Author Affiliations: Dr Cole is Contributing Editor, JAMA. Dr Johnson is a Yerby Fellow at the Harvard Injury Control Research Center, Harvard School of Public Health, Boston, Mass.
The seventh leading “actual,” or preventable, cause of death in the United States in 20001 was firearm injury, ranked after tobacco, poor diet and physical activity, alcohol consumption, microbial agents, toxic agents, and motor vehicle injury, and ahead of sexual behavior and illicit drug use. Firearms are present in about one third of US households.2 Children and adolescents may be tempted to play or practice with firearms,3 and those who have access to firearms sometimes handle them without adult supervision.4 Not surprisingly, the presence of a firearm in the home is associated with an increased risk for suicide5 - 7 ; the relative risk of unintentional firearm injury is not known.
In 2002, 1057 US children and adolescents ranging in age from less than 1 year to 20 years died of firearm suicide and another 190 of unintentional gunshot wounds.8 In a King County, Washington, study, household firearms were used in almost one fourth of unintentional shootings of children and adolescents and one third of self-inflicted shootings between 1990 and 1995.9 More than three fourths of the firearms in this study had been stored in the homes of the injured children, a relative, or a friend. To prevent unsupervised access of children to firearms, 18 states had enacted child access prevention laws as of 2001.10 These laws make it a crime to store firearms in a manner that allows them to be easily accessed by children and adolescents.
However, locking away firearms from children and adolescents may also limit access to the firearms by their adult owners. Many households keep firearms for protection against potentially violent intruders,11 and surveys indicate that firearms are often used for this purpose in the United States.12 Consequently, families may perceive that keeping a gun for protection and protecting their children from firearm injury are equally important.
To appeal to the safety consciousness of gun-owning families with children, groups such as the National Shooting Sports Foundation,13 the trade association for the firearms and recreational shooting sports industry, and the American Academy of Pediatrics14 recommend that firearms in the home be stored locked and unloaded to prevent access to them by children. The National Shooting Sports Foundation Web site advises, “Keeping a gun to defend your family makes no sense if that same gun puts your family members or visitors to your home at risk. Many home firearms accidents occur when unauthorized individuals, often visitors, discover loaded firearms that were carelessly left out in the open. . . . Special lockable cases that can be quickly opened only by authorized individuals are options to consider.”15
Intuitively, storing firearms locked and unloaded should prevent firearm injuries to children who do not intend to harm themselves. Safe storage might also discourage or delay access to firearms by adolescents who do intend to harm themselves, or divert them to less lethal means of self-harm. However, previous studies of household firearms and adolescent suicide have not shown statistically significant associations of specific safe storage practices and a reduced risk of firearm injury in homes with children and adolescents, either because these studies lacked statistical power to examine these associations5 - 7 or did not analyze data for children and adolescents separately from adult data.16 - 17
In this issue of JAMA , Grossman et al18 report that guns stored locked or unloaded were less likely to be used by children or adolescents to shoot themselves or to shoot others unintentionally. To measure the association of specific household firearm storage practices (locking guns, locking ammunition, and keeping guns unloaded), Grossman et al18 conducted a case-control study of unintentional and self-inflicted firearm injuries to children and adolescents. Each of these safe storage practices was associated with reductions in the relative risk of firearm injury. The protective associations remained strong and statistically significant after controlling for county of residence, ages of children in the home, characteristics of the survey respondents, type of firearm, number of guns stored in the home, and whether the study gun was kept for recreation or protection. Results were similar for suicide attempts and unintentional injuries. Firearm assaults and homicides were not studied because of the difficulty in acquiring accurate data on the source and storage of firearms.
More research is needed to determine whether safe storage practices are equally effective for adolescents as for younger children. In theory, suicidal adolescents may be persistent and determined enough to access firearms and ammunition even if safely stored or may kill themselves by other methods. In apparent support of this theory, a national study of adults and adolescents aged 15 years and older found that those who killed themselves with firearms were less likely to have locked or unloaded firearms in their homes than persons who died of other causes, but the protective effect of safe storage declined as the presumed intention to die increased.17 Grossman et al18 were unable to determine whether the 5% of children and adolescents in their study who survived suicide attempts died of subsequent attempts after the study. If suicidal children and adolescents in homes with safely stored firearms use alternate methods to kill themselves, then safe gun storage may be viewed as only temporarily successful in preventing suicide.
Despite this limitation, the study by Grossman et al18 strongly suggests that unsafe firearm storage is associated with firearm suicide and unintentional firearm death. Each method of safe storage of firearm and ammunition examined by Grossman et al18 was associated with a reduction in unintentional or self-inflicted shooting. Therefore, if physicians can persuade parents to adopt at least 1 safe storage practice, their children’s risk of unintentional or self-inflicted firearm injury is likely to decrease. Options for safe storage may facilitate firearm safety counseling and increase compliance with physicians’ recommendations.
Social science research on persuasion suggests that the likelihood of compliance is greater if a smaller, more feasible, recommendation can be made when there is resistance to a more substantial recommendation.19 In terms of firearm storage, the initial, substantial recommendation might be to keep all firearms unloaded, in a locked compartment, secured with an extrinsic safety device, and to keep ammunition locked in a different compartment. If parents are unwilling to comply with all components of this recommendation, the physician could encourage adoption of 1 or 2 of the specific storage practices. Behavioral theory suggests that this type of strategy could allow gun-owning adults to store their firearms in a manner that they might perceive as effective for defensive use and yet foster a safe home environment for children.
The study by Grossman et al18 establishes that safe firearm storage is associated with a reduced risk for firearm injury. The next step is to help families make informed decisions about safe storage of firearms, recognizing that keeping children safe is as important to parents who own guns as those who do not. Experience suggests that persuading gun-owning families to store their firearms safely is not an easy task. Educational interventions to promote safe storage of firearms (including physician counseling) have not been successful in the past.20 - 21 Part of the problem may be that safe storage programs may not have been informed by a comprehensive understanding of the determinants of firearm storage practices.
Generating widespread improvement in firearm storage practices will require a commitment to conducting behavioral science research and applying new information to design effective interventions. First, research outlining the determinants of storage practices is needed. Specifically, studies should address parents’ risk perceptions about firearm injury to children in conjunction with their beliefs about the effectiveness of guns for defense and motivations underlying parents’ firearm storage practices. Surprisingly, little of this information is available. Next, what is learned from behavioral research should be applied to small-scale interventions, using behavioral science theory to guide intervention development.
The effectiveness of different strategies for eliciting behavioral change should be evaluated using experimental design. In addition, strategies that have been demonstrated in intervention studies as being effective should be distributed and incorporated into a standard of care. Most families with children and adolescents have chosen not to keep firearms in their homes, but for families who feel safer with a gun for protection, safe storage of firearms and ammunition can reduce the risk of unintentional and self-inflicted firearm injury.
Corresponding Author: Thomas B. Cole, MD, JAMA , 515 N State St, Chicago, IL 60610.
Editorials represent the opinions of the authors and THE JOURNAL and not those of the American Medical Association.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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