8
Firearm Injury Prevention Programs

In this chapter we review the research on the effectiveness of primary, secondary, and tertiary programs for the prevention of firearms injury. Special attention is given to efforts to prevent the use of firearms by youth. The first section summarizes behavioral interventions targeted toward reducing firearms injury. The second part considers what is known about technological interventions aimed at preventing firearms injury. In both cases, the existing research is very limited.

BEHAVIORAL INTERVENTIONS

In this section we review two aspects of behavioral interventions that have been designed to prevent firearms injury: the structure and effectiveness of the program plans in each case and the quality of the associated outcomes research data.

The prevention of firearms violence has been addressed in a number of ways, from legislative reform, to media campaigns, to educational interventions. Educational interventions are typically employed in school settings, with a focus on modifying the attitudes, knowledge, or behavior of individual children. Other educational and media interventions have targeted parents and older youth with messages designed to increase their knowledge of the dangers of firearms as well as methods to ensure safe use and storage. Most of these interventions are developed by well-meaning groups or organizations whose concern for violence—or the potential of violence—among the children leads them to be proactive. However, these programs are rarely based on theoretical models or preliminary effectiveness data.



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Firearms and Violence: A Critical Review 8 Firearm Injury Prevention Programs In this chapter we review the research on the effectiveness of primary, secondary, and tertiary programs for the prevention of firearms injury. Special attention is given to efforts to prevent the use of firearms by youth. The first section summarizes behavioral interventions targeted toward reducing firearms injury. The second part considers what is known about technological interventions aimed at preventing firearms injury. In both cases, the existing research is very limited. BEHAVIORAL INTERVENTIONS In this section we review two aspects of behavioral interventions that have been designed to prevent firearms injury: the structure and effectiveness of the program plans in each case and the quality of the associated outcomes research data. The prevention of firearms violence has been addressed in a number of ways, from legislative reform, to media campaigns, to educational interventions. Educational interventions are typically employed in school settings, with a focus on modifying the attitudes, knowledge, or behavior of individual children. Other educational and media interventions have targeted parents and older youth with messages designed to increase their knowledge of the dangers of firearms as well as methods to ensure safe use and storage. Most of these interventions are developed by well-meaning groups or organizations whose concern for violence—or the potential of violence—among the children leads them to be proactive. However, these programs are rarely based on theoretical models or preliminary effectiveness data.

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Firearms and Violence: A Critical Review The implementation strategies lack structured evaluations and are not commonly informed by an appreciation of the limitations of children’s developmental stages. Table 8-1 is a summary of the targeted populations, program design, and evaluations of 11 selected interventions. This selection has been based on the popularity of the program and whether the program has been peer-evaluated using randomized control groups. Most of these programs are centered on educating children themselves about firearms and violence or through programs involving parents or health care providers. Other comprehensive programs, such as those listed by the Office of Juvenile Justice and Delinquency Prevention (e.g., Boston Strategy to Prevent Youth Violence) were not listed either because they incorporated suppression and TABLE 8-1 Firearms Prevention Programs Program Developer, Sponsor and/or Publisher Type of Program Target Age or Grade Eddie Eagle Gun Safety Program National Rifle Association “Just say no” Pre-K to grade 6 Steps to Prevent Firearm Injury (STOP 2) Brady Center to Prevent Gun Violence Physician-directed parent education Parents

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Firearms and Violence: A Critical Review prevention strategies for many types of violence, or they were designed specifically to deter illegal gun possession and use. Outcome Measures The impact of most of these types of behavioral interventions is measured in terms of changes in knowledge, attitudes, and behavior. Specific outcomes may include knowledge of the danger of guns and attitudes toward firearms and violence. Changes in behavior are detected by proximal and distal outcome measures for the individuals targeted. For example, if the program is designed to educate parents about firearms safety, a proximal behavior goal would be related to how a gun is stored in the home Description of Program Evaluation Motivational program for children in pre-K through grade 1, with easy-to-understand rhymes; activity books for grades 2-6; 7-minute video, reward stickers, parent letter, instructor guides, in-service video. The message: If you see a gun, stop, don’t touch it, leave the area, and tell an adult. Hardy et al. (1996) evaluated a similar program and in posttest found no difference between children’s behavior toward firearms in both treated and control groups. Of three programs evaluated (STAR and STOP, see below), Howard (2001) ranks the Eddie Eagle program the best based on educational material appropriate for developmental level and presentation appearance of printed material. Kit prepares health care providers to talk with patients/clients and their families about the dangers of keeping a gun in the home. The fundamental goal is to assist the health care provider in incorporating gun violence prevention into routine injury prevention counseling. Oatis et al. (1999) demonstrate in a pre- and post-randomized trial that there was not a statistically significant drop in gun ownership or improvement in gun storage after a practice-based intervention aimed to promote these behaviors.

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Firearms and Violence: A Critical Review Program Developer, Sponsor and/or Publisher Type of Program Target Age or Grade Straight Talk About Risks (STAR) Brady Center to Prevent Gun Violence Skills-building Pre-K to grade 12 Safe Alternatives and Violence Education (SAVE) San Jose Police Department (San Jose, CA) Skills-building Juvenile offenders ages 10-18 Options, Choices, and Consequences (Cops and Docs) Roy Farrell, M.D., Washington Physicians for Responsibility Social Shock Grades 7 and 8 In a Flash National Emergency Medicine Association Shock Middle school children (ages 10-14)

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Firearms and Violence: A Critical Review Description of Program Evaluation Straight talk about risks of firearm injury and death. Age-appropriate lessons help children identify trusted adults, deal with peer pressure, and recognize risks related to gun handling. Using a randomized prospective study design with 600 students, the Education Development Center, Inc. (LeBrun et al., 1999) found STAR to be most effective for increasing gun safety knowledge and attitudes for children in grades 3-5 and only moderately effective for older children. Hardy (2002b) in a randomized control study (34 children ages 4 to 7) concludes that STAR-like programs are ineffective in deterring children’s play with guns. One-day, 6-hour violence awareness class for juvenile offenders and their parents. Arredono et al. (1999) demonstrate in pretest and posttest evaluations that recidivism rates declined at 2-year follow-up, but no comparison group was used. Doctor and police officer give a 2-hour presentation of medical, legal, and emotional consequences of gun violence; students are shown photos of gunshot victims whose injuries are the result of gang and domestic violence and suicide attempts. Health Partners Research Foundation (1999) observes that program improves students’ knowledge about guns but does not change attitudes and behaviors. Detailed information about this evaluation is not available. 20-minute video with graphic depiction and as emotional impact of gun violence through interviews with children who have been paralyzed, disfigured, or blinded by gunshot wounds. No evaluation of effectiveness of 2002.

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Firearms and Violence: A Critical Review Program Developer, Sponsor and/or Publisher Type of Program Target Age or Grade Calling the Shots Michael McGonigal, Regions Hospital, St. Paul, Minnesota Shock Juvenile offenders M.D., ages 15-17 The Living Classroom Foundation The Living Foundation, Baltimore, MD, contact: John Dillow, Director of the Maritime Institute Shock Adjudicated middle school Classroom students with drug or gun offenses Teens on Target (TNT) Operated by Youth Alive! Oakland, CA Peer-based education, intervention, and mentoring program Urban youth at risk

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Firearms and Violence: A Critical Review Description of Program Evaluation Hospital-based 4-hour program. While children are being lectured on trauma resuscitation, a gunshot victim (teenage actor) is brought in, and children are asked to help resuscitate, but “patient” dies. Children are then directed to counselors to discuss their emotions and told that the situation was not real but a realistic rendering of what happens in emergency rooms every day Health Partners Research Foundation (1999), in randomized treatment and control groups 2 weeks before and after the program, found that levels of discomfort with aggression increased after program. No changes in behavior around firearms were found in this evaluation. The main purpose of this 9week program is employment training and GED preparation. One section of one day is spent on gun violence prevention; students are shown a video depicting a violent scene of a juvenile shot in a drug dispute. After the video, children share personal experiences and think up behaviors that can prevent violent outcomes. No evaluation of effectiveness as of 2002 Peers meet with youth who have been suspended from school for carrying weapons or engaging in destructive behavior. Peers also visit adolescents recovering from violent injuries who convince them not to retaliate. The National Council on Crime and Delinquency (2001) conducted a randomized prospective study of the program assessing attitudes and behavior toward guns and truancy rates following completion of the program, but results are not yet available.

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Firearms and Violence: A Critical Review Program Developer, Sponsor and/or Publisher Type of Program Age or Target Grade Hands Without Guns Office of Programs, Education Fund to End Handgun Violence, Joshua Horwitz. Based in Washington, DC, but implemented in several U.S. cities Peer-based education and outreach Middle school and high school Justice students Child DevelopmentCommunity Policing (CD-CP) Program A collaborative effort by the New Haven, CT, Department of Police Services and the Child Study Center at the Yale University School of Medicine Interrelated training and consultation focusing on sharing knowledge and developing ongoing collegial relationships between police and mental health workers. Police officers and mental health professions (locked, loaded, etc.), whereas the distal behavior goal might be to reduce the rare acts of gun violence involving children. If the program is designed to educate young children about firearms, then a proximal behavior goal would be avoidance of a nearby gun, and a distal behavior goal would be the reduction of child gun accidents.

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Firearms and Violence: A Critical Review Description of Program Evaluation Public health and education campaign aimed at providing a forum for youth encouraging them to develop their own constructive responses to gun violence. Internal evaluation of the program (1999) reports that pre- and post-campaign surveys with a sample of 400 Washington, DC, students show that kids who could identify the program were less likely to carry guns than those who had never heard of the program. Police supervisors spend 3 full days in training activities to become familiar with developmental concepts, patterns of psychological disturbance, methods of clinical intervention, and settings for treatment. Mental health clinicians spend time with police officers in squad cars, at police stations, and on the street learning directly from officers about their day-to-day activities. No evaluation of effectiveness as of 2002 The outcome data may come from a number of sources—self-report, proxy report (e.g., peers, teachers, parents) and direct observation using school records, and criminal records. Most of the programs described in this chapter assess children’s knowledge or attitudes about firearms, and most used self-report and questionnaires to assess change in knowledge or attitudes.

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Firearms and Violence: A Critical Review A review of the literature reveals only one standardized measure of children’s attitudes toward firearms and violence: the Attitudes Toward Guns and Violence Questionnaire (AGVQ), developed by Shapiro and his colleagues (1997) at the Applewood Centers in Cleveland, Ohio. The AGVQ demonstrates satisfactory internal consistency (Cronbach’s alpha = .94) and concurrent validity, with 23 items relating to violence, guns, or conflict behavior answered on a 3-point Likert-type scale (disagree, not sure, agree). A factor analysis of the AGVQ revealed four factors associated with participants owning or wanting to own a gun: (1) aggressive response to shame: the belief that shame resulting from being insulted can be undone only through aggression; (2) comfort with aggression: general beliefs, values, and feelings about aggression and violence; (3) excitement: feelings of being excited and stimulated by guns; and (4) power/safety: feeling the need to carry a gun to be powerful and safe on the streets. Shapiro and his colleagues (1998), administering the AGVQ to 1,619 children and adolescents, found that the measure was useful for predicting gun ownership. Validity coefficients were lower for girls in elementary school. Measuring behavior in the presence of firearms is more difficult and rarely done as part of the evaluation of firearm violence programs. When behavior is measured, one of two sources of information is typically obtained: Community-wide or school-wide measures of the consequences of gun-carrying or gun violence—for example, school suspensions, mortality and morbidity rates, arrest rates for firearm-related offenses, suicide attempts using firearms. The behaviors that firearm violence programs are typically designed to modify or prevent are often rare events (e.g., accidental firearm deaths), so from a program evaluation point of view it is difficult to assess the effectiveness of a program designed to keep something of low frequency from actually happening. This is because data must be collected from a large number of individuals and often over a long period of time to obtain adequate numbers for analysis. Program participants’ description of their experiences around firearms through focus groups, class discussions, or questionnaires. Younger children may be asked if they have ever seen or touched a gun, and adolescents may be asked if they carry a gun or if they would use a gun in certain situations. While this information may be of interest, self-reports are subject to biases that may lead to underreporting, particularly when children and adolescents are asked about socially sensitive behaviors (Moskowitz, 1989). The most direct outcome measure of behavior is an unobtrusive observation of children and adolescents when they encounter a gun. None of

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Firearms and Violence: A Critical Review the firearms safety programs we discuss has actually utilized this method of evaluation, however, usually because of policy regulations at schools prohibiting even disabled firearms on campus. Nonetheless, direct observation may be the most accurate method of discerning what a child or adolescent would do when confronted with a firearm. Researchers who have directly observed children’s behaviors around firearms following an intervention have found high rates of gun play (see Hardy et al., 1996; Hardy, 2002b). The best evaluation of a firearm violence prevention program should assess its impact on knowledge, attitudes, and behavior from a variety of sources, particularly since these variables are not highly correlated. Inconsistencies between children’s knowledge and behavior following participation in more general violence prevention programs is well documented (Arcus, 1995). Moreover, Wilson-Brewer and colleagues (1991) found in a survey of 51 programs that fewer than half claimed to reduce actual violence levels. Those that did claim to do so had limited empirical data to support their claims. The correlation between children’s knowledge about guns and the likelihood that they will handle a gun is less well studied. However, a recent study by Hardy (2002b) suggests that the two outcomes following a firearm violence prevention program are unrelated. In this study, 70 children ages 4 to 7 were observed in a structured play setting in which they had access to a semiautomatic pistol. Observers coded several behaviors, including gun safety statements (“Don’t touch that!”) and gun touching. Assuming that children who say “Don’t touch that gun!” to another child have some knowledge that guns are dangerous (or for some other reason should not be touched), one might expect that these children would themselves not touch the guns. Nonetheless, 15 of the 24 children who made such comments in the study subsequently touched the gun themselves during the 10-minute interval. Another way Hardy (2002b) assessed the correlation between firearms safety knowledge and behavior was to examine the relationship between a child’s belief that a gun is real and his or her behavior around that gun. Again, however, the evidence suggests no significant relationship. Specifically, the children who correctly identified the real gun as such were no less likely to play with the gun (n = 19) than were children who believed the gun was a toy (n = 16). These findings were later replicated in a study with children ages 9 to 15 (Hardy, 2002a). Study Design Once the appropriate outcome measures are identified and operationally defined, program developers must decide on the design of the evalua-

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Firearms and Violence: A Critical Review tion. Serious evaluations have the goal of excluding alternative explanations for the result; the goal is to ensure that any changes noted in the targeted knowledge, attitudes, and behaviors are due to the program and are not due to extraneous variables and events—environmental changes, developmental changes, practice effects, etc. There are several steps that program developers can take so as to exclude such alternative explanations. First, depending on whether the program is individual-based, school-based or community-based, developers should identify the target population; for example, a school-based prevention program may be developed for grade schools, or a media-based campaign may be developed for rural communities. Next, the evaluation should be based on a sample of individuals, schools, or communities that are representative of the target population; otherwise the obtained results may depend in some unknown way on the sample and may not be generalizable to the population. For example, if the sample includes only grade schools with highly motivated teachers, then the results may not be generalizable to all grade schools. The key point is that the sample should be representative of an identified population; in the above example, the population is more accurately identified as grade schools with highly motivated teachers. A second step that program developers can take to exclude alternative explanations is to assess the targeted knowledge, attitudes, and behaviors in a control or comparison group not exposed to the program. Ideally, the comparison group should differ from the treatment group only in the subsequent exposure to the program. Developers can compare baseline data concerning the knowledge, attitudes, or behaviors targeted for change to check that the groups do not differ in systematic ways prior to the intervention. Of course the comparison group and experimental group may differ in unmeasured ways. The ideal way to exclude alternative explanations, including explanations due to unmeasured differences between groups, is by random assignment of individuals or schools or communities to the experimental and comparison conditions. (See Weisburd and Petrosino, forth-coming; Flay, 2002; and Boruch et al., 2004, for discussions of the advantages of randomization in the field of criminology, for school-based prevention programs, and for place-based trials, respectively.) Randomized trials exclude alternative explanations for the estimated differences between the groups because, on average, randomization produces groups that differ only in terms of the prevention intervention. That is, the randomized trials produce defensible evidence because alternative explanations for outcome are spread evenly across the treatment and comparison groups. Even when we randomize to experimental and comparison conditions, it is useful to collect and compare baseline data concerning the knowledge, attitudes, or

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Firearms and Violence: A Critical Review behavior(s) targeted for change to check that the groups do not, by chance, differ in systematic ways prior to the intervention. Quality of the Research Firearm violence prevention programs are disseminated widely in U.S. public school systems to children ranging in age from 5 to 18. Every day children are taught to say “no” to guns and violence by educators who use a variety of methods to get the message across, from depicting the deadly consequences of firearm violence, to building skills needed to resist peer pressure, to using peer educators to reach students at risk. On the surface, this primary prevention approach to reducing firearm deaths and injuries among children and adolescents appears to be a worthwhile venture. A closer examination of these programs, however, suggests that present educational efforts may not be effective at reducing the risk of firearm morbidity and mortality among children, and in fact may have the opposite effect for some youth. Only a few firearm prevention programs have been evaluated for outcome measures of attitudes and behavior using at least some of the criteria listed above: pretest data and randomized experimental and control groups. One of these is Straight Talk about Risks (STAR), a Brady Center to Prevent Gun Violence program designed to educate children (in pre-K to grade 12) on the risks of handling a firearm. Younger children are taught to identify a trusted adult, obey rules, and solve problems without fighting. Lessons for older children center on understanding emotions that may lead to conflict, identifying mixed messages from the media, dealing with peer pressure, and learning about implications for victims of gun violence. Evaluations of STAR have produced mixed results. In a randomized prospective study design with 600 students, the Education Development Center, Inc. (LeBrun et al., 1999) found STAR to be most useful for increasing gun safety knowledge and attitudes for children in grades 3 to 5 and only moderately helpful for older children. However, in a small randomized control study of 70 preschool children (mean age 4.77 years), Hardy (2002b) concludes that STAR-like programs are ineffective in deterring children’s play with guns. Of the more than 80 other programs described at least briefly in the literature, few have been adequately evaluated as to their effectiveness. Those that have been evaluated provide little empirical evidence that they have a positive impact on children’s knowledge, attitudes, and beliefs. The field of firearm violence prevention is in its infancy and thus can draw lessons from the related fields of injury, violence, and substance abuse prevention. These fields have experienced the same kinds of developmental

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Firearms and Violence: A Critical Review issues. For example, substance abuse scientists recognize that care must be taken in devising preventive interventions. In the early stages of substance abuse prevention, prevention programs sometimes increased knowledge about where to get and how to use drugs and cigarettes (Glasgow et al., 1981; Goodstadt, 1978; Thompson, 1978). Similarly, simplistic efforts to educate children about firearms safety and violence are likely to be ineffective and may be potentially counterproductive. For young children, firearm violence prevention curricula may be insufficient to overcome their natural curiosity about guns, impulsivity, and inability to generate preventive strategies in dangerous situations. For older children, the lessons may be unlikely to alter their perceptions of invulnerability and overcome the influence of peer pressure. Moreover, the lessons may result in increases in the very behaviors they are designed to prevent, by enhancing the allure of guns for young children and by establishing a false norm of gun-carrying for adolescents. In light of the lack of evidence, the committee recommends that existing and future firearm violence prevention programs should be based on general prevention theory and research and incorporate evaluation into implementation design. Theory—that is, education, psychological and sociological theories—can be used to formulate prevention programs. This is widely the case in the field of preventive interventions (see Flay, 2002). Prevention scientists use a sequence of studies to test the utility of the theories for prevention and aid in the further refinement of the prevention program (Flay and Best, 1982). These studies are conducted prior to wide-scale evaluation of the prevention program (Flay, 1986, 2002). Similarly, the ideas and theories underlying firearm violence prevention programs should be tested and refined by a sequence of studies. These studies may include structured laboratory observations—that is, researchers working closely with the schools and community groups can recruit a representative sample of children and adolescents and randomize the children to experimental and comparison conditions, collect pretest and posttest behavior, and structure an experimental setting to elicit the targeted behavior. FIREARMS SAFETY TECHNOLOGY Safety technologies have often been suggested as an alternative means of preventing injury and crime. Locking technology might be used to limit who can use a particular firearm. Protection technology might be used to shield vulnerable persons or reduce the lethality of weaponry. Sensor and tracking technology might be used to detect concealed weapons, provide situational awareness for law enforcement, detect lost or stolen firearms, limit when or where firearms can be discharged, or identify firearms that have been discharged. To varying degrees, these different classes of tech-

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Firearms and Violence: A Critical Review nologies are all being developed or considered by the National Institute of Justice, the Office of Science and Technology, and other public and private organizations.1 The potential of technology can be especially alluring. If widely adopted and effective, safety technologies may alter the rates of gun ownership, discharge, and mortality, as well as, more generally, the markets for weaponry and injury. The actual effects of a particular safety device on violence and injury, however, are difficult to predict. Even if perfectly reliable, technology that serves to reduce injury among some groups may lead to increased deviance or risk among others (Viscusi, 1992; Violence Policy Center, 1998; Leonardatos et al., 2001). Many persuasive arguments have been made about the benefits and costs of different firearms safety technologies. Despite the rhetoric, however, there is almost no research that evaluates the efficacy and cost-effectiveness of different interventions. The numerous arguments on the potential benefits and costs of technology are largely speculative. Locking Technology To illustrate both the complexities of the issue and the lack of evidence, it is useful to consider what is known about locking devices, perhaps the most widely debated, studied, funded, and utilized firearms safety technology. From simple trigger locks and gun safes to more sophisticated personalized and “smart” guns, the promise of this technology is to reduce the unauthorized transfer and use of firearms.2 Unauthorized transfers occur in households, for example, from a parent to a child, in seizures from victims to assailants, in thefts from residences, vehicles, and commercial places, and in illicit transfers on the secondary market. Much of the interest in locking technologies stems from the desire to decrease the number of injuries and fatalities involving children. Children under the age of 18 are not, in general, legally allowed to possess a handgun. Yet each year, hundreds of children are fatally shot or injured in firearms accidents and suicides. Juveniles also use handguns in criminal activities, including the inner-city gang wars associated with the steep rise in the juvenile homicide rate during the late 1980s and the highly publicized 1   See the Office of Science and Technology web page, http://www.ojp.usdoj.gov/nij/sciencetech/welcome.html, for more details. 2   Basic safety technologies have been around and widely used for over a century. Smith and Wesson, for example, manufactured more than 500,000 guns with grip safeties between 1886 and 1940 (Teret and Culross, 2002). Mechanical locks are available commercially at negligible cost. More sophisticated personalized guns, however, are either not yet developed or not widely distributed.

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Firearms and Violence: A Critical Review mass school shootings in which, in many cases, the assailants obtained firearms from their own homes (National Research Council and Institute of Medicine, 2002). While much of the attention and legislation regarding gun locks has focused on reducing juvenile fatalities, these locking technologies may also impact broader classes of unauthorized possession and discharge. The National Institute of Justice has been particularly interested in the potential of these technologies for reducing the handful of fatalities that occur each year when police officers are fatally shot with their own firearm. More generally, certain types of locking systems may decrease injuries that result from firearms seizures, theft, and illegal transfers on the secondary market.3 While the specific numbers are unknown, the majority of criminals do not obtain handguns via licensed dealers, and a large fraction of violent handgun crimes are committed by proscribed users (see Chapter 5; Wright and Rossi, 1986; Pacific Research Institute for Public Policy 1997; Cook and Braga, 2001). Locking technologies may also cause unintended injuries. In particular, locking devices may compromise the ability of authorized users to defend themselves. A lock may fail entirely or may take too much time for the weapon to be of use. In fact, Wirsbinski (2001) and Weiss (1996), in reviewing the engineering design of the different locks for the Sandia National Laboratories, concluded that the existing personalized locking technologies did not meet the reliability standards required for on-duty law enforcement officers.4 The interaction between gun safety technology and the behavior of users may also lessen the effectiveness of locking technologies. At the most basic level, authorized users may not lock their guns and unauthorized users may design ways to disable locks, access unlocked guns, or use different weaponry. Safety technology may also lead to less cautious behavior around firearms: authorized users may be careless in storing weapons, juveniles familiar with locked guns may not be cautious around unlocked guns, and so forth. Finally, these technologies may create new markets for firearms among consumers who otherwise would not be inclined to own a gun. 3   Presumably, for locks to deter illegal transfers in the secondary market, the key must be maintained by a third party—for example, the authorized dealer—rather than the owner of the gun (Cook and Leitzel, 2002). This may be possible with some of the automated biomechanical technologies being developed (e.g., fingerprint technology) but may be more difficult with many of the manual technologies. 4   Wirsbinski (2001) and Weiss (1996), and the New Jersey Institute of Technology (2001) evaluated the reliability of different locking technologies in laboratory settings. A workshop report of the National Academy of Engineering (2003) summarizes some of the key technological and practical barriers to developing personalized handguns.

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Firearms and Violence: A Critical Review To evaluate the effect of locking technologies on injury, a number of researchers have laid out conceptual models linking technology interventions to injury. These models suggest that the efficacy of personalization technology depends on the type and reliability of the technology, the extent to which these technologies are integrated into the stock of firearms, and the behavioral response of consumers and producers of firearms. Different sets of assumptions about the nature of these factors lead to different qualitative conclusions about the efficacy of safety technologies. Assuming they are unreliable, not widely used, or result in unintended behavioral responses, many conclude that locking devices may increase injury (see, for example, Violence Policy Center, 1998; Leonardatos et al., 2001). Others, under different sets of assumptions, conclude that these technologies may decrease crime and injury (see, for example, Cook and Leitzel, 2002; Teret and Culross, 2002). It is not known, however, which assumptions are correct. Thus, without credible empirical evidence, the realized effects of different safety technologies are impossible to assess. In the absence of direct empirical evidence, a number of researchers have appealed to the lessons learned from other product safety innovations and legislation, especially automobile safety technologies. These analogies, however, ultimately do not answer the question at hand—namely, how firearms safety technologies impact injury. While a review of the product safety literature is beyond the scope of this report, it seems clear that (1) the efficacy of product safety innovations varies by product and (2) there are ongoing and controversial debates on the effects of some of the most well-known innovations, including seat belts. In fact, scientists have long warned that safety innovations can lead to offsetting behavioral responses. Auto safety innovations may lead to increased recklessness (Peltzman, 1975); child safety caps may lead to unsafe storage behaviors (Viscusi, 1984); and low-tar cigarettes may lead to increased smoking (Benowitz et al., 1983; Institute of Medicine, 2001). There is hardly consensus on the effects of product safety innovations on injury. Furthermore, in contrast to most other consumer products, firearms safety technology invariably reduces the effectiveness of the weapon. Firearms, after all, are designed to injure. Other safety devices do not generally impair the primary function of the product. Seatbelts, for example, do not reduce the effectiveness of automobiles, and safety caps do not reduce the effectiveness of medication. Child Access Prevention Laws Child access prevention (CAP) laws, sometimes referred to as “safe storage” or “gun owner responsibility” laws, make owners liable if a child uses an unlocked firearm. The first of these of laws was passed in Florida in 1989, and at least 17 other states and several cities have adopted similar

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Firearms and Violence: A Critical Review provisions (Brady Campaign, 2002). State laws differ in what age children are covered, ranging from 12 to 18, in the penalty imposed, from civil to criminal liability, and what it means to safely store a gun. Effectively, however, CAP laws require gun owners with children to lock their firearms. Two papers evaluate the effects of CAP laws on accidents, suicide, and crime. Lott and Whitley (2002), using the same basic data and methods as in the Lott and Mustard (1997) analysis of right-to-carry laws (see Chapter 6), conclude that CAP laws have no discernible effect on juvenile accidents or suicide, but they do result in a substantial increase in violent and property crime. In sharp contrast, Cummings et al. (1997) find that CAP laws reduce accidents and may reduce suicide and homicide among youth as well, although these are imprecisely estimated.5 They conclude that during the five-year period from 1990 to 1994, these statutes prevented approximately 39 deaths of young children, and another 216 children might have lived had these laws been in effect in all states. It is difficult to explain the conflicting estimates. Using state-level injury statistics, both analyses rely on interrupted-time-series designs that assume, after controlling for observed factors, that CAP laws were the only notable change in the environment. The formal models and specifications differ. Cummings et al. (1997) estimates a negative binomial count model with fixed state and time effects but an otherwise parsimonious specification of control variables. Lott and Whitley (2002) use Tobit and log-linear models with fixed state and time effects and a rich specification of 36 control variables to account for variation in demographics (e.g., age, race, income, education) and firearms laws. Lott and Whitley also evaluate different outcomes and assess the sensitivity of their findings more generally. In both studies, it is unreasonable to assume that CAP laws were the only notable event that may have affected firearms related injury and crime. Time-series variation in crime is thought to be a highly complex process that depends on numerous economic, demographic, and social factors. Moreover, CAP laws and other local firearms legislation may be adopted in response to the local variation in the outcomes of interest. For example, a sharp increase in accidental injuries and fatalities spurred a Florida legislature that had previously turned down similar legislation to adopt the CAP law in 1989 (Morgan, 1989). If the 1988-1989 wave of accidental injuries would have naturally regressed back to some steady-state level, any observed correlations between Florida’s CAP law and the injury rate would be spurious. Even if all the other factors that may influence injury or crime are time invariant, the dynamics that connect the law to the outcomes of inter- 5   Webster and Starnes (2000), updating the Cummings et al. (1997) analysis, draw similar conclusions.

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Firearms and Violence: A Critical Review est are likely to be complex. The impact of a CAP law adopted in a particular place and time will almost certainly depend on how the law is enforced and advertised over time, how this affects storage practices over time, and how this in turn affects injury and crime over time. The problems with this research are compounded due to the lack of detailed data on the law, on ownership and storage, and on outcomes. The data do not reveal information on the storage practices of particular households or in the aggregate or how the laws are implemented and enforced. The data do not link ownership to outcomes. Rather, we simply observe aggregate correlations between injury and crime, and CAP law legislation (see the discussion of ecological associations in Chapter 7). It is not known whether the observed associations reflect changes in the behavior of firearms owners, whether changes in accidents are associated with juvenile shooters, or whether changes in victimization are associated with crimes committed in households. A final data related concern is the possibility of changes in reporting behavior. Webster and Starnes (2000) suggest that whether a death is coded as an accident, a suicide, or a homicide is “likely to vary across place and time.” If the coding behaviors change in response to the legislation, for example, if after the law is passed accidental shootings are more likely to be classified as suicides or homicides, then the observed empirical results may be due to coding changes rather than the law. Thus, in the committee’s view, until independent researchers can perform an empirically based assessment of the potential statistical and data related problems, the credibility of the existing research cannot be assessed. Conclusions In general, we find that the scientific bases for understanding the impact of different technologies on the rates of injury is sorely lacking. The existing research outlines a number of interesting hypotheses, but, in the end, the extent to which different technologies affect injury remains unknown. We should note that this conclusion stands in contrast to a recently released report from the Institute of Medicine (2002). In particular, the report, Reducing Suicide: A National Imperative, recommends safety devices as an effective means of reducing injury associated with firearms. While this recommendation may (or may not) be justified for many reasons, we found no credible scientific evidence in the Institute of Medicine’s report or elsewhere that demonstrates whether safety devices can effectively lower injury. Rather, the lack of research on this potentially important intervention is a major shortcoming in the body of knowledge on firearms. Without a much stronger research base, the benefits and harms of technology remain largely unknown.

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Firearms and Violence: A Critical Review Thus, the committee recommends that a sustained body of empirical research be developed to study the effects of different safety technologies on violence and crime. There are many obstacles to answering the key empirical questions, not the least of which is the lack of detailed individual-level data on firearms ownership, the use of safety devices and firearms, and the outcomes of interest that, in the case of accidents, are especially rare. Without better individual-level data, researchers will continue to be forced to rely on aggregated data that are subject to many different interpretations and strong assumptions that are rarely justified. Researchers may exploit the fact that many of these technologies have been used for over a century and, more recently, have been widely disseminated. Well-designed experimental evaluations that subsidize technologies in different locales may be an alternative approach to reveal the demand for these technologies as well as their effects on crime and violence.