Evidence to Assess Potential Policy-Oriented Solutions for Reducing Adolescent Firearm Carriage

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Evidence to Assess Potential

Policy-Oriented Solutions for Reducing

Adolescent Firearm Carriage

Patrick M. Carter, MD,a,b,c,d_{April M. Zeoli, PhD,}a,e_{Monika K. Goyal, MD, MSCE}a,f

Firearm injuries are the second leading cause of death among US children and adolescents from age 1 through 19 years of age, responsible for 3400 deaths and an estimated 18 000 nonfatal injuries annually.1,2Since 2013, there has been an increase in

ﬁrearm-related fatalities, with

homicides and suicides increasing 37% and 48%, respectively.2Mass school shootings, although responsible for a small amount of the overallﬁ rearm-related deaths, have also been

increasing in frequency, with signiﬁcant psychosocial and emotional impacts on families and surrounding

communities.3,4Economic costs for the acute care of pediatricﬁrearm injuries are substantial, rising in recent analyses to nearly $400 million annually, before factoring in the costs for long-term medical care, lost wages, and legal proceedings.5As a result of such trends, there has been greater societal awareness about this public health problem, especially as parents and policy makers now recognize that inaction onﬁrearm safety has

contributed to a situation in which high school students are now more likely to die of aﬁrearm injury than any other cause of death.2

Despite research results demonstrating thatfirearm access and carriage are 2 of the most significant risk factors for pediatricfirearm injuries,6–16there has been little progress in developing effective evidence-based

countermeasures to address the ease of adolescentﬁrearm availability. This is

due in large part to a lack of federal

ﬁrearm research funding since the Dickey amendment was introduced in 1996.17,18Although not an outright ban, the amendment added language to the Centers for Disease Control and Prevention appropriations bill

stipulating that research funding could not“be used to advocate or promote gun control.”The annual renewal of this amendment has had a chilling impact on efforts to advance the science of

firearm injury prevention through federally funded research, leading to a significant discrepancy between the overall disease burden and the scientific output needed to achieve progress in reducing child and adolescentfirearm injury and death.19–21

In the current issue ofPediatrics, Timsina et al22begin to unravel some of the key questions underlying how

ﬁrearms policies might work as effective countermeasures for adolescentﬁrearm availability and carriage. Researchers analyzed cross-sectional data from the Youth Risk Behavior Survey collected biennially between 1993 and 2017 to examine whether the 1998 nationwide

implementation of the National Instant Criminal Background Check System (NICS) was associated with reduced adolescentfirearm carriage and whether that association varied by state laws extending background checks to privatefirearm sales (ie, whether states had either point-of-sale background check requirements for privatefirearm

a_{Firearm Safety Among Children and Teens Consortium,} b

Department of Emergency Medicine, School of Medicine,

c_{Youth Violence Prevention Center, and}d_{Department of}

Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan;e_School

of Criminal Justice, Michigan State University, East Lansing, Michigan; andf_{Department of Pediatrics, Children}_’_{s National}

Medical Center, The George Washington University, Washington, DC

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

DOI:https://doi.org/10.1542/peds.2019-2334 Accepted for publication Oct 14, 2019

Address correspondence to Monika K. Goyal, MD, MSCE, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

FINANCIAL DISCLOSURE:The authors have indicated they have noﬁnancial relationships relevant to this article to disclose.

FUNDING:No external funding.

POTENTIAL CONFLICT OF INTEREST:The authors have indicated they have no potential conﬂicts of interest to disclose.

COMPANION PAPER:A companion to this article can be found online at www.pediatrics.org/cgi/doi/10. 1542/peds.2019-1071.

To cite:Carter PM, Zeoli AM, Goyal MK. Evidence to Assess Potential Policy-Oriented Solutions for Reducing Adolescent Firearm Carriage.

Pediatrics. 2020;145(1):e20192334

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sales or permit-to-purchase licensing requirements forﬁrearm sales). Although notﬁnding a reduction in carriage associated solely with NICS implementation, researchers

identiﬁed that the combination of the NICS system with state laws

extending background checks to private sales resulted in an estimated 25% reduction in the absolute risk of adolescentfirearm carriage. Given that a key mechanism underlying adolescentfirearm acquisition is the diversion offirearms from legal to illegal channels (eg, straw

purchases),9,23the authors argue that these policies have the potential to affect adolescentﬁrearm availability and downstream injury-related outcomes.

Findings from the Timsina et al22 study, although a valuable addition to the literature, must be considered in the context of several limitations. Youth Risk Behavior Survey data, although representative of a national sample of school-aged adolescents, are not necessarily representative of statewide samples in pooled analyses and fail to capture data on

nonenrolled students (ie, adolescents with illegalﬁrearm possession are less likely to be attending school)9, an important consideration when analyzing state law impacts on

ﬁrearm carriage. In addition, examining laws requiring point-of-sale background checks for private sales and permit-to-purchase licensing laws as a uniﬁed policy variable precludes individual examination of the different state-level policies, which in previous analyses have demonstrated differential associations with outcomes. In studies of permit-to-purchase licensing policies, researchers found they were

associated with reductions inﬁrearm suicides and homicides24–27but not intimate partner homicide.28

Conversely, in studies of point-of-sale background checks for private sales, researchers have generally not

identified decreases infirearm mortality,28–31although background checks for private sales have been associated with reductions infirearm diversion.32,33Finally, given that states may differentially implement policies, analyzing state-level implementation methods is an important consideration for future studies.34

Despite such limitations, Timsina et al22should be commended for beginning to address a key research question in thisﬁeld: how do current

firearm policy initiatives directly affect pediatric-specificfirearm outcomes?35Although available research has examined the effects of policies overall, such research remains in the nascent stages when considered in the context of pediatric injury prevention. More focus is needed on understanding the effectiveness and mechanisms by which state and federal policy initiatives may impact adolescent

firearm acquisition and the downstream behaviors offirearm carriage and use. In addition to policy, foundational research is needed to understand the contextual factors surrounding adolescentfirearm carriage (eg, motives underlying carriage) as well as large-scale trials to examine the efficacy of individual-level behavioral interventions applied in school, health care, and community settings. In a recent research

agenda36published by theEunice Kennedy ShriverNational Institute of Child Health and Human

Development–funded Firearm Safety Among Children and Teens

Consortium, authors highlight these knowledge deficits regarding adolescentfirearm behaviors and outline a series of research priorities to build on this work. Central to expanding this knowledge is the pressing need to continue to increase federal sources of research funding. The sound application of rigorous scientific and public health methods has achieved marked success in other

disciplines of injury prevention (eg, motor vehicle crash deaths,

drowning), and parallel investments to advance the science ofﬁrearm injury prevention have the potential to reverse current trends in child and adolescentﬁrearm deaths.

ACKNOWLEDGMENT

The authors wish to acknowledge Carrie Musolf for her assistance in the preparation of this article.

ABBREVIATION

NICS: National Instant Criminal Background Check System

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DOI: 10.1542/peds.2019-2334 originally published online December 2, 2019;

2020;145;

Pediatrics

Patrick M. Carter, April M. Zeoli and Monika K. Goyal

Firearm Carriage

Evidence to Assess Potential Policy-Oriented Solutions for Reducing Adolescent

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DOI: 10.1542/peds.2019-2334 originally published online December 2, 2019;

2020;145;

Pediatrics

Patrick M. Carter, April M. Zeoli and Monika K. Goyal

Firearm Carriage

Evidence to Assess Potential Policy-Oriented Solutions for Reducing Adolescent

http://pediatrics.aappublications.org/content/145/1/e20192334

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