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1 Introduction

In contemporary America, there is little doubt that gun violence is a pervasive public health problem. There are over 80,000 firearm injuries annually, and over 39,000 fatalities—an average of over 100 people die by firearms per day, 9 of whom are children [1, 2]. Among fatal injuries in youth 15–19 years of age in 2018, more than 1 in 3 (34.4%) were firearm related. In youth under 20 years, almost 1 in 4 (24.0%) were firearm related [2]. The role of firearms in community and domestic violence endanger children’s lives, create toxic stress, and increase risks of depression and mental health disorders [3]. Moreover, firearms in homes are associated with an increase in suicide in youth 10–19 years old. For every 10% increase in household gun ownership, youth suicide increased by 26.9% [4]. Public health research has also made important contributions to firearm injury prevention. For example, its methodologies, including epidemiological methods such as network analysis, have illustrated “how violence is transmitted by social interaction through networks of people” [5].

There is widespread consensus that firearm injury prevention is not the same as “gun control ” [6]. “Gun control,” or firearms regulation , includes the set of laws or policies regulating the manufacture, sale, transfer, possession, modification, or use of firearms by civilians. From a politicized perspective, people who advocate for gun control are frequently labeled as individuals who aim to broadly restrict or prohibit firearm use, motivated by opposition to the Second Amendment or the use of firearms in general, though this may not be accurate. In contrast, public health efforts to prevent or reduce firearm injury support narrowly tailored, evidence-based measures (regulatory and non-regulatory) that can reduce the incidence of the most common and preventable forms of firearm violence. These include efforts to decrease firearm access to individuals at risk for harming others or themselves: universal background checks and waiting periods; measures prohibiting felons, individuals convicted of domestic violence misdemeanors, and those with certain types of mental illness from gaining access to firearms; and child access prevention laws to reduce pediatric fatalities. These injury prevention efforts also include restrictions on the possession of military-style weapons and high-capacity magazines as well as other regulations.

This chapter will discuss pediatric clinician advocacy for firearm injury prevention legislation. It will first describe the sweeping changes the last 20 years have wrought across legislative, commercial, and cultural landscapes. It will then explore the evolution of medical professionals’ advocacy efforts to reduce firearm violence. Finally, it will explore particular ways in which pediatricians can advocate to reduce firearm injuries from firearm violence.

2 Recent Changes in Firearm Markets, Laws, and Cultures

2.1 Changes in Firearm Markets

The annual “Firearms Commerce in the United States” report published by the Bureau of Alcohol, Tobacco, and Firearms (“ATF”) reveals a clear and compelling pattern. Between 1986 and 2008, the number of firearms manufactured in the United States (US) remained within a relatively limited range, from a high of 5.2 million in 1994 to a low of 2.9 million in 2001 [7]. From 2004 to 2013, however, this figure steadily increased on average (with a sharp increase in 2009, the year after President Obama was elected) until it reached a high of 11.5 M in 2016 (see Fig. 13.1) [7]. Approximately 165 million guns entered the US market between 2000 and 2017 [7]. At the same time, the total number of forms processed under the National Firearms Act ,Footnote 1 which are completed for items such as silencers, machine guns, and modified shotguns, displayed the same upward trend, from 193,224 in 2004 to a high of 2,530,209 in 2016 [7]. Finally, firearm background checks have grown dramatically from 8.5 million in 2000 to an all-time high of 28,369,750 in 2019 (Fig. 13.2) [7]. By the end of 2020, background checks will have risen another 42% in a single year to just shy of a staggering 40 million. These trends indicate that more guns are being manufactured, purchased, and changing hands in the US.

Fig. 13.1
figure 1

Firearms manufactured in the US, 1986–2017; from the US Department of Justice, Bureau of Alcohol, Tobacco, Firearms, and Explosives, Firearms Commerce in the United States, Annual Statistical Update; 2019. https://www.atf.gov/firearms/docs/report/2019-firearms-commerce-report/download

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Fig. 13.2
figure 2

US National Instant Criminal Background Check System (NICS) firearm background checks per year, 1999–2019; from the US Department of Justice, Federal Bureau of Investigation, NICS Firearm Checks (May 31, 2020). https://www.fbi.gov/file-repository/nics_firearm_checks_-_month_year.pdf/view

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2.2 Changes in Firearm Laws and Cultures

2.2.1 Federal Law

Federal law plays a limited role in firearm regulation, setting a floor rather than a ceiling for firearm regulation. The National Firearms Act of 1934 , codified at 26 U.S.C. § 5801, includes taxes on the manufacture, sale, and transfer of some types of firearms, including machine guns, short-barreled shotguns, and silencers. The Gun Control Act of 1968 (which repealed the Federal Firearms Act of 1938 but reenacted many of its provisions) is codified at 18 U.S.C. § 921 and requires manufacturers, importers, and sellers to possess a federal license and maintain proper records, prohibits transfers to prohibited purchasers (those with “disabilities,” such as prior felony conviction), establishes a minimum age for firearms purchases, requires all firearms to have serial numbers, and bans the importation of firearms with “no sporting purpose.” The Firearm Owners Protection Act of 1986 relaxed restrictions on firearm sellers and liberalized the definition of what it meant to “engage in the business” of selling firearms, allowing licensed dealers to sell at gun shows in the same state, and repealing requirements that ammunition sellers be licensed and that dealers track ammunition sales. It also explicitly banned a central federal database of dealer records. One of the best-known federal firearms regulations is the Brady Handgun Violence Prevention Act of 1993 , which imposed a background check to determine whether a buyer is a prohibited purchaser. It also mandated if a check could not be completed quickly on the day of purchase, a buyer is entitled to take possession of the firearm in 3 days unless further information emerges. Contemporary background checks conducted by federally licensed firearms dealers involve submitting information to the National Instant Criminal Background Check System (NICS). The Brady Act’s requirements were extended to shotguns and rifles in 1998. The Federal Assault Weapons Ban, passed in 1994 , prohibited the manufacturer, transfer, and possession of semi-automatic assault weapons and the transfer and possession of large capacity magazines holding more than 10 rounds of ammunition, and outlawed 19 assault weapons by name along with any semi-automatic firearm with more than two military features and a detachable magazine (except for shotguns). This ban “sunsetted” or expired in 2004.

Two more federal laws have been passed after the turn of the century. The Protection of Lawful Commerce in Arms Act and Child Safety Lock Act of 2005 enacted protections for the gun industry from torts suits, barring parties from suing for injuries resulting from the criminal or unlawful misuse of a firearm. There are exceptions for lawsuits alleging breach of contract or warranty, defective design or manufacturer, or negligence per se or negligent entrustment (supplying a firearm or ammunition to persons the seller reasonably should know or knows are likely to use them in ways creating unreasonable risk of physical injury) as well as lawsuits against transferors convicted of transferring a firearm knowing it would be used to commit a violent crime or who knowingly violated state or federal laws about the sale or marketing of firearms or ammunition. Finally, the National Instant Criminal Background Check System Improvement Amendments Act of 2007 gave states financial incentives to report certain information to NICS (including disqualifying mental health records). It also authorized a grant program for states to establish and upgrade reporting capabilities. Participating states must create a program allowing eligible individuals to appeal and potentially remove disabilities from their records.

2.2.2 State Laws and Firearm Culture

For a comprehensive understanding of current state laws across the US, the interactive map at www.statefirearmlaws.org is a very useful resource and shows the evolution of state firearm laws from 1991 to the present. There is specific data available about each state and its laws. Figure 13.3 provides an overview of how many laws per state exist as of 2020 [8].

Fig. 13.3
figure 3

Overview of gun laws per state as of 2020; from Dr. Michael Siegel, State Firearm Laws Database, www.statefirearmlaws.org/

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The unprecedented expansion in firearms markets that began in 2009 has been accompanied by state legislative reforms that relax or repeal “gun control” laws across the US regarding firearm sales, purchase, possession, and storage. State laws affect several types of conduct, including:

  • Restricting or prohibiting possession by individuals because of mental health, substance use, or criminal histories (including domestic violence)

  • Background checks

  • Regulations on ammunition sales, firearm possession, concealed and open carry, “assault weapons,” and large-capacity magazines (especially associated with the 2004 sunsetting of the Public Safety and Recreational Firearms Use Protection Act , commonly called the Federal Assault Weapons Ban, which was a part of the Violent Crime Control and Law Enforcement Act of 1994 )

  • Safe gun storage and child access prevention

  • Gun trafficking

  • State preemption of local gun regulations

  • State immunity statutes for gun manufacturers and sellers [8]

Recent trends in “gun rights” legislation include:

  • Reforming state law to permit firearm concealed carry in traditionally sensitive areas such as schools, houses of worship, college campuses, and courthouses

  • Repeal of license requirements for firearm purchases and concealed carry (“Constitutional Carry” laws)

  • Preempting cities and municipalities from passing their own firearm regulations

  • “Stand your ground” self-defense statutes

  • Protective immunity legislation limiting or eliminating legal liability of gun manufacturers and sellers for violent acts committed with a firearm [8]

Since 2008, however, many states have also enacted “gun control” laws, including those regulating firearm possession for domestic violence offenders, background checks for concealed carry permits, and prohibitions on firearm possession for felons and those involuntarily committed for mental health treatment [8].

Attempting to identify whether the surges in firearm sales and state legislation were related to National Rifle Association (NRA) activities, Reich and Barth found that two variables contributed to these issues [9]. Conservative state legislatures were more likely to deregulate from 2009 to 2013 [9]. Moreover, NRA election spending (not lobbying) furthered deregulation in states where more residents flocked to buy firearms in the months before and after President Obama’s election [9]. Reich and Barth have argued that preemptive firearm sales before the election opened the door for the NRA to influence state legislation in the direction of deregulation [9]. Many laws were passed in the wake of some of the largest mass killings in US history, including the shootings at Sandy Hook Elementary School in Newtown, Connecticut in 2012; the Pulse night club in Orlando, Florida in 2016; and the Marjory Stoneman Douglas High School in Parkland, Florida in 2018, among others.

These laws have both stemmed from and reinforced recent changes in US firearm culture, from recreational shooting to an emphasis on armed self-defense [10]. Carlson’s research connects men’s decisions to carry firearms as “citizen-protectors” to changing conceptions of masculinity, patterns of socioeconomic decline, perceptions of economic and physical insecurity, and concerns about perceived increases in crime and police ineffectiveness [11]. Stroud examines the cultural meanings of concealed carry for Texas permit holders [12]. In this article, respondents emphasized masculine goals such as protecting themselves and family members and compensating for lost physical strength due to age, or sex differences between women and male attackers.

2.2.3 State Laws That Could Reduce Gun Violence

The causal impact of state and federal laws on firearm violence and suicide remains controversial. Most studies use a panel regression method to “model differences in violent outcomes between states with and without a particular type of law over time” [8]. This methodology requires “data from a large number of states over a substantial period of time” to determine that the enactment or repeal of a law has a statistically significant association. However, until www.statefirearmlaws.org became available in 2017, no publicly available database allowed researchers to access “comprehensive information on a wide range of state firearm laws over an extended period of time,” let alone an analysis of how the same firearm laws applied differently across states [8].

Research on gun violence was stymied after the Dickey Amendment in 1996 eliminated $2.6 million from the Centers for Disease Control and Prevention (CDC) budget. This occurred after the agency began to support firearms research, which demonstrated, among other findings, the increased risk of harm that firearms pose to members of a household. After passage of the Dickey Amendment, the role of the CDC was “relegated to monitoring firearm injuries by surveillance of firearm statistics,” without making policy recommendations [13]. This restriction on firearm research funding quickly spread to the Nation Institute of Health (NIH) and Department of Health and Human Services (DHHS). Soon thereafter, databases related to firearm sales and ownership were eliminated , and data from background checks were destroyed within 24 hours [13]. Fortunately, since the Obama administration’s action, the Institute of Medicine (now the National Academy of Medicine) has developed a research agenda aiming to reduce firearm-related violence, and funding for firearm research has finally been reinstated [14].

There are several types of laws that research suggests are effective and should be included in legislative advocacy efforts. Ultimately, these laws will be most effective if several of them are implemented across the country, for a robust interstate effect [15, 16].

  • Universal background checks : This goal would be best achieved by requiring all firearm transfers and ammunition sales be completed through federally licensed dealers [17, 18]. It would ensure that all individuals who lawfully take possession of a firearm complete a background check and that records are kept for all sales and transfers. At a minimum, all firearm sales at gun shows, and all firearm sales between individuals, should include a background check and the requirement that transaction records are kept.

  • “Assault weapons” bans : This could help prevent gun violence by restricting access to the types of weapons most frequently used in mass shootings. These weapons are capable of injuring or killing the most people at one time, without requiring the shooter to reload the weapon. Most current state bans on military-style rifles (predominantly enacted in the Northeast) list banned weapons by name or through listed features (banning weapons with one or two features).They require assault weapon registration, prohibit transfers of previously owned qualifying weapons, and mandate owners have a location or license for previously owned qualifying weapons.

  • Limiting numbers of firearms that can be purchased within a certain time period: One example includes laws limiting a firearm purchase to one per month [18]. These provisions help reduce illegal gun trafficking and deter dangerous individuals from building arsenals in a short period of time.

  • Buyer safety regulations : These include laws require buyers to obtain a permit or license, require background checks, or mandate buyers undergo requisite safety training.

  • Child Access Prevention (CAP) laws : These laws regulate the safe storage of guns from children by gun owners. Under strong CAP laws, prosecutors can charge owners who negligently store firearms and who know or reasonably should know that a minor could gain access, regardless of whether a minor actually accesses the firearm and/or harm occurs. A weaker version imposes criminal liability only when a child actually gains access, and the weakest version imposes criminal liability only if a child gains access and carries or uses the firearm. A less effective type of CAP law prohibits intentionally, knowingly, or recklessly allowing minors to access firearms, excluding negligence. Sometimes weak CAP laws only permit liability for parents or guardians if they provide a firearm to a minor knowing there is a substantial risk that the minor will use it to commit a crime.

  • Extreme risk protection order (ERPO) laws: These laws help to remove access to firearms for a person who is at risk of harming themselves or others. Violence against one’s self or others is often preceded by warning signs that family members or friends can detect. For this reason, as of 2020, 18 states and the District of Columbia allow family or household members, and in some cases law enforcement and health officials, to submit a petition for an ERPO. Other states allow others such as mental health professionals, coworkers, educators, or school administrators to petition. ERPOs can be ordered without notice (but may then last for a shorter time), or they can be issued after notice and a hearing. Final orders can last up to a year (depending on the state) and are subject to renewal, but individuals can request a hearing to prove that they are no longer a risk.

2.2.4 Notable Shifts Following Mass Shootings

The legislative “gun rights” tide is slowly ebbing, however. After the Sandy Hook Elementary School shooting in Newtown, CT, on December 14, 2012, some Northeastern states passed bans on “assault weapons” and high-capacity magazines , but federal reforms including a comprehensive background check requirement were not passed. On January 16, 2013, President Obama initiated 23 executive actions and 12 Congressional proposals mandating that federal agencies allow the National Instant Criminal Background Check System (NICS) access to relevant data, requiring traces of recovered crime guns, incentivizing states to share information with NICS, providing guidance for federally licensed firearms dealers on how to conduct background checks for private sellers, training for armed attacks, reviewing current safety standards for gun locks and gun safes and gun safety technologies, developing model emergency response plans, and other measures. Connecticut revised its existing “assault weapons” ban prohibiting the sale of magazines holding more than ten ammunition rounds and requiring comprehensive background checks, which has been upheld as constitutional in federal court. New York’s SAFE act, enacted on January 16, 2013, expanded the definition of “assault weapons ” under state law, created a pistol permit database, implemented universal background checks, and prohibited all magazines holding over seven rounds. A federal court subsequently struck down the seven-round prohibition but upheld the “assault weapons ” ban. Maryland enacted the Firearm Safety Act of 2013 , which banned 45 types of firearms, required handgun licensing and fingerprinting for new owners, and restricted those who have been involuntarily committed to a mental health institution from possessing a firearm. This ban has also been upheld as constitutional by a federal court.

Finally, the Sandy Hook Elementary School and subsequent shootings have had a revolutionary effect on gun violence prevention advocacy. Moms Demand Action for Gun Sense in America (https://momsdemandaction.org/), founded the day after Sandy Hook, is a grassroots gun-violence prevention organization supporting measures to prevent gun violence, such as universal background checks. In April 2014, Moms Demand Action merged with Mayors Against Illegal Guns to form Everytown for Gun Safety (https://everytown.org), which has undertaken educational, policy, and lobbying activities, and spent more in the 2018 election cycle than the NRA and other gun rights organizations. Immediately after the shooting at Marjory Stoneman Douglas High School in Parkland, FL in 2018, student survivors founded March For Our Lives (https://marchforourlives.com), advocating student walkouts in schools across the country one month after the shooting. Thereafter, the organization dedicated itself to student-led activism to end gun violence and mass shootings.

3 Advocacy by Medical Professional Associations

Medical professionals have traditionally taken stands against public health issues such as tobacco use, unintentional poisoning , motor vehicle safety [19], and most recently, gun violence prevention. As Laine and Taichman emphasized in an Annals of Internal Medicine editorial:

[w]hen public health crises arise, our powerful health care complex responds by doing what our scientific training and duty to help others require. We formulate questions that need answers, collect and analyze data to answer them, test hypotheses to discover remedies, study how to implement them, and monitor progress. . . . But it seems to stop when it comes to firearm injury. Why? [14]

This is especially true since safe storage has been shown to reduce the risk of suicide and unintentional injury for children and adolescents [20]. Research suggests that popular children’s gun safety programs such as Eddie Eagle from the NRA are not effective, since when a child finds a gun, their behavior will likely not follow program guidelines [21]. Moreover, these programs place the burden of avoiding firearm injury on the child, instead of the adults around them. Child Access Prevention laws, specifically negligence laws promoting safe storage of firearms, are associated with reductions in pediatric firearm fatalities including homicides, suicides, and unintentional deaths [22]. In addition to addressing firearms in the child’s home, parents and caregivers should also consider whether there are firearms in other homes visited by the child. The American Academy of Pediatrics (AAP) promotes the ASK (Asking Saves Kids) program [23], with the goal of increasing parents’ willingness to ask about whether there are guns in the homes that their children visit [24].

As the gun violence prevention advocacy movement has grown, professional medical organizations such as the American Bar Association (ABA), American Medical Association (AMA), American Academy of Family Physicians (AAFP), American College of Emergency Physicians (ACEP), American Congress of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP), American College of Surgeons (ACS), American Psychiatric Association (APA), and the American Academy of Pediatrics (AAP) have joined together to “press… for increased research . . . to discover strategies to diminish firearm-related harms,” supporting universal background checks and restrictions on “military-style weapons and high capacity magazines” [14, 24]. Individually, these organizations have created professional practice guidelines and policy recommendations and conducted member surveys. They have also published consensus statements that advocate approaching firearm violence as a medical or public health problem, encourage firearms counseling on safe storage and other initiatives, promote the development of research agendas, and support evidence-based violence prevention programs, federal research funding, and legislation such as that increasing funding and availability of mental health programs.

The AAP in particular has made firearm injury prevention a “high priority,” including “advocating for better regulation of the use of and sale of firearms” [24]. Pediatricians have a unique opportunity to “play a critical role . . . in framing a message to convey to families in terms of child development and safety” [24]. The American College of Physicians, active in gun violence prevention for over 20 years, urges its members to “advocate for national, state, and local efforts to enact legislation to implement evidence-based policies . . . including, but not limited to universal background checks.” They also support “appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths,” as well as completion of a firearms training program, domestic violence restraining orders and purchasing restrictions, bans on firearms undetectable through security screening, implementation of waiting periods following purchase, limiting concealed-carry expansion, and bans on future sales and possession of military-style firearms [25]. The AAP is openly supportive of child access prevention legislation as well as (1) mandatory waiting periods, (2) universal background checks, (3) mental health restrictions for gun purchases, and (4) restoration of the “assault weapons” ban [26]. It advises practitioners to connect with state AAP chapters, engage local media by sending letters to the editor (with speaking points), contact state and federal legislators to advocate for “improved gun safety legislation and funding for mental health services,” and provide firearm safety anticipatory guidance [27].

Most recently, medical professionals have demonstrated a willingness to directly assert ownership over efforts to reduce gun violence and prevent firearm injury. In response to the publication of an American College of Physicians position paper in November 2018, the NRA tweeted that “self-important anti-gun doctors [should] stay in their lane.” This spurred an avalanche of responses from medical professionals across the country, accelerated by another mass shooting that occurred less than 12 hours after the NRA tweet [6]. As Ranney et al. remarked, “the broad and rapid response to #ThisIsOurLane reflects not a new movement, but rather the convergence of multiple paths on which physicians had already embarked” [6].

4 Opportunities for Advocacy and Intervention for Pediatric Health Care Professionals

Like other successful health interventions requiring multi-pronged approaches, effectively addressing gun violence requires pediatric clinicians to engage in several activities, ranging from clinical practices to private expert testimony to initiating or joining professional associations’ programming or participating in safety coalitions.

4.1 Counseling Patients

One of the most important advocacy opportunities is discussing firearms as a safety concern and providing anticipatory guidance to parents and patients, as one would for car seats, wood-burning stoves, or smoking in the home (See Chap. 7). This option, however, may not be easy, depending on caregiver attitudes toward firearms. Discussions on firearms, including firearm safety, between clinicians and families became highly controversial after state legislatures began to debate or enact laws restricting this conduct. The most infamous of these laws, Florida’s Firearm Owners’ Protection Act of 2011 (FOPA) (also known as the Physician Gag Law ), was passed on the heels of legislative testimony alleging that patients had been dismissed from practices, told that Medicaid would not cover visits if they refused to answer firearm-related questions, or otherwise were treated disparagingly. FOPA prohibited medical professionals from asking patients about firearms or intentionally entering disclosed information about firearm ownership into a patient’s medical record unless it was relevant to the patient’s or others’ medical care or safety. In February of 2017, the US Court of Appeals for the Eleventh Circuit ruled that key FOPA provisions were unconstitutional for physicians on First Amendment grounds, because they impinged on medical professionals’ First Amendment free speech rights. They held that patients had a right to learn such information and that no evidence suggested medical professionals had been inappropriately intrusive concerning patients’ firearms ownership or been involved in firearms confiscation efforts [28]. The court did find that providers could not dismiss patients for refusing to discuss firearms. Other states have passed less draconian laws that still regulate some elements of physician-patient communication about firearms [29]. Minnesota, Missouri, and Montana all have restrictions on how firearm information can be collected and stored, but do not prohibit physician inquiries. However, these laws may still make health care workers wary about discussing guns.

Despite the outcome of this case, and assertions from the American Bar Association that firearm screening is compatible with the Second Amendment [19], researchers have found many practitioners are reluctant to screen for firearms or give anticipatory guidance, lest they seem “intrusive or offensive” [24]. Parents are receptive to physician counseling and most believe that pediatricians should provide safe storage advice [30]. In addition, 66% to 85% of physicians believe they have the right to counsel patients about firearm safety and a responsibility to prevent firearm-related injuries [31]. Yet, these beliefs are not carried over into practice, as few physicians counsel patients about firearms [32, 33]. This pattern has changed little over decades. In a 1997 study involving pediatric residents, firearms were not discussed in a single child-well visit out of 178 that were recorded [34]. A 2014 survey of 573 internists reported that 58% never asked whether patients had guns in the home, and 77% never discussed strategies for reducing the risk of gun-related injury [35].

This professional reluctance is unfortunate, because physician counseling can effectively promote safe storage [24]. During counseling, pediatricians can tailor advice to a child’s developmental stage and discuss safety practices appropriate to those capacities, as well as describing “layers” of separation, such as both “gun safety” programs and physically separating the firearm from the child [24]. Screening for firearms is especially critical when there is an acute risk that a patient or parent will be violent to themselves or others (suicidal or homicidal ideation) and when certain individual factors are present (history of violence or substance abuse, serious mental illness, and conditions impairing cognition) [31]. Pediatricians are also readily able to debunk common myths about pediatric firearm injuries, such as that most firearm deaths are caused by mentally ill mass shooters, a gun in the home makes residents safer, and children don’t know where parents’ guns are kept in the home [36]. Critically, pediatric clinicians can also recommend emergency removal of firearms from a home where adolescents are depressed or have other indications of violence against self or others. Thus, it is paramount that clinicians know and understand their state laws regarding removal or prohibition of possessing or acquiring firearms for at-risk individuals.

For these reasons, several professional organizations, including the AAP and the AMA, are developing continuing education programs to educate physicians about how to discuss firearm safety with patients [37].

Clinicians who are reluctant to screen for firearms in the home can provide all patients with firearm safety information, but research has not yet demonstrated the efficacy of that approach [24]. Sanberg and Wang recommend a simple rubric, the “5 Ls”: “If there is a gun in the home: (1) is it Locked, (2) is it Loaded, (3) are there Little children, (4) is anyone in the house feeling Low, and (5) is the owner Learned?” [36] As to the last point, even the most knowledgeable firearm owners can underestimate the risks associated with keeping loaded firearms in the home. It should also be noted regarding the presence of little children that adolescents are at significantly greater risk for death from firearms (i.e., suicide) than young children.

There are some potential barriers to firearm counseling. For example, patients could perceive that medical professionals are not trustworthy nor reliable sources of information because they “are not likely to be familiar with or accepting of firearms or firearm culture” [38]. To overcome this obstacle, firearms screening and counseling should be culturally sensitive, acknowledging both the protection of constitutional rights and protecting self and others from harm [39, 40]. To these ends, Betz et al. recommend that medical professionals educate themselves about federal and state laws (particularly Extreme Risk Protection Order “red-flag” laws applicable in high-risk situations passed in 18 states as of February 2020) to effectively discuss firearm safety and provide counsel [28, 36]. Physicians can also strive to learn about perceived risks and benefits of firearm ownership [28]. Physicians who own firearms could “provide leadership to their peers around developing competencies in firearm safety counseling” [38]. Researchers have also recommended that counseling include free gun locks, a step identified as “critical” in firearm safety promotion.

4.2 Collaborating with Community Organizations and Coalitions

Pediatric clinicians can also reach out to local community organizations , such as school districts and community mental health organizations, to offer their expertise with crisis planning. Such action increases public familiarity with a district’s emergency plans and can make it easier to coordinate in case of a firearm-related incident. Community engagement can also allow pediatric clinicians to invite local officials or experts to visit professional settings or attend organizational events in turn to share expertise and stories.

Pediatric clinicians can participate in interdisciplinary coalitions to prevent firearm violence and injury. Some coalitions exist to achieve specific, pragmatic goals, such as the American College of Surgeons Committee on Trauma’s “Stop the Bleed” program, a national public awareness campaign to train members of the public to help in a bleeding emergency (such as a significant trauma or a shooting) before professional medical help arrives. The program has excellent intentions, although it is unclear whether it has medical value. Nor do we know the unintended consequences of training people, including children and youth, to feel medically responsible during a mass shooting events, when this is something most people will never experience.

A second example is local partnerships that have developed between firearm ranges and public health professionals, with the purpose of providing suicide prevention education to gun shop customers and training employees how to identify at-risk customers. Of particular note, the National Shooting Sports Foundation has partnered with the American Foundation for Suicide Prevention to disseminate educational materials about suicide risk factors and warning signs to gun owners through firearms retailers and shooting ranges nationwide [6]. Finally, one residency program at Indiana University trains residents through Everytown’s “Be Smart” program (https://besmartforkids.org/about), which raises awareness that storing guns locked, unloaded, and separate from locked ammunition can save children’s lives. Residents are taught to perform bedside discussions with patients and chart these conversations. In addition, residents staff a table in support of the Be Smart program at community events while wearing their white coats.

Other collaborations are engaged in research and policy change. Health care leaders from several specialties formed the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), with the goal of producing research and collaborative action [6]. In more than 20 states, collaborations between firearm stakeholders and public health experts have been founded to “inform the development and implementation of effective, culturally-sensitive prevention and intervention efforts” [38]. For example, public health practitioners, firearm retailers, and local firearm instructors formed the New Hampshire Firearm Safety Coalition in 2009 following several suicides with recently purchased firearms, with the goal of preventing future instances [41]. This group is developing and sharing guidelines on how to identify potentially suicidal individuals. Part of their efforts also includes displaying and distributing suicide prevention materials tailored to firearm purchasers at firearm retailers. A similar group, the Colorado Firearm Safety Coalition, includes firearm instructors, Colorado Department of Public Health and Environment employees, and public health researchers. This group has also trained physicians and medical students on how to use and store firearms [38].

4.3 Engaging in Legislative Advocacy Through Letter-Writing or Expert Testimony

Legislative and legal advocacy to promote evidence-based policy measures can be efficacious in decreasing youth firearm injury and mortality [16]. These activities include both helping to pass certain types of legislation that can reduce firearm injury and actively opposing other legislation that could increase it. Recent years have witnessed a number of accomplishments for medical professional advocacy. It would be difficult to advocate for firearm screening and safety counseling if physicians had not challenged the constitutionality of FOPA on the grounds that such regulations may “interfere with medical practice [and quality of care] by substituting politics and legislative judgment for medical expertise” [42]. Moreover, physicians have successfully challenged similar laws in other states. In 2015, North Carolina physicians opposed House Bill 562, which barred any health care provider from asking a patient about their ownership or storage of firearms, except to prevent imminent deadly harm, or risk being fined. The medical community sent out press releases, called reporters, and had hallway conversations with legislators in a “White Coat Wednesday” event.

An excellent way to garner support for or against particular legislative initiatives is to publish a letter to the editor in a respected local or national publication. Individuals looking for assistance can consult the AAP website for speaking points on firearms, mental health, and school violence, and lists of media outlets and contacts by zip code. One area of regulation that needs to be addressed is the absence of safety regulations for firearms, over which the U.S. Consumer Product Safety Commission (CPSC) has elected not to exercise jurisdiction.

Engaging in legislative advocacy can require creative strategies depending on the context. The first question is what evidence legislators will find most persuasive. Peer-reviewed studies, the gold standard in evidence-based medical practice, are an excellent way to establish relationships between legislative actions and social trends. But they may not be useful in hearings where legislators attempt to debunk statistical conclusions or dismissively remark, “Correlation , not causation.” Analyses using complex methodology such as the synthetic control technique can be difficult to explain in the few moments allotted for testimony [43]. In the age of “post-truth” politics, legislators may simply deem statistics and studies too abstract and elitist. Anecdotes, on the other hand, carry a great deal of emotional weight, but lack generalizability. Ideally, then, pediatricians who engage in legislative advocacy will equip themselves both with research evidence and anecdotes to both illustrate the consequences of legislative action or inaction and give their testimony the necessary sticking power. Effective advocates can also build relationships with news media and reporters, who cover legislative hearings and air interviews with experts.

Through letter-writing, speaking to legislators, and providing legislative testimony, pediatric clinicians can advocate for several specific state-level regulations to reduce gun violence.

  • Comprehensive background checks for all firearm purchases (including private sales between individuals). These laws could prevent some firearms from reaching prohibited purchasers; currently, 40% of transfers (an estimated 6.6 million) take place outside a federally licensed dealer [19].

  • Paired waiting periods of 3 days to pick up a firearm after purchase. These laws have also been associated with reducing fatalities.

  • Increasing funding for and access to mental health care. Most mental illness by itself is not a disqualifying factor for firearm ownership [19].

  • Extreme Risk Protective Order (ERPO) “red flag” laws . These laws allow families and law enforcement to report patients at risk of harming themselves or others. They could be advantageous so long as they balance rights with public safety , promote confidentiality, and do not deter patients from seeking treatment [19]. Most ERPO laws do not allow health care clinicians (including psychiatrists) to petition the courts, but they can still be an effective tool in times of crisis. Expanding current ERPO laws to allow health care clinicians to petition is another way to help patients.

  • Releasing the facilitation of temporary transfer of firearms during times of crisis. These laws are needed to protect recipients of firearms from liability [44, 45].

  • Regulating or prohibiting private ownership of “military-style” weapons and high-capacity magazines. These laws could reduce the risk of shooting casualties [19].

5 Conclusions

For nigh on three decades, the majority of medical professional associations, including the American Academy of Pediatrics, have incorporated firearm injury prevention advocacy into their policy statements, standards of care, and organizational calls to action. Years ago, it was easier to understand why medical professionals might initially be uncomfortable with advocating to reduce firearm injury and violence. Not only were firearms highly politicized, but also it was easier to construe “advocacy” to mean promoting subjective viewpoints over evidence-based practices and forsaking the role of trusted professional for that of biased pundit. Now, in the face of irrefutable evidence that firearm injuries are a public health crisis, staying silent runs counter to a healing ethos. It is no longer ethical [46] to passively confront the impact that firearm injuries and deaths have upon the families and youth; advocacy and local action are prime weapons against this epidemic [47, 48].

Take Home Points

  • Most laws regulating the sale, purchase, and ownership of firearms are instituted on the state, not the federal, level.

  • Pediatric clinicians should be aware of the certain types of laws in their state, including child access prevention (CAP) and extreme risk protection order (ERPO) laws, that are directly related to child safety.

  • Anticipatory guidance by pediatrician clinicians to their patients is important to decrease firearm injuries and deaths to children and youth. Recent attempts by state legislatures to limit physicians’ ability to provide firearm safety anticipatory guidance to patients and families have not been upheld in higher courts.

  • Advocacy on the state level for effective firearm injury prevention legislation can be done in various ways by pediatric clinicians and public health advocates.