Intervention research priorities
to reduce gun injury
Charles Branas, PhD
University of Pennsylvania
Philadelphia, USA
Public health intervention research
priorities to reduce gun injury
1) Alcohol and mental health
2) Place-based strategies
3) Laboratory simulation trials
Chosen based on:
Innovation, scale of impact, feasibility/acceptability,
and/or sustainability
Alcohol abuse
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Alcohol abusers at increased risk of victimization and perpetration of
gun violence and self harm
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“Federal law does not bar alcohol abusers from acquiring firearms”
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Drunk driving laws have been generally effective
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Intervention studies pertaining to firearms and acute intoxication,
alcohol points-of-sale, and public drunkenness
•
Some state laws prohibit alcohol abusers from buying guns but lack
objective disqualifiers for background checks (e.g. “habitual drunkard”)
Rivara et al, JAMA 1997
Webster et al, IP 2009
Branas et al, ACER 2009
Branas et al, SUM 2012
Variation in alcohol and firearms laws
In 2009:
• 18 states restricted gun
ownership by habitual
alcohol users
• 12 states restricted gun
possession where alcohol
was sold
• 26 states restricted guns
for intoxicated persons
(sale or possession)
For intoxicated persons:
Carr et al, PHR 2010
Mental health
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“Perpetrators of mass violence are often mentally ill” but the link
between mental illness and violence is incompletely understood
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Interventions that don’t exacerbate stigma of seeking mental
healthcare or violate confidentiality
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Studies to define “serious” mental illness, with respect to firearms
•
Intervention studies of firearms and access to mental health
services, social isolation, stress, rural populations, gun suicide
•
Federal law prohibits sale of firearms to mentally ill but does not
require states to report mental health data for background checks
Record et al, JAMA 2013
Swanson, JAMA 2013
Elbogen et al, AGP 2009
Branas et al, AJPH 2004
Variation in mental illness and firearms laws
In 2012:
• 38 states required or authorized reporting of mental health
information for use in firearm purchaser background checks
• 16 states required courts to provide mental health
information to a centralized state agency in order to transmit
to federal database.
• 19 states required reporting of mental health information
within a specified time frame
http://smartgunlaws.org/
mental-health-reportingpolicy-summary/
Place-based strategies
“Programs that focus on places or structural dimensions can
influence the lives of more people and for longer periods of
time than individually based interventions”
IOM: “It is unreasonable to expect that people will change
their behavior when so many forces in the social, cultural,
and physical environment conspire against such change”
Examples:
• Business improvement districts
• Patrols targeting illegal guns in high-crime areas
• Alcohol sales locations, especially liquor to-go
• Abandoned housing and vacant lot remediation
Yen et al, ARPH 1999
Smedley et al, IOM 2000
MacDonald et al, IP 2009
Cohen et al, BI 2003
Branas et al, ACER 2009
Branas et al, AJE 2011
Philadelphia LandCare Program
Before
After
Difference-in-differences study, 1999-2008
Greened
vacant lots
(n = 4,436)
Eligible but
ungreened
control lots
(n = 13,308)
Impact of Greening
Out of 17 different outcomes:
Gun crime
(in all city sections) *
Vandalism (in West Philadelphia) *
Stress (in North Philadelphia) *
Inactivity (in West Philadelphia) *
* p < 0.01
Branas, AJE 2011
Randomized community trial *
Random selection:
Hundreds of
vacant lots in
sampling frame
Random assignment:
Random assignment:
Cleaning + Greening + Maintenance
(1) Cleaning + Greening +
Cleaning + Maintenance
Maintenance
(2) Cleaning + Maintenance
Control lots
(3) No Treatment
* For illustrative purposes only; actual random assignments and lot locations not shown
Who’s been interested in the
Philadelphia LandCare Program
Flint
Cambridge
Brooklyn
Detroit
Milwaukee
New York City
Cleveland
Chicago Akron Pittsburgh
Youngstown
Baltimore
Indianapolis
Kansas City
Blacksburg
Minneapolis
London
Los Angeles
Huntsville
Phoenix
Dresden
Madrid
Irkutsk
New Orleans
Houston
Tokyo
Laboratory simulation trials
Laboratory simulation trials
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Realistic use-of-force, marksmanship and judgment simulators
Real firearms, untethered and retroffited to fire highly accurate “laser bullets”
Videos with branching technology, “airmunitions” for recoil, shootback cannon
Safe, certainly far safer than live-fire experiments
Many major police agencies train with such simulators
•
Can study fatigue, alcohol, over-the-counter/Rx meds, aggression, stress,
training programs, firearm type, magazine size, etc.
Can study police, civilians, school personnel, etc
Can study lethal and less-lethal weapons as well as effectiveness of various
self-protection measures (akin to “comparative effectiveness trials”)
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Laboratory simulation trials
www.ais-sim.com
www.simunition.com
Very few studies to date
Mixed methods
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Randomized controlled trials
Natural or “found” experiments
Controlled observational studies
Qualitative studies
Rapid cycle learning
References
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Branas CC, Elliott MR, Richmond TS, Culhane D, Ten Have TR, Wiebe DJ.: Alcohol consumption, alcohol outlets, and the risk of
being assaulted with a gun. Alcoholism: Clinical and Experimental Research 11(4): 906-915, 2009.
Branas CC, Richmond TS, Ten Have TR, Wiebe DJ: Acute alcohol consumption, alcohol outlets, and gun suicide. Substance Use
& Misuse 46(13): 1592-1603, 2011.
Branas CC, Cheney RA, MacDonald JM, Tam VW, Jackson TD, Ten Have TR: A difference-in-differences analysis of health,
safety, and greening vacant urban space. American Journal of Epidemiology 174: 1-11, 2011.
Branas CC, Nance ML, Elliott MR, Richmond TS, Schwab CW: Urban-rural shifts in intentional firearm death: different causes,
same results. American Journal of Public Health 94(10): 1750-1755, 2004.
Carr BG, Wiebe DJ, Richmond TS, Cheney R, Branas CC: A randomised controlled feasibility trial of alcohol consumption and
the ability to appropriately use a firearm. Injury Prevention 15: 409-412, 2009.
Carr BG, Porat G, Wiebe DJ, Branas CC: A review of legislation restricting the intersection of firearms and alcohol in the US.
Public Health Reports 125(5): 674-679, 2010.
Cohen J, Ludwig J. Policing Crime Guns. In:Ludwig and Cook, eds. Evaluating Gun Policy: Effects on Crime and Violence. 2003;
Washington, DC: The Brookings Institution.
Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic
Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009;66(2):152-61.
James L, Vila B, Daratha K. Results from experimental trials testing participant responses to white, Hispanic, and black suspects
in high-fidelity deadly force judgment and decision-making simulations. Journal of Experimental Criminology 2012:1-24.
MacDonald J, Golinelli D, Stokes RJ, Bluthenthal R. The effect of business improvement districts on the incidence of violent
crimes. Injury Prevention 2009;15:323-336.
Manzi J. Uncontrolled: The Surprising Payoff of Trial-and-Error for Business, Politics, and Society. Basic Books, 2012: 1-320.
Record KL, Gostin LO. A systematic plan for firearms law reform. JAMA 2013;309(12):1231-1232.
Rivara FP, Mueller BA, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA
1997;278(7):569-75.
Smedley BD, Syme SL. Promoting Health: Intervention Strategies from Social and Behavioral Research. Institute of Medicine.
Washington DC: National Academy Press; 2000.
Swanson J. Mental illness and new gun law reforms. JAMA 2013;309(12): 1233-1234.
Webster DW, Vernick JS. Keeping firearms from drug and alcohol abusers. Injury Prevention 2009; 15(6): 425-427.
Yen IH, Syme SL. The social environment and health: a discussion of the epidemiologic literature. Annual Review Public Health
1999;20:287-308.