Gun violence and firearm policy in the U.S.: A brief history and the current status

In light of the pervasiveness of gun violence and increasing frequency of mass casualty shootings, the Resident and Associate Society of the American College of Surgeons (RAS-ACS) Advocacy and Issues Committee endeavors to explore the issues of gun violence and firearm policy in the U.S. As surgeons and surgical trainees, we are confronted with the consequences of gun violence in our hospitals daily. This article discusses the history and current landscape of national firearm policy.

Epidemiology of gun violence in the U.S.

Firearm violence accounted for 36,252 U.S. deaths in 2015 and continues to be a leading cause of death for individuals 10–24 years old, constituting a public health crisis.¹ The age-adjusted death rate due to firearm injury by all intents, after remaining stable for several years, increased by 7.8 percent in 2015.¹ The U.S. Centers for Disease Control and Prevention (CDC) data reveal that deaths from firearm injury accounted for almost 17 percent of all injury-related deaths in 2014.² Of these mortalities, suicides remain relatively unchanged at 63 percent of all firearm-related deaths, and homicides comprise approximately 37 percent of firearm deaths.

The 2014 Annual Review of Public Health found that the increase in the mortality rate from firearm violence had greatly differed from other etiologies. Notably, while significant progress has been made in reducing the incidence of death from other injuries through public health interventions and federal policies, similar trends have not been observed in mortality rates due to firearm injuries, leaving room for interventional strategies in this area.³

Compared with other member nations in the Organisation for Economic Co-operation and Development, the U.S. is an outlier in mortality rates from firearm violence, with exceptionally high rates of firearm-related homicide and suicide.⁴ A number of studies demonstrate that access to a firearm greatly increases the risk of injury. In a 2014 meta-analysis conducted at the University of California, San Francisco, researchers assessed 16 observational studies on firearm-related death and found that access to firearms is associated with increased likelihood of both completed suicide and of being the victim of homicide.⁵

In addition to the public health costs, firearm-related injuries add significant financial burdens to the U.S. health care system and result in reduced productivity of U.S. workers. According to the National Violent Death Reporting System (NVDRS), in 2010 the medical costs for the approximately 30,000 people killed by firearms were an average of $5,891 per person and nearly $186.6 million overall.⁴ The 38,500 injured individuals who survived firearm-related injuries but required hospitalization accrued nearly an additional $852.9 million and more than $3 billion in lost wages.⁴ Another group of patients whose injuries were less severe and were discharged without inpatient admission had medical and lost wages expenses totaling an additional $200 million.⁴

Gun violence legislation: A brief history

Federal research funding

The CDC’s National Center for Injury Prevention and Control has a history of studying gun violence as it relates to public health. However, for the past two decades, federal firearm injury prevention research has stalled due to the 1996 Omnibus Consolidated Appropriations Act.⁶ In 1996, the National Rifle Association—in reaction to CDC-funded studies demonstrating that firearm ownership was a risk factor for homicide in the home—lobbied Congress to eliminate $2.6 million from the CDC budget, the exact amount the CDC had allocated to gun violence research the previous year.⁷ As a result, the 1996 appropriations bill included a rider proposed by Rep. Jay Dickey (R-AR) that stated “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”⁸

Congress subsequently reallocated the funds for firearm injury research to the prevention of traumatic brain injuries, and the CDC ultimately ceased all firearm-related research. In a study of scientific publications related to firearms from 1991 to 2010, the number of firearm studies was significantly fewer than other major causes of death, highlighting a detrimental result of the funding ban.⁹ The CDC provision was then expanded in 2012 to include other agencies in the U.S. Department of Health and Human Services (HHS), further limiting research related to this topic.

However, in January 2013 President Barack Obama encouraged Congress to invest several million dollars to expand the NVDRS to all 50 states to facilitate a better understanding of the role of firearms in violent deaths.

In addition, the Gun Violence Research Act, introduced in November 2015, amended the Public Health Service Act to include gun violence-related injury as an acceptable area of research for the CDC. The Gun Violence Research Act failed to pass but was reintroduced in March 2017 and sought to repeal the prohibition of the HHS from researching gun-related violence. The National Institutes of Health also responded to the presidential directive and funded nine proposals aimed at researching firearm violence and its prevention; however, this program has since been suspended.⁶

Firearm sales and regulations

The National Instant Criminal Background Check System (NICS) initiated 27 million background checks for gun buyers in 2016, which was a record high for the gun industry.¹⁰ Although this number does not reflect the total sum of guns sold in the U.S. that year, it is the best marker to track their sales. The NICS, established in November 1998, requires a criminal background check of all gun buyers and was amended in January 2008 by President George W. Bush to screen for known mentally ill individuals, who are ineligible to purchase firearms.¹¹ Gun sales seem to ebb and flow with the changing political climate, yet the popularity of certain firearms, such as automatic guns, has remained constant.

Fully automatic weapons, as outlined in the National Firearms Act, have been illegal since 1934. However, semiautomatic rifles with large magazines were only recently outlawed in 1994 through the Assault Weapons Ban (AWB) by President Bill Clinton.¹² These firearms, which have become synonymous with assault weapons, also include military-style handguns and shotguns, which remained illegal in the U.S. for 10 years. The AWB expired despite the efforts of Rep. David Cicilline (D-RI), who introduced the AWB of 2015, which would have made it illegal to knowingly import, sell, manufacture, transfer, or possess a semiautomatic assault weapon or large-capacity ammunition-feeding device.

Over the years, an unfortunate pattern has developed, in which it takes a mass shooting event, defined as an incident involving the murder of four or more people, to spur national discussion of firearm-related violence and injury prevention. In the wake of the December 2012 mass shooting at Sandy Hook Elementary School in Newtown, CT, where 20 children and six teachers were killed, President Obama urged the Consumer Product Safety Commission to review gun storage codes.¹³ To date, only 11 states have legislation pertaining to locking devices.¹⁴ Massachusetts’ law is the most stringent, requiring that all firearms be stored and locked.

California, Connecticut, Illinois, Maryland, Michigan, New Jersey, New York, Ohio, Pennsylvania, and Rhode Island have varying laws about maintaining firearms in locked states and supplying locks to accompany dealer and private sales.¹⁴ Gov. Andrew Cuomo (D-NY) supported the state’s Secure Ammunition and Firearms Enforcement Act (SAFE Act) after the Sandy Hook massacre. This bill includes provisions that prevent individuals convicted of crimes and people with mental illness from purchasing a gun. These deterrents include universal background checks and increased penalties for illegal use. The law also imposes the strictest assault weapons ban in the U.S. The SAFE Act was passed by the New York State Legislature and signed into law by Governor Cuomo in January 2013.

States regulate high-capacity magazines—ones that contain large amounts of ammunition to promote firing without pausing to reload—through five mechanisms: AWBs, high-capacity magazine bans, gun possession prohibitions for high-risk individuals, gun possession prohibitions for individuals with domestic violence convictions, and mandatory background checks.¹⁵ California, Connecticut, the District of Columbia, Maryland, Massachusetts, New Jersey, and New York have the strictest firearm laws in the country. Idaho and Montana have almost no firearm laws except for the federally mandated Brady Law background checks.¹⁵ In June 2016, President Obama advocated for renewed legislation against high-capacity assault-style weapons after the Orlando, FL, Pulse nightclub shooting where 49 lives were taken.¹⁵ Because of vaguely designed plans and claims that such new legislation would violate the Second Amendment, the bill failed to gain traction.

Gun violence legislation: The current status

At press time, an estimated 149 firearm-related bills and resolutions are pending in Congress. The bills cover a range of issues, including the Sportsmen’s Act, S. 733, which aims to enhance the hunting and fishing experience; the Silencers Help Us Save Hearing (SHUSH) Act, S. 1505, which would require silencers to be treated the same as other firearm accessories; H.R. 4018, a bill requiring a three-day waiting period to take ownership of a handgun; and several bills in support of the Second Amendment. In addition, House and Senate resolutions introduced in 2017 ask for support of a national gun violence awareness day and national gun violence awareness month. As of press time, these particular bills and resolutions are stalled in committee and are unlikely to make it to the floor of their respective chamber for a debate and a vote.

However, of the 149 pending bills and resolutions, at press time, six had passed through a House or Senate committee, and four had been voted on and passed in the House and were awaiting Senate debate.

The discussion around firearm safety comes down to efforts to reduce gun-related violence while protecting the rights of gun owners. Several bills have been introduced specifically in response to some of the recent mass shootings. For example, the Automatic Gun Fire Prevention Act, H.R. 3999/S. 1916, was proposed in the aftermath of the Las Vegas, NV, shooting in October 2017, in which the shooter used a bump stock, a device that transforms a semiautomatic weapon into an automatic weapon; this bill would make bump stocks illegal. The Consolidated Appropriations Act (P.L. 115-141), which was signed into law in March 2018, included $20 million for reducing gun crime and gang violence. This legislation prohibits the use of funds to promote firearm control efforts.

Recent congressional efforts to reduce firearm-related injuries and deaths include measures to allow additional research and enhance secure storage of weapons for sale. Of particular relevance to physicians is a bill pending in the House, the Safer Communities Act of 2017, H.R. 4142, that addresses strengthening the national mental health infrastructure and expanding reporting of mental health records to the NICS. The ACS supports the Fix NICS Act, H.R. 4477/S. 2135, which would enhance reporting requirements to the NICS. Other examples of firearm-related legislation are included in Table 1.

Although there has been a robust effort to initiate legislation to reduce gun-related violence, most bills never make it to law. After mass shootings, the number of proposals increases; however, few make it to the House or Senate floor, and fewer still are signed into law.^16,17 State legislatures may provide an opportunity for improvements in laws regulating firearm safety, as a number of studies have shown an association between more stringent state laws on gun ownership and a lower number of gun-related deaths.⁴

Table 1. Examples of federal firearm-related legislation

Surgeon involvement

In 2015, the ACS participated in a call to action involving eight health care professional organizations and the American Bar Association to address firearm-related injury and death. The recommendations included implementing universal background checks on gun purchasers, eliminating physician “gag laws” limiting the discussion of firearm ownership with patients, restricting the manufacture and sale of assault weapons and large-capacity magazines for civilian use, improving child safety devices and storage regulations, and increasing federal gun violence research support.¹⁸ Additionally, the ACS Committee on Trauma (COT) recently published a consensus-based approach to address firearm-related injury.¹⁹ The basis for this approach stemmed from a survey of 254 members of the COT and trauma surgeon leaders, with a response rate of 93 percent. Key results of this survey include the following:

• 86 percent of respondents support universal background checks
• 90 percent support preserving the right of health care providers to counsel patients on safe firearm ownership
• 92 percent support making funds more available for gun violence research
• 92 percent support more severe penalties for those who purchase guns to illegally supply to others

One major goal of the consensus-based approach to firearm injury prevention is primary prevention of initial injury and tertiary prevention through hospital-based violence intervention programs to treat complications from firearm injuries.¹⁹

Although surgeons frequently are involved in the clinical care of victims of gun violence, residents are rarely trained to play an active role in the process of emotional, mental, and socioeconomic rehabilitation  related to patients suffering from firearm-related injuries. Hospital-based violence intervention programs are a form of tertiary prevention through which patients are engaged during the “teachable moment” immediately following injury.²⁰ Programs provide support while in the hospital, as well as additional resources necessary for change and advancement once patients are discharged. The services offered vary by program but often include conflict resolution skills, access to mental health and substance abuse counseling, job and education placement, housing relocation, and legal assistance.²⁰

Trauma surgeon Carnell Cooper, MD, FACS, worked to establish one of the flagship hospital-based violence intervention programs at the University of Maryland Shock Trauma Center, Baltimore, in 1998. The center’s violence intervention program (VIP) has received national recognition for its efforts.²¹ The VIP provides an initial needs assessment and continued counseling and social support from a multidisciplinary team of surgeons, nurses, case managers, and social workers. The phases of service include stabilization, recovery and rehabilitation, community reintegration, and self-reliance.²² In a case-control study to establish a target population for the program, independent risk factors for recurrent injury included ethnicity, employment status, income of less than $10,000 annually, drug use, and past or present drug dealing activity.²³ The VIP participants had significant improvements when compared with a control group. The VIP experienced an 83 percent decrease in repeat hospitalization, a 66.7 percent decrease in violent crime, and an 82 percent employment rate at the time of follow-up.²⁴

Previous studies have shown the efficacy of other health care-based violence intervention programs. A recent systematic review of 22 randomized control trial and observational studies representing 14 individual programs showed that studies with appropriate statistical power and length of follow-up not only increased use of services, but also changed attitudes toward violence, decreased violent behavior, and significantly reduced injury recidivism.²⁰

The cost savings to both the criminal justice and health care systems also have been assessed. One program assessed its cost savings based on subsequent arrests and convictions after program enrollment. Following the program intervention, approximately $500,000 was spent for incarceration of the intervention group versus more than $2 million for the control based on conviction rate and time of imprisonment.²⁴ Additionally, the hospital readmission rate for the intervention group was 5 percent, accounting for an estimated $138,000 in actual hospital costs and average length of stay, compared with 36 percent in the control group, accounting for an estimated $736,000.²⁴

The Wraparound Project VIP at the University of California, San Francisco, established by founding director and trauma surgeon Rochelle Dicker, MD, FACS, addresses violence prevention with a focus on cultural appropriateness and individuals at high risk for re-injury or incarceration.²⁵ The program works in conjunction with community partners to place participants in vocational training programs, after-school programs, and cognitive behavioral therapy; assist with education completion; and assist in obtaining a driver’s license and even tattoo removal.²⁵ A critical tenet of the program is expansion to other sites to further the treatment of trauma and violence. A standard model of program evaluation was approved by the CDC and incorporated to assess the exportability of services of the Wraparound Project VIP to another local trauma center.²⁶ Even with variability in patient population, both programs provided more than 50 percent of the needed services for their participants, highlighting potential for continued successful progress.

There is a growing wealth of available knowledge through the COT on program infrastructure to further enhance exportability.¹⁹ The National Network of Hospital-based Violence Intervention Programs is a consortium of programs across the country working to standardize development, implementation, and evaluation. They provide information on how to establish a program and highlight the necessary components based on best practice models. The group is developing a national registry that would standardize data collection and enhance the statistical power of future studies.²⁷ Although efforts to address violence on a national level continue, progress remains to be made on the smaller scale, such as COT-developed materials that health care professionals can incorporate into patient discussions.

Physicians, particularly surgeons, should be facile at discussing firearm safety with patients. A physician’s attitude should be impartial and nonjudgmental to ensure the message is received. Unfortunately, many providers are uncomfortable discussing this contentious topic; however, no federal or state law prohibits physicians from inquiring about firearms when it is germane to patient health. Although the Affordable Care Act bars the required collection of firearm information by certain health programs, it does not regulate physician-patient discussions.^28,29 Expert physicians in this area suggest directing conversations regarding firearms toward patients exhibiting suicidal or homicidal ideation; those with risk factors for future violence (substance abuse, mental illness, and so on); and patients in high-risk demographic groups, such as middle-aged white men and young black males. To promote safety, a physician could use the five “Ls” mnemonic: Locked, Loaded, Little children, feeling Low, Learned owner. The educational goal is to encourage the storage of unloaded guns in a locked place away from children and oneself, especially if feeling dejected.²⁹

Gun violence prevention: A public health approach

While mass shootings often garner nationwide attention, surgeons address the ramifications of gun violence on a local level daily. Trauma surgeons such as Jessica Beard, MD, FACS, and Carrie Sims, MD, FACS, at the University of Pennsylvania, Philadelphia, recognize the need for a multifaceted approach to address all victims of firearm violence, including families, and highlight the socioeconomic disadvantages and lack of political voice of the affected.³⁰ Research on the trends in gun violence, as well as the effect of legislation, can provide vital information to develop strategies to help curb this public health crisis.

Surgeons and surgical trainees are equipped to be leaders and advocates in gun violence education, prevention, and recidivism reduction efforts. A number of resources are available for ACS members who are interested in becoming more involved. The RAS Advocacy and Issues Committee’s Gun Violence Workgroup welcomes interested RAS Members of the ACS to join in our efforts and share new ideas (e-mail RASnews@facs.org to join the Advocacy and Issues Committee).

Other steps to become more involved include the following:

• Educating others on the mental health ramifications of gun violence
• Initiating research projects examining firearm violence at local trauma centers
• Supporting hospital-based intervention programs at local institutions
• Encouraging program development using the ACS COT VIP primer
• Contacting local ACS chapters and/or the ACS Division of Advocacy and Heath Policy for advocacy opportunities
• Reaching out to local and state legislators to share experiences and perspectives as physicians who care for the injured patient

Acknowledgments

The authors thank Jennifer Lynde, MD, for her contributions to the research for this article, and Justin Rosen, ACS Congressional Lobbyist, Division of Advocacy and Health Policy, Washington, DC, for helping us ensure accuracy related to legislation and ACS efforts. We also thank the RAS-ACS Advocacy and Issues Committee leadership and the RAS-ACS Executive Committee for their support.

References

1. Murphy SL, Xu J, Kochanek KD, Curtin SC, Arias E. Deaths: Final data for 2015. Natl Vital Stat Rep. 2017;66(6):1-75.
2. Centers for Disease Control and Prevention: National Vital Statistics Reports, Volume 65, Number 4. Deaths: Final data for 2014. Available at: www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf. Accessed December 31, 2017.
3. Wintemute GJ. The epidemiology of firearm violence in the twenty-first century United States. Annu Rev Public Health. 2015;36:5-19.
4. Centers for Disease Control and Prevention. National Violent Death Reporting System. Available at: www.cdc.gov/injury/wisqars/nvdrs.html. Accessed May 15, 2018.
5. 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(2):101-110.
6. Rubin R. Tale of 2 agencies: CDC avoids gun violence research but NIH funds it. JAMA. 2016;315(16):1689-1691.
7. Kellerman AL, Rivara FP. Silencing the science on gun research. JAMA. 2013;309(6):549-550.
8. Dzau VJ, Rosenberg M. Congress hasn’t banned research on gun violence. It just won’t fund it. The Washington Post. March 21, 2018. Available at: www.washingtonpost.com/opinions/how-research-can-help-us-address-gun-violence/2018/03/21/ecde2128-2c4d-11e8-8ad6-fbc50284fce8_story.html?utm_term=.ad7c443b6193. Accessed May 25, 2018.
9. Ladapo JA, Rodwin BA, Ryan AM, Trasande L, Blustein J. Scientific publications on firearms in youth before and after congressional action prohibiting federal research funding. JAMA. 2013;310(5):532-534.
10. Federal Bureau of Investigation. NICS firearm background checks: Month/year. Available at: www.fbi.gov/file-repository/nics_firearm_checks_-_month_year.pdf/view. Accessed May 15, 2018.
11. National Rifle Association of America. Background checks for guns. Available at: www.nraila.org/get-the-facts/background-checks-nics/. Accessed May 15, 2018.
12. Chu VS. Federal assault weapons ban: Legal issues. Congressional Research Service report. Available at: www.scribd.com/document/149713675/Federal-Assault-Weapons-Ban-Legal-Issues. Accessed May 15, 2018.
13. National Archives and Records Administration. Now is the time: The president’s plan to protect our children and our communities by reducing gun violence. Available at: https://obamawhitehouse.archives.gov/node/193271. Accessed May 15, 2018.
14. Giffords Law Center to Prevent Gun Violence. Safe storage. Available at: http://lawcenter.giffords.org/gun-laws/policy-areas/child-consumer-safety/safe-storage/. Accessed May 15, 2018.
15. Shapiro L, Sahil C, Williams A. How strictly are guns regulated where you live? The Washington Post. February 20, 2018. Available at: www.washingtonpost.com/graphics/2017/national/assault-weapons-laws/?utm_term=.1a11e3b32672. Accessed May 15, 2018.
16. Shabad R. Why more than 100 gun control proposals in Congress since 2011 have failed. CBS News. June 20, 2016. Available at: www.cbsnews.com/news/how-many-gun-control-proposals-have-been-offered-since-2011/. Accessed May 15, 2018.
17. Berman R. The gun legislation with the best chance of passing Congress. The Atlantic. October 3, 2017. Available at: www.theatlantic.com/politics/archive/2017/10/the-gun-legislation-with-the-best-chance-of-passing-congress/541788/. Accessed May 15, 2018.
18. Weinberger SE, Hoyt DB, Lawrence HC, 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):513-516.
19. Stewart R, Kuhls D, Campbell B, et al. The COT’s consensus-based approach to firearm injury: An introduction. Bull Am Coll Surg. Available at: bulletin.facs.org/2017/10/a-consensus-based-approach-to-firearm-injury. Accessed May 15, 2018.
20. Strong BL, Shipper AG, Downton KD, Lane WG. The effects of health care-based violence intervention programs on injury recidivism and costs: A systematic review. J Trauma Acute Care Surg. 2016;81(5):961-970.
21. Toner K. Surgeon heals patients and their violent ways. CNN. Available at: www.cnn.com/2009/HEALTH/03/25/cnnheroes.carnell.cooper/. Accessed May 15, 2018.
22. National Network of Hospital-based Violence Intervention Programs. Violence intervention program. Available at: http://nnhvip.org/network-membership/violence-intervention-program-baltimore-md/. Accessed May 15, 2018.
23. Cooper C, Eslinger D, Nash D, al-Zawahri J, Stolley P. Repeat victims of violence: Report of a large concurrent case-control study. Arch Surg. 2000;135(7):837-843.
24. Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. J Trauma Inj Infect Crit Care. 2006;61(3):534-537.
25. UCSF San Francisco Wraparound Project. Overview. Available at: https://violenceprevention.surgery.ucsf.edu/services/overview.aspx. Accessed May 15, 2018.
26. Smith R, Evans A, Adams C, Cocanour C, Dicker R. Passing the torch: Evaluating exportability of a violence intervention program. Am J Surg. 2013;206(2):223-228.
27. National Network of Hospital-based Violence Intervention Programs. Welcome. Available at: http://nnhvip.org/. Accessed December 5, 2017.
28. Betz M. Physician counseling on firearm safety. JAMA. 2015;314(5):449-451.
29. Wintemute G, Betz M, Ranney M. Yes, you can: Physicians, patients, and firearms. Ann Intern Med. 2016;165(3):205-213.
30. Beard J, Sims C. Structural causes of urban firearm violence: A trauma surgeon’s view from Philadelphia. JAMA Surg. 2017;152(6):515-516.