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From gunstore to smoking gun: Tracking guns that kill children in North Carolina
From Gunstore to Smoking Gun: Tracking Guns That Kill Children in North Carolina By Brendan T. Campbell, Deborah L. Radisch, J. Duncan Phillips, and Daniel von Allmen Chapel Hill, North Carolina
Purpose: This study reviews the epidemiology of pediatric firearm deaths in North Carolina and estimates the time from the retail sale of guns to their involvement in pediatric firearm deaths. Methods: The authors reviewed autopsy reports for all children 0 to 14 years of age that died of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained included demographic information, firearm type, and manner of death. Data from the Bureau of Alcohol, Tobacco and Firearms, which traced guns involved in crimes and determined the time elapsed from purchase to their involvement in a crime (ie, time-to-crime were also reviewed). Results: During the study period, 40 children died of firearm injuries. Mean age was 7.6 years. Handguns were responsi-
T
HE UNITED STATES has the highest rates of firearm-related deaths among industrialized countries. The overall rate of firearm-related deaths for American children less than 15 years of age is nearly 12 times greater than that found for 25 other industrialized countries combined.1 One third of children in the United States live in homes in which a firearm is present, and 13% of US homes have guns and ammunition stored in a such way that they are accessible to children.2 Many gun-owning parents substantially underestimate the risk of injury firearms pose to their children and do not realize that a gun in the home is more dangerous than protective.3-5 The purpose of this study was to review the epidemiology of pediatric firearm deaths in North Carolina and to estimate the time from firearms retail sale to their involvement in pediatric firearm-related deaths.
From the Department of Surgery and the Office of the Chief Medical Examiner, University of North Carolina at Chapel Hill, Chapel Hill, NC. Presented at the 37th Annual Meeting of the Pacific Association of Pediatric Surgeons, Seoul, Korea, May 16-20, 2004. Address reprint requests to Brendan T. Campbell, MD, MPH, Arkansas Childrens Hospital, Pediatric Surgery, 800 Marshall St, Little Rock, AR 72202. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3912-0037$30.00/0 doi:10.1016/j.jpedsurg.2004.08.004 1874
ble for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and undetermined cause (10%). Most deaths were homicides (67%) followed by unintentional death (18%), suicide (13%), and undetermined cause (2%). Most crime guns (76%) were purchased legally, and many (40%) had a time-to-crime of less than 3 years. Conclusions: Legally purchased firearms pose a significant threat to children in North Carolina. A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States. J Pediatr Surg 39:1874-1876. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Firearms, injury, trauma, violence.
MATERIALS AND METHODS North Carolina law mandates that all deaths occurring under “suspicious, unusual, or unnatural circumstances” be investigated by the North Carolina Office of the Chief Medical Examiner (General Statutes of the state of North Carolina, Chapter 130, Article 21, Title 138-148). We reviewed the Office of the Chief Medical Examiner cases for all children aged 0 to 14 years of age dying of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained from each case file included date of death, demographic information (ie, age, sex, and race), county where death occurred, type of firearm, and manner of death. We also reviewed firearms tracking data from the Bureau of Alcohol, Tobacco and Firearms (BATF) Crime Gun Trace Reports (2000) collected as part of The Youth Crime Gun Interdiction Initiative.6 This report summarizes crime gun tracing data submitted in 2000 by law enforcement officials from selected metropolitan areas in the United States. Firearms tracking data were collected in the North Carolina metropolitan areas of Charlotte/Mecklenberg and Greensboro/WinstonSalem/High Point by the BATF for this report. Crime gun tracing was developed by the BATF and uses the serial number located on all guns sold in the United States to identify the Federal firearms licensee who originally sold the gun and the date the gun was manufactured. The Crime Gun Trace Reports (2000) determined the length of time from retail sale to involvement in a crime (ie, time-to-crime) for North Carolina firearms. This study was approved by the Institutional Review Board at the University of North Carolina School of Medicine (IRB #03-SURG-423).
RESULTS
From January 1999 through December 2002, 40 children 14 years of age or younger died of firearm-related injuries in North Carolina. Mean age was 7.6 years. Most victims were boys (n ⫽ 26, 65%). Handguns were
Journal of Pediatric Surgery, Vol 39, No 12 (December), 2004: pp 1874-1876
GUNSHOT INJURIES IN CHILDREN
Fig 1. Firearm types used in pediatric firearm deaths in North Carolina.
responsible for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and unknown firearm type (10%) (Fig 1). Most deaths were homicides (67%), followed by unintentional death (18%), suicide (13%), and undetermined cause (2%) (Table 1). The majority of victims were white (n ⫽ 23, 58%) followed by African Americans (n ⫽ 15, 37%) and American Indians (n ⫽ 2, 5%). The sample of firearm types from the BATF crime gun analyses in North Carolina (handguns, 76%; shotguns, 11%; rifles, 11%; other, 2%) was roughly comparable with the firearm types found in the pediatric firearm deaths in North Carolina during our study period (handguns, 59%; shotguns, 27%; rifles, 10%; other, 10%). The median time from retail sale to involvement in a crime (ie, time-to-crime) for North Carolina crime guns was 4.4 years. Forty percent of crime guns had a time-to-crime of less than 3 years, and 11% had a time-to-crime of less than 1 year. A majority of North Carolina crime guns were bought in-state (62%), and more than three quarters were purchased legitimately from Federally licensed dealers. An additional 19% of the crime guns were purchased from Federally licensed dealers in nearby states (ie, Florida, Georgia, South Carolina, and Virginia).
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and rifles (16%), respectively.7 Our data show that handguns have since overtaken long guns as the type of firearm responsible for the majority of pediatric deaths in North Carolina. Our findings also are consistent with national trends in terms of the manner of death and the fact that handguns are responsible for the majority of pediatric firearm deaths.8,9 This study has several limitations. The epidemiologic data for this study were collected retrospectively, and the quality of the data is only as good as the information available in the medical examiner’s case files. Second, it included only firearm fatalities. Fatalities are only the tip of the iceberg in terms of the morbidity and economic cost associated with firearm injuries. A previous study from Johnston County North Carolina showed a firearm injury case fatality rate of 1:1.8 (fatal to nonfatal), but other estimates of firearm injury case fatality rate are significantly higher (ie, 1:20).10,11 The internal validity of this study is affected by the fact that the guns that were traced as part of the BATF Crime Gun Trace Reports (2000) were only from 2 metropolitan areas in North Carolina and may not have been representative of the entire state. Second, these data included all crime guns, not just those crime guns involved in pediatric firearm-related deaths. One way to more accurately predict the impact that stricter regulation on the sale of handguns would have on the number of pediatric firearm-related deaths in the United States would be to prospectively collect a nationally representative sample of pediatric firearm deaths including specific information about the circumstances of the shooting and the culprit guns’ serial numbers. This would allow you to determine with precision the number of recently purchased firearms that are involved in pediatric deaths. Injury prevention is more effective and economically more advantageous than treating injuries after the fact. Injury cannot be eliminated totally by prevention strategies, but the incidence and severity can be reduced significantly.12,13 The most effective prevention strategies are those that work automatically (ie, passive strategies). In contrast, active strategies require behavioral
DISCUSSION
Firearms are a major cause of mortality among North Carolina children and youth. Handguns are responsible for a disproportionate number of deaths compared with other firearm types. This is the first study of which we are aware that combines epidemiologic data with BATF firearm tracking data to assess the impact recently purchased guns have on pediatric firearm deaths. A previous study of unintentional firearm deaths in North Carolina reviewed 65 “accidental gunshot fatalities” that occurred in children aged 14 years or younger from 1976 through 1980. The types of guns responsible for these deaths were shotguns (41%), handguns (39%),
Table 1. Sociodemographic Characteristics of Pediatric Firearm Deaths in North Carolina Characteristic
Sex (%) Male Female Mean age (yr) Type of firearm (%) Handgun Shotgun Rifle
Homicide (n ⫽ 27)
Suicide (n ⫽ 5)
Unintentional (n ⫽ 7)
16 (40) 11 (28) 6.6
4 (10) 1 (2) 12
5 (13) 2 (4) 7.6
14 (35) 2 (4) 8 (20)
3 (8) 2 (4) 3 (8)
3 (8) 2 (4) 3 (8)
NOTE. Manner of death undetermined in 1 case.
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CAMPBELL ET AL
change, and people must remember to repeat the new behavior every time they are exposed to risk. In reality, a multifaceted approach to injury prevention programs for pediatric firearm injuries would consist of both active and passive strategies, but an emphasis on the passive strategies is more likely to result in a sustained decrease in injuries.14 Despite the fact that there are an estimated 192 million working firearms in the United States, BATF firearm tracking data show that many guns used in crimes move rapidly from retail sale to recovery by law enforcement after involvement in a crime or death.15 Of the many variables that influence violence in American society, access to handguns can be most directly addressed.16,17
Despite the popularity of guns in American culture, there is broad support for strengthening handgun laws. In a recent national survey, greater than 80% of respondents favored limiting handgun purchases to no more than 1 per month and favored mandatory registration of handguns and pistols.18 A majority of North Carolinians feel that laws covering handgun sales should be made more strict, and nearly half of gun owners wanted stricter regulation of handguns.19 Over the last 2 decades, a growing body of literature has clearly shown the hazards that handguns pose to American children.20 A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States.
REFERENCES 1. Centers for Disease Control and Prevention: Rates of homicide, suicide, and firearm- related death among 26 industrialized countries. Morb Mortal Wkly Rep CDC Surveill Summ 46:101-105, 1997 2. Schuster MA, Franke TM, Bastian AM, et al: Firearm storage patterns in US homes with children. Am J Public Health 90:588-594, 2000 3. Webster DW, Wilson MEH, Duggan AK, et al: Parents’ beliefs about preventing gun injuries to children. Pediatrics 89:908-914, 1992 4. Farah MM, Simon HK, Kellermann AL: Firearms in the home: Parental perceptions. Pediatrics 104:1059-1063, 1999 5. Kellermann AL, Reay DT: Protection or peril? An analysis of firearm-related deaths in the home. N Engl J Med 314:1557-1560, 1986 6. Bureau of Alcohol, Tobacco and Firearms (BATF): Crime Gun Trace Reports (2000). Available at http://www.atf.gov/firearms/ycgii/ 2000 7. Morrow PL, Hudson P: Accidental firearm fatalities in North Carolina, 1976-1980. Am J Public Health 76:1120-1123, 1986 8. Arias E, MacDorman MF, Strobino DM, et al: Annual summary of vital statistics—2002. Pediatrics 112:1215-1230, 2003 9. Zavoski RW, Lapidus GD, Lerer TJ, et al: A population-based study of severe firearm injury among children and youth. Pediatrics 96:278-282, 1995 10. Sadowski LS, Munoz SR: Nonfatal and fatal firearm injuries in a rural county. JAMA 275:1762-1764, 1996 11. Sinauer N, Annest SL, Mercy JA: Unintentional, nonfatal fire-
arm-related injuries: A preventable public health burden. JAMA 275: 1740-1743, 1996 12. Meyer AA: Death and disability from injury: A global challenge. J Trauma 44:1-12, 1998 13. Stewart RM, Myers JG, Dent DL, et al: Seven hundred fiftythree consecutive deaths in a level I trauma center: The argument for injury prevention. J Trauma 54:66-71, 2003 14. Rivara FP, Grossman DC, Cummings P: Injury prevention: First of two parts. N Engl J Med 337:543-548, 1997 15. Cook PJ, Ludwig J: Guns in America: Results of a comprehensive national survey on firearms ownership and use. Washington, DC, US Department of Justice, National Institute of Justice, 1996 16. Stylianos S: The impact of firearm violence on children: Support for prevention strategies. J Pediatr Surg 34:1445-1446, 1999 17. Sloan JH, Kellermann AL, Reay DT, et al: Handgun regulation, crime, assaults, and homicide: A tale of two cities. N Engl J Med 319:1256-1262, 1988 18. Teret SP, Webster DW, Vernick JS, et al: Support for new policies to regulate firearms: Results of two national surveys. N Engl J Med 339:813-818, 1998 19. Williamson D: Survey: North Carolina majority favors stricter laws on gun sales. UNC- CH News Services. Available at www. unc.edu/news/newsserv/archives/nov99, accessed April 4, 2004 20. Schetky DH: Children and handguns: A public health concern. Am J Dis Child 139:229-231, 1985
Purpose: This study reviews the epidemiology of pediatric firearm deaths in North Carolina and estimates the time from the retail sale of guns to their involvement in pediatric firearm deaths. Methods: The authors reviewed autopsy reports for all children 0 to 14 years of age that died of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained included demographic information, firearm type, and manner of death. Data from the Bureau of Alcohol, Tobacco and Firearms, which traced guns involved in crimes and determined the time elapsed from purchase to their involvement in a crime (ie, time-to-crime were also reviewed). Results: During the study period, 40 children died of firearm injuries. Mean age was 7.6 years. Handguns were responsi-
T
HE UNITED STATES has the highest rates of firearm-related deaths among industrialized countries. The overall rate of firearm-related deaths for American children less than 15 years of age is nearly 12 times greater than that found for 25 other industrialized countries combined.1 One third of children in the United States live in homes in which a firearm is present, and 13% of US homes have guns and ammunition stored in a such way that they are accessible to children.2 Many gun-owning parents substantially underestimate the risk of injury firearms pose to their children and do not realize that a gun in the home is more dangerous than protective.3-5 The purpose of this study was to review the epidemiology of pediatric firearm deaths in North Carolina and to estimate the time from firearms retail sale to their involvement in pediatric firearm-related deaths.
From the Department of Surgery and the Office of the Chief Medical Examiner, University of North Carolina at Chapel Hill, Chapel Hill, NC. Presented at the 37th Annual Meeting of the Pacific Association of Pediatric Surgeons, Seoul, Korea, May 16-20, 2004. Address reprint requests to Brendan T. Campbell, MD, MPH, Arkansas Childrens Hospital, Pediatric Surgery, 800 Marshall St, Little Rock, AR 72202. © 2004 Elsevier Inc. All rights reserved. 0022-3468/04/3912-0037$30.00/0 doi:10.1016/j.jpedsurg.2004.08.004 1874
ble for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and undetermined cause (10%). Most deaths were homicides (67%) followed by unintentional death (18%), suicide (13%), and undetermined cause (2%). Most crime guns (76%) were purchased legally, and many (40%) had a time-to-crime of less than 3 years. Conclusions: Legally purchased firearms pose a significant threat to children in North Carolina. A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States. J Pediatr Surg 39:1874-1876. © 2004 Elsevier Inc. All rights reserved. INDEX WORDS: Firearms, injury, trauma, violence.
MATERIALS AND METHODS North Carolina law mandates that all deaths occurring under “suspicious, unusual, or unnatural circumstances” be investigated by the North Carolina Office of the Chief Medical Examiner (General Statutes of the state of North Carolina, Chapter 130, Article 21, Title 138-148). We reviewed the Office of the Chief Medical Examiner cases for all children aged 0 to 14 years of age dying of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained from each case file included date of death, demographic information (ie, age, sex, and race), county where death occurred, type of firearm, and manner of death. We also reviewed firearms tracking data from the Bureau of Alcohol, Tobacco and Firearms (BATF) Crime Gun Trace Reports (2000) collected as part of The Youth Crime Gun Interdiction Initiative.6 This report summarizes crime gun tracing data submitted in 2000 by law enforcement officials from selected metropolitan areas in the United States. Firearms tracking data were collected in the North Carolina metropolitan areas of Charlotte/Mecklenberg and Greensboro/WinstonSalem/High Point by the BATF for this report. Crime gun tracing was developed by the BATF and uses the serial number located on all guns sold in the United States to identify the Federal firearms licensee who originally sold the gun and the date the gun was manufactured. The Crime Gun Trace Reports (2000) determined the length of time from retail sale to involvement in a crime (ie, time-to-crime) for North Carolina firearms. This study was approved by the Institutional Review Board at the University of North Carolina School of Medicine (IRB #03-SURG-423).
RESULTS
From January 1999 through December 2002, 40 children 14 years of age or younger died of firearm-related injuries in North Carolina. Mean age was 7.6 years. Most victims were boys (n ⫽ 26, 65%). Handguns were
Journal of Pediatric Surgery, Vol 39, No 12 (December), 2004: pp 1874-1876
GUNSHOT INJURIES IN CHILDREN
Fig 1. Firearm types used in pediatric firearm deaths in North Carolina.
responsible for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and unknown firearm type (10%) (Fig 1). Most deaths were homicides (67%), followed by unintentional death (18%), suicide (13%), and undetermined cause (2%) (Table 1). The majority of victims were white (n ⫽ 23, 58%) followed by African Americans (n ⫽ 15, 37%) and American Indians (n ⫽ 2, 5%). The sample of firearm types from the BATF crime gun analyses in North Carolina (handguns, 76%; shotguns, 11%; rifles, 11%; other, 2%) was roughly comparable with the firearm types found in the pediatric firearm deaths in North Carolina during our study period (handguns, 59%; shotguns, 27%; rifles, 10%; other, 10%). The median time from retail sale to involvement in a crime (ie, time-to-crime) for North Carolina crime guns was 4.4 years. Forty percent of crime guns had a time-to-crime of less than 3 years, and 11% had a time-to-crime of less than 1 year. A majority of North Carolina crime guns were bought in-state (62%), and more than three quarters were purchased legitimately from Federally licensed dealers. An additional 19% of the crime guns were purchased from Federally licensed dealers in nearby states (ie, Florida, Georgia, South Carolina, and Virginia).
1875
and rifles (16%), respectively.7 Our data show that handguns have since overtaken long guns as the type of firearm responsible for the majority of pediatric deaths in North Carolina. Our findings also are consistent with national trends in terms of the manner of death and the fact that handguns are responsible for the majority of pediatric firearm deaths.8,9 This study has several limitations. The epidemiologic data for this study were collected retrospectively, and the quality of the data is only as good as the information available in the medical examiner’s case files. Second, it included only firearm fatalities. Fatalities are only the tip of the iceberg in terms of the morbidity and economic cost associated with firearm injuries. A previous study from Johnston County North Carolina showed a firearm injury case fatality rate of 1:1.8 (fatal to nonfatal), but other estimates of firearm injury case fatality rate are significantly higher (ie, 1:20).10,11 The internal validity of this study is affected by the fact that the guns that were traced as part of the BATF Crime Gun Trace Reports (2000) were only from 2 metropolitan areas in North Carolina and may not have been representative of the entire state. Second, these data included all crime guns, not just those crime guns involved in pediatric firearm-related deaths. One way to more accurately predict the impact that stricter regulation on the sale of handguns would have on the number of pediatric firearm-related deaths in the United States would be to prospectively collect a nationally representative sample of pediatric firearm deaths including specific information about the circumstances of the shooting and the culprit guns’ serial numbers. This would allow you to determine with precision the number of recently purchased firearms that are involved in pediatric deaths. Injury prevention is more effective and economically more advantageous than treating injuries after the fact. Injury cannot be eliminated totally by prevention strategies, but the incidence and severity can be reduced significantly.12,13 The most effective prevention strategies are those that work automatically (ie, passive strategies). In contrast, active strategies require behavioral
DISCUSSION
Firearms are a major cause of mortality among North Carolina children and youth. Handguns are responsible for a disproportionate number of deaths compared with other firearm types. This is the first study of which we are aware that combines epidemiologic data with BATF firearm tracking data to assess the impact recently purchased guns have on pediatric firearm deaths. A previous study of unintentional firearm deaths in North Carolina reviewed 65 “accidental gunshot fatalities” that occurred in children aged 14 years or younger from 1976 through 1980. The types of guns responsible for these deaths were shotguns (41%), handguns (39%),
Table 1. Sociodemographic Characteristics of Pediatric Firearm Deaths in North Carolina Characteristic
Sex (%) Male Female Mean age (yr) Type of firearm (%) Handgun Shotgun Rifle
Homicide (n ⫽ 27)
Suicide (n ⫽ 5)
Unintentional (n ⫽ 7)
16 (40) 11 (28) 6.6
4 (10) 1 (2) 12
5 (13) 2 (4) 7.6
14 (35) 2 (4) 8 (20)
3 (8) 2 (4) 3 (8)
3 (8) 2 (4) 3 (8)
NOTE. Manner of death undetermined in 1 case.
1876
CAMPBELL ET AL
change, and people must remember to repeat the new behavior every time they are exposed to risk. In reality, a multifaceted approach to injury prevention programs for pediatric firearm injuries would consist of both active and passive strategies, but an emphasis on the passive strategies is more likely to result in a sustained decrease in injuries.14 Despite the fact that there are an estimated 192 million working firearms in the United States, BATF firearm tracking data show that many guns used in crimes move rapidly from retail sale to recovery by law enforcement after involvement in a crime or death.15 Of the many variables that influence violence in American society, access to handguns can be most directly addressed.16,17
Despite the popularity of guns in American culture, there is broad support for strengthening handgun laws. In a recent national survey, greater than 80% of respondents favored limiting handgun purchases to no more than 1 per month and favored mandatory registration of handguns and pistols.18 A majority of North Carolinians feel that laws covering handgun sales should be made more strict, and nearly half of gun owners wanted stricter regulation of handguns.19 Over the last 2 decades, a growing body of literature has clearly shown the hazards that handguns pose to American children.20 A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States.
REFERENCES 1. Centers for Disease Control and Prevention: Rates of homicide, suicide, and firearm- related death among 26 industrialized countries. Morb Mortal Wkly Rep CDC Surveill Summ 46:101-105, 1997 2. Schuster MA, Franke TM, Bastian AM, et al: Firearm storage patterns in US homes with children. Am J Public Health 90:588-594, 2000 3. Webster DW, Wilson MEH, Duggan AK, et al: Parents’ beliefs about preventing gun injuries to children. Pediatrics 89:908-914, 1992 4. Farah MM, Simon HK, Kellermann AL: Firearms in the home: Parental perceptions. Pediatrics 104:1059-1063, 1999 5. Kellermann AL, Reay DT: Protection or peril? An analysis of firearm-related deaths in the home. N Engl J Med 314:1557-1560, 1986 6. Bureau of Alcohol, Tobacco and Firearms (BATF): Crime Gun Trace Reports (2000). Available at http://www.atf.gov/firearms/ycgii/ 2000 7. Morrow PL, Hudson P: Accidental firearm fatalities in North Carolina, 1976-1980. Am J Public Health 76:1120-1123, 1986 8. Arias E, MacDorman MF, Strobino DM, et al: Annual summary of vital statistics—2002. Pediatrics 112:1215-1230, 2003 9. Zavoski RW, Lapidus GD, Lerer TJ, et al: A population-based study of severe firearm injury among children and youth. Pediatrics 96:278-282, 1995 10. Sadowski LS, Munoz SR: Nonfatal and fatal firearm injuries in a rural county. JAMA 275:1762-1764, 1996 11. Sinauer N, Annest SL, Mercy JA: Unintentional, nonfatal fire-
arm-related injuries: A preventable public health burden. JAMA 275: 1740-1743, 1996 12. Meyer AA: Death and disability from injury: A global challenge. J Trauma 44:1-12, 1998 13. Stewart RM, Myers JG, Dent DL, et al: Seven hundred fiftythree consecutive deaths in a level I trauma center: The argument for injury prevention. J Trauma 54:66-71, 2003 14. Rivara FP, Grossman DC, Cummings P: Injury prevention: First of two parts. N Engl J Med 337:543-548, 1997 15. Cook PJ, Ludwig J: Guns in America: Results of a comprehensive national survey on firearms ownership and use. Washington, DC, US Department of Justice, National Institute of Justice, 1996 16. Stylianos S: The impact of firearm violence on children: Support for prevention strategies. J Pediatr Surg 34:1445-1446, 1999 17. Sloan JH, Kellermann AL, Reay DT, et al: Handgun regulation, crime, assaults, and homicide: A tale of two cities. N Engl J Med 319:1256-1262, 1988 18. Teret SP, Webster DW, Vernick JS, et al: Support for new policies to regulate firearms: Results of two national surveys. N Engl J Med 339:813-818, 1998 19. Williamson D: Survey: North Carolina majority favors stricter laws on gun sales. UNC- CH News Services. Available at www. unc.edu/news/newsserv/archives/nov99, accessed April 4, 2004 20. Schetky DH: Children and handguns: A public health concern. Am J Dis Child 139:229-231, 1985