Applying Behavioral Economics to Enhance Safe Firearm Storage Katelin Hoskins, MSN, MBE,a,b Unmesha Roy Paladhi, MPH,d Caitlin McDonald, MPH,d Alison Buttenheim, PhD, MBAa,b,c

Behavioral economics applies key principles from psychology and economics abstract to address obstacles to behavior change. The important topic of pediatric firearm injuries has not yet been explored through a behavioral economic lens. Pediatric firearm-related injuries are a significant public health problem in the United States. Despite American Academy of Pediatrics guidelines advising that firearms be stored unloaded, in a locked box or with a locking device, and separate from ammunition, estimates suggest that ∼4.6 million children live in homes with at least 1 loaded and unlocked firearm. In this article, we use behavioral economic theory to identify specific cognitive biases (ie, present bias; in-group, out-group bias; and the availability heuristic) that may influence parental decision-making around firearm storage. We illustrate situations in which these biases may occur and highlight implementation aDepartment of Family and Community Health, School of Nursing, bLeonard Davis Institute of Health Economics, prompts, in-group messengers, and increased salience as behaviorally cCenter for Health Incentives and Behavioral Economics, and informed strategies that may counter these biases and subsequently enhance dPerelman School of Medicine, University of Pennsylvania, safe firearm storage. We also describe other opportunities to leverage the Philadelphia, Pennsylvania behavioral economic tool kit. By better understanding the individual Ms Hoskins, Ms Roy Paladhi, and Ms McDonald behavioral levers that may impact decision-making around firearm storage, drafted the initial manuscript and reviewed and revised the manuscript; Dr Buttenheim revised the behavioral scientists, pediatric providers, and public health practitioners can manuscript critically for important intellectual partner to design and test tailored interventions aimed at decreasing content; and all authors conceptualized and pediatric firearm injuries. Further empirical study is warranted to identify the designed the manuscript, approved the final fi manuscript as submitted, and agree to be presence of speci c biases and heuristics and determine the most effective accountable for all aspects of the work. behavior change strategies for different subpopulations. DOI: https://doi.org/10.1542/peds.2019-2268 Accepted for publication Dec 9, 2019 Address correspondence to Katelin Hoskins, MSN, BEHAVIORAL ECONOMICS AND FIREARM a cognitive bias that refers to the MBE, School of Nursing, University of Pennsylvania, STORAGE BEHAVIORS “ ” 418 Curie Blvd, Philadelphia, PA 19104. E-mail: tendency to rely heavily ( anchor )on [email protected] 1 value when making decisions; the Behavioral economics applies key PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, principles from psychology and initial, irrelevant starting point then 1098-4275). influences future estimates.1 By economics to address obstacles to Copyright © 2020 by the American Academy of behavior change. Whereas economists addressing the subtle decision errors Pediatrics that occur in everyday life, behavioral describe human beings as logical, FINANCIAL DISCLOSURE: The authors have indicated rational decision-makers, behavioral economics offers insights and tools that they have no financial relationships relevant to this economists recognize that predictable can support better choices. Although article to disclose. and systematic errors in judgment pediatricians and behavioral FUNDING: No external funding. 1,2 characterize human decision-making. economists recently have POTENTIAL CONFLICT OF INTEREST: The authors have To adapt to a complex world, humans collaborated on ideas to support indicated they have no potential conflicts of interest rely on unconscious cognitive biases parental behavior change and boost to disclose. and simplifying heuristics. These clinical effectiveness (notably around – processing aids and mental shortcuts vaccination),3 5 the important topic of To cite: Hoskins K, Roy Paladhi U, McDonald C, can be helpful, but they can also lead to pediatric firearm injuries has not yet et al. Applying Behavioral Economics to Enhance decisions not in one’s best interests. been explored through a behavioral Safe Firearm Storage. Pediatrics. 2020;145(3): e20192268 For example, the anchoring effect is economic lens.

Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 145, number 3, March 2020:e20192268 SPECIAL ARTICLE Pediatric firearm-related injuries are stored.19 Shifting patterns of gun We aim to educate pediatricians a significant public health problem in ownership, especially the increase in about behavioral economic concepts the United States, with firearms as the handgun ownership for personal that could inform clinical practice leading mechanism of injury death for protection, amplifies the risk of but are still in need of testing to 10- to 24 year-olds in 2017.11 More pediatric injury given that handguns determine if, and in which groups, than half of child and adolescent are more likely to be stored loaded they are effective. We will explore firearm deaths were homicides and unlocked.14,17,20 Estimates implementation prompts, in-group (59%), followed by suicides (35%) suggest that ∼4.6 million children live messengers, and increased salience as and unintentional injuries (4%).12 in homes with at least 1 loaded and behaviorally informed strategies that From 2007 to 2014, firearm suicides unlocked firearm.14 may enhance safe firearm storage in children trended up, and between practices. We will also describe other Evidence to date for safe storage 2002 and 2014, 60% of the firearm relevant behavioral science interventions is varied. Gun suicides among children were constructs. avoidance programs directed to completed with a handgun.13 The children do not reduce risk,18,21 and majority of both younger and older the effects of child access laws vary DEPLOY IMPLEMENTATION INTENTION children who died by firearm suicide by strength and state.22,23 Firearm PROMPTS TO COUNTER PRESENT BIAS or unintentional firearm injury training in its current form is not received the fatal injury in the Present bias is the tendency of most associated with storing firearms home.13 Firearms are present in individuals to overemphasize the safely.24 In contrast, pediatrician approximately one-third of US present and discount the future. In screening, brief counseling, and households.14 Households, especially health-related decisions, present bias distribution of cable locks to firearm- those with children, with a firearm leads to overweighting the immediate owning parents (bundled with other present are at an increased risk for costs of following through with an violence prevention interventions) intentional and unintentional intention and underweighting led to improvements in parental injury.15,16 potential future benefits.6 Take reports of lock use.25 The physical activity for example: Consistent safe firearm storage may development and evaluation of individuals will overvalue the short- meaningfully reduce both fatal and approaches to engage parents in safe term costs, such as the time, energy, nonfatal pediatric injuries. Safe firearm storage are urgently needed, and financial costs, associated with storage is defined as “practices that especially in light of the Monuteaux exercising as opposed to the long- limit accessibility to guns by et al26 finding that a modest (20%) term benefits, such as weight loss, unauthorized users.”17 The American uptake of a direct safe firearm storage reduced risk of heart disease, and Academy of Pediatrics (AAP) states recommendation among adult overall improvements in health.6 The that the absence of guns in homes and firearm owners in households with future seems uncertain and unknown, communities is the most effective children could result in meaningful leading individuals to put more value way to prevent pediatric firearm- reductions in both unintentional on the present. Although individuals related injuries.18 If firearms are injuries and suicide. may have strong intentions to present in the home, AAP guidelines The problem of unsafe firearm accomplish a particular task, present advise that pediatricians counsel storage reflects broad structural bias may interfere with execution. families that firearms should be challenges but is also an individual Implementation intention prompts stored unloaded, in a locked box or behavior driven by individual are a potential strategy to counter with a locking device, and separate decision-making. By focusing on present bias. One type of an from ammunition.18 Locked boxes individual behavioral levers, the field implementation intention prompt is include gun safes or cabinets, and of behavioral economics offers a commitment contract. Simply locking devices include trigger or insights that may complement asking people to declare, “In situation cable locks. current public health approaches to X, I plan to do Y” can increase Despite these recommendations, increasing safe firearm storage. In achievement of the desired goal.27 approximately one-fifth of gun this article, we use behavioral Developing this intention fosters owners store at least 1 gun loaded economic theory to identify specific a connection between the desired and unlocked.14,16 Strikingly, only cognitive biases that may influence action and a concrete future moment. 46% of US adults who own a firearm parental decision-making, illustrate Milkman et al27 found that employees report safely storing all of their situations in which these biases may who received a specific prompt to firearms,17 and nearly 40% of parents occur, and propose potential write down both a date and time for wrongly believe that their child does strategies from the behavioral flu vaccination had a significantly not know where their firearm is economic tool kit to counter them. higher vaccination rate.

Downloaded from www.aappublications.org/news by guest on September 23, 2021 2 HOSKINS et al Actual parental firearm storage that increases the likelihood of norm to increase disapproval of behaviors may not align with completing the desired action.28 This texting while driving. Promotion of intentions. Parents may indeed intend commitment could include a write-in skin protective behaviors, such as to store their firearms safely, but section for buyers to identify the applying sunscreen, has been logistic issues or obstacles interfere. exact date and time this action would influenced by interventions seeking Hassle factors are the minor occur; for example, “I am committed to harness social descriptive norms.29 inconveniences that interfere with the to keeping my child safe from injury. I Multiple stakeholder groups, alignment of intentions and actions. will do this by securing my firearms including shop owners, large Although yet to be explored by [insert storage method] on [insert retailers, and law enforcement empirically, the presence of minor date] at [insert time].” Additional officers, may influence firearm inconveniences may impede venues where commitment contracts owners’ behaviors. Barber et al31 consistent completion of safe firearm may be implemented include school highlight the success of the Gun Shop storage. Furthermore, parents may functions, pharmacies, and Project, a collaborative endeavor to lack urgency to store firearms safely pediatrician practices, which may engage firearm retailers, gun rights if they do not believe that their child effectively target the subpopulation of advocates, and suicide prevention will actually handle an unsecured parents that is open to safe firearm groups in an effort to reduce suicide firearm. Although storage intentions storage but needs prompting to take by firearms. Gun owner groups were not specifically addressed, action. are trusted members within their Baxley and Miller19 found that communities and thus key parents misperceived their children’s USE IN-GROUP MESSENGERS TO messengers; building on shared knowledge about firearm storage and INFLUENCE SOCIAL NORMS values of protection and how their children would react if they responsibility enabled this successful encountered a firearm. Parents may Social norms are the common partnership.31 In a nationally perceive the present risk (fatal or standards for behavior for members representative survey, Crifasi et al17 nonfatal injury) as low and the of a social group.29 Descriptive norms found that firearm owners identified potential future benefits (not being relate to perceptions of how others the National Rifle Association, injured) as too intangible or generally behave in a given situation, hunting or outdoor groups, active improbable. The low perceived whereas injunctive norms relate to duty military personnel, and law benefits are insufficient to overcome socially approved or unapproved enforcement as the most effective the immediate costs. Cost may also be behavior (ie, how one should communicators of safe gun storage, in conceptualized as the time spent behave).29 When a particular course contrast to physicians and celebrities. developing a safe storage plan, such of action is unknown or unclear (such Jager-Hyman et al32 noted the as selecting the storage device (eg, as recycling a specific item) opportunity for community- specific type of safe), deciding where descriptive norms provide helpful partnered approaches to ensure that to locate it in the home, and guidance (recycle X item in Y firearm safety interventions respect establishing consensus between container). The threat of disapproval various stakeholders’ needs. caregivers. for inappropriate behavior or assurance of approval for compliance One strategy to target social norms As a nudge (that is, an intervention to drives injunctive norms (recycling is with positive messaging is for socially influence behavior predictably expected in our community) and connected retailers to position gun without restricting choice)2 toward subsequently motivates behavior.29 locks in aisles with baby-proofing safe firearm storage that would Given that individuals tend to trust safety items, such as outlet plug counter present bias through individuals within their communities covers and infant gates. Walmart, one implementation intentions, firearm as opposed to outsiders (in-group, of the nation’s largest firearm distributors could offer buyers out-group bias), engagement of in- retailers, offers hundreds of baby- a commitment contract at the point of group messengers is one strategy to proofing items and even displays sale. In the commitment contract, harness injunctive norms by applying a “safety guards and locks” category the buyer commits to following social pressure on peers to perform on their Web site.33 Firearm safes, best practices for safe storage. the expected behavior.7 For example, electronic lock boxes, standard lock Commitment contracts compel in their study of teenagers, Atchley boxes, firearm cases, and cable locks individuals to align future actions et al30 found that teenagers viewed could be cross-listed in this category. with current intentions. They require both driving drunk and driving while Adding lock boxes and locking neither material rewards nor texting as irresponsible. Various devices to the standard baby-proofing penalties; the writing of the public health texting and driving checklist not only capitalizes on this commitment itself is the mechanism campaigns leveraged this injunctive parental subpopulation’s desire to

Downloaded from www.aappublications.org/news by guest on September 23, 2021 PEDIATRICS Volume 145, number 3, March 2020 3 protect children from harm but also own a gun.34 Individuals who own could not only increase salience but sends a message that the social norm guns for protection are more likely to also change mental models, the is to secure firearms in the earliest store at least 1 gun loaded and identities and concepts that help stages of a child’s development. unlocked.14 Furthermore, nearly 40% people make sense of the world,9 by Adding a message (based on previous of owners report that a gun is both normalizing conversations around evidence) that the majority of gun loaded and easily accessible to them firearm safety. Given that owners report that “all guns should all of the time at home, consistent pediatricians may be perceived as an be kept in a locked place when there with the desire to be prepared in the out-group by some firearm owners, are children living in the home”34 event of a home invasion.34 In this local firefighters and law enforcement further reinforces that the in-group subpopulation, the availability could also distribute these finds safe storage acceptable. heuristic may contribute to gun prescriptions during neighborhood owners overweighting the risk to car seat installation safety checks and INCREASE SALIENCE TO ADDRESS their personal safety compared with emphasize a key message: keep your AVAILABILITY HEURISTIC the risk of their child or adolescent kids safe on the road and at home. gaining access to the firearm, which These interventions would reframe The availability heuristic refers to the could result in injury to self or others. the idea of safety as more than tendency to overweight events that Excess worry about the wrong, but protection from threats out in the are brought to mind more easily than more culturally salient, risk can have world but also those potentially events that are less easily imagined.8 major consequences. In a Philadelphia present in the home. This mental shortcut relies on top-of- magazine article, Temple University mind examples when making an trauma outreach coordinator, Charles LEVERAGING THE FULL BEHAVIORAL evaluation. Individuals may use the Young, attempts to debias threat ECONOMIC TOOL KIT number of examples recalled to infer risk assessments informed by the the frequency of broader occurrence. Many other constructs from availability heuristic: “I did the math. Reliance on example recall can lead to behavioral science may impact You know how many hours a bad guy errors in assessing probabilities.8 parental decision-making around was in my house last year? Zero.… Consequently, individuals may base firearm storage (Table 1). For You know how many hours children beliefs on the most readily accessible example, the overconfidence effect is were in my house? Several thousand. fact or a quick impression rather than the misreckoning of probabilities in I’m just playing the laws of fully considering the issue at hand. which an individual’s subjective probability.”37 For example, an individual’s confidence in their ability (ie, assessment that train travel is adeptness, skill) is greater than their It is possible to capitalize on the 9 increasingly dangerous, based on availability heuristic by increasing the actual performance. Given the 24 fi recall of 2 recent train crashes, may salience (ie, the vividness) of an event Berrigan et al nding that gun lead to the erroneous belief that car to promote recall. Interventions that owners who reported having received 35 36 fi travel is safer. In a study by An, increase the salience of both formal rearms training were more individuals with a high recall for intentional and unintentional injury likely to store a gun loaded and antidepressant direct-to-consumer due to unsafe storage may be unlocked, is there a link between fi ’ advertising estimated a higher particularly effective for the training and overcon dence in one s fi prevalence of depression than subpopulation of parents who keep ability to handle a rearm safely? If fi individuals with low advertising firearms in the home for protection. so, speci c elements of training could recall. The antidepressant advertising To cue parents to the importance of be tailored to address this bias. fi was the basis for their determination safe firearm storage, pediatricians Furthermore, if rearm-owning of the prevalence of depression; the parents do in fact routinely misjudge 36 could provide preprinted media primed this belief. “prescriptions” with key elements of their ability to act in a crisis state, Individuals may be primed to threats the AAP guidelines along with the training or other interventions could outside the home given the locations of nearby retailers that sell systematically address the hot-cold prominence of mass shootings and locking devices. Firearm safety empathy gap, the tendency to fl gun violence in the media. Overall, prescriptions could be bundled with underestimate the in uence of 69% of all US adults (and 75% of other routine preventive touchpoints visceral states (eg, anger, fear) on ’ 9 those who own a gun) say the world (eg, screenings for lead at a 9-month one s behavior. has become a more dangerous well visit or substance use in Optimism bias is the tendency to place.34 Most (67%) gun owners adolescents). The bundling of firearm overestimate the likelihood of report that personal or family safety prescriptions with other positive events and underestimate protection is a major reason that they routine pediatric health interventions the likelihood of negative events.9

Downloaded from www.aappublications.org/news by guest on September 23, 2021 4 HOSKINS et al TABLE 1 Examples of Behavioral Insights to Enhance Safe Firearm Storage the choice communicator by Behavioral Science Definition Potential Application to Firearm emphasizing losses tied to the Construct Storage Behavior nonpreferred alternative42: “I want to Present bias Tendency to overemphasize the present Poor follow-through on storage due to store my firearm unloaded and locked versus the future6 immediate costs (eg, time, energy) in a gun safe to reduce my child’s risk and intangible and/or improbable of injury” versus “I don’t want to fi future bene ts store my firearm unloaded and locked In-group, out-group Tendency of people to trust individuals Increased trust of in-group members ’ bias within their communities as opposed (eg, military, law enforcement) in a gun safe and don t want to reduce to outsiders7 my child’s risk of injury.” Like other Availability Tendency to overweight events that are Overweighting the risk to personal firearm safety interventions, use of heuristic brought to mind more easily than safety (eg, from home invasion) enhanced active choice would require 8 events that are less easily imagined compared with the risk of accidental stakeholder input into the wording child injury Mental models Identities, concepts, and stereotypes Identity of parents as protectors from and broader implementation to that help people make sense of the outside harms support, rather than undermine, the world9 belief that individuals are making the Overconfidence Misestimation of probabilities in which Overconfidence in one’s ability to handle safe choice for their households. effect an individual’s subjective confidence a firearm safely in their ability is greater than their actual performance9 Hot-cold empathy Tendency to underestimate the Overestimating the ability to protect CONCLUSIONS gap influence of visceral states (eg, oneself in a crisis-hot state anger, fear) on one’s behavior or Although the field of public health has 9 preferences made great strides in reducing the Optimism bias Tendency to overestimate the Belief that one’s own child is unlikely to probability of positive events and experience an injury number of childhood injury-related underestimate the probability of deaths, such as those caused by negative events9 motor vehicle crashes and drownings, Information Physical avoidance, biased Avoidance in attending to child’s progress to date in preventing avoidance interpretation of information, or increased risk for suicide firearm-related deaths (specifically inattention to readily available information9,10 intentional injuries) has been more 12 Choice overload The greater the number or complexity Wide range of firearm storage options limited. We believe that behavioral of offered choices, the more likely the and suboptions leading to deferred economic insights can contribute individual is to defer the choice9 action to injury prevention efforts. Implementation prompts, engaging in-group messengers, and increasing Individuals tend to view the risks for Ongoing research on risk salience are 3 discrete strategies to themselves as lower than for others communication, particularly related promote safe firearm storage by in similar situations. Optimism bias is to visual aids,10 may help counter addressing present bias; in-group, more likely to occur if negative these barriers. out-group bias; and the availability outcome is perceived as unlikely. heuristic. Mental models, Scott et al38 found that a child’s With choice overload, the greater the overconfidence effect, hot-cold history of risk factors for self-harm number or complexity of offered empathy gap, optimism bias, does not appear to affect caregiver choices, the more likely the individual information avoidance, and choice decisions about whether to keep is to defer the choice.9 Given the wide overload are other relevant firearms in the home or store range of storage options (firearm behavioral constructs that may factor firearms locked and unloaded. safes, electronic lock boxes, standard into the decision-making of parents Parents or other caregivers may lock boxes, firearm cases, and cable who elect to keep firearms in the overestimate their child’s well-being locks41) and suboptions within all of home. Although these behavioral or underestimate their child’s risk for these categories, are parents ever constructs are supported by suicide.39 Information avoidance overwhelmed with choices? If so, behavioral economic theory, 1 (physical avoidance, biased a default option might be used to limitation is that they have not yet interpretation of information, or reduce friction around choice; been studied empirically in the inattention) may also factor in.9,40 defaults are frequently used in the context of firearm storage. We also Given the difficult topic of suicide, behavioral economic “choice recognize that parental decision- parents may be more likely to avoid architecture” tool kit. Alternatively, making is complex, inevitably value information to mitigate anxiety or enhanced active choice is one strategy laden, and not cleanly bounded by maintain consonance in their beliefs. that promotes the option preferred by behavioral science.

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2020/02/21/peds.2 019-2268 References This article cites 30 articles, 8 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2020/02/21/peds.2 019-2268#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Injury, Violence & Poison Prevention http://www.aappublications.org/cgi/collection/injury_violence_-_poi son_prevention_sub Firearms http://www.aappublications.org/cgi/collection/firearms_sub Public Health http://www.aappublications.org/cgi/collection/public_health_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

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