SPECIAL ARTICLE

Firearm Injury in the United States: An Overview of an Evolving Problem

Sotirios Tasigiorgos, MS, Konstantinos P Economopoulos, MD, PhD, Robert D Winfield, MD, FACS, Joseph V Sakran, MD, MPH, MPA

Firearm injury is a serious public health problem in the this increase in the crude numbers of firearm-related United States. The prevalence varies among different states deaths, by discharge of firearms dropped out of and age groups. Firearm injuries represent a serious economic the top 15 causes of death in the US in 2010, ending a burden for the US health care system, costing more than $70 45-year period in which had been among the billion annually. The motives for gun purchase and the med- top causes.7 Finally, overall mortality (ie, all gun-related ical and socioeconomic background of gun owners vary deaths) was stable and ranged from 31,224 to 31,672 among the US population, depicting the complexity of the deaths between 2007 and 2010.8 problem. The increasing number of firearm-related inci- Two national public opinion surveys, conducted by the dents, including mass shootings in schools, justifies the Department of Health Policy and Management and the urge for taking preventive measures in order to decrease Center for Gun Policy and Research at the Johns Hopkins the number of gun-related injuries and deaths. These mea- Bloomberg School of Public Health in Baltimore, showed sures entail the contribution of many disciplines within that 33% of respondents have a gun in their home or health care, including physicians, medical organizations, garage; of these, 22% are gun owners themselves and and immediate action from social and political parties. 11% live in an environment with a gun present.9 Among gun owners, the type of gun also varies: 71% own a hand- EPIDEMIOLOGY gun, 62% a shotgun, and 61% a rifle.9 Firearm injury has long been among the leading causes of Gun injuries do not leave children and youth unaf- preventable death in the US,1 accounting for up to 6.6% fected. According to the Centers for Disease Control of premature deaths.2 Recent data show that 67% of ho- (CDC), in 2005, there were more than 3,000 firearm- micides, 50% of , 43% of robberies, and 21% of related deaths in individuals under 15 years of age, of aggravated involve the use of firearms.2 In general, which 822 were suicides, 1,972 were homicides, and 10 gunshots account for 30,000 deaths every year and 160 212 were accidental deaths. Since 1985, firearm death nonfatal injuries every day.2 In 2011, 88 deaths and rates have increased in those under the age of 25 and in 202 nonfatal injuries due to gunshots were noted daily.3 2007, a noteworthy 17% of firearm homicide victims 2 are the second leading cause of injury death were identified as being less than 20 years old. In behind motor vehicle crashes.4 Over the past 30 years, 2010, guns resulted in 6,750 deaths in individuals ages an average of 32,300 deaths were caused by firearms 1 to 24, with the remarkable rate of 7 deaths per 11 annually, with the highest rate observed in 1993 100,000 in those less than 19 years old. On average, (40,000 deaths) and the lowest in 1999 (30,000 deaths).2 20 children and adolescents sustain firearm injuries 12 In 2008, firearms resulted in 12,179 homicides and requiring hospitalization every day. According to a study 56,626 nonfatal injuries2,5; in 2011, there were 32,000 out of Yale and Boston University School of Medicine, firearm deaths and 74,000 nonfatal injuries.6 In spite of 7,391 hospital admissions were due to firearm injuries in children and adolescents younger than 20 years old in 2009.13 However, there was a decrease in the firearm Disclosure Information: Nothing to disclose. death rate (from 8/100,000 in 1993 to 3.5/100,000 in Received July 18, 2015; Revised August 26, 2015; Accepted August 31, 2003) among those under 20 years of age.14 These 2015. From the University of Athens, School of Medicine (Tasigiorgos) and the numbers are understandable when one considers that Society of Junior Doctors (Tasigiorgos, Economopoulos), Athens, Greece; guns are present in one-third of households with children and the Departments of Surgery, Massachusetts General Hospital, Harvard and many times, the guns are left unlocked (32% to 43%) Medical School, Boston, MA (Economopoulos), The University of Kansas 10 Medical Center, Kansas City, KS (Winfield), and Medical University of and loaded (14% to 30%). South Carolina, Charleston, SC (Sakran). Correspondence address: Konstantinos P Economopoulos, MD, PhD, Rural vs urban areas Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 101 Merrimac St, 3rd floor, Office #340, Boston, MA 02114. There is a prevailing misconception that firearm injury is email: [email protected] only a problem in urban environments, but this is not

ª 2015 by the American College of Surgeons. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.430 All rights reserved. 1005 ISSN 1072-7515/15 1006 Tasigiorgos et al Firearm Injury in the United States J Am Coll Surg supported by the literature. Rural areas exhibit greater countries, with a death rate almost 8 times higher than rates of firearm and unintentional injury in other countries, and almost twice as high as that in compared with urban areas, while homicide and the second country in the list.2,6 The US has a mortality are more common in urban areas.2 Specifically, urban rate that is 70 times higher than that in high-income counties have double the homicide rates of rural countries in Asia.3 The US, , South Africa, counties.15 Accounting for these differences in epidemi- Brazil, and Mexico have the highest rates of firearm- ology, rural and urban countries have similar rates of related death.3 Only Brazil has gun homicide rates that firearm deaths overall.15 dramatically exceed those in the US; In 2002, the firearm homicide rates were 21.7/100,000 in Brazil and 10.7/ Comparison of firearm use and morbidity among 100,000 in the US.2 states The US has the second highest rate of private gun Firearm usage rates and firearm morbidity and mortality ownership (Switzerland is higher due to military require- rates vary among states in the US. This variation exists ments).2 Finally, the US leads the list of countries with the mainly due to the different firearm legislation prevailing highest gun-related death rate in youths and children un- in each state. According to a cross-sectional study con- der 15, and this is true for homicides, suicides, and unin- ducted by Fleegler and colleagues,8 the stricter the firearm tentional deaths.2 In the US, firearm-related death rates in laws are in a state, the lower the rates of firearm deaths will children are 12 times higher compared with those in 25 be. Specifically, more intense background checks of gun industrialized countries combined.2 owners lead not only to decreased firearm fatality rates, 8 but also more infrequent household gun ownership. PUBLIC HEALTH IMPACT OF FIREARM INJURY Massachusetts had the strictest laws, while Utah had min- imal regulations, with the expected sequelae in firearm fa- Health care importance tality rates.8 According to data from the WISQARS Firearm injury typically requires immediate treatment at a (Web-based Injury Statistics Query and Reporting Sys- trauma center. Intentional gunshots have a great tendency > tem), Utah had an overall mean of 9.8 firearm fatalities ( 50%) to involve the region of the head and neck, often 2 (homicides and suicides both included) per 100,000 indi- being fatal. On the contrary, unintentional gunshots are > viduals per year; Massachusetts had an overall mean of 3.4 usually ( 70%) in the extremities, where prompt treat- 2 firearm fatalities per 100,000 individuals per year.8 Ac- ment is potentially lifesaving. The length of hospitaliza- cording to CDC reports, firearm death rates were the tion of firearm injury patients is approximately 3 days highest in Louisiana, Alaska, Nevada, Mississippi, and for trauma patients with 4 gunshot wounds and approx- Arizona, and the lowest in Hawaii, Massachusetts, Rhode imately 8 days for patients with 5 gunshot wounds or 2 Island, New York, and Connecticut.2 Firearm suicides 3 affected anatomic regions. were almost always more common than homicides.2 As far as school-related firearm accidents are concerned, the Nonfatal injuries, unintentional injury, death, and 5 states with the most frequent events, from the most costs to the least common, are California (n ¼ 58), Texas Unintentional firearm deaths predominate in those under (n ¼ 31), Florida (n ¼ 24), New York (n ¼ 21), and the age of 20 (16%), and 14% of all firearm death in chil- Pennsylvania (n ¼ 19).16 dren below 15 years old are caused by unintentional gun In another study conducted by the Injury Research injuries.2 Nonfatal firearm injuries exceed the number of Center, the Department of Population Health and the firearm deaths.2,18 The most serious disabilities can range Department of Family and Community Medicine from from amputations to spinal cord injuries, resulting in an the Medical College of Wisconsin, in Milwaukee, it was impaired quality of life and independence, which subse- observed that states having lower firearm fatality rates quently lead to increased cost to society.2 According to are the ones that used local-level (local police or sheriff’s the CDC, the US Department of the Treasury, and the department) background checks.17 The proposed explana- National Institutes of Health Office of the Budget re- tion was that such checks are far more thorough than ported data, the societal cost of firearm injury ranks eighth those at the federal and state level.17 in the US government expenditure list of 2010, with a cost of $174.1 billion.19 If work loss, emergency transport, Comparison of the United States with the rest of police service, criminal justice, insurance claims process- the world ing, employment cost, lost quality of life, lost US govern- The US is first in overall firearm-related deaths when ment tax revenue, medical care, and mental health services compared with the world’s other 22 high-income are taken into consideration, the cost of caring for Vol. 221, No. 6, December 2015 Tasigiorgos et al Firearm Injury in the United States 1007

firearm-related victims was 3 times higher than the expen- firearm injury-related patients, private insurers pay for ditures for the US Department of Homeland Security.19 18%, and the rest is paid by the patients.22

Psychological impact PSYCHOSOCIAL IMPLICATIONS A survey published after the in 2007 at Vir- ginia Tech demonstrated that all female victims had Motives for gun purchase developed post-traumatic stress disorder (PTSD) within The most common motive for firearm purchase is per- 2 2 months after the event.20 Symptoms persisted at 6 sonal protection. Data are lacking as to whether gun months in 25% of patients.20 Loss of resources after ownership decreases or increases the risk of being 2,23 such mass shooting events plays a major role in predicting assaulted, with the odds favoring the latter. Some whether victims will develop post-traumatic stress disor- have proposed that owning a gun imbues the perception der and if they will be able to adjust back to the same of excessive power, which can lead to potentially rhythms of life that they used to live.20,21 Resources may dangerous situations, such as over-reacting or entering include tangible items (eg, clothing, vehicles) or condi- dangerous environments, that otherwise might be 23 24 tions (eg, employment), and may be interpersonal (eg, avoided. This theory is known as “contagion.” Young affection, intimacy) or intrapersonal (eg, sense of people tend to exaggerate and overestimate the situation, hope).21 Littleton and colleagues21 stated that after the believing that most of their peers actually carry a gun and 24 mass shooting at Northern Illinois University, most stu- are dangerous. A belief that may be true is that some of dents witnessing the shooting suffered primarily from the young urban dwellers, especially those living in large loss of motivation to get things done (52%), had trouble cities, usually carry a gun in order to defend themselves 3,15 sleeping (50%), believed their life was no longer peaceful when being threatened or insulted. (47%), and lost their optimism (40%). Motives could also be completely different based on the type of gun. Short guns (handguns, not rifles or shotguns) Medical costs are usually purchased for protection; long guns are bought 25 Firearm injuries represent a serious economic burden for mostly for sporting reasons. Other motives for gun the US health care system, costing more than $70 billion ownership that are not commonly presented in the litera- annually, including both costs from medical expenditures ture include: concomitant drug trafficking (mainly for and loss of productivity.6 Total costs from all firearm in- protection in case “things go wrong”), alcohol abuse, juries are estimated to be $123 billion (direct costs from fights over the opposite sex, cultural and religious beliefs, 11,26 injury plus cost of pain, suffering, and lost quality of life).3 gun club memberships, and racism. In 1994, the cost per injury was estimated to be $17,000, with lifetime costs for all injuries reaching Medical and socioeconomic background of gun $2.3 billion; acute care costs for living gunshot trauma pa- owners tients range from $11,023 to $21,324 and lifetime costs The average gun owner has been described as a middle- per nonfatal injury are $35,367.2,3,22 Acute care costs are aged man, living in a rural area in the South or Midwest, insignificant compared with the lifelong medical coming in contact with guns from a young age, and being needs.2,3,22 Specifically, in 2005, firearm deaths and raised with a “gun mentality.”3,25 The leading cause of nonfatal injuries cost $122 million and $599 million death among US black males and the second leading cause from the health care funds, respectively.8 Loss of working of death in US Hispanics is homicide, 9 of 10 times being hours resulted in an estimated $40.5 billion economic due to firearm injury.15 Previous conviction for crimes or loss.8 Noticeably, government resources cover 40% to misdemeanors increases the likelihood of involvement in 50% of these costs, 18% are covered by private insurance, gun violence by a factor of 9.27 Women in the US, and 33% by other resources.3 According to a primary although a minority in gun deaths, die at a higher rate research study from Massachusetts General Hospital, when compared with rates in other countries worldwide.3 approximately 75% of firearm injury-related patients pre- The question as to whether or not mental illness poses a senting to the were not insured or significant risk for firearm injury has been addressed; covered by Medicare/Medicaid programs, resulting in an mental illness, per se, does not lead to firearm injuries.4 increased burden on society.19 Because many victims are Mentally ill people are not more predisposed to violent unable to pay for their medical expenses and hospitals behavior compared with mentally healthy ones, but defer this unpaid debt, the costs burden other patients, rather, they need to be emotionally provoked or chal- resulting in increases in private insurers’ claims.3 Govern- lenged to precede to such actions.4 For example, usually ment programs pay for 44% of the cost of hospitalized a big shooting massacre is concluded to be a matter of 1008 aiiro tal et Tasigiorgos

Table 1. Mass Shootings from 1990 to 2015 in the United States Previous access to States United the in Injury Firearm Deaths, Injuries, Status of History of Criminal Cause of guns*/ history y Date Location n n killer mental illness background death of using guns June 17, 201544 Emanuel African Methodist 9 1 Eastover citizen No History of arrests, e No Episcopal Church, narcotics, racial Charleston, SC discrimination October 16, 201345 Headquarters of the 12 3 Former US Paranoia and History of felonies Killed by Yes Naval Sea Systems Navy member other minor and misconduct police fire Command (NAVSEA), mental illnesses, Navy Yard, the Hum (persistent Southeast Washington, DC and invasive low-frequency humming, rumbling, or droning noise not audible to all people) July 20, 201246 Century Movie Theater, 12 70 Audience member n/a No e n/a Aurora, CO April 3, 200946 American Civic Association 13 4 Former English n/a Forgery Committed n/a immigration center, student suicide Binghamton, NY October 16, 199147 Restaurant, Killeen, TX 23 27 Killeen citizen No No Committed Yes suicide *Previous access to guns through family or friends or membership in gun clubs. y Incidents of illegal behavior using guns. mCl Surg Coll Am J Vol. 221, No. 6, December 2015 Tasigiorgos et al Firearm Injury in the United States 1009

Figure 1. Mass shootings from 1990 to 2015 in the United States. revenge, anger, and long-term planning, and access to until today. Table 2 and Figure 2 summarize the mass guns.4,9 However, mental illness is strongly associated school shootings (occurring exclusively in the campus of with increased risk of suicide, which accounts for more each school) with more than 5 victims occupying the than half of US firearms-related deaths.28,29 mass media from 1990 until today. The main source of the tables was the comprehensive databases listed in Wiki- Rehabilitation of gunshot victimsdpsychological pedia. Additional data were extracted from various sources impact for each shooting event, as indicated in Tables 1 and 2. Interestingly, social media appears to be playing a role in If we sum up all the school shootings that took place victim rehabilitation after school shootings. A study after across the US in the past 5 years, we will note 8 school the Virginia Tech incident demonstrated that victims turned shootings in 2010, 10 in 2011, 14 in 2012, 32 in 2013, to the internet, and specifically, social networks such as Face- and 39 shootings in 2014 (up to October 31, 2014). book, to help facilitate their rehabilitation.30 Although there This steady increase in numbers and the big difference be- is no consensus in the literature that such activities improve tween 2012 and 2013 are not enough to justify the urge for the victims’ psychological status, they constitute a means of taking measures with the aim to prevent mass shootings, expressing their feelings.30 In this context, social media may especially in the school environment. Contrary to common meliorate the psychological aftermath through organized belief, however, mass shootings are uncommon. Their fre- rehabilitation efforts and initiatives. quency is not increasing, and they account for only a small fraction of firearm-related deaths and injuries.4 IS THE URGE FOR TAKING PREVENTIVE MEASURES JUSTIFIED? PREVENTION Table 1 and Figure 1 summarize all the mass shootings with According to the American College of Surgeons (ACS) more than 9 victims occupying the mass media from 1990 Statement on Firearm Injuries, published on January 1010 aiiro tal et Tasigiorgos

Table 2. School Shootings from 1990 to 2015 in the United States Previous History of access to

Deaths, Injuries, Status mental Criminal Cause guns*/ history States United the in Injury Firearm y Date Location n n of killer illness background of death of using guns May 23, 201448 University of California, 713 Santa Barbara, Isla Vista, CA December 14, Sandy Hook Elementary 28 2 Former student Sensory-integration No Committed Yes 201249 School, Newtown, CT disorder, Asperger suicide syndrome, obsessive- compulsive disorder April 2, Oikos University, 7 3 Former student Paranoid schizophrenia Minor felonies e No 201250 Oakland, CA April 16, Virginia Polytechnic Institute 32 17 Senior student Severe depression, Incidents of aberrant Committed Yes 200751 and State University, selective mutism, behavior suicide Blacksburg, VA anxiety disorder March 21, Red Lake Senior High School, 10 7 Former Behavioral issues, No Committed Yes 200551,52 Red Lake MN student depression suicide April 20, Columbine High School, 15 21 Senior students Depression, anger, No Committed Yes 199953 Columbine, CO suicidal thoughts, suicide bullying victims March 24, Westside Middle School, 5 10 Students Sexual abuse Incidents of aberrant e Yes 199854 Craighead County, AR behavior, sexual abuse November 1, University of Iowa, 5 1 Former graduate No No Committed No 199155 Iowa City, IA student suicide *Previous access to guns through family or friends or membership in gun clubs. y Incidents of illegal behavior using guns. mCl Surg Coll Am J Vol. 221, No. 6, December 2015 Tasigiorgos et al Firearm Injury in the United States 1011

Figure 2. School shootings from 1990 to 2015 in the United States.

16, 2013, any prevention measures are subject to 5 main more time in research to better understand behavioral directions: counseling and screening by health care profes- factors that potentially lead to firearm-related injuries.4 sionals; evidence-based research and national firearm Pediatricians engage in counseling by advising parents injury database creation; programs aimed at improving owning firearms to take safety measures and encourage gun safety and forming a nonviolent culture; legislation discussions with them regarding potential risks.11 banning civilian access to military and law enforcement Studies have shown that pediatricians support the efforts associated weaponry; and mandatory background checks for restricting guns more than the general population, for firearm purchase.31 The ACS, along with other physi- but they may need more training and expertise to fulfill cian organizations (American College of Physicians, this great responsibility.14 Social and political organiza- American Academy of Family Physicians, American tions usually look to emergency physicians and trauma Academy of Pediatrics, American College of Emergency surgeons to address firearm-related incidents and Physicians, American Congress of Obstetricians, and Gy- contribute to a solution by taking the appropriate mea- necologists and American Psychiatric Association), and sures each time, such as informing the public about gun supported by the American Public Health Association violence, forewarning gun carriers about gun safety, and and the American Bar Association, has already advocated screening for mental illness.6 The American College of a multifaceted public health approach to the problem and Physicians, which represents US internists and related suggested that the Second Amendment does not preclude subspecialists, in addition to advising patients about taking measures to reduce firearm violence.32,33 gun ownership, needs to encourage their members to advocate for legislative measures to reduce gun Counseling and screening by health care violence.34 Betz and Wintemute35 proposed that physi- professionals cians who own guns (13% to 41% among doctors) Prevention of firearm violence is pertinent to many dis- need to develop “cultural competence” in firearm- ciplines within health care. Psychiatrists need to invest related issues and, in a nonjudgmental, respectful, and 1012 Tasigiorgos et al Firearm Injury in the United States J Am Coll Surg empathetic way, provide gun owners and other high risk than poverty and limited education.10 Other factors iden- groups (eg, suicidal patients,children)withproperand tified are night-time activities or limited guardianship for relevant counseling. children; however, these have only a minor impact in increasing the risk of being a victim of a gun-related Evidence-based research and national firearm injury event.3 Miller and associates41 suggest that gun ownership database creation increases the possibility of overall suicide and firearm sui- In 1995, gun rights advocates, having the support of the cide, but it does not affect the unrelated-with-firearm sui- National Rifle Association (NRA), unsuccessfully cide rates.41 required Congress to eliminate the already functioning Collective efforts to reduce gun carrying through adult National Center for Injury Prevention and Control mentorship and youth advocacy programs may reduce (NCIPC). However, CDC and NIH funding was cut gang involvement.24 More research is needed to examine by $2.6 million, leading to decreased funding for gun the potential association of media/video games violence control-related research.6,36,37 As a result, research with firearm injury.11 regarding firearm injury has become more scarce, leading Teachers, school nurses, parents, police officers, and to the increased number of publications addressing this military personnel could play an important role in issue.2 Physicians were also restricted by federal laws decreasing firearm-related tragedy rates by informing chil- from discussing gun safety issues with their patients.6,36,37 dren on matters related to firearm usage and subsequent The HELP network (Handgun Epidemic Lowering Plan) injuries.10,16 On the other hand, some believe that it and the DAHI network (Doctors Against Handgun Injury) should be avoided because this information could unin- are 2 organizations that include large medical societies, tentionally expose children to gun usage and lead them including the American College of Surgeons, the American to purchasing and using guns.10,16 College of Physicians, and the American Medical Associa- An encouraging step toward reducing firearm carrying tion.38 In addition to focusing on educating physicians and and subsequent injuries and death has been made in Bal- discussing new legislations on gun policy, respectively, they timore, where a program has formed according to the could urge their members into more research on this field.38 standards of a similar program in Chicago known as The Children’s Hospital of Philadelphia launched the “CeaseFire.” In summary, “SafeStreets,” as the Baltimore Violence Prevention Initiative, a program using research program has been called, sends social workers (sometimes protocols to integrate evidence-based ways of firearm ex-offenders) into action, particularly during evening injury prevention into everyday practice.39 hours, when most shootings take place, and they interact with young people who are at high risk of carrying a gun Programs aimed at improving gun safety and and being involved in associated violence. Such social forming a nonviolent culture workers build a relationship, discuss, exchange ideas Exposure to violence in the community and development with potential future gun carriers, and try to steer them of a violent behavior are major factors that put individuals away from violence. In the context of these programs, at great risk when using firearms.40 The Firearm and possible conflicts between gangs are also solved, and Injury Center at the University of Pennsylvania acknowl- monthly educational events are organized. These pro- edges that risks factors for firearm injury can be divided grams have been able to demonstrate a post- into 2 major categories: gun-related, shooter-related, implementation decrease in firearm-related events.15 and environment-related.2 Gun-related factors entail a Finally, gun buyback programs could potentially gun’s sale, its safe storage, and whether its design makes decrease gun carrying in the population.1 The Injury it easy to use.2 Attitude and behavior, special incentives, Free Coalition for Kids-Worcester (IFCK-W) Goods for political factors, and psychosocial factors are a few of Guns buyback in Worcester, MA aims to empty houses the important risk factors related to the shooter and the of inappropriately stored guns, to educate the public on environment.2 the relationship between unsafely stored guns in homes Another risk factor worth mentioning is gang member- and increased gun accidents, and it offers alternatives ship, which primarily concerns young members of society. and solutions.1 This relatively inexpensive measure resulted Members of gangs have reported using a firearm 34% of in 1,861 guns being collected.1 In addition, 7,010 people the time (vs 3.5% of young people who are not gang returned their guns (gun buyback) and 75 trigger locks members).24 The ability to easily access a gun is a notable have been distributed per year, resulting in safer storage.1 risk factor for firearm-related injury, especially in children This resulted in a significant decrease in firearm injuries who familiarize themselves with guns at young ages within and mortality in Worcester County compared with other their homes. This correlation has a more significant effect Massachusetts counties in the last 15 years.1 Vol. 221, No. 6, December 2015 Tasigiorgos et al Firearm Injury in the United States 1013

Legislation banning civilian access to military 2. Penn FICa. Firearm injury in the US. 2011. Available at: weaponry and mandatory background checks for http://www.thecrimereport.org/system/storage/2/73/6/1011/ firearm purchase ficap.pdf. Accessed: July 15, 2015. 3. Baroni S, Richmond T. Firearm violence in america: a growing Recently, after the Newtown mass shooting, the govern- health problem. Crit Care Nursing Clin N Am 2006;18:297e303. ment published a list of measures that it was willing to 4. Wintemute GJ. Tragedy’s legacy. N Engl J Med 2013;368: take in order to control gun violence, one being extensive 397e399. background checks for gun owners. Government could 5. Vittes KA, Vernick JS, Webster DW. Legal status and source of offenders’ firearms in states with the least stringent criteria keep guns out of the hands of people with a history of for gun ownership. Inj Prev 2013;19:26e31. violence, drug addicts, previous convicts, and under- 6. 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