Priorities for Research to Reduce the Threat of Firearm-Related Violence

INTRODUCTION

On January 16, 2013, President Barack Obama announced Now Is the Time, a plan to address firearm violence1 in order “to better protect our children and our communities from tragic mass shootings like those in Newtown, Aurora, Oak Creek, and Tucson” (White House, 2013a, p. 2). These multiple-victim homicides, because of their shocking nature, have commanded the attention of the public, the media, and policy officials, even though they are relatively rare and account for a small proportion of all firearm-related injuries and deaths in the United States. Mass shootings are part of a larger, complex firearm violence burden that encompasses nonfatal and unintentional injuries, homicides, suicides, and crimes involving firearms. In the past decade, firearm-related violence has claimed the lives of more than a quarter-million people in the United States.2 By their sheer magnitude, injuries and deaths involving firearms constitute a pressing public health problem.

Firearm-related injuries and deaths have devastating health consequences for individuals, families, and communities. In addition to these individual, familial, and community effects, public mass shootings have huge consequences for the larger society as it attempts to respond to such

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1 For the purposes of this report, the terms “firearm violence,” “gun violence,” and “firearm-related violence” refer to morbidity and mortality associated with the possession and use of firearms. Firearms use a propellant or powder charge to fire a projectile and are distinct from other guns, such as BB, pellet, and other airsoft guns.

2 NCIPC (National Center for Injury Prevention and Control). 2013. WISQARS injury mortality reports: Firearm deaths and rates per 100,000—2000-2010, United States, all races, both sexes, all ages (accessed May 1, 2013).



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Priorities for Research to Reduce the Threat of Firearm-Related Violence INTRODUCTION On January 16, 2013, President Barack Obama announced Now Is the Time, a plan to address firearm violence1 in order “to better protect our children and our communities from tragic mass shootings like those in Newtown, Aurora, Oak Creek, and Tucson” (White House, 2013a, p. 2). These multiple-victim homicides, because of their shocking nature, have commanded the attention of the public, the media, and policy offi- cials, even though they are relatively rare and account for a small propor- tion of all firearm-related injuries and deaths in the United States. Mass shootings are part of a larger, complex firearm violence burden that en- compasses nonfatal and unintentional injuries, homicides, suicides, and crimes involving firearms. In the past decade, firearm-related violence has claimed the lives of more than a quarter-million people in the United States.2 By their sheer magnitude, injuries and deaths involving firearms constitute a pressing public health problem. Firearm-related injuries and deaths have devastating health conse- quences for individuals, families, and communities. In addition to these individual, familial, and community effects, public mass shootings have huge consequences for the larger society as it attempts to respond to such 1 For the purposes of this report, the terms “firearm violence,” “gun violence,” and “firearm-related violence” refer to morbidity and mortality associated with the possession and use of firearms. Firearms use a propellant or powder charge to fire a projectile and are distinct from other guns, such as BB, pellet, and other airsoft guns. 2 NCIPC (National Center for Injury Prevention and Control). 2013. WISQARS injury mortality reports: Firearm deaths and rates per 100,000—2000-2010, United States, all races, both sexes, all ages (accessed May 1, 2013). 11

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12 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE tragedies. All these events occur in the context of a civil society that has millions of guns lawfully owned by citizens who use them for protection, hunting, sport, or work. There are also an unknown number of guns in the hands of criminals and others who are prohibited by law from pos- sessing them. To help minimize future firearm-related deaths, President Obama is- sued 23 executive orders directing federal agencies to improve knowledge of the causes of firearm violence, the interventions that pre- vent firearm violence, and strategies to minimize the public health bur- den of firearm violence (White House, 2013b). One of these executive orders, Action #14, noted that “in addition to being a law enforcement challenge, gun violence is also a serious public health issue that affects thousands of individuals, families, and communities across the Nation” (White House, 2013b). This order directed the Centers for Disease Con- trol and Prevention (CDC), along with other relevant federal agencies, to immediately begin identifying the most pressing research problems in firearm-related violence with the greatest potential for broad public health impact. Based on this directive, the CDC and the CDC Founda- tion3 requested that the Institute of Medicine (IOM), in collaboration with the National Research Council (NRC), identify questions that would define a public health research agenda for firearm violence prevention and intervention. Broadly, the committee was charged with identifying the most critical research questions in the following areas:  The characteristics of firearm violence  Risk and protective factors  Interventions and strategies  Gun safety technology  The influence of video games and other media The evidence generated by implementing a public health research agenda can enable the development of sound policies that support both the rights and the responsibilities central to gun ownership in the United States. In the absence of this research, policy makers will be left to de- bate controversial policies without scientifically sound evidence about their potential effects. 3 The CDC Foundation’s support originated from The Annie E. Casey Foundation, The California Endowment, The California Wellness Foundation, The Joyce Foundation, Kaiser Permanente, the Robert Wood Johnson Foundation, and one anonymous donor.

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 13 Scope of the Public Health Problem Injuries and Fatalities Unintentional injury is the leading cause of death in Americans aged 1 to 44 (NCHS, 2012). Firearm-related injury, in particular, is a serious threat to the health of the nation, with direct costs to the victims of vio- lence as well as societal costs to families, friends, and communities. In 2010, there were twice as many nonfatal firearm-related injuries (73,505) as deaths.4,5 Between the years 2000 and 2010, firearm-related suicides signifi- cantly outnumbered homicides for all age groups, annually accounting for 61 percent of the more than 335,600 people who died from firearm- related violence in the United States.6,7 The number of public mass shootings of the type that occurred at Sandy Hook Elementary School accounted for a very small fraction of all firearm-related deaths. Specifi- cally, since 1983 there have been 78 events in which 4 or more individu- als were killed by a single perpetrator in 1 day in the United States, resulting in 547 victims and 476 injured persons (Bjelopera et al., 2013). Although overall crime rates have declined in the past decade and violent crimes, including homicides specifically, have declined in the past 5 years (FBI, 2011a), crime-related deaths involving firearms re- main a serious threat. According to the Federal Bureau of Investigation’s (FBI’s) Uniform Crime Reporting Program, 68,720 people were mur- dered in firearm-related violence between 2007 and 2011. During that same time frame, firearms accounted for more than twice as many mur- ders as all other weapons combined (FBI, 2011b). More than two-thirds of victims murdered by a spouse or ex-spouse died as a result of a gun- shot wound (Cooper and Smith, 2011). More than 600,000 victims of 4 NCIPC. 2013. WISQARS nonfatal injury reports: Overall firearm gunshot nonfatal in- juries and rates per 100,000—2010, United States, all races, both sexes, all ages (ac- cessed May 1, 2013). 5 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot nonfatal injuries and rates per 100,000—2010, United States, all races, both sexes, all ages (ac- cessed May 1, 2013). 6 NCIPC. 2013. WISQARS injury mortality reports: Suicide firearm deaths and rates per 100,000—2000-2010, United States, all races, both sexes, all ages (accessed May 1, 2013). 7 NCIPC. 2013. WISQARS injury mortality reports: Firearm deaths and rates per 100,000—2000-2010, United States, all races, both sexes, all ages (accessed May 1, 2013).

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14 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE robbery and other crimes reported that they faced an assailant armed with a gun (Truman and Rand, 2010). Demographic Characteristics of Victims in the United States There are major disparities among subpopulations of people in the United States in terms of mortality rates from firearm violence. The pat- terns for homicide and suicide are vastly different depending on econom- ic conditions and geography, with homicides occurring more frequently among youth in high-poverty urban environments and suicides occurring more frequently among middle-aged males in rural areas. Inclusive of homicide, suicide, and unintentional death, African American males have the highest overall rate of firearm-related mortality: 32 per 100,000,8 twice that of white, non-Hispanic males (at 16.6 per 100,000),9 and three times that of Hispanic and American Indian males (at 10.410 and 11.811 per 100,000, respectively). The rate of mortality by firearm for Asian/Pacific Islander males is 4.2 per 100,000.12 The rates of mortality for females are much lower, ranging from a low of 0.6 per 100,000 for Asian/Pacific Islander females13 to 3.3 per 100,000 for African American and 3.0 for white, non-Hispanic females.14 As will be discussed in further 8 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, black, males, all ages (accessed May 15, 2013). 9 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, white, non-Hispanic, males, all ages (accessed May 15, 2013). 10 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, Hispanic, males, all ages (accessed April 30, 2013). 11 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, American Indian/Alaskan Native, males, all ages (accessed May 15, 2013). 12 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, Asian/Pacific Islander, males, all ages (accessed April 30, 2013). 13 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, Asian/Pacific Islander, females, all ages (accessed April 30, 2013). 14 NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal inju- ries and rates per 100,000—2010, United States, black, females, all ages (accessed April 30, 2013); NCIPC. 2013. WISQARS injury mortality reports: Overall firearm gunshot fatal injuries and rates per 100,000—2010, United States, white, non-Hispanic, females, all ages (accessed May 15, 2013).

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 15 detail later in the report, the reasons for these differences may include a variety of factors such as socioeconomic status, urban/rural factors, and crime and policing in neighborhoods. Individual factors that may influ- ence these differences include age; substance use; engagement or associ- ation with risky, delinquent, violent, or unlawful behaviors; propensity for suicide; and whether the perpetrator of a homicide is a family mem- ber, acquaintance, or stranger. Many of these factors are confounding, and careful analysis is required to understand the independent and inter- active effects, supporting the need for rigorous research. Availability of Firearms Guns are widely used for recreation, self-protection, and work in the United States. However, it is difficult to determine the exact number and distribution of guns currently in homes and communities due to lack of data. Between 1986 and 2010, the domestic production of firearms in- creased by 79 percent, firearm exports increased by 11 percent, and fire- arm imports increased by 305 percent (ATF, 2012). A December 2012 poll found that 43 percent of those surveyed reported having a gun in the home (Gallup, 2013). Defensive Use of Guns Defensive use of guns by crime victims is a common occurrence, although the exact number remains disputed (Cook and Ludwig, 1996; Kleck, 2001a). Almost all national survey estimates indicate that defen- sive gun uses by victims are at least as common as offensive uses by criminals, with estimates of annual uses ranging from about 500,000 to more than 3 million (Kleck, 2001a), in the context of about 300,000 vio- lent crimes involving firearms in 2008 (BJS, 2010). On the other hand, some scholars point to a radically lower estimate of only 108,000 annual defensive uses based on the National Crime Victimization Survey (Cook et al., 1997). The variation in these numbers remains a controversy in the field. The estimate of 3 million defensive uses per year is based on an extrapolation from a small number of responses taken from more than 19 national surveys. The former estimate of 108,000 is difficult to interpret because respondents were not asked specifically about defensive gun use. A different issue is whether defensive uses of guns, however numer- ous or rare they may be, are effective in preventing injury to the gun- wielding crime victim. Studies that directly assessed the effect of actual

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16 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE defensive uses of guns (i.e., incidents in which a gun was “used” by the crime victim in the sense of attacking or threatening an offender) have found consistently lower injury rates among gun-using crime victims compared with victims who used other self-protective strategies (Kleck, 1988; Kleck and DeLone, 1993; Southwick, 2000; Tark and Kleck, 2004). Effectiveness of defensive tactics, however, is likely to vary across types of victims, types of offenders, and circumstances of the crime, so further research is needed both to explore these contingencies and to confirm or discount earlier findings. Even when defensive use of guns is effective in averting death or in- jury for the gun user in cases of crime, it is still possible that keeping a gun in the home or carrying a gun in public—concealed or open carry— may have a different net effect on the rate of injury. For example, if gun ownership raises the risk of suicide, homicide, or the use of weapons by those who invade the homes of gun owners, this could cancel or out- weigh the beneficial effects of defensive gun use (Kellermann et al., 1992, 1993, 1995). Although some early studies were published that re- late to this issue, they were not conclusive, and this is a sufficiently im- portant question that it merits additional, careful exploration. Firearm-Related Violence as a Public Health Issue The public health field focuses on problems that are associated with significant levels of morbidity and mortality. The complexity and fre- quency of firearm-related violence combined with its impact on the health and safety of the nation’s residents make it a topic of considerable public health importance and suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries. Violence, including firearm-related violence, has been shown to be contagious. Recognizing this, the academic community has suggested that research examine violence much like is done for conta- gious diseases (IOM, 2013). In the past, responses to firearm violence typically have been based in the criminal justice system, which is crucial to public safety, but a more comprehensive and multidisciplinary approach is necessary to re- duce the burden of firearm-related violence on individuals, families, communities, and general society (Kellermann et al., 1991). Public health approaches focus efforts on the prevention of violence by charac- terizing the scope or magnitude of the problem, evaluating potential risk

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 17 and protective factors associated with specific outcomes, and developing and evaluating interventions to affect these risk factors (Satcher, 1995). Topics previously viewed as purely criminal in nature, such as firearm-related violence, require a multidisciplinary approach (Kellermann et al., 1991) because, frequently, health and crime share the same risk and protective factors, or complex determinants (Akers and Lanier, 2009; Akers et al., 2013). Public health and behavioral and social science (to include criminology) are two compatible disciplines that together can aid understanding and address broad challenges to health and safety, as both disciplines benefit from scientific methods and from each other’s per- spectives. A recent example of this synergism is reflected in a bulletin by the Department of Justice devoted to the application of public health principles to violent crime (Markovic, 2012). Developing an integrated and collaborative public health and crimi- nal justice injury prevention paradigm will improve interventions to re- duce harms associated with firearm-related violence. This approach was suggested in the 1985 Surgeon General’s Workshop on Violence and Public Health (HHS and DOJ, 1996) and in a 1985 NRC and IOM report Injury in America: A Continuing Public Health Problem. This recom- mended strategy has been reaffirmed and reinforced over the years, in- cluding in a 1999 IOM report Reducing the Burden of Injury: Advancing Prevention and Treatment, which argued that “the injury field has much to contribute to scientific understanding of firearm injuries and to the prevention of violence, complementing the contributions made by crimi- nal justice, mental health, and other approaches” (p. ix). Applying Public Health Strategies to Reducing Firearm Violence A public health approach involves three elements: (1) a focus on prevention, (2) a focus on scientific methodology to identify risk and patterns, and (3) multidisciplinary collaboration to address the issue (IOM, 2008). The ecological framework, a tool used in both criminology and public health, may further guide the analysis of potential interven- tions to achieve the necessary scale to prevent or reduce firearm vio- lence. The sheer number of firearm-related injuries and fatalities, coupled with the broad range of settings and circumstances under which firearm violence can occur, requires a multidimensional approach based on the interrelation among individual characteristics, family history and

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18 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE dynamics, community context and gun availability, and national or inter- national influences. This multidimensional approach is necessary in or- der to direct an intervention at the level of influence necessary to bring about the desired change. Assessing and ultimately implementing public health strategies to deal with societal problems requires a comprehensive research agenda with contributions from the many scientific disciplines relevant to under- standing the complex etiology and prevention of firearm violence (Hemenway and Miller, 2013). For example, public health outcomes re- search may include an investigation of product safety options combined with strategies to change the “prevalence, social norms, and cultures of harmful behaviors” (Mozaffarian et al., 2013, p. 551; see also Hemenway, 2001; Mozaffarian et al., 2012). Beginning in the late 1960s, a comprehensive approach was adopted based largely on the work of William Haddon, who developed a model for the systematic exploration of causation and countermeasures based on the epidemiological triangle of host, agent, and environment in the pre-event, event, and post-event phases (Haddon, 1967, 1968, 1980). Such strategies are designed to interrupt the connection among three es- sential elements: (1) the “agent” (the source of injury [weapon or perpe- trator]), (2) the “host” (the injured person), and (3) the “environment” (the conditions under which the injury occurred). This public health ap- proach has produced successes in reduction of tobacco use, unintentional poisoning, and motor vehicle fatalities. These successes suggest the fol- lowing strategies for reducing firearm-related injuries:  Individual- and family-level interventions focused on the victim (host) pre-event: o Routine primary care counseling o Education o Family risk factors  Individual-, family-, or community-level interventions focused on the perpetrator or gun (agent) pre- or post-event: o Recognition of at-risk behaviors o Early detection of risk factors o Safety standards o Active protection (requires an overt action by the user) o Passive protection (requires no action by the user)  Community- and society-level interventions focused on the envi- ronment pre- or post-event:

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 19 o Hotlines o Licensing o Public education and media campaigns o Economic development (to decrease concentrated disadvantage) o Physical environment (e.g., converting vacant lots to green spaces) Motor vehicle–related injury reduction provides a useful analogy for using a public health approach to a problem that also has criminal justice considerations. For example, in both motor vehicle and gun use, there is a need to balance health and safety with the practical reality of a poten- tially dangerous tool that is embedded in U.S. society. Efforts to reduce motor vehicle–related injuries were limited initially to improving driver skills (licensing in the 1930s) and evolved to include safety technology (collapsible steering columns, shatter-resistant glass, and seat belts in the 1950s and 1960s). This approach resulted in a multi- faceted effort based on  thorough data analysis and surveillance systems—tracking trends and patterns in injuries and identifying research questions;  performance standards—setting safety standards for vehicles;  research in behavioral human factors and engineering—examining the host, agent, and environment (injury mechanisms, crashwor- thiness, vehicle safety countermeasures, road characteristics);  state and local programs addressing equipment and human fac- tors such as fatigue and alcohol; and  public education and law enforcement programs. A similar multifaceted program, through the development of a public health research agenda, is needed to ultimately reduce the burden of gun violence. Study Goals, Methods, and Organization of the Report Study Process and Methods The committee was charged with articulating the topics that should make up a public health firearm violence research agenda (see Box 1). The charge to the committee included conducting an expert assessment

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20 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE of critical research questions, developing guidance, and recommending priorities for the CDC within a 3-month time frame. To meet this obliga- tion the committee held a single 4-day meeting on April 22-25, 2013. The meeting included a public workshop and closed sessions of the committee for deliberations and report drafting (see Appendix B for the open agenda). The workshop was organized in order to hear from a range of authorities in the area of firearm violence research; policy makers and advocates with long-standing interest in gun policy; and researchers with expertise in injury prevention, media influences, and firearms technolo- gy, as well as to seek general public comment about the development of a public health research agenda to reduce firearm-related violence. In addition, the committee performed a literature review on the specific research areas to be addressed. The committee also considered the data and research methodology challenges in the area of firearm-related violence. The committee identified potential research topics by conduct- ing a survey of previous relevant research, considering input received during the workshop, and using its expert judgment. The committee was not asked to consider funding for the research agenda, and in addition to the CDC, it is likely that other agencies and private foundations will also implement the research agenda. Consequently, the committee identified a full range of high-priority topics that could be explored with significant progress made in 3-5 years. Research on these topics will improve cur- rent knowledge of the causes of firearm violence, the interventions that prevent firearm violence, and strategies to minimize the public health burden of firearm violence. To allow the research community flexibility in designing the research protocols, the report does not specify the meth- odologies that should be used to address the research topics. However, the committee does provide examples of specific questions that could be explored under each research topic.

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 21 BOX 1 Statement of Task An ad hoc committee will be appointed to develop for the Centers for Dis- ease Control and Prevention a proposed public health research agenda to improve knowledge of the causes of gun violence, the interventions that pre- vent gun violence, and strategies to minimize the public health burden of gun violence. Consideration of optimal methodological approaches to address gaps in knowledge is also important. The proposed agenda should identify the most critical research questions that can be answered in the short term (particularly within a 3-year time frame). In the view of the committee, the answers to the questions should be those with the potential for the greatest public health impact and shed light on the characteristics of gun violence and the potential to prevent gun vio- lence. As general guidance on the extent of the envisioned research pro- gram, the proposed agenda should be one that could be completed in 3-5 years:  Characteristics of gun violence: Identify research questions necessary to improve understanding of the characteristics of both fatal and non- fatal gun violence.  Interventions and strategies: Identify research questions that are nec- essary to improve understanding of the effectiveness of interventions and strategies to prevent or reduce gun-related injuries. These may include, but should not be limited to, research questions related to the impact of public education campaigns, youth access to and use of guns, safe storage practices, access to guns, and improved personal protection.  Technology: Identify research questions related to the impact of po- tential technologies that may reduce gun-related violence, including how guns and ammunition can be designed and engineered to im- prove safety and prevent misuse.  Video games and other media: Identify questions that improve the un- derstanding and impact of violence in video games, the media, and social media on real-life violence.  Risk and protective factors: Identify research questions that will as- sess potential risk and protective factors and other critical issues, such as the socioeconomic and socio-cultural environment. With respect to the scope of the recommended research agenda, the ar- eas of public health surveillance and behavioral/mental health should not be a focus of the committee’s work. Additionally, questions related to clinical practice and treatment should not be a focus. The committee will produce a brief consensus report that may include a summary of the most significant research gaps, a consolidation of committee findings, and the identification of proposed research questions to inform the public health approach to pre- venting gun violence.

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58 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE Location Although still a theory and not currently awareness under development, with a tracking device embedded in the firearm, GPS (global positioning system) technology could al- low guns to know their own location and the location of other guns within a certain range. This has the potential, for example, to reduce unintentional injuries for hunters or intentional injuries of police officers by armed assailants. Target Still a theory and not currently under devel- recognition opment, target-sensing technology could prevent a gun from being fired if a child is within the target field. SOURCES: Chen and Recce, 2007; NAE, 2005; Newcombe, 2013; Valenta et al., 2013; Weiss, 1996. Current and Ongoing Research Like past technologies that reduce injury, the development of “smart” or user-authorized guns has progressed and likely will have an impact on firearm violence. The research to date illustrates three com- mon conclusions: 1. It is unlikely that one technology will address all circumstances and requirements. 2. Connecting particular technologies with specific scenarios is critical. 3. Technologies will always vary in simplicity, cost, effectiveness, and reliability. The current state of smart-gun technology appears to be reaching a level of maturity at which private-industry adoption is important and necessary to move the technology to broader use. For example, a smart gun developed in Germany has been approved for importation to the United States (Bulwa, 2013; Teret, 2013). The committee did not deter- mine the exact status of smart-gun technology, but instead focused on the potential public health benefits of such technological developments. A determination of the state of the technology is part of President Obama’s 2013 executive orders to reduce firearm violence; a directive under Ac-

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 59 tion #2 directs the attorney general to “issue a report on the availability and most effective use of new gun safety technologies and challenge the private sector to develop innovative technologies” (White House, 2013a, p. 10). In addition to user-authorization technologies, there are active measures (requiring an overt action by the consumer, such as gun locks, gun safeties, and trigger locks) that responsible gun owners can use to reduce unauthorized access to firearms and help reduce firearm-related deaths (Grossman et al., 2005). Other technologies, such as less-than- lethal weaponry, video surveillance, micro-stamping of ammunition, and gunshot recognition systems using acoustics triangulation, were not con- sidered by this committee. However, technologies that can reduce fire- arm violence are critically important to complement behavioral and population-level interventions. Research Questions Outstanding research questions include an examination of the most effective application of gun safety technology, the potential for general acceptance and usage of the safety features, and different policy ap- proaches to implementation. In order to address the gaps in knowledge related to public health, the committee has identified three priority areas for research: 1. the effect of specific gun safety technologies on firearm-related injuries and deaths; 2. past consumer adoption lessons to address the challenge of con- sumer acceptance of gun safety features; and 3. the experiences of various states and countries with gun safety technology to identify effective methods for introducing and dis- seminating gun safety technologies. The Effect of Specific Technological Approaches to Reducing Firearm- Related Injuries and Deaths Injury prevention science has compared the strengths and limitations of various active strategies to control injuries and has found that passive strategies have a greater effect than attempts to change individual behav- ior (Teret and Culross, 2002). Therefore, passive strategies, such as per-

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60 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE sonalized guns, show promise in reducing firearm violence and may have benefits across multiple public health contexts. In addition, passive strat- egies may also reduce the incidence of stolen guns and the resulting crimes (NAE, 2003). More data are needed to examine the potential im- pact of personalized guns in several areas of public health interest. Identify the effects of different technological approaches to re- duce firearm-related injury and death. Examples of topics that could be examined:  What is the projected impact of passive technologies on reduc- tion of firearm violence, and which of the technologies will have the greatest impact on one or more of the types of harm from firearm violence (i.e., homicide, suicide, unintentional injury)? o Are there feasible mechanisms to child-proof, and what is the projected impact of these technologies?  How would potential technologies impact professional sectors (e.g., police and private security) in performing their duties effectively?  How compliant would firearm owners be with safety technolo- gies, or would owners disable technologies to assure their ability to use the firearms in an emergency? Past Consumer Acceptance Experiences to Inform the Development and Dissemination of Gun Safety Technology Previous successful injury prevention strategies have been informed by examining consumer acceptance challenges (Braitman et al., 2010). The integration of passive safety systems in cars, such as airbags, re- quired many years of technology development as well as many years of public discussions before airbags became fully integrated and accepted in the United States. Improved understanding of how product safety measures are accepted and used at the population level is critical to ultimately achieving a reduction of preventable deaths and injuries related to fire- arms through gun safety technologies.

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 61 Examine past consumer experiences with accepting safety tech- nologies to inform the development and uptake of new gun safety technologies. Examples of topics that could be examined:  Are there lessons from the adoption of other public health inter- ventions involving passive technology improvements that could facilitate the acceptance and dissemination of passive gun safety technologies? Would consumer engagement accelerate acceptance and dissemination of gun safety technologies?  What were the key factors that led to eventual population-level acceptance of various public safety technologies? Were these factors different for passive versus active technology changes? Were these factors different when active and passive technolo- gies were combined?  In previous product safety efforts, how long did it take for the safety feature to become reliable and how did that time frame impact consumer acceptance? Would this experience of timing and acceptance impact projections of gun safety technology im- plementation?  To what extent did additional costs associated with safety fea- tures influence consumer acceptance and adoption? State and International Experiences with Gun Safety and Technology Another challenge is the implementation of new technologies through various policy mechanisms. There is a range of approaches be- ing adopted by U.S. states and other countries, from mandating that all firearms sold include passive safety features immediately upon availabil- ity to requiring that all transfers of firearms include provision of a lock- ing mechanism. Dissemination and adoption levels across states and countries for active strategies, such as gun locks and safeties, as well as for passive strategies, such as personalized guns, are largely unknown. Comparative analyses of state and international policy approaches to im- plementing active and passive gun safety strategies will improve the un- derstanding of the impact of these interventions and help determine the resulting effect on rates of firearm-related injuries and deaths.

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62 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE Explore individual state and international policy approaches to gun safety technology for applicability to the United States as a whole. Examples of topics that could be examined:  What can be learned from various state or international policy approaches to implementing passive and active gun technology changes, and what has been the impact of these changes on fire- arm violence? o What can be learned about the effects of these changes on the types of firearm-related injuries and deaths? o What was the impact of these approaches on consumer adop- tion and acceptance?  What have been the adoption rates and effectiveness of active protection technologies among law enforcement users? However, cross-national comparisons, as suggested here, are suscep- tible to large ecological biases and unmeasured confounding biases, and therefore conclusions from these studies may not apply to individuals. VIDEO GAMES AND OTHER MEDIA Although research on the effects of media violence on real-life violence has been carried out for more than 50 years (Cook et al., 1983; Eron and Huesmann, 1980; Eron et al., 1972; Huesmann, 1986; Huesmann and Miller, 1994; Huesmann et al., 2003; McIntyre et al., 1972; Milavsky et al., 1982; Robinson and Bachman, 1972; Rubenstein, 1983; Surgeon General’s Scientific Advisory Committee on Television and Social Behavior, 1972), little of this research has focused on real-life firearm violence in particular (Boxer et al., 2009; Huesmann et al., 2003; Ybarra et al., 2008). As a result, a direct relationship between media violence and real-life firearm violence has not been established. Although the bulk of past media violence research has focused on violence portrayed in television and film, more recent research has expanded to include music, video games, social media, and the Internet. Interest in media effects is fueled by the fact that youth spend an increasing amount of time engag- ing with media. The most recent estimates indicate that 8- to 18-year- olds in the United States spend an average of 7.5 hours per day using

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 63 entertainment media, including television, movies, music, cell phones, video games, and the Internet (Kaiser Family Foundation, 2010). Media content is also a concern: more than 800 violent acts are shown on televi- sion each hour in the United States; about 15 percent of music videos portray interpersonal violence (Beresin, 2010); and two-thirds of the 97 percent of children who play video games play games that may include violence (Lenhart et al., 2008). However, data on the prevalence of fire- arm violence in the media are absent. The following section reviews po- tential associations of exposure to media violence and violent acts, but is not specific to firearm violence. Overview of Past and Ongoing Research on Media Violence and Violent Acts Short-Term Experimental Studies on Exposure to Media Violence The vast majority of research on the effects of media violence is based on short-term laboratory or field experiments. These studies exam- ine short-term effects of media exposure on physical and verbal aggres- sive behavior, thoughts, and emotions; hostility; fearful behaviors; physiological arousal (e.g., changes in heart rate); the tendency to mimic behavior; and changes in helpful behaviors, empathy, and pro-social be- haviors in both males and females (Anderson, 2004; Anderson and Bushman, 2001; Anderson and Dill, 2000; Anderson et al., 2003, 2010; Bartholow et al., 2005; Browne and Hamilton-Giachritsis, 2005; Bushman and Huesmann, 2006; Fuld et al., 2009). Fewer studies examine the link between short-term exposure to media violence and violent behaviors such as arguing, fighting, aggravated or sexual assault, shooting, stab- bing, and robbery (Gentile et al., 2004; Ybarra et al., 2008). These short-term experimental studies consistently document significant effects of experimentally manipulated media exposure on a wide range of short-term outcomes. Results are broadly similar in studies of television and film violence (Bandura et al., 1963; Bushman and Huesmann, 2001; Huesmann et al., 2000; Paik and Comstock, 1994; Wood et al., 1991) and violent video games (Anderson, 2004; Anderson and Bushman, 2001; Anderson and Dill, 2000; Bartholow et al., 2005; Gentile et al., 2004). However, effects vary as a complex function of interactions among media content, viewer characteristics, and social contexts (Anderson et al., 2003) and are open to a number of interpretations other than those

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64 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE favored by the majority of researchers in the area, such as the suggestion that portrayals of competitiveness, rather than violence, account for these negative effects of media exposure (Adachi and Willoughby, 2011a,b; Przybylski et al., 2010). Copycat Behaviors as a Result of Media Violence Some research suggests that media violence may be imitated or cop- ied in real life, especially in cases of suicide (which may or may not in- volve a gun) (Bollen and Phillips, 1982; Chen et al., 2012; Gould et al., 2003; Phillips, 1982; Pirkis et al., 2006; Stack, 2003, 2005; Tousignant et al., 2005). Research has shown an increase in suicide attempts after the publicized suicide of a political or entertainment celebrity (Chen et al., 2012; Stack, 2003, 2005; Tousignant et al., 2005), as well as publicity surrounding mass suicides or murder-suicides (Pirkis et al., 2006). A dose–response relationship has also been documented between the inten- sity of media exposure and the number of subsequent presumably copy- cat suicides (Etzersdorfer et al., 2001). Evidence has also been found for consistencies between the methods of suicide detailed in media stories and presumably imitative suicides that occur in the wake of media stories (Etzersdorfer et al., 2001; Tousignant et al., 2005), adding to the plausi- bility of the interpretation that these events are copied. Research has also shown that the strength of effects on presumably imitative suicides varies by type of media, with television publicity sometimes seeming to result in more suicide imitators (Pirkis et al., 2006) and sometimes fewer (Stack, 2003, 2005) than if the suicide was publicized in newspapers. Although there is not much research in this area, the existing re- search on broad patterns of presumably copycat acts is sufficiently strong to suggest that it might be useful to carry out more in-depth studies, such as retrospective case-control psychological autopsy studies, in an effort to learn more about the characteristics of people who are susceptible to such media effects and determine if there are any modifiable risk factors that could provide insights on effective preventive interventions. Such in- depth studies might also produce insights that could advise media pur- veyors about changes in frequency or type of violent content to help re- duce copycat effects or encourage help-seeking behaviors (Pirkis et al., 2006; Stack, 2003). In addition to concerns about direct imitations of media violence, there are other possible adverse effects of media stories such as evening news reports about violent incidents in the community and ongoing sen-

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 65 sationalized stories about high-profile murders and mass shootings (i.e., the “mean world syndrome” [Gerbner et al., 1980, 1986]). Some evi- dence exists that these types of news stories are associated with unrealis- tic perceptions of low community safety (Chiricos et al., 2000; Ditton et al., 2004; O’Keefe, 1984) as well as, in some cases, secondhand trauma- related fear, depression, feelings of vulnerability, and PTSD (Ahern et al., 2002; Bernstein et al., 2007; Comer et al., 2008; Fremont et al., 2005; Otto et al., 2007; Saylor et al., 2003). The extent to which high exposure to such stories leads to changes in proneness to violence for the exposed individuals, though, has not been the subject of systematic research. Longer-Term Longitudinal Studies in Youth on Exposure to Media Violence A number of longitudinal studies document long-term associations between violent media exposure in childhood and the later occurrence of real-life aggression or violence (Anderson et al., 2010; Boxer et al., 2009; Browne and Hamilton-Giachritsis, 2005; Eron and Huesmann, 1980; Eron et al., 1972; Huesmann, 1996; 2007; Huesmann and Taylor, 2006; Huesmann et al., 1984; Krahé and Möller, 2010; Savage, 2004; Savage and Yancey, 2008; Slater et al., 2003). Some studies have shown that children who favor violent television, movies, or video games or who are heavily exposed to these types of media have elevated rates of later aggression and violence, such as bullying, physical fights, spousal abuse, responding to insults with violence, committing and being con- victed of crimes, violent delinquency, and committing moving traffic violations (Anderson et al., 2008; Hopf et al., 2008; Huesmann et al., 2003; Olson et al., 2009). However, the fact that these studies are nonexperimental introduces uncertainties in interpreting the associations they document because of the possibility that unmeasured common caus- es could account for the associations. Advocates of a causal interpreta- tion of these associations have argued that a causal link is indirectly supported by evidence of dose–response relationships between the mag- nitude of exposure and subsequent violence (Anderson and Dill, 2000; Anderson et al., 2008; Huesmann et al., 2003) and by the fact that asso- ciations persist after introducing statistical controls for plausible con- founders (Anderson et al., 2008, 2010; Huesmann et al., 2003; Olson et al., 2009). However, the adequacy of these controls has been disputed by critics (Ferguson, 2011; Ferguson et al., 2008, 2012; Savage, 2004).

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66 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE Causal interpretations of long-term associations between habitual exposure to media violence and later real-life violence are based on the observational learning process (Carroll and Bandura, 1987) that media violence leads to children learning long-term “aggressive scripts, inter- pretational schemas, and aggression-supporting beliefs about social be- havior” (Anderson et al., 2003, p. 8) that result in more aggressive personalities (Anderson and Bushman, 2001; Bushman and Huesmann, 2006). Children observe others behaving violently, encode scripts for behaving violently themselves, and encode beliefs that violence is nor- mal, increasing the risk that they will act aggressively or violently. Some studies suggest that repeated exposure to media violence may result in desensitization or a decrease in negative emotional response to violence (Anderson et al., 2003, 2010; Bartholow et al., 2005, 2006; Carnagey and Anderson, 2004; Carnagey et al., 2007; Fuld et al., 2009; Funk et al., 2004; Krahé et al., 2011), thereby reducing psychological barriers to committing violent acts. These theories are in line with some naturalistic specifications of the long-term associations documented in studies, such as the finding that associations are stronger for children than for adults (Bushman and Huesmann, 2006). As previously discussed, some mass murders may in fact be suicides preceded by mass murders. It is not, however, understood if media reporting events such as the ones that oc- curred in Columbine High School; Platte Canyon High School; an Amish school in Nickel Mines, Pennsylvania; Virginia Tech; and Northern Illi- nois may inadvertently promote these behaviors (IOM, 2013). Further, no experimental or quasi-experimental research (only research based on observational longitudinal and survey studies) has been carried out to provide definitive evidence that the long-term associations are causal rather than due to unmeasured common causes that select violence-prone youth into high levels of exposure to media violence. However, data from existing studies have shown that long-term associations cannot be solely explained by these unmeasured common causes. Research Question The limited evidence reviewed above is quite clear in arguing that significant relationships exist between violent media exposure and some measures of aggression and violent behavior. For example, it seems clear that there is a relationship between news stories of suicide and imitative suicides. The experimental literature is also very convincing in document-

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RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE 67 ing effects of short episodes of violent media exposure on short-term outcomes, although, as noted above, some question the assumption that it is the violence of the media content that is the active component in these effects (Adachi and Willoughby, 2011a,b; Przybylski et al., 2010). There is also controversy about the extent to which evidence of such short-term effects is relevant to the long-term associations found between persistent violent media exposure in youth and subsequent real-life violence (Browne and Hamilton-Giachritsis, 2005; Ferguson, 2011; Ferguson et al., 2013; Savage, 2004); the absence of experimental data renders it impossible to make unequivocal interpretations of these long- term associations (Ferguson, 2009; Grimes et al., 2008; Gunter and Daly, 2012). Critics note additional limitations of studies documenting long- term associations between violent media exposure and real-life violence, including poorly validated outcome measures and inconsistent measures across studies of aggression, childhood media exposure, and later violence (Ferguson, 2011; Ferguson and Kilburn, 2009; Kutner and Olson, 2008; Savage, 2004). The number and variety of long-term prospective studies are sufficient to warrant systematic parallel secondary analyses to address criticisms regarding appropriateness of measures and adequacy of controls. Appropriateness of measures could be addressed by sensitivity analyses to examine variation in results, based on recoding the baseline measures of media exposure and refining outcomes to focus on the subset of violent behaviors with more public health significance. Concerns about adequacy of controls in original analyses could be ad- dressed by applying consistent methods of control analysis using modern statistical methods for supporting causal inferences based on non- experimental data. Examine the relationship between exposure to media violence and real-life violence. Examples of topics that could be examined:  Synthesize evidence from existing studies and relevant databases that would reveal long-term associations between violent media exposure in childhood and subsequent adolescent or adult firearm-related violence. Studies should focus on evidence re- garding the consistency and strength of these associations and the sensitivity of effect-size estimates.

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68 RESEARCH TO REDUCE THE THREAT OF FIREARM-RELATED VIOLENCE o Is there a relationship between long-term exposure to media violence and subsequent firearm-related violence? To what degree do violence-prone individuals disproportionately ex- pose themselves to media violence? o If such a relationship exists, is it causal and who is most susceptible? o If a plausible case can be made that the relationship is caus- al, what kinds of people are most susceptible to the effects of media violence? o If the relationship is causal, which dimensions of media ex- posure are driving the relationship (e.g., competitiveness, violence, particular violence subtypes or contexts)? o Are the magnitude and consistency of the plausibly causal relationship sufficient to suggest a public health research agenda on interventions related to media violence?