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Unintentional firearm deaths: A comparison of other-inflicted and self-inflicted shootings
Accident Analysis and Prevention 42 (2010) 1184–1188
Contents lists available at ScienceDirect
Accident Analysis and Prevention journal homepage: www.elsevier.com/locate/aap
Unintentional firearm deaths: A comparison of other-inflicted and self-inflicted shootings David Hemenway ∗ , Catherine Barber, Matthew Miller Harvard Injury Control Research Center, Harvard School of Public Health, 677 Huntington Ave., 3rd Fl., Boston, MA 02115, USA
a r t i c l e
i n f o
Article history: Received 5 October 2009 Received in revised form 22 December 2009 Accepted 13 January 2010 Keywords: Firearm Guns Accidental shootings Other-inflicted National Violent Death Reporting System
a b s t r a c t This study compares other-inflicted and self-inflicted unintentional firearm fatalities. Data come from the National Violent Death Reporting System, a new surveillance system from the Centers for Disease Control and Prevention. Data are currently available from 16 states and parts of California for various years 2003–2006. Of the 363 unintentional firearm fatalities, about half (49%) were other-inflicted, ranging from 78% of child (aged 0–14) deaths to 19% of older adult (aged 55+) deaths. In other-inflicted shooting deaths, the shooters were overwhelmingly young (81% under age 25). The shooters in the other-inflicted deaths were primarily friends (43%) or family (47%); brothers were the most common family shooter. To learn how to prevent unintentional injuries, it is critical to have information not only on the victim, but also on the person who inflicted the injury. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Between 1965 and 2006, over 64,000 Americans died from unintentional firearm shootings, more Americans than were killed in our wars during the same period (Hemenway, 2006). Except for the age and gender distribution of these decedents, surprisingly little else is known about the circumstances of these deaths. What is known is largely based on a few studies, usually focused on children and adolescents with data often limited to a specific county (Dowd et al., 1994; Grossman et al., 1999; Schaechter et al., 2003), city (Ranney et al., 2009) or state (Cherry et al., 2001; Martin et al., 1991; Zavoski et al., 1995). Data on the circumstances of unintentional firearm fatalities in the United States have recently become available from the National Violent Death Reporting System (NVDRS) of the Centers for Disease Control and Prevention (Hemenway et al., 2009; Karch et al., 2008; Steenkamp et al., 2006). The NVDRS includes data related to the circumstances of unintentional firearm fatalities for all age groups across 16 states. Before the creation of NVDRS, there were no systematically collected data that allowed for the comparison of unintentional shootings that were other-inflicted (i.e., getting accidentally shot by someone else) vs. self-inflicted (i.e., accidentally shooting oneself).
∗ Corresponding author. Tel.: +1 617 432 4493; fax: +1 617 432 3699. E-mail addresses: [email protected] (D. Hemenway), [email protected] (C. Barber), [email protected] (M. Miller). 0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2010.01.008
National data on unintentional firearm fatalities previously came from death certificates (e.g. tabulated in WISQARS, the Webbased Injury Statistics Query and Reporting System) (CDC, 2009). Such mortality data are victim-based, but it is the shooter who is usually the more relevant target for prevention. This paper uses data from the NVDRS to describe the circumstances of unintentional firearm deaths in the United States and to compare and contrast shootings that are other-inflicted with those that are self-inflicted. The characteristics of cases in which the shooter is someone other than the victim have not previously been examined in a large cross-state dataset of fatal firearm accidents. 2. Methods 2.1. Data The NVDRS is a federally funded, state-based surveillance system that links data from the death certificate, police report, crime lab, and coroner/medical examiner records on all deaths that occur following a suicide, homicide, legal intervention, unintentional firearm injury, and injuries of unknown intent. Data cover a census of all deaths that were classified on the death certificate as a suicide, homicide, legal intervention, unintentional firearm injury, or injury of unknown intent. Data are linked into a single data repository at the CDC and are incident-based, covering information on the persons (victims and suspects), weapons, and circumstances involved. The information is gathered by trained abstracters who usually work for the state health department or in some cases the medical examiner’s office or a subcontracted entity. Data may be extracted
D. Hemenway et al. / Accident Analysis and Prevention 42 (2010) 1184–1188 Table 1 Participating US States and California Counties, 2003–2006, NVDRS Restricted Access Dataset. NVDRS jurisdiction
Data years
Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, Wisconsin Kentucky, New Mexico, Utah, Oakland CA, San Francisco County CA, Santa Clara County CA Alameda County CA, Los Angeles County CA, Riverside County CA
2003–2006 2004–2006 2005–2006 2006
manually or imported electronically and are coded in accordance with a detailed coding manual (CDC, 2004). For quality control purposes, 10% of all narratives are reviewed by staff at the CDC to assess how accurately the abstractors apply the coding definitions for type of death and precipitating circumstances. CDC staff send corrections to the states on an ongoing basis to improve coding. NVDRS has been described in further detail elsewhere (Steenkamp et al., 2006). Data for this study are from the NVDRSs Restricted Access Dataset (RAD) for the years 2003–2006, released in January 2009. Sixteen states and parts of California submitted data (Table 1). Use of the data in this study was approved by the Harvard School of Public Health’s Institutional Review Board.
2.2. Case definition NVDRS defines unintentional firearm injuries as “A death resulting from a penetrating injury or gunshot wound from a weapon that uses a powder charge to fire a projectile when there was a preponderance of evidence that the shooting was not intentionally directed at the victim.” Examples include a hunter mistaking another hunter for an animal, a man shooting himself or another person with a gun he believed was unloaded, a child under age 6 shooting a person (even if “intentionally”), and a criminal unintentionally shooting himself during the commission of a crime. Firearm-related deaths that do not meet the case definition are those that occur to another person during the commission of a crime or assault or when a gun is used to intentionally harm, control or frighten another person, even if the person who dies was an unintended target. So, for example, if during a robbery a passer-by is shot unintentionally, the death is classified as a homicide, not an accident. If, on the other hand, the shooter stumbles and shoots himself, the death is classified as an accident. Russian roulette (firing a revolver at oneself after spinning a cylinder that the shooter knows is partially loaded) is classified as suicide in NVDRS. One of the authors (CB) reviewed the incident narrative for each firearm-related death that met any of the following criteria to determine whether it met the NVDRS case definition for an unintentional firearm incident: it was classified as an accident by the abstractor, death certificate, or coroner/medical examiner report; it was assigned an underlying cause of death code of W32, W33, W34 or Y86; or it was classified by the Supplementary Homicide Report as a “negligent manslaughter.” A second author (DH) reviewed all cases in which the NVDRS abstractor and author disagreed to resolve disagreements. A total of 398 deaths met the NVDRS case definition. These included 391 that were classified by the NVDRS abstractor as accidents and 7 that were classified by the abstractor as homicides (2 were hunting accidents and 5 involved children or adolescents playing with guns). Another 10 deaths that were classified by the NVDRS abstractor as accidents were excluded because they involved a BB gun injury (1 case), Russian roulette (4 cases), legal intervention (3 cases), or assault (2 cases).
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2.3. Data hierarchies If more than one suspect or weapon was identified in an incident, we used the one that was listed first. Firearm type and relationship of victim to suspect were reported according to multiple data sources in NVDRS. When more than one data source supplied substantive information, we applied a hierarchy based on the assumed reliability of that source. For firearm type the hierarchy was crime laboratory, law enforcement, coroner/medical examiner; for relationship the hierarchy was law enforcement, coroner/medical examiner, Supplementary Homicide Report. In 14 cases, relationship was not coded but was stated in the narrative and was therefore assigned by the authors based on that description. The NVDRS abstractor coded the context in which a firearm accident occurred, coding as many as applied from among the categories of hunting, playing/fooling around, self-defense, target shooting, celebratory firing, loading/unloading, cleaning, showing to others, and other. In 20% of cases no context was selected. We reviewed narratives for all cases to identify whether contexts could be further characterized, adding categories for exiting/entering a motor vehicle, suicide play (e.g., pointing a gun believed to be unloaded at oneself and pulling the trigger), threats/assault (i.e. self-inflicted accident during a threat or assault with a gun), suicide attempt (e.g., accidental shooting while swatting a gun away from a suicide attempter), and miscellaneous carrying/handling. We expanded the definition of “cleaning” to include repairing or assembling/disassembling a gun and “self-defense” to include carrying a gun for protection. Unknowns were reduced to 12%. For analytic purposes, we assigned contexts to a collapsed, mutually exclusive list using the following hierarchy: hunting, playing (also includes celebratory firing and suicide play), self-defense, target shooting, cleaning/loading/unloading, showing, carrying/handling, and other (also includes accident during a suicide attempt or threat/assault). 2.4. Statistical analysis Pearson’s chi square test was used to assess bivariate associations between the proportion of shootings that were other- (vs. self-) inflicted and characteristics of the victim and incident. We also ran a multivariate logistic regression examining which factors explained why shootings were self-inflicted vs. other-inflicted. We collapsed some of the context and firearm type variables since the numbers were small. 3. Results A total of 398 people died from unintentional firearm injuries in the NVDRS jurisdictions over the 4-year period. In 35 cases (9%), it was unknown whether the shooting was inflicted by self or other, so these cases were set aside, leaving a final dataset of 363 deaths. In almost half of these fatalities, the victim was shot by another person (Table 2). The younger the victim, the more likely the decedent was shot by someone else. For children aged 0–14, over three quarters (78%) of the deaths were other-inflicted. This percentage fell with the victim’s age; for older adult victims aged 55+, less than one-fifth (19%) were other-inflicted. The relationship between age and whether or not the shooting was self-inflicted also held in the multivariate analysis (Table 3). Victims of unintentional shootings were overwhelmingly male. So were the shooters. Ninety-two percent (92%) of the shooters who killed another person were male (Table 4). The few females who died were usually (73%) shot by another person (almost always male) (Table 2).
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Table 2 Unintentional firearm fatalities by proportion other-inflicted (vs. self-inflicted), selected states, 2003–2006, National Violent Death Reporting System. N b
Column %
% Other-inflicted
pa
Total
363
100
49
Age of victim 0–14 15–24 25–54 55+
72 121 127 43
19 33 35 12
78 60 33 19
*** ***
Gender of victim Male Female
330 33
91 9
47 73
– **
Place of incident Home of victim Other home Elsewhere
150 89 124
41 25 34
36 66 53
– *** **
Context Playing Hunting Cleaning/loading Carrying/handling Showing Target shooting Self-defense Other Unknown
140 77 39 18 13 10 9 30 27
39 21 11 5 4 3 2 8 7
61 62 36 22 62 50 0 27 22
** **
Firearm type Handgun Rifle Shotgun Unknown
187 76 68 32
52 21 19 9
39 66 59 50
–
– * NA
– *** **
a Asterisks refer to the probability that the proportion of cases that were other-inflicted (vs. self-inflicted) varied significantly in the listed subgroup compared with the reference group (“–”) in a bivariate logistic regression: *p ≤ .05; **p ≤ .01; ***p ≤ .001. b The total of 363 excludes 35 incidents in which it was unknown whether the shooting was self- or other-inflicted.
Most unintentional firearm victims were young; in this data set the median victim was under 25 years old (Table 2). Most shooters were also young: 81% of shooters who unintentionally killed another person were under age 25 (Fig. 1).
Table 3 Adjusted odds ratios for other-inflicted (vs. self-inflicted) among unintentional firearm fatalities, selected states, 2003–2006, National Violent Death Reporting System. Adjusted OR (95% CI)a Age (years)
pb
.96 (.94–.97)
***
Gender of victim Male Female
– 6.1 (2.2–17.2)
– ***
Place of incident Home of victim Other home Elsewhere
– 3.7 (1.9–7.1) 2.1 (1.0–4.2)
– *** *
2.1 (1.1–4.0) 2.1 (0.9–4.6)
*
Collapsed context Playing Hunting/target shooting All other Collapsed firearm type Handgun Long gun Unknown
Most firearm deaths occurred in the context of someone playing with the gun, hunting, cleaning or loading the gun (Table 2). Most (over 60%) of both the hunting and playing fatalities were otherinflicted. In more than half (58%) of all unintentional firearm fatalities, the shooting occurred away from the victim’s home. In shootings away from home, another person shot the victim 60% of the time (Table 2). Handguns rather than long guns caused most of the unintentional firearm deaths (Table 2). While accidental handgun deaths were more likely than long gun deaths to be self-inflicted, 39% of victims killed accidentally with a handgun were shot by another person. Comparing other- and self-inflicted deaths, the shooters and victims in other-inflicted incidents were much younger. Whereas 81% of shooters who killed another person were under age 25, Table 4 The shooter in other-inflicted unintentional firearm fatalities. Percent (n = 179)
–
5.2 (2.6–10.2) 3.0 (1.2–7.4)
– *** *
Note: This model excludes the 9 incidents involving a self-inflicted defensive act (because these by definition cannot be other-inflicted). a Adjusted odds ratio with 95% confidence intervals report the ratio of the odds that the fatality was other-inflicted (vs. self-inflicted) in the listed group compared with the reference group (“–”) in a multivariate logistic regression controlling for all other listed variables. b Probability: *p ≤ .05; **p ≤ .01; ***p ≤ .001.
Shooter age (n = 141) 0–14 15–24 25–54 55+
35 46 14 4
Shooter gender (n = 165) Male Female
92 8
Relationship to victim (n = 171) Family Friend Acquaintance Stranger
47 43 9 1
D. Hemenway et al. / Accident Analysis and Prevention 42 (2010) 1184–1188
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Fig. 1. Percentage by age category of shooters and victims in other-inflicted and self-inflicted unintentional firearm deaths.
only 35% of shooters in self-inflicted deaths were under age 25 (Fig. 1). For example, among the 62 hunting incidents for which the shooter’s age was known, the shooter was under 25 in 55% of the other-inflicted incidents vs. 14% of the self-inflicted incidents (not shown). As with the shooters, victims in other-inflicted deaths were younger than victims in self-inflicted deaths. Seventy-two percent (72%) of victims in other-inflicted shootings were under age 25, compared with the 35% of victims in self-inflicted shootings (Fig. 1). In over 70% of other-inflicted incidents, both parties were under age 25 (not shown). Even though most other-inflicted deaths occurred outside the home, shooters were likely to be family (including intimate partners) (47%) or friends (43%). In fewer than 2% of the cases was the other person a stranger (Table 4). Among family members, husbands, fathers, grandfathers, uncles and in-laws were all represented. But by far the most common shooter among the relatives were siblings (45% of family shootings), nearly always brothers (not shown).
4. Discussion Outside of motor vehicle injuries, surprisingly little is known about self-inflicted vs. other-inflicted unintentional injuries (see Levy et al., 2002 for one of the rare articles that makes the distinction). Very few surveys ask about the person who may have unintentionally injured another or even make a distinction between self-inflicted and other-inflicted unintentional injuries. For example, the World Health Organization (2004) “Guidelines for Conducting Community Surveys on Injuries and Violence” includes questions about the perpetrators of intentional injury, but for unintentional injuries, there are no questions even about whether the injury was self-inflicted or inflicted by someone else. The current article focuses on the issue of self-inflicted vs. otherinflicted unintentional firearm fatalities. For most unintentional injuries, there are often gray areas about the extent of others’ involvement in the injury (e.g., a driver swerves to avoid another motorist and runs off the road). One of the features of unintentional firearm deaths is that there is usually little question about who pulled the trigger. We find that in almost half of all unintentional firearm fatalities, someone other than the victim fired the shot. In the large majority of the unintentional shooting deaths of children, someone else shot them; by contrast the large majority of the shooting deaths of older adults were self-inflicted. A study of unintentional firearms deaths in North Carolina, using medical examiner data, also found that younger victims were likely to be shot by someone else, whereas most older victims shot themselves (Cherry et al., 2001). By contrast, for nonfatal unintentional firearm injuries, a national study exclusively of children using data from hospital
emergency departments found that more of the injuries were selfinflicted (48%) rather than other-inflicted (40%), with 12% unknown (Eber et al., 2004). In our study, for other-inflicted deaths, the shooter is almost always a male and almost half the time is from the same family as the victim, often a brother. The most common type of circumstance in unintentional gun deaths is someone playing with the gun, and in these instances, most of the time the injury is other-inflicted. Our results show that the danger to children and adolescents is largely from being shot by others—typically friends or siblings. These findings lend credence to programmatic and policy proposals to improve gun storage, and to make it normative for parents to ask about the availability of guns in the homes visited by their children. The real costs of unintentional firearm death are not borne exclusively by the victim and his family, but also include the guilt and grief of the shooter and his family. In half of all other-inflicted unintentional fatal firearm incidents—a quarter of all unintentional shooting deaths—the shooter was a friend or acquaintance. Usually, both shooter and victim are young, with many expected years of life ahead of them. The current study has important limitations. The fact that the NVDRS is not currently a national system limits its value. Although a third of the states are included in the system, these are not a representative or random sample of all fifty states. Our results certainly may not be generalizable outside the United States. Another limitation is that the NVDRS does not provide the level of detailed information about the shooter or the victim that a case–control study might provide. One case–control study (Waller and Whorton, 1973), which looked exclusively at other-inflicted unintentional shootings, obtained information about the shooter in 34 shootings (both fatal and nonfatal) in Vermont. The study found that these shooters were more likely than the victim (or than the typical licensed motorist) to misuse alcohol, to have been investigated or arrested for acts of violence, and to be involved in highway crashes. Despite these limitations the information provided by this study is a marked advance over death certificate data. Mortality datasets like WISQARS that rely solely on death certificate data only have information about the victim. In addition, the intent of the shooter is not always easily determined, and medical examiners are not uniform in their classifications (Barber et al., 2002; Hanzlick and Goodin, 1997). A strength of the National Violent Death Reporting System is that it uses information from multiple sources to try to consistently and accurately distinguish unintentional from intentional firearm deaths. In addition, for this article, where there were discrepancies among primary sources, we carefully read the information provided from NVDRS sites to increase uniformity in classification. By using NVDRS data, the current study provides basic descriptive information about the circumstances of unintentional firearm deaths across a wide range of states. By dividing unintentional
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fatalities into other-inflicted and self-inflicted injuries, our study underscores the need to examine another party along with the victim—the shooter—and suggests that prevention of accidental firearm fatalities, like prevention of intentional firearm fatalities, should focus on influencing the shooter as well as the victim. References Barber, C., Hemenway, D., Hochstadt, J., Azrael, D., 2002. Underestimates of unintentional firearm fatalities: comparing Supplementary Homicide Report data with the National Vital Statistics System. Injury Prevention 8 (3), 252– 256. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Accessed August 2009. Centers for Disease Control and Prevention, 2004. Coding manual: National Violent Death Reporting System, NVDRS, version 2. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA (http://www.cdc.gov/ncipc/pub-res/nvdrs-coding/VS2/NVDRS% 20Coding%20Manual%20Full.pdf). Cherry, D., Runyan, C., Butts, J., 2001. A population based study of unintentional firearm fatalities (in North Carolina). Injury Prevention 7 (1), 62–65. Dowd, M.D., Knapp, J.F., Fitzmaurice, L.S., 1994. Pediatric firearm injuries, Kansas City, 1992: a population-based study. Pediatrics 94 (6 Pt 1), 867–873. Eber, G.B., Annest, J.L., Mercy, J.A., Ryan, G.W., 2004. Nonfatal and fatal firearmrelated injuries among children aged 14 years and younger: United States, 1993–2000. Pediatrics 113 (6), 1686–1692. Grossman, D.C., Reay, D.T., Baker, S.A., 1999. Self-inflicted and unintentional firearm injuries among children and adolescents (in King County, Washington). Archives of Pediatrics and Adolescent Medicine 153 (8), 875–878.
Hanzlick, R., Goodin, J., 1997. Mind your manners. Part III. Individual scenario results and discussion of the National Association of Medical Examiners Manner of Death Questionnaire, 1995. American Journal of Forensic Medicine and Pathology 18 (3), 228–245. Hemenway, D., 2006. Private Guns, Public Health. University of Michigan Press, Ann Arbor, MI. Hemenway, D., Barber, C.W., Gallagher, S.S., Azrael, D.R., 2009. Creating a national violent death reporting system: a successful beginning. American Journal of Preventive Medicine 37 (1), 68–71. Karch, D.L., Lubell, K.M., Friday, J., Patel, N., Williams, D.D., 2008. Surveillance for violent deaths—National Violent Death Reporting System, 16 states, 2005. MMWR Surveillance Summary 57 (3), 1–45. Levy, D.T., Miller, T.R., Mallonee, S., Spicer, R.S., Romano, E.O., Fisher, D.A., Smith, G.S., 2002. Blood alcohol content-negative victims in alcohol-involved incidents. Addiction 97, 909–914. Martin, J.R., Sklar, D.P., McFeeley, P., 1991. Accidental firearm fatalities among New Mexico children. Annals of Emergency Medicine 20 (1), 58–61. Ranney, M.L., Verhoek-Oftedahl, W., Rommel, J., Mello, M.J., 2009. Analysis of intentional and unintentional injuries caused by firearm and cutting/piercing instruments among Providence youth, Nov 2004–Dec 2007. Medicine and Health Rhode Island 92 (6), 200–203. Schaechter, J., Duran, I., DeMarchena, J., Lemard, G., Villar, M.E., 2003. Are accidental gun deaths as rare as they seem? A comparison of medical examiner manner of death coding with an intent-based classification approach (for Miami-Dade county). Pediatrics 111 (4 Pt 1), 741–744. Steenkamp, M., Frazier, L., Lipskiy, N., Beberry, M., Thomas, S., Barker, L., Karch, D., 2006. The national violent death reporting system: an exciting new tool for public health surveillance. Injury Prevention 12 (Suppl. 2), ii3–ii5. Waller, J.A., Whorton, E.B., 1973. Unintentional shootings, highway crashes, and acts of violence. Accident Analysis and Prevention 5 (4), 351–356. Zavoski, R.W., Lapidus, G.D., Lerer, T.J., Banco, L.T., 1995. A population-based study of severe firearm injury among children and youth (in Connecticut). Pediatrics 96 (2 Pt 1), 278–282.
Contents lists available at ScienceDirect
Accident Analysis and Prevention journal homepage: www.elsevier.com/locate/aap
Unintentional firearm deaths: A comparison of other-inflicted and self-inflicted shootings David Hemenway ∗ , Catherine Barber, Matthew Miller Harvard Injury Control Research Center, Harvard School of Public Health, 677 Huntington Ave., 3rd Fl., Boston, MA 02115, USA
a r t i c l e
i n f o
Article history: Received 5 October 2009 Received in revised form 22 December 2009 Accepted 13 January 2010 Keywords: Firearm Guns Accidental shootings Other-inflicted National Violent Death Reporting System
a b s t r a c t This study compares other-inflicted and self-inflicted unintentional firearm fatalities. Data come from the National Violent Death Reporting System, a new surveillance system from the Centers for Disease Control and Prevention. Data are currently available from 16 states and parts of California for various years 2003–2006. Of the 363 unintentional firearm fatalities, about half (49%) were other-inflicted, ranging from 78% of child (aged 0–14) deaths to 19% of older adult (aged 55+) deaths. In other-inflicted shooting deaths, the shooters were overwhelmingly young (81% under age 25). The shooters in the other-inflicted deaths were primarily friends (43%) or family (47%); brothers were the most common family shooter. To learn how to prevent unintentional injuries, it is critical to have information not only on the victim, but also on the person who inflicted the injury. © 2010 Elsevier Ltd. All rights reserved.
1. Introduction Between 1965 and 2006, over 64,000 Americans died from unintentional firearm shootings, more Americans than were killed in our wars during the same period (Hemenway, 2006). Except for the age and gender distribution of these decedents, surprisingly little else is known about the circumstances of these deaths. What is known is largely based on a few studies, usually focused on children and adolescents with data often limited to a specific county (Dowd et al., 1994; Grossman et al., 1999; Schaechter et al., 2003), city (Ranney et al., 2009) or state (Cherry et al., 2001; Martin et al., 1991; Zavoski et al., 1995). Data on the circumstances of unintentional firearm fatalities in the United States have recently become available from the National Violent Death Reporting System (NVDRS) of the Centers for Disease Control and Prevention (Hemenway et al., 2009; Karch et al., 2008; Steenkamp et al., 2006). The NVDRS includes data related to the circumstances of unintentional firearm fatalities for all age groups across 16 states. Before the creation of NVDRS, there were no systematically collected data that allowed for the comparison of unintentional shootings that were other-inflicted (i.e., getting accidentally shot by someone else) vs. self-inflicted (i.e., accidentally shooting oneself).
∗ Corresponding author. Tel.: +1 617 432 4493; fax: +1 617 432 3699. E-mail addresses: [email protected] (D. Hemenway), [email protected] (C. Barber), [email protected] (M. Miller). 0001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.aap.2010.01.008
National data on unintentional firearm fatalities previously came from death certificates (e.g. tabulated in WISQARS, the Webbased Injury Statistics Query and Reporting System) (CDC, 2009). Such mortality data are victim-based, but it is the shooter who is usually the more relevant target for prevention. This paper uses data from the NVDRS to describe the circumstances of unintentional firearm deaths in the United States and to compare and contrast shootings that are other-inflicted with those that are self-inflicted. The characteristics of cases in which the shooter is someone other than the victim have not previously been examined in a large cross-state dataset of fatal firearm accidents. 2. Methods 2.1. Data The NVDRS is a federally funded, state-based surveillance system that links data from the death certificate, police report, crime lab, and coroner/medical examiner records on all deaths that occur following a suicide, homicide, legal intervention, unintentional firearm injury, and injuries of unknown intent. Data cover a census of all deaths that were classified on the death certificate as a suicide, homicide, legal intervention, unintentional firearm injury, or injury of unknown intent. Data are linked into a single data repository at the CDC and are incident-based, covering information on the persons (victims and suspects), weapons, and circumstances involved. The information is gathered by trained abstracters who usually work for the state health department or in some cases the medical examiner’s office or a subcontracted entity. Data may be extracted
D. Hemenway et al. / Accident Analysis and Prevention 42 (2010) 1184–1188 Table 1 Participating US States and California Counties, 2003–2006, NVDRS Restricted Access Dataset. NVDRS jurisdiction
Data years
Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, Virginia Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, Wisconsin Kentucky, New Mexico, Utah, Oakland CA, San Francisco County CA, Santa Clara County CA Alameda County CA, Los Angeles County CA, Riverside County CA
2003–2006 2004–2006 2005–2006 2006
manually or imported electronically and are coded in accordance with a detailed coding manual (CDC, 2004). For quality control purposes, 10% of all narratives are reviewed by staff at the CDC to assess how accurately the abstractors apply the coding definitions for type of death and precipitating circumstances. CDC staff send corrections to the states on an ongoing basis to improve coding. NVDRS has been described in further detail elsewhere (Steenkamp et al., 2006). Data for this study are from the NVDRSs Restricted Access Dataset (RAD) for the years 2003–2006, released in January 2009. Sixteen states and parts of California submitted data (Table 1). Use of the data in this study was approved by the Harvard School of Public Health’s Institutional Review Board.
2.2. Case definition NVDRS defines unintentional firearm injuries as “A death resulting from a penetrating injury or gunshot wound from a weapon that uses a powder charge to fire a projectile when there was a preponderance of evidence that the shooting was not intentionally directed at the victim.” Examples include a hunter mistaking another hunter for an animal, a man shooting himself or another person with a gun he believed was unloaded, a child under age 6 shooting a person (even if “intentionally”), and a criminal unintentionally shooting himself during the commission of a crime. Firearm-related deaths that do not meet the case definition are those that occur to another person during the commission of a crime or assault or when a gun is used to intentionally harm, control or frighten another person, even if the person who dies was an unintended target. So, for example, if during a robbery a passer-by is shot unintentionally, the death is classified as a homicide, not an accident. If, on the other hand, the shooter stumbles and shoots himself, the death is classified as an accident. Russian roulette (firing a revolver at oneself after spinning a cylinder that the shooter knows is partially loaded) is classified as suicide in NVDRS. One of the authors (CB) reviewed the incident narrative for each firearm-related death that met any of the following criteria to determine whether it met the NVDRS case definition for an unintentional firearm incident: it was classified as an accident by the abstractor, death certificate, or coroner/medical examiner report; it was assigned an underlying cause of death code of W32, W33, W34 or Y86; or it was classified by the Supplementary Homicide Report as a “negligent manslaughter.” A second author (DH) reviewed all cases in which the NVDRS abstractor and author disagreed to resolve disagreements. A total of 398 deaths met the NVDRS case definition. These included 391 that were classified by the NVDRS abstractor as accidents and 7 that were classified by the abstractor as homicides (2 were hunting accidents and 5 involved children or adolescents playing with guns). Another 10 deaths that were classified by the NVDRS abstractor as accidents were excluded because they involved a BB gun injury (1 case), Russian roulette (4 cases), legal intervention (3 cases), or assault (2 cases).
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2.3. Data hierarchies If more than one suspect or weapon was identified in an incident, we used the one that was listed first. Firearm type and relationship of victim to suspect were reported according to multiple data sources in NVDRS. When more than one data source supplied substantive information, we applied a hierarchy based on the assumed reliability of that source. For firearm type the hierarchy was crime laboratory, law enforcement, coroner/medical examiner; for relationship the hierarchy was law enforcement, coroner/medical examiner, Supplementary Homicide Report. In 14 cases, relationship was not coded but was stated in the narrative and was therefore assigned by the authors based on that description. The NVDRS abstractor coded the context in which a firearm accident occurred, coding as many as applied from among the categories of hunting, playing/fooling around, self-defense, target shooting, celebratory firing, loading/unloading, cleaning, showing to others, and other. In 20% of cases no context was selected. We reviewed narratives for all cases to identify whether contexts could be further characterized, adding categories for exiting/entering a motor vehicle, suicide play (e.g., pointing a gun believed to be unloaded at oneself and pulling the trigger), threats/assault (i.e. self-inflicted accident during a threat or assault with a gun), suicide attempt (e.g., accidental shooting while swatting a gun away from a suicide attempter), and miscellaneous carrying/handling. We expanded the definition of “cleaning” to include repairing or assembling/disassembling a gun and “self-defense” to include carrying a gun for protection. Unknowns were reduced to 12%. For analytic purposes, we assigned contexts to a collapsed, mutually exclusive list using the following hierarchy: hunting, playing (also includes celebratory firing and suicide play), self-defense, target shooting, cleaning/loading/unloading, showing, carrying/handling, and other (also includes accident during a suicide attempt or threat/assault). 2.4. Statistical analysis Pearson’s chi square test was used to assess bivariate associations between the proportion of shootings that were other- (vs. self-) inflicted and characteristics of the victim and incident. We also ran a multivariate logistic regression examining which factors explained why shootings were self-inflicted vs. other-inflicted. We collapsed some of the context and firearm type variables since the numbers were small. 3. Results A total of 398 people died from unintentional firearm injuries in the NVDRS jurisdictions over the 4-year period. In 35 cases (9%), it was unknown whether the shooting was inflicted by self or other, so these cases were set aside, leaving a final dataset of 363 deaths. In almost half of these fatalities, the victim was shot by another person (Table 2). The younger the victim, the more likely the decedent was shot by someone else. For children aged 0–14, over three quarters (78%) of the deaths were other-inflicted. This percentage fell with the victim’s age; for older adult victims aged 55+, less than one-fifth (19%) were other-inflicted. The relationship between age and whether or not the shooting was self-inflicted also held in the multivariate analysis (Table 3). Victims of unintentional shootings were overwhelmingly male. So were the shooters. Ninety-two percent (92%) of the shooters who killed another person were male (Table 4). The few females who died were usually (73%) shot by another person (almost always male) (Table 2).
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Table 2 Unintentional firearm fatalities by proportion other-inflicted (vs. self-inflicted), selected states, 2003–2006, National Violent Death Reporting System. N b
Column %
% Other-inflicted
pa
Total
363
100
49
Age of victim 0–14 15–24 25–54 55+
72 121 127 43
19 33 35 12
78 60 33 19
*** ***
Gender of victim Male Female
330 33
91 9
47 73
– **
Place of incident Home of victim Other home Elsewhere
150 89 124
41 25 34
36 66 53
– *** **
Context Playing Hunting Cleaning/loading Carrying/handling Showing Target shooting Self-defense Other Unknown
140 77 39 18 13 10 9 30 27
39 21 11 5 4 3 2 8 7
61 62 36 22 62 50 0 27 22
** **
Firearm type Handgun Rifle Shotgun Unknown
187 76 68 32
52 21 19 9
39 66 59 50
–
– * NA
– *** **
a Asterisks refer to the probability that the proportion of cases that were other-inflicted (vs. self-inflicted) varied significantly in the listed subgroup compared with the reference group (“–”) in a bivariate logistic regression: *p ≤ .05; **p ≤ .01; ***p ≤ .001. b The total of 363 excludes 35 incidents in which it was unknown whether the shooting was self- or other-inflicted.
Most unintentional firearm victims were young; in this data set the median victim was under 25 years old (Table 2). Most shooters were also young: 81% of shooters who unintentionally killed another person were under age 25 (Fig. 1).
Table 3 Adjusted odds ratios for other-inflicted (vs. self-inflicted) among unintentional firearm fatalities, selected states, 2003–2006, National Violent Death Reporting System. Adjusted OR (95% CI)a Age (years)
pb
.96 (.94–.97)
***
Gender of victim Male Female
– 6.1 (2.2–17.2)
– ***
Place of incident Home of victim Other home Elsewhere
– 3.7 (1.9–7.1) 2.1 (1.0–4.2)
– *** *
2.1 (1.1–4.0) 2.1 (0.9–4.6)
*
Collapsed context Playing Hunting/target shooting All other Collapsed firearm type Handgun Long gun Unknown
Most firearm deaths occurred in the context of someone playing with the gun, hunting, cleaning or loading the gun (Table 2). Most (over 60%) of both the hunting and playing fatalities were otherinflicted. In more than half (58%) of all unintentional firearm fatalities, the shooting occurred away from the victim’s home. In shootings away from home, another person shot the victim 60% of the time (Table 2). Handguns rather than long guns caused most of the unintentional firearm deaths (Table 2). While accidental handgun deaths were more likely than long gun deaths to be self-inflicted, 39% of victims killed accidentally with a handgun were shot by another person. Comparing other- and self-inflicted deaths, the shooters and victims in other-inflicted incidents were much younger. Whereas 81% of shooters who killed another person were under age 25, Table 4 The shooter in other-inflicted unintentional firearm fatalities. Percent (n = 179)
–
5.2 (2.6–10.2) 3.0 (1.2–7.4)
– *** *
Note: This model excludes the 9 incidents involving a self-inflicted defensive act (because these by definition cannot be other-inflicted). a Adjusted odds ratio with 95% confidence intervals report the ratio of the odds that the fatality was other-inflicted (vs. self-inflicted) in the listed group compared with the reference group (“–”) in a multivariate logistic regression controlling for all other listed variables. b Probability: *p ≤ .05; **p ≤ .01; ***p ≤ .001.
Shooter age (n = 141) 0–14 15–24 25–54 55+
35 46 14 4
Shooter gender (n = 165) Male Female
92 8
Relationship to victim (n = 171) Family Friend Acquaintance Stranger
47 43 9 1
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Fig. 1. Percentage by age category of shooters and victims in other-inflicted and self-inflicted unintentional firearm deaths.
only 35% of shooters in self-inflicted deaths were under age 25 (Fig. 1). For example, among the 62 hunting incidents for which the shooter’s age was known, the shooter was under 25 in 55% of the other-inflicted incidents vs. 14% of the self-inflicted incidents (not shown). As with the shooters, victims in other-inflicted deaths were younger than victims in self-inflicted deaths. Seventy-two percent (72%) of victims in other-inflicted shootings were under age 25, compared with the 35% of victims in self-inflicted shootings (Fig. 1). In over 70% of other-inflicted incidents, both parties were under age 25 (not shown). Even though most other-inflicted deaths occurred outside the home, shooters were likely to be family (including intimate partners) (47%) or friends (43%). In fewer than 2% of the cases was the other person a stranger (Table 4). Among family members, husbands, fathers, grandfathers, uncles and in-laws were all represented. But by far the most common shooter among the relatives were siblings (45% of family shootings), nearly always brothers (not shown).
4. Discussion Outside of motor vehicle injuries, surprisingly little is known about self-inflicted vs. other-inflicted unintentional injuries (see Levy et al., 2002 for one of the rare articles that makes the distinction). Very few surveys ask about the person who may have unintentionally injured another or even make a distinction between self-inflicted and other-inflicted unintentional injuries. For example, the World Health Organization (2004) “Guidelines for Conducting Community Surveys on Injuries and Violence” includes questions about the perpetrators of intentional injury, but for unintentional injuries, there are no questions even about whether the injury was self-inflicted or inflicted by someone else. The current article focuses on the issue of self-inflicted vs. otherinflicted unintentional firearm fatalities. For most unintentional injuries, there are often gray areas about the extent of others’ involvement in the injury (e.g., a driver swerves to avoid another motorist and runs off the road). One of the features of unintentional firearm deaths is that there is usually little question about who pulled the trigger. We find that in almost half of all unintentional firearm fatalities, someone other than the victim fired the shot. In the large majority of the unintentional shooting deaths of children, someone else shot them; by contrast the large majority of the shooting deaths of older adults were self-inflicted. A study of unintentional firearms deaths in North Carolina, using medical examiner data, also found that younger victims were likely to be shot by someone else, whereas most older victims shot themselves (Cherry et al., 2001). By contrast, for nonfatal unintentional firearm injuries, a national study exclusively of children using data from hospital
emergency departments found that more of the injuries were selfinflicted (48%) rather than other-inflicted (40%), with 12% unknown (Eber et al., 2004). In our study, for other-inflicted deaths, the shooter is almost always a male and almost half the time is from the same family as the victim, often a brother. The most common type of circumstance in unintentional gun deaths is someone playing with the gun, and in these instances, most of the time the injury is other-inflicted. Our results show that the danger to children and adolescents is largely from being shot by others—typically friends or siblings. These findings lend credence to programmatic and policy proposals to improve gun storage, and to make it normative for parents to ask about the availability of guns in the homes visited by their children. The real costs of unintentional firearm death are not borne exclusively by the victim and his family, but also include the guilt and grief of the shooter and his family. In half of all other-inflicted unintentional fatal firearm incidents—a quarter of all unintentional shooting deaths—the shooter was a friend or acquaintance. Usually, both shooter and victim are young, with many expected years of life ahead of them. The current study has important limitations. The fact that the NVDRS is not currently a national system limits its value. Although a third of the states are included in the system, these are not a representative or random sample of all fifty states. Our results certainly may not be generalizable outside the United States. Another limitation is that the NVDRS does not provide the level of detailed information about the shooter or the victim that a case–control study might provide. One case–control study (Waller and Whorton, 1973), which looked exclusively at other-inflicted unintentional shootings, obtained information about the shooter in 34 shootings (both fatal and nonfatal) in Vermont. The study found that these shooters were more likely than the victim (or than the typical licensed motorist) to misuse alcohol, to have been investigated or arrested for acts of violence, and to be involved in highway crashes. Despite these limitations the information provided by this study is a marked advance over death certificate data. Mortality datasets like WISQARS that rely solely on death certificate data only have information about the victim. In addition, the intent of the shooter is not always easily determined, and medical examiners are not uniform in their classifications (Barber et al., 2002; Hanzlick and Goodin, 1997). A strength of the National Violent Death Reporting System is that it uses information from multiple sources to try to consistently and accurately distinguish unintentional from intentional firearm deaths. In addition, for this article, where there were discrepancies among primary sources, we carefully read the information provided from NVDRS sites to increase uniformity in classification. By using NVDRS data, the current study provides basic descriptive information about the circumstances of unintentional firearm deaths across a wide range of states. By dividing unintentional
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fatalities into other-inflicted and self-inflicted injuries, our study underscores the need to examine another party along with the victim—the shooter—and suggests that prevention of accidental firearm fatalities, like prevention of intentional firearm fatalities, should focus on influencing the shooter as well as the victim. References Barber, C., Hemenway, D., Hochstadt, J., Azrael, D., 2002. Underestimates of unintentional firearm fatalities: comparing Supplementary Homicide Report data with the National Vital Statistics System. Injury Prevention 8 (3), 252– 256. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WISQARS (Web-based Injury Statistics Query and Reporting System). Available at: http://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Accessed August 2009. Centers for Disease Control and Prevention, 2004. Coding manual: National Violent Death Reporting System, NVDRS, version 2. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA (http://www.cdc.gov/ncipc/pub-res/nvdrs-coding/VS2/NVDRS% 20Coding%20Manual%20Full.pdf). Cherry, D., Runyan, C., Butts, J., 2001. A population based study of unintentional firearm fatalities (in North Carolina). Injury Prevention 7 (1), 62–65. Dowd, M.D., Knapp, J.F., Fitzmaurice, L.S., 1994. Pediatric firearm injuries, Kansas City, 1992: a population-based study. Pediatrics 94 (6 Pt 1), 867–873. Eber, G.B., Annest, J.L., Mercy, J.A., Ryan, G.W., 2004. Nonfatal and fatal firearmrelated injuries among children aged 14 years and younger: United States, 1993–2000. Pediatrics 113 (6), 1686–1692. Grossman, D.C., Reay, D.T., Baker, S.A., 1999. Self-inflicted and unintentional firearm injuries among children and adolescents (in King County, Washington). Archives of Pediatrics and Adolescent Medicine 153 (8), 875–878.
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