious harm to themselves or others may have unintended consequences. They can stigmatize persons with mental or substance use disorders, create a disincentive for them to seek treatment, and undermine the patient–physician relationship. The health professional organizations represented in this article urge legislators considering such proposals to do so in a way that protects confidentiality and does not deter patients from seeking treatment of a mental or substance use disorder. For persons whose right to purchase or possess a firearm has been suspended on grounds relating to a mental or substance use disorder, there should be a fair, equitable, and reasonable process established for restoration that balances the individual's rights with public safety.

The need for reasonable federal laws, compliant with the Second Amendment, about “assault weapons” and large-capacity magazines has been debated recently. We believe that private ownership of military-style assault weapons and large-capacity magazines represents a grave danger to the public, as several recent mass shooting incidents in the United States have demonstrated. Although evidence to document the effectiveness of the Federal Assault Weapons Ban of 1994 on the reduction of overall firearm-related injuries and deaths is limited, our organizations believe that a common-sense approach compels restrictions for civilian use on the manufacture and sale of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. It seems that such restrictions could only reduce the risk for casualties associated with mass shootings.

As data-driven decision makers, we advocate for robust research about the causes and consequences of firearm violence and unintentional injuries and for strategies to reduce firearm-related injuries. The Centers for Disease Control and Prevention, National Institutes of Health, and National Institute of Justice should receive adequate funding to study the effect of gun violence and unintentional gun-related injury on public health and safety. Access to data should not be restricted, so researchers can do studies that enable the development of evidence-based policies to reduce the rate of firearm injuries and deaths in this nation.

These recommendations do not come solely from a group of health organizations without expertise in constitutional law but have been developed in collaboration with colleagues from the ABA, which has confirmed that these recommendations are constitutionally sound. For 50 years, the ABA has acknowledged the tragic consequences of firearm-related injury and death in our society and expressed strong support for meaningful reforms to the nation's gun laws, as well as for other measures designed to reduce gun violence that do not fall under Second Amendment scrutiny. Because the courts have repeatedly held that the Second Amendment is consistent with a wide variety of laws to reduce gun-related deaths and injuries in our nation (yet confusion exists among the public about whether the Second Amendment is an obstacle to sensible laws), one mission of the ABA has been to educate its members, as well as the public at large, about the true meaning and application of the Second Amendment.

The Supreme Court, in its controlling 2008 decision, District of Columbia v. Heller, concluded that Second Amendment rights are not unlimited with regard to who may possess firearms, what kinds of firearms they may possess, or where they may possess them (29). The Court made clear that the Second Amendment should not be understood as conferring a “right to keep and carry any weapon whatsoever in any manner whatsoever and for whatever purpose”; identified a nonexhaustive list of “presumptively lawful regulatory measures”; and noted that the Second Amendment is consistent with laws banning “dangerous and unusual weapons” not in common use, such as firearms that are most typically used by the military (29).

Further, after Heller, more than 900 court decisions have upheld a wide variety of regulations to reduce gun violence (30), and only a few rulings have struck down certain types of firearm laws (3132). No ruling of the Supreme Court (or any other court, for that matter) calls into question any of the specific proposals that we recommend.

We believe that multidisciplinary, interprofessional collaboration is critical to bringing about meaningful changes to reduce the burden of firearm-related injuries and death on persons, families, communities, and society in general. We are committed to working with all stakeholders to find effective solutions through reasonable regulation to keep firearms out of the hands of persons who are at risk for using them to intentionally or unintentionally harm themselves or others, as well as prevention, early intervention, and treatment of mental and substance use disorders.

Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: the importance of physician engagement. Ann Intern Med. 2013; 158:697-8.
CrossRef
 
Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013; 158:493-4.
CrossRef
 
Butkus R, Doherty R, Daniel H, Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160:858-60.
CrossRef
 
American Academy of Family Physicians.  Firearms and Safety Issues. Accessed at www.aafp.org/about/policies/all/weapons-laws.html on 30 January 2015.
 
American Academy of Pediatrics.  Federal Policies to Keep Children Safe. Accessed at www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Pages/AAPFederalGunViolencePreventionRecommendationstoWhiteHouse.aspx on 30 January 2015.
 
American Congress of Obstetricians and Gynecologists.  Gun Violence and Safety. Washington, DC: American Congress of Obstetricians and Gynecologists; 2014. Accessed at www.acog.org/-/media/Statements-of-Policy/Public/2014GunViolenceAndSafety.pdf on 30 January 2015.
 
American College of Emergency Physicians.  Firearm Safety and Injury Prevention. Irving, TX: American College of Emergency Physicians; 2013. Accessed at www.acep.org/Clinical—Practice-Management/Firearm-Safety-and-Injury-Prevention on 30 January 2015.
 
American College of Surgeons.  Statement on Firearm Injuries. Chicago, IL: American College of Surgeons; 2013. Accessed at www.facs.org/about-acs/statements/12-firearm-injuries on 30 January 2015.
 
American Psychiatric Association.  Position Statement on Firearm Access, Acts of Violence and the Relationship to Mental Illness and Mental Health Services. Arlington, VA: American Psychiatric Association; 2014. Accessed at www.psychiatry.org/File%20Library/Learn/Archives/Position-2014-Firearm-Access.pdf on 30 January 2015.
 
American Public Health Association.  Handgun Injury Reduction. Washington, DC: American Public Health Association; 1998. Accessed at www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/14/37/handgun-injury-reduction on 2 February 2015.
 
American Public Health Association.  Support Renewal with Strengthening of the Federal Assault Weapons Ban. Washington, DC: American Public Health Association; 2003. Accessed at www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/17/55/support-renewal-with-strengthening-of-the-federal-assault-weapons-ban on 2 February 2015.
 
American Bar Association Standing Committee on Gun Violence.  Policy. Accessed at www.americanbar.org/groups/committees/gun_violence/policy.html on 30 January 2015.
 
Centers for Disease Control and Prevention.  FastStats: All Injuries. Accessed at www.cdc.gov/nchs/fastats/injury.htm on 30 January 2015.
 
Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011; 70:238-43.
PubMed
CrossRef
 
Centers for Disease Control and Prevention.  Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/ncipc/wisqars on 12 January 2015.
 
Centers for Disease Control and Prevention . Nonfatal Injury Reports, 2001–2013. Atlanta, GA: Centers for Disease Control and Prevention; 28 March 2013. Accessed at http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html on 13 February 2015.
 
Hoyert DL, Xu J. Deaths: preliminary data for 2011. Natl Vital Stat Rep. 2012; 61: (6) 1-51.
PubMed
 
Karp A.  Completing the Count: Civilian Firearms. Accessed at www.smallarmssurvey.org/fileadmin/docs/A-Yearbook/2007/en/full/Small-Arms-Survey-2007-Chapter-02-EN.pdf on 10 February 2015.
 
Krouse WJ.  Gun Control Legislation. Washington, DC: U.S. Congressional Research Service; 14 November 2012:8-9. Accessed at www.fas.org/sgp/crs/misc/RL32842.pdf on 11 February 2015.
 
Alpers P, Rossetti A, Salinas D, Wilson M.  Rate of Civilian Firearm Possession per 100 Population. United States—Gun Facts, Figures and the Law. Sydney, Australia: Sydney School of Public Health, The University of Sydney; 2015. Accessed at www.gunpolicy.org/firearms/region/united-states on 12 February 2015.
 
Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014; 160:101-10.
 
Miller TR.  The Cost of Firearm Violence. Calverton, MD: Children's Safety Network; 2012. Accessed at www.childrenssafetynetwork.org/publications/cost-firearm-violence on 30 January 2015.
 
Federal Bureau of Investigation.  National Instant Criminal Background Check System (NICS) Operations 2010. Washington, DC: U.S. Department of Justice; 2010. Accessed at www.fbi.gov/about-us/cjis/nics/reports/2010-operations-report/2010-operations-report-pdf on 30 January 2015.
 
Cook PJ, Ludwig J.  Guns in America: National Survey on Private Ownership and Use of Firearms. Washington, DC: U.S. Department of Justice, National Institute of Justice Research in Brief; May 1997. Accessed at www.ncjrs.gov/pdffiles/165476.pdf on 30 January 2015.
 
Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012; 367:1557-9.
PubMed
CrossRef
 
Treatment Advocacy Center.  Treatment Advocacy Center Briefing Paper: Law enforcement and people with several mental illness. Arlington, VA: Treatment Advocacy Center; 2005. Accessed at www.popcenter.org/problems/mental_illness/PDFs/TAC_2005a.pdf on 9 February 2015.
 
Friedman RA. Violence and mental illness—how strong is the link? N Engl J Med. 2006; 355:2064-6.
PubMed
CrossRef
 
Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear. Ann Intern Med. 2013; 159:423-4.
CrossRef
 
District of Columbia v. Heller, 128 S.Ct. 2783 (2008).
 
Law Center to Prevent Gun Violence.  Post-Heller Litigation Summary. 21 November 2014. Accessed at http://smartgunlaws.org/wp-content/uploads/2013/09/Post-Heller-Litigation-Summary-November-2014.pdf on 9 February 2015.
 
Moore v. Madigan, 702 F3d 933, 942 (7th Cir 2012).
 
Ezell v. City of Chicago, 651 F3d 684 (7th Cir 2011).
 

Figures

Tables

References

Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: the importance of physician engagement. Ann Intern Med. 2013; 158:697-8.
CrossRef
 
Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013; 158:493-4.
CrossRef
 
Butkus R, Doherty R, Daniel H, Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160:858-60.
CrossRef
 
American Academy of Family Physicians.  Firearms and Safety Issues. Accessed at www.aafp.org/about/policies/all/weapons-laws.html on 30 January 2015.
 
American Academy of Pediatrics.  Federal Policies to Keep Children Safe. Accessed at www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Pages/AAPFederalGunViolencePreventionRecommendationstoWhiteHouse.aspx on 30 January 2015.
 
American Congress of Obstetricians and Gynecologists.  Gun Violence and Safety. Washington, DC: American Congress of Obstetricians and Gynecologists; 2014. Accessed at www.acog.org/-/media/Statements-of-Policy/Public/2014GunViolenceAndSafety.pdf on 30 January 2015.
 
American College of Emergency Physicians.  Firearm Safety and Injury Prevention. Irving, TX: American College of Emergency Physicians; 2013. Accessed at www.acep.org/Clinical—Practice-Management/Firearm-Safety-and-Injury-Prevention on 30 January 2015.
 
American College of Surgeons.  Statement on Firearm Injuries. Chicago, IL: American College of Surgeons; 2013. Accessed at www.facs.org/about-acs/statements/12-firearm-injuries on 30 January 2015.
 
American Psychiatric Association.  Position Statement on Firearm Access, Acts of Violence and the Relationship to Mental Illness and Mental Health Services. Arlington, VA: American Psychiatric Association; 2014. Accessed at www.psychiatry.org/File%20Library/Learn/Archives/Position-2014-Firearm-Access.pdf on 30 January 2015.
 
American Public Health Association.  Handgun Injury Reduction. Washington, DC: American Public Health Association; 1998. Accessed at www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/14/37/handgun-injury-reduction on 2 February 2015.
 
American Public Health Association.  Support Renewal with Strengthening of the Federal Assault Weapons Ban. Washington, DC: American Public Health Association; 2003. Accessed at www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/17/55/support-renewal-with-strengthening-of-the-federal-assault-weapons-ban on 2 February 2015.
 
American Bar Association Standing Committee on Gun Violence.  Policy. Accessed at www.americanbar.org/groups/committees/gun_violence/policy.html on 30 January 2015.
 
Centers for Disease Control and Prevention.  FastStats: All Injuries. Accessed at www.cdc.gov/nchs/fastats/injury.htm on 30 January 2015.
 
Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011; 70:238-43.
PubMed
CrossRef
 
Centers for Disease Control and Prevention.  Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/ncipc/wisqars on 12 January 2015.
 
Centers for Disease Control and Prevention . Nonfatal Injury Reports, 2001–2013. Atlanta, GA: Centers for Disease Control and Prevention; 28 March 2013. Accessed at http://webappa.cdc.gov/sasweb/ncipc/nfirates2001.html on 13 February 2015.
 
Hoyert DL, Xu J. Deaths: preliminary data for 2011. Natl Vital Stat Rep. 2012; 61: (6) 1-51.
PubMed
 
Karp A.  Completing the Count: Civilian Firearms. Accessed at www.smallarmssurvey.org/fileadmin/docs/A-Yearbook/2007/en/full/Small-Arms-Survey-2007-Chapter-02-EN.pdf on 10 February 2015.
 
Krouse WJ.  Gun Control Legislation. Washington, DC: U.S. Congressional Research Service; 14 November 2012:8-9. Accessed at www.fas.org/sgp/crs/misc/RL32842.pdf on 11 February 2015.
 
Alpers P, Rossetti A, Salinas D, Wilson M.  Rate of Civilian Firearm Possession per 100 Population. United States—Gun Facts, Figures and the Law. Sydney, Australia: Sydney School of Public Health, The University of Sydney; 2015. Accessed at www.gunpolicy.org/firearms/region/united-states on 12 February 2015.
 
Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014; 160:101-10.
 
Miller TR.  The Cost of Firearm Violence. Calverton, MD: Children's Safety Network; 2012. Accessed at www.childrenssafetynetwork.org/publications/cost-firearm-violence on 30 January 2015.
 
Federal Bureau of Investigation.  National Instant Criminal Background Check System (NICS) Operations 2010. Washington, DC: U.S. Department of Justice; 2010. Accessed at www.fbi.gov/about-us/cjis/nics/reports/2010-operations-report/2010-operations-report-pdf on 30 January 2015.
 
Cook PJ, Ludwig J.  Guns in America: National Survey on Private Ownership and Use of Firearms. Washington, DC: U.S. Department of Justice, National Institute of Justice Research in Brief; May 1997. Accessed at www.ncjrs.gov/pdffiles/165476.pdf on 30 January 2015.
 
Weinberger SE, Lawrence HC 3rd, Henley DE, Alden ER, Hoyt DB. Legislative interference with the patient-physician relationship. N Engl J Med. 2012; 367:1557-9.
PubMed
CrossRef
 
Treatment Advocacy Center.  Treatment Advocacy Center Briefing Paper: Law enforcement and people with several mental illness. Arlington, VA: Treatment Advocacy Center; 2005. Accessed at www.popcenter.org/problems/mental_illness/PDFs/TAC_2005a.pdf on 9 February 2015.
 
Friedman RA. Violence and mental illness—how strong is the link? N Engl J Med. 2006; 355:2064-6.
PubMed
CrossRef
 
Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear. Ann Intern Med. 2013; 159:423-4.
CrossRef
 
District of Columbia v. Heller, 128 S.Ct. 2783 (2008).
 
Law Center to Prevent Gun Violence.  Post-Heller Litigation Summary. 21 November 2014. Accessed at http://smartgunlaws.org/wp-content/uploads/2013/09/Post-Heller-Litigation-Summary-November-2014.pdf on 9 February 2015.
 
Moore v. Madigan, 702 F3d 933, 942 (7th Cir 2012).
 
Ezell v. City of Chicago, 651 F3d 684 (7th Cir 2011).
 

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Comments

Submit a Comment/Letter
Liberal academics push anti-gun agenda through medical societies.
Posted on April 14, 2015
Duane White, MD, FACP, SHM
None
Conflict of Interest: None Declared
The reason the CDC funding on guns was cut off in the 1990's was because the Center was using tax dollars to fund anti-gun agendas rather than unbiased research. This was clearly documented in the work of Dr. Timothy Wheeler in "Public Health Gun Control: A Brief History." In addition, the research on guns and crime has been done for decades by criminologists. That research has shown that as gun ownership increases and as states pass right to carry laws, the crime rate has gone down (John Lott, "More guns, less crime") It has not shown any "causal relationship between the ownership of firearms and the causes or prevention of criminal violence or suicide" ("Firearms and Violence: A Critical Review" National Academies of Science.)
Guns and Suicide
Posted on April 15, 2015
E. Michael Lewiecki, MD
New Mexico Clinical Research & Osteoporosis Center, Albuquerque, New Mexico
Conflict of Interest: None Declared
Kudos to the American College of Physicians and other like-minded organizations for taking a strong, and long overdue, position on gun violence in America (1). Identification of gun violence as a public health issue is appropriate and necessary. The recommendations to reduce gun violence (background checks, elimination of physician “gag laws,” mental health care, sensible reporting laws, restrictions on assault weapons, and robust research) should be implemented. Hopefully this “call to action” will be followed by a more favorable response than what followed the position paper on the same topic published in this journal 20 years ago (2). However, there is more to be done.
There is an aspect of gun violence that was briefly noted in the discussion of the new recommendations and accompanying editorial (3) that warrants further attention and action: suicide. About two-thirds of gun deaths in America are suicides; most suicides in this country are by gun; and suicide attempts with a gun are more likely to be fatal that attempts by other means, such as drug overdose. Despite the horrific personal and societal consequences of suicides, the majority of suicides go unnoticed except by family and close friends.
Most suicides are impulsive in nature. That is, the act of suicide often occurs within minutes or hours of the first thought of suicide (4). If a gun is easily available to a vulnerable person, it may be used in an impulsive act that is likely to result in death. The impulsivity of suicide creates opportunities for suicide prevention through means restriction. There are robust empiric data demonstrating that limiting access to highly lethal means of suicide reduces suicides, not just by that method, but overall suicides as well (5). This concept applies not just to guns, but also to other means of suicide. This is why there are barriers to jumping off some bridges that are notorious for suicides. Fortunately, death by suicide is not the inevitable outcome of one who survives a suicide attempt- the vast majority of suicide attempters do not later die by suicide.
Means restriction for suicide prevention includes a waiting period for purchasing guns (especially handguns), requirements for gun safety training, and safe gun storage in the home. Each of these provides a “cooling off” time for self-destructive impulses to pass. Means restriction can save lives and harms no one. This should be added to other strategies to reduce gun violence.


References

1. Weinberger SE, Hoyt DB, Lawrence HC, 3rd, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the american bar association. Ann Intern Med. 2015;162(7):513-6.
2. American College of Physicians. Preventing firearm violence: a public health imperative. Ann Intern Med. 1995;122(4):311-3.
3. Taichman DB, Laine C, On behalf of the Annals editors. Reducing firearm-related harms: time for us to study and speak out. Ann Intern Med. 2015;162(7):520-1.
4. Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24.
5. Florentine JB, Crane C. Suicide prevention by limiting access to methods: a review of theory and practice. Soc Sci Med. 2010;70(10):1626-32.
Onslaught of "Scientific" Support for Gun-Control Laws is Flawed
Posted on April 14, 2015
Robert B. Sklaroff, M.D., F.A.C.P.
Nazareth Hospital, Philadelphia, PA
Conflict of Interest: None Declared
Key-fallacies in the tetrad of gun-related articles in the April 7th issue of the Annals emerge by following the faux-thread from “Original Research” to “Medicine and Public Issues,” and then from one historical editorial to another contemporary editorial. Their broad-brush conclusions fail to address key-concerns raised by the National Rifle Association’s “Institute for Legislative Action” regarding background-checks and assault-weaponry. Because the gravamen of this initiative is overtly intended to delimit individual-ownership of firearms, it is necessary to recall how, last year, I debunked a prodrome of paired-pieces in the Annals on gun-control [Anglemyer’s review and Hemenway’s editorial], showing they advocated preordained restrictions on home-use of firearms (1). Assumptions animating the 2014-dyad plague the 2015-quartet, comparable efforts to politicize awareness of residential violence.

Anglemyer ignored concerns regarding selection-bias of articles invoked in his meta-analysis, instead endorsing Hemenway’s opinions. Hemenway recoiled at citation of his prior attack on the “disease” of gun violence [despite my specific reference and his book’s Wikipedia entry], and he cited his study correlating gun-homicide with higher gun-ownership and weaker gun-laws while disingenuously ignoring its five limitations that precluded claiming a cause-and-effect relationship. After he defended his sweeping conclusion by positing the predictable inability to “disprove a negative” [“the ecologic fallacy”], I concluded their weak responses validated my view that they’d violated the scientific method.

Such loose-logic recurred, manifesting overt intent to invoke the suasive capacity of an amalgam of professional organizations. The Original Research yielded an intuitive conclusion [firearm-related hospitalization presages “violent victimization or crime perpetration”], but its recommendation [counseling] stopped short of necessitating an alteration of public policy (2). Thus, this and Anglemyer’s piece did not validate the multi-organization policy-statement (3), regardless of nomenclature employed [“Public Health” vs. “Public Safety”] per Cotton’s editorial and duly recognizing the stridency permeating the Editors’ editorial; absent the ability to cite “tight” data renders it to be solely a political position-paper, and NOT the inescapable outcome of rigorous research.

Indeed, SCOTUS-Justice Antonin Gregory Scalia would claim that the joint-statement’s proposed limits would violate the Second Amendment, for he wrote of the right to “bear arms” for traditionally lawful purposes such as self-defense [D.C. v. Heller, 554 U.S. 570 (2008)] while recognizing that hand-carried firearms are not akin to "rocket launchers" (4). Indeed, efforts to translate the consensus-statement into legislation would inter alia violate Federalism, as elucidated in a recently-published text by Utah Senator Mike Shumway Lee (5).
References

1. Sklaroff R. Guns, Suicide, and Homicide [Letter]. Ann Intern Med. 2014;160(12):876-877.

2. Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration. A cohort study. Ann Intern Med. 2015; 162:492-500.

3. Weinberger S, Hoyt D, Lawrence H, Levin S, Henley D, Alden E, Wilkerson D, Benjamin G, Hubbard W. Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association. Ann Intern Med. 2015;162(7):492-500.

4. Scalia opens door for gun control legislation, extends slow-burning debate. Accessed at http://www.foxnews.com/politics/2012/07/29/scalia-opens-door-for-gun-control-legislation/ on April 9, 2015 (starting @ minute #7).

5. Lee M. Our Lost Constitution: The Willful Subversion of America’s Founding Document. Sentinel (a member of the Penguin Random House Company), New York, New York (2015).

A Call to Action on Firearm-Related Injury and Death
Posted on April 22, 2015
Steven E. Weinberger, MD
American College of Physicians
Conflict of Interest: None Declared

TO THE EDITOR: We, representing the leadership of 8 health professional organizations and the American Bar Association, recently published an article stressing the importance of firearm-related injury and death as a major public health problem in the United States (1). We advocated measures to reduce the health and public health consequences of firearms, and the American Bar Association confirmed that the recommended measures do not conflict with either the Second Amendment or previous rulings of the U.S. Supreme Court.
We have subsequently invited a wide variety of organizations to endorse the document. In addition to the organizations represented by the authors of the article, the following organizations are officially endorsing the article and its recommendations.

American Academy of Child and Adolescent Psychiatry
American Academy of Neurology
American College of Chest Physicians
American College of Medical Genetics and Genomics
American College of Nurse-Midwives
American College of Occupational and Environmental Medicine
American Medical Student Association
American Psychological Association
American Thoracic Society
Association of Chiefs and Leaders of General Internal Medicine
Brady Campaign and Center to Prevent Gun Violence
Children’s Defense Fund
Institute for Patient- and Family-Centered Care
National Board of Medical Examiners
National Coalition Against Domestic Violence
National Medical Association
National Partnership for Women & Families
National Physicians Alliance
National Urban League
Prevention Institute
Sandy Hook Promise
Society for Adolescent Health and Medicine
Society of Critical Care Medicine
Society of General Internal Medicine
Violence Policy Center

Additional organizations are awaiting review of the paper at their next Board of Directors meeting before they are able to provide formal endorsement.

Steven E. Weinberger, MD
David B. Hoyt, MD
Hal C. Lawrence III, MD
Saul Levin, MD, MPA
Douglas E. Henley, MD
Errol R. Alden, MD
Dean Wilkerson, JD, MBA
Georges C. Benjamin, MD
William C. Hubbard, JD

References
1. Weinberger SE, Hoyt DB, Lawrence HC III, Levin S, Henley DE, Alden ER, Wilkerson D, Benjamin GC, Hubbard WC. Firearm-related injury and death in the United States: A call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015; 162:513-16.

Author's Response
Posted on May 27, 2015
Steven E. Weinberger, MD
American College of Physicians
Conflict of Interest: None Declared
Dr. Lewiecki raises a sensible recommendation for a waiting period after gun purchase to mitigate the risk of an impulsive suicide with a firearm, particularly a handgun. The recommendations in our recent “Call to Action” paper (1) were based on pre-existing policies of the organizations represented by the co-authors. Since the issue of a waiting period had not generally been addressed in the policies of these organizations, it was not included in the paper. However, the previously published position statement from the American College of Physicians (ACP) on firearm-related injury and death does note that “waiting periods may reduce the incidence of death by suicide, which account for nearly two thirds of firearm deaths…” (2). As a result, ACP formally recommended that a waiting period “should be considered as part of a comprehensive approach to reducing preventable firearms-related deaths.”
Dr. White’s suggestion that “CDC funding on guns was cut off in the 1990s because the Center was using tax dollars to fund anti-gun agendas rather than unbiased research” is the accusation that was made at the time by the NRA. As a result of the NRA’s lobbying power, The Washington Post noted that “Congress threatened to strip the agency’s funding. The CDC’s self-imposed ban dried up a powerful funding source and had a chilling effect felt far beyond the agency: Almost no one wanted to pay for gun violence studies, researchers say. Young academics were warned that joining the field was a good way to kill their careers” (3).
Dr. White goes on to cite the work of Dr. Timothy Wheeler and John Lott, both of whom are strong gun rights advocates whose writings have consistently demonstrated a pro-gun bias. He then argues that the 2004 report of the Institute of Medicine (IOM) entitled Firearms and Violence: A Critical Review (4) states that research “has not shown any ‘causal relationship between the ownership of firearms and the causes or prevention of criminal violence or suicide.’” Unfortunately, Dr. White has taken this statement out of context and has implied that absence of evidence is the same as evidence of absence, which is not the case. In fact, the report’s primary finding is that there has been a lack of research on firearms, and its consistent message is that more research needs to be conducted.
I would like to stress that our “Call to Action” paper, developed by major organizations representing the medical, public health, and legal communities and endorsed so far by 30 additional organizations, was intended to recognize that measures need to be taken to reduce firearm-related injury and death. With 32,000 deaths annually in the United States as a result of firearm-related violence, suicides, and accidents, this is clearly a public health problem that needs to be addressed. The recommendations in the paper are reasonable approaches to mitigate this important public health problem that do not in any way restrict use of the appropriate types of firearms by those individuals who will use them for acceptable purposes.


References:
1. Weinberger SE, Hoyt DB, Lawrence HC III, Levin S, Henley DE, Alden ER, Wilkerson D, Benjamin GC, Hubbard WC. Firearm-related injury and death in the United States: A call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015; 162:513-16.
2. Butkus R, Doherty R, Daniel H, for the Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014; 160:858-860.
3. Frankel TC. Why the CDC still isn’t researching gun violence, despite the ban being lifted two years ago. The Washington Post, January 14, 2015. Accessed at http://www.washingtonpost.com/news/storyline/wp/2015/01/14/why-the-cdc-still-isnt-researching-gun-violence-despite-the-ban-being-lifted-two-years-ago/ on May 23, 2015.
4. Wellford CF, Pepper JV, Petrie CV, eds. Firearms and Violence. A Critical Review. Washington, DC, The National Academies Press, 2004.
Updated list of endorsers of Call to Action paper on Firearms Violence
Posted on November 14, 2015
Steven E. Weinberger, MD, MACP
American College of Physicians
Conflict of Interest: None Declared
TO THE EDITOR:
In April, 2015, the American College of Physicians joined with 6 other medical specialty societies, plus the American Public Health Association and the American Bar Association, in publishing a “Call to Action” regarding firearms violence as a major public health problem needing to be addressed with sensible regulations that do not conflict with either the Second Amendment or with prior U.S. Supreme Court decisions (1). Since that time, many other organizations have endorsed the paper and its recommendations, and a list of endorsing organizations was previously published in August, 2015 (2). In the face of continuing tragic episodes of firearms violence, a total of 52 organizations listed below, including the 9 organizations that co-authored the original paper (denoted with an asterisk), have now formally endorsed the paper. The updated list as of November 14, 2015 includes the following organizations:
1. Alliance for Academic Internal Medicine
2. American Academy of Child and Adolescent Psychiatry
3. American Academy of Family Physicians*
4. American Academy of Neurology
5. American Academy of Otolaryngology – Head and Neck Surgery
6. American Academy of Pediatrics*
7. American Academy of Physical Medicine and Rehabilitation
8. American Bar Association*
9. American College of Chest Physicians
10. American College of Emergency Physicians*
11. American College of Medical Genetics and Genomics
12. American College of Nurse-Midwives
13. American College of Obstetricians and Gynecologists*
14. American College of Occupational and Environmental Medicine
15. American College of Physicians*
16. American College of Preventive Medicine
17. American College of Surgeons*
18. American Geriatrics Society
19. American Medical Student Association
20. American Medical Women’s Association
21. American Psychiatric Association*
22. American Psychological Association
23. American Public Health Association*
24. American Society for Clinical Pathology
25. American Society of Hematology
26. American Thoracic Society
27. Association of Chiefs and Leaders of General Internal Medicine
28. Brady Campaign and Center to Prevent Gun Violence
29. CeaseFirePA
30. Children’s Defense Fund
31. Council of Medical Specialty Societies
32. Doctors for America
33. Institute for Patient- and Family-Centered Care
34. Law Center to Prevent Gun Violence
35. National Association of Pediatric Nurse Practitioners
36. National Association of Social Workers
37. National Board of Medical Examiners
38. National Coalition Against Domestic Violence
39. National Medical Association
40. National Partnership for Women and Families
41. National Physicians Alliance
42. National Urban League
43. Newtown Action Alliance
44. Patient-Centered Primary Care Collaborative
45. Physicians for Social Responsibility
46. Prevention Institute
47. Sandy Hook Promise
48. Society for Adolescent Health and Medicine
49. Society of Critical Care Medicine
50. Society of General Internal Medicine
51. Society of Thoracic Surgeons
52. Violence Policy Center

Steven E. Weinberger, MD
American College of Physicians

1. Weinberger SE, Hoyt DB, Lawrence HC 3rd, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015; 162:513-6.
2. Weinberger SE, Hoyt DB, Lawrence HC, Levin S, Henley DE, Alden ER, et al. Firearm-Related Injury and Death in the United States. Ann Intern Med. 2015;163:322-323. doi:10.7326/L15-5124
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