Evidence-based policies to promote gun safety

During ACP’s annual meeting in Orlando recently, the American College of Physicians released a new position paper on reducing injuries and deaths from firearms — the first comprehensive update of College policy since the late 1990s. (I am a co-author of the paper.)

Published as an online-first article in the Annals of Internal Medicine, the paper is the result of an extraordinarily comprehensive review of the evidence of the causes and solutions to firearms-related injuries and deaths in the United States conducted by ACP staff and its Health and Public Policy Committee.  (Of note, the members of HPPC included several internists who themselves own firearms.) A team of four reviewers examined over 120 studies and utilized CDC, ATF and other databases.

A draft of the paper was reviewed by outside experts in mental health and firearms issues, by expert reviewers selected by the Annals of Internal Medicine, and by ACP’s Board of Regents, Board of Governors, and Councils during a 45-day review period; appropriate revisions were made in the final draft to address the substantive comments from reviewers. The paper was approved by the Board of Regents on April 7, 2014.

As we developed our recommendations, we had one simple standard: What does the published evidence say about the causes, effects, and prevention of firearms injuries and deaths?    (To read about all of the evidence behind our recommendations, click on the link in the executive summary to appendix 1).

In assessing the evidence, we identified where the evidence was strongest before we advocated for a particular policy recommendation, where it was weakest, and where more research is needed.

Our paper found strong evidence that having firearms in the home is associated with a greater risk of deaths and injuries (accidents, homicides, suicides combined) especially when children, adolescents, people with mental illness, and drug and alcohol abusers are present.  It found strong evidence for treating firearms violence as a public health issue. For universal background checks,  for subjecting firearms to consumer safety standards, for incorporating safety features like trigger locks, and for firearms owners themselves adopting best practices to reduce the risk of accidental or intentional injuries and deaths from their guns.

We also found that, although there is limited evidence that banning future sales of firearms with features that allow them to kill as many people as possible, as quickly as possible (commonly called “assault” weapons and certain types of semi-automatics) and large capacity ammunition would be effective in reducing overall homicide rates, such a ban would be warranted to reduce casualties in mass shooting situations.

We also found very limited evidence that waiting periods  are effective in reducing overall homicide rates from firearms although there is evidence that waiting periods may be effective in reducing suicides.  We found limited evidence on the impact of concealed carry laws in increasing or reducing deaths and injuries from firearms.  We called for better access to mental health services while calling for more research on the impact of laws requiring physicians to report persons with mental illnesses who may be a risk to themselves or others.

A companion original research paper published in Annals found that ACP’s policy prescriptions had strong support from large majorities of surveyed ACP members.  Although members’ views are of obvious  interest to us, the policy paper was not based on the opinion survey, but on the published evidence on what is effective in reducing firearms injuries and deaths.

Predictably, the National Rifle Association (NRA) unloaded over on ACP’s recommendations, calling us “the anti-gun” American College of Physicians. It linked release of ACP’s policy paper to the fight over confirming Dr. Vivek Murthy, an ACP member, who has been nominated as surgeon general but whose confirmation vote has been put off because of strong NRA opposition.  (ACP strongly supports Dr. Murthy’s nomination — and he is absolutely right that firearms injuries and deaths are a public health issue — but release of our position paper was purely coincidental and unrelated to his nomination.)  “Murthy’s nomination is currently on hold, due to concerns about his true motives for seeking the Surgeon General’s post,” says the NRA. “The ACP’s endorsement of massive federal gun control only underscores how well-founded those concerns really are.”

Anti-gun? Massive gun control? 

ACP’s policy recommendations are neither pro nor anti-gun; they are pro-gun safety.  Our paper acknowledges that any regulations must be consistent with the Second Amendment right to bear arms.  We do not propose banning any guns, except certain types of semi-automatics that have features that would allow a mass shooter to kill as many people as possible as quickly as possible, as well as high capacity ammunition clips.  Closing the “gun show loophole” in the current background check system would ensure that prohibited purchasers, such as felons, persons involuntarily committed for mental illness or otherwise “adjudicated mentally defective,” cannot own firearms because of the risk they present to themselves and others.

Unlike the NRA, we followed the evidence on what will be effective in reducing firearms injuries and deaths, resulting in a common-sense and scientifically rigorous position paper.  We encourage all physicians to read our paper and speak out for evidence-based policies to reduce the number of Americans — 32,000 a year, 88 per day — that are killed by firearms, and the 74,000 that are injured each year by a gun.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • JPedersenB

    Bravo! The pro-gun lobby will fight this tooth and nail. It seems that common sense is sorely lacking in many who own guns. Why would they be opposed to gun safety?

  • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

    Wait… the conclusions by the ACP are the opposite of what the IOM concluded about guns:


    Namely, that there is no strong evidence for Universal Background Checks, or that owning firearms in the home is necessarily dangerous enough to recommend against ownership.

  • edwinleap

    Can anyone explain to me why concealed carry rates are skyrocketing, gun purchases astronomical, and yet violent crime rates are falling? Could it be that the research, the paradigm itself, is wrong? And does anyone have the slightest interest in the fact that the vast majority of violent crime is related to gang and drug activity? Sounds like the answer is a better economy and promotion of intact families with emphasis on the latter. The problem with gun control measures is this: if they don’t work, advocates say we need more. And if they do seem to work, advocates say we need more. There is no negative feedback loop. As for assault-style weapons, there are millions of them and they are rarely used in crimes; it’s just that those crimes are high profile. I don’t want to see anyone killed, but the medical community is losing this one by making it adversarial. Encourage education, the way we do with sexuality and birth control or other issues! Get on the side of gun owners and you might make headway. This is a re-hash of the same arguments that haven’t held water, and haven’t worked. The people have spoken on this one. Try to catch up.

  • NormRx

    There are not 100,000 gun deaths a year, read the article again. We have about 20,000 suicides and about 12,000 murders/year. Some of the highest suicide rates are in countries that have strict gun control. One could totally eliminate guns and it would not eliminate or decrease suicide rates, people merely change their methods. We have states with physician assisted suicide. Why do I have to go to a physician to commit suicide? If a person is young and depressed that is one thing, but if you are old and infirmed that is something else. I don’t need the approval from a physician to end my life. A recent post stated that there are 27,000 prescription opioid deaths a year and over 100,000 deaths a year from nosocomial infections. I would suggest that physicians spend their time working to reduce deaths that are in their realm of expertise and not worry about something that they know nothing about.

  • Eric W Thompson

    There are a lot of things that correlate with negative
    outcomes in society. Children in single parent homes are much worse off than in two parent homes. Ban this perhaps? Having multiple sexual partners spreads STDs; make it a punishable offense? The right to privacy greatly aids criminals and terrorists; why not rescind that right? You could fill a book with similar issues.

  • Thomas D Guastavino

    Does anyone else think that reduction of gun violence might best be served if the powers that be partnered with the NRA and rely on their expertise rather then just use them for political fodder?

  • SteveCaley

    Say, Edwin…” Sounds like the answer is a better economy and promotion of intact families with emphasis on the latter.” Where’s that going on? Might have to move there.

  • Paul

    These recommendations, like the ones the ACP made in 1998, will go nowhere. I remember being at the ACP convention in Philadelphia and looking at the list of recommendations by the surveyed physicians. The top 3 were already in place. It is as if a panel of plumbers were surveyed regarding the NEW proper treatment of diabetes, and came up with 1) diet, 2) exercise, and 3) insulin. Any physician would reject such advice as useless and redundant with respect to current therapies. Similarly, the ACP has no idea what it is talking about, and should refrain from expressing opinions on such topics. I say that not to silence opposition, but to advise the ACP that it looks ignorant, and it should not fritter away its credibility.

    I have perused the references that the ACP cites in its “evidence based” recommendations, and I find them biased and agenda-driven. If there were consideration of banning “gun free zones”, since those seem to be favored by spree mass killers, it would be more credible. But to advocate the banning of guns that have bayonet launchers and flash hiders in order to prevent killings is just stupid. Wouldn’t it be simpler and more effective to simply make murder illegal? Fewer loopholes that way.

    But the bottom line, speaking as a gun owner and citizen, is that we don’t trust you. We don’t trust you not to follow registration with confiscation, as it has happened. We don’t trust you to not change the rules ex post facto, as with decreeing prohibited persons to suddenly include anyone found guilty of misdemeanor domestic violence. That was a shock to many people who had pled out, thinking they knew the consequences, only to have those consequences change. We don’t trust you to produce unbiased research, as the quality of research on gun violence in the medical literature is truly dreadful and biased. I could go into detail, but this is long enough already.

    So do yourself a favor, ACP. Stick with what you are good at: diseases of adults. Don’t destroy your credibility. Don’t fall victim to the Gell-Mann effect.

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