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POSITION STATEMENT

Youth and firearms in Canada

Posted: Oct 1 2005 Updated: Dec 1 2008 Reaffirmed: Feb 1 2014

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Principal author(s)

JY Frappier, K Austin Leonard, D Sacks; Canadian Paediatric Society, Adolescent Health Committee
Paediatr Child Health 2005;10(8):473-7 Appendix

Firearm injury is a significant and preventable cause of death in Canada, both in the general population and in the paediatric age group. The present statement describes the problem of firearm injuries in Canadian youths and reviews the risks associated with the presence of a firearm in the home. The dangers of nonpowder firearms (such as BB guns and ‘air’ guns) are discussed. Lastly, this statement explores the issues of physician counselling on firearm safety and children’s firearm safety education programs.

Background information

In 2002, 811 Canadians of all ages died from firearm injuries [1]. This number includes injuries from unintentional (accidental) and intentional (suicides and homicides) firearm injuries. Of these, 67 deaths occurred in youths younger than 20 years of age. Canada’s youth mortality from firearms is one of the highest in the world. A study [2] by the United States Centers for Disease Control and Prevention ranked 26 industrialized countries by firearm mortality in youths younger than 15 years of age. Canada ranked fifth, behind the United States, Finland, Northern Ireland and Israel (see Figure 1).

Figure 1) Rates of firearm-related death* per 100,000 children younger than 15 years of age for one year during 1990 to 1995 in 26 industrialized countries (ie, all countries classified in the high-income group with populations of 1,000,000 or greater that provided complete data; in this analysis, Hong Kong, Northern Ireland and Taiwan were considered as countries). *Homicides by firearm (International Classification of Diseases, Ninth Revision, codes E965.0 to E965.4), suicides by firearm (E955.0 to E955.4), unintentional deaths caused by firearm (E922.0 to E922.9) and firearm-related deaths for which the intention was undetermined (E985.0 to E985.4); †Reported only unintentional firearm-related deaths

Adolescent males, in particular, have a disproportionate share of firearm injuries; of all firearm deaths among 15- to 19-year-old Canadians in 2002, 96% were male [1]. In Canada, 15- to 19-year-old males are more likely to die from firearm injuries than from cancer, or from fires, falls and drowning combined. Gunshot wounds accounted for 8% of all deaths in 15- to 19-year-old Canadian males in 2002 [1]. The majority of Canadian adolescent firearm deaths are suicides, accounting for 79% of all firearm deaths in 2002 among those 15 to 19 years of age. Among younger Canadians (14 years of age and younger), suicides are less common, and unintentional injuries and homicides are more predominant. In 2002, 13% of the 31 Canadian deaths from unintentional firearm injuries were in youths 19 years of age or younger.

Canadian laws

Canadian federal gun control laws require a screening process before the purchase of a firearm, and all firearm owners must be licensed. All firearms (both handguns and rifles) must be registered individually by the owner. Storage regulations require that a firearm be stored locked (either in a locked container or with a trigger lock) and unloaded, and separate from its ammunition. Registration requirements for handguns have been in place since the late 1970s, and the recent legislation phased in during the 1990s includes registration requirements for long guns, such as rifles and shotguns.

Statement of the problem

Risks of keeping a firearm in the home

Estimates of the rate of home ownership of guns in Canada range from 21% to 34% nationwide, although one recent survey suggested a lower rate of 17% [3][4][5][6]. Provincial rates of firearm ownership vary widely, from 15% in Ontario to 67% in the Yukon and Northwest Territories. Most Canadian firearm owners own a rifle or shotgun; only 12% own a handgun [7]. Gabor et al [8], who studied mortality from unintentional firearm injury in Canada, found a strong positive correlation between provincial rates of home ownership of guns and death rates from unintentional firearm injuries.

The presence of a firearm in the home has been shown to increase rates of homicide and suicide compared with homes without a firearm [9]-[12]. In studies of adolescent suicide conducted by Brent et al [13][14], the presence of a firearm in the home was found to be a strongly positive risk factor for completed adolescent suicide. Apparently, the adolescent without a firearm in the home is more likely either to use a less lethal method or to not attempt suicide. Birckmayer and Hemenway [15] analyzed the relationship between suicide rates and household firearm ownership for four age groups. They found that firearm ownership was correlated with increased suicide rates for 15- to 24-year-olds and 65- to 84-year-olds, but not for 25- to 64-year-olds [15]. This suggests that the availability of a firearm in the home is a suicide risk factor for some, but not all, age groups. It is likely that certain developmental characteristics of adolescents, such as impulsivity, sensitivity to peer pressure, and experimentation with alcohol and substances, are responsible for this effect.

Firearms play an important role in domestic violence incidents in Canada. A Statistics Canada study [16] of family violence between 1991 and 1999 found that the majority of Canadian child and adolescent homicide victims are killed by family members. Firearms are the leading method of homicide used against those in the 12- to 18-year-old age group.

Handguns, homicide and youth

Before 1990, approximately 30% of Canadian firearm homicides involved handguns, and 70% involved rifles and shotguns [17]. Since then, the rate of homicides committed with rifles and shotguns has steadily declined, whereas the homicide rate involving handguns has remained relatively stable. The result of the decline in the use of rifles and shotguns is that handgun-related homicides now account for approximately two-thirds of firearm homicides. Data collected since 1997 suggest that most handguns used to commit homicides were not legally acquired. Over the past decade, Canadian youths aged 12 to 17 years comprised 9% of those charged with homicide, and 43% of their victims were aged 12 to 24 years. Wintemute [18] has described the widespread movement of guns from the legal US firearms market into the illegal market, resulting in the easy availability of inexpensive small handguns to American youths. An understanding of where and how handguns are acquired by Canadian youths will be key to reducing the youth homicide rates in Canada.

Nonpowder firearms

Nonpowder firearms, such as BB guns and air guns, are not benign toys. These firearms have been associated with significant morbidity and even mortality. Marshall et al [19] found air gun injuries to be the leading cause of enucleation secondary to trauma, in youths 18 years of age and younger in Ottawa, Ontario, from 1974 to 1993. In a review of the literature on fatal nonpowder firearm injuries, Lawrence [20] found that present day nonpowder firearms, which use air or CO2 compression or a spring-loaded piston to propel the small-calibre pellets or BBs, can obtain projectile velocities high enough to cause skin penetration and significant internal damage. He reviewed 11 cases of death from nonpowder firearms, of which 10 were from injuries to the eye or the frontotemporal region. One death resulted from a wound to the chest. Of these 11 cases, nine were in youths ranging in age from three to 17 years.

In Canada, only firearms whose bullets fire at a velocity of greater than 152 m/s are regulated by federal gun control legislation. Most air guns have a lower projectile velocity than 152 m/s and are therefore not regulated by federal gun control laws. They are also not regulated by the Hazardous Products Act. Certain provinces and municipalities have laws regulating nonpowder firearms; for example, the province of Ontario requires the purchaser of ammunition for air guns and BB guns to be 18 years of age or older, and the municipality of Halifax, Nova Scotia, forbids the discharge of this type of firearm within the municipality [21][22]. The price for nonpowder firearms ranges from $70 to several hundred dollars [23].

Paintball guns, used in the increasingly popular sport of paintball, fire a small ball with a hard, thin outer shell filled with paint that splatters on impact. They may be powered by CO2, nitrogen or compressed air [24]. The paintballs may attain velocities of 76 m/s to 91 m/s, twice the velocity needed to penetrate the eye (39 m/s) [25]. Paintball guns have been associated with severe eye injuries. Easterbrook and Pashby [26][27] described 44 patients with ocular paintball injuries, of whom 17 became legally blind, 13 became visually impaired, and only 14 recovered normal vision. In reputable paintball arenas, the use of helmets and goggles is enforced and projectile velocity is monitored. Most ocular injuries from paintballs occur during informal play at home, not at official facilities where goggles are required [28][29]. Ocular injury from paintball guns usually occurs when eye protection is not being worn or is worn improperly [30].

Interventions to reduce firearm injuries

Counselling

On the subject of firearms and injury prevention counselling, studies from the United States have shown that while most physicians feel it is worthwhile, few actually include it in their practice [31]; Canadian physicians’ attitudes have not been studied.

Parents’ attitudes (in the United States) about physician counselling on firearm dangers have also been studied. Webster et al [32] found that 17% of gun-owning parents would be willing to remove a firearm from the home if their physician recommended it, and 84% would be willing to follow advice about storing firearms safely. However, two studies [33][34] evaluating the effectiveness of office-based counselling alone in improving gun storage habits showed no improvement in the gun storage habits after the counselling. In a more successful intervention, Brent et al [35] gave parents information about the risks of a firearm in the home and recommended removal of a firearm from the homes of adolescents diagnosed with depression. Twenty-seven per cent of the families did remove the firearm from the home.

Education plus environmental modification

In a different kind of intervention, Horn et al [36] developed and evaluated a program in which gun safes (lock boxes for guns) and trigger locks were distributed to homes of gun owners in Alaska, USA, along with safety information. This intervention resulted in a large increase in safe storage practices. A review [37] of seven studies (including the four cited above) was conducted to evaluate the efficacy of programs designed to improve the safe storage of firearms. The authors concluded, “We are in the early stages of understanding what types of interventions, or what components of interventions, prompt gun owners to securely store their firearms” [37].

Technological modifications to firearms

Another promising passive strategy is the use of safety devices on firearms. Vernick et al [38] reviewed all unintentional and undetermined (intent not established) firearm deaths in Maryland, USA, from 1991 to 1998. They assessed whether each of these deaths may have been prevented if one of three safety devices had been used. The safety devices were personalization devices (allow only the owner to fire the gun), loaded chamber indicators (show the gun is loaded) and magazine safeties (keep a semiautomatic gun from firing when the ammunition magazine is removed, even if there is a bullet left in the chamber of the gun). The authors estimated that 44% of the deaths were preventable by the use of at least one safety device, and that deaths involving children were even more likely to be preventable.

Children’s firearm safety education

Educating children about gun safety has been proposed as a desirable method for reducing firearm injury rates in children [39]. School-based programs have been developed for elementary school-age children to learn strategies for remaining safe if a firearm is encountered in their home or environment. However, studies evaluating children’s firearm safety education have cast doubt on its effectiveness. Himle et al [40] compared children who participated in a popular firearm safety program, Eddie the Eagle (developed by the National Rifle Association), with children who participated in another firearm safety program developed by the authors. They also had a control group of children who had no firearm safety education. Children who had the Eddie the Eagle program were superior to the control group in verbalizing the correct safety message; however, in a role-playing situation and in a simulated ‘real-life’ situation, children who had the Eddie the Eagle program were no better than children in the control group in practicing the desired gun safety behaviour (eg, Don’t touch! Run and tell an adult!). The children who participated in the authors’ program did better than the children in the control group in verbalizing the safety message and in role playing, but, again, they were not significantly better than the control group in the simulated real-life setting. Hardy et al [41][42] performed a randomized, controlled study comparing four- to seven-year-old children who participated in a week-long firearm safety program with a control group who had no educational program. After the program, pairs of the children were covertly observed playing in a setting in which there was a semiautomatic pistol. Fifty-three per cent of the pairs played with the gun, and there was no difference between the control and intervention groups.

Injury prevention educational programs may have unintended effects [43][45][46]. It is possible that firearm safety education for children may increase their comfort level around guns, particularly in programs that include gun-handling techniques. Parents may be inclined to reduce their supervision or use of safe storage practices if their children learn gun safety at school. At present, no children’s firearm safety programs have been shown to be effective in simulated real- life situations. Further research is required to find an effective way to change children’s behaviour around firearms. Widespread use of these programs is unwise until an effective program is developed.

Conclusions

Firearm injuries result in significant mortality in Canadian children and adolescents. The rates of firearm injury in Canadian youth are among the highest in developed countries. The presence of a firearm in the home increases the risk of suicide, homicide and unintentional injuries in the home. Nonpowder firearms and paintball guns are not regulated as firearms by Canadian gun control laws yet can cause significant injury, especially ocular injury. Children’s school-based firearm safety education programs have not been shown to be effective and may have unintended negative effects.

Recommendations

  • The position of the Canadian Paediatric Society is that it is best for firearms not to be present in homes or environments in which children and adolescents live and play. If a firearm must be present, it should be stored according to the regulations of the Canadian Firearms Act, that is, unloaded, locked and separate from its ammunition.
  • Paediatricians should support legislative measures to strictly control the acquisition, ownership and storage of firearms.
  • Physicians should routinely inquire about the presence of a firearm in the home and inform parents of the risks of home ownership if one is present. Physicians have an obligation to share this information with parents, until such time that an effective approach to anticipatory guidance relating to the prevention of firearm injuries is established.
  • A recommendation to remove the firearm from the home should be made in cases where there are risk factors for adolescent suicide. Physicians may similarly wish to recommend the removal of the firearm from the home when there are risk factors for childhood unintentional injury or domestic violence, although the effectiveness of such a recommendation has not been evaluated.
  • Firearm safety interventions that include education and environmental interventions – such as the provision of trigger locks and gun safes – would likely be more effective than an education-only program. However, our present level of evidence does not clearly indicate the best way to improve gun safety in the home.
  • Childhood firearm safety education cannot be recommended at present because currently available programs have not been shown to result in behaviour change in children, and such education may have unintended negative effects, such as reduced parental vigilance. Further study is needed before the implementation of any childhood firearm safety education programs.
  • The use of technological innovations, such as personalization of firearms, is a promising strategy and deserves further study. Research is also needed on the subject of Canadian youths and their acquisition of illegal firearms.
  • Nonpowder firearms (air guns and BB guns) are dangerous weapons and should not be considered as toys for children or adolescents. Youths should never use these weapons unless supervised closely by an adult. Physicians assessing children with injuries caused by these guns should be aware that the pellets can cause significant internal injury. Paintball guns should be used only in supervised arenas with proper safety gear. A nationwide policy regulating the sale and use of nonpowder firearms is needed.

Quality of evidence and classification of recommendations

The evidence demonstrating the association between a firearm in the home and increased risk of unintentional firearm injury, suicide or homicide is based on numerous well-designed cohort and case-controlled studies in Canada and the United States (quality of evidence II-2). The evidence relating to the effectiveness of a recommendation to parents to remove the firearm from the home of a depressed adolescent is based on a well-designed randomized controlled trial (quality of evidence I) and would be considered a classification of recommendation A. The evidence demonstrating the lack of effectiveness of children’s firearm safety education is based on several randomized controlled trials (quality of evidence I).

Acknowledgements

The Adolescent Health Committee thanks the Injury Prevention Committee for reviewing this position statement.

ADOLESCENT HEALTH COMMITTEE

Members: Sheri M Findlay MD; Jean-Yves Frappier MD (chair); Eudice Goldberg MD; Jorge Pinzon MD; Koravangattu Sankaran MD (board representative); Danielle Taddeo MD
Liaison: Karen Mary Leslie MD, Adolescent Health Section, Canadian Paediatric Society
Principal authors: Jean-Yves Frappier MD; Katherine Austin Leonard MD; Diane Sacks MD

References

  1. Statistics Canada. Mortality, Summary List of Causes, 2002. Catalogue no. 84-208-XIE, December 2004.
  2. Centers for Disease Control and Prevention (CDC). Rates of homicide, suicide, and firearm-related death among children – 26 industrialized countries. MMWR Morb Mortal Wkly Rep 1997;46:101-5.
  3. Angus Reid Group. Firearm Ownership in Canada. March 1991.
  4. Gabor T. Firearms and Self-Defence: A comparison of Canada and the United States.
  5. Canadian Firearms Centre. Study Released on Firearms in Canada, August 20, 2002 .
  6. Block R. Firearms in Canada and Eight Other Western Countries: Selected Findings of the 1996 International Crime (Victim) Survey. Department of Justice, Canadian Firearms Centre, January 1998.
  7. Canadian Firearms Centre. Focus on Firearms, March 1999.
  8. Gabor T, Roberts JV, Stein K, DiGiulio L. Unintentional firearm deaths: Can they be reduced by lowering gun ownership levels? Can J Public Health 2001;92:396-8.
  9. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med 1992;327:467-72.
  10. Shah S, Hoffman RE, Wake L, Marine WM. Adolescent suicide and household access to firearms in Colorado : Results of a case-control study. J Adolesc Health 2000;26:157-63.
  11. Killias M. International correlations between gun ownership and rates of homicide and suicide. CMAJ 1993;148:1721-5.
  12. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med 1993;329:1084-91. (Erratum in 1998;339:928-9)
  13. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988;45:581-8.
  14. Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, Zelenak JP. The presence and accessibility of firearms in the homes of adolescent suicides. A case-control study. JAMA 1991;266:2989-95.
  15. Birckmayer J, Hemenway D. Suicide and firearm prevalence: Are youth disproportionately affected? Suicide Life Threat Behav 2001;31:303-10.
  16. Dauvergne M. Homicide in Canada, 2001. Statistics Canada , Catalogue no. 85-002-XIE, Vol 22, No 7.
  17. Savoie J. Homicide in Canada, 2002. Statistics Canada , Catalogue no. 85-002-XIE, Vol 23, No 8.
  18. Wintemute GJ. Where the guns come from: The gun industry and gun commerce. Future Child 2002;12:54-71.
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  20. Lawrence HS. Fatal nonpowder firearm wounds: Case report and review of the literature. Pediatrics 1990;85:177-81.
  21. Halifax County Municipality By-law 08 – Mischiefs & Nuisances – Halifax Regional Municipality. http://www.halifax.ca/legislation/bylaws/county/blno8.pdf (Version current at September 13, 2005 ).
  22. Imitation Firearms Regulation Act, 2000. S.O. 2000, Chapter 37.
  23. Canadian Tire Online Catalog. http://www.canadiantire.ca (Version current at January 17, 2005 ).
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  29. Fineman MS. Ocular paintball injuries. Curr Opin Ophthalmol 2001;12:186-90.
  30. Hargrave S, Weakley D, Wilson C. Complications of ocular paintball injuries in children. J Pediatr Ophthalmol Strabismus 2000;37:338-43.
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  35. Brent DA, Baugher M, Birmaher B, Kolko DJ, Bridge J. Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression. J Am Acad Child Adolesc Psychiatry 2000;39:1220-6.
  36. Horn A, Grossman DC , Jones W, Berger LR. Community based program to improve firearm storage practices in rural Alaska. Inj Prev 2003;9:231-4.
  37. McGee KS, Coyne-Beasley T, Johnson RM. Review of evaluations of educational approaches to promote safe storage of firearms. Inj Prev 2003;9:108-11.
  38. Vernick JS, O’Brien M, Hepburn LM, Johnson SB, Webster DW, Hargarten SW. Unintentional and undetermined firearm related deaths: A preventable death analysis for three safety devices. Inj Prev 2003;9:307-11.
  39. Blackman PH. Children and guns, the NRA’s perception of the problem and its policy implications. Paper presented at the meeting of the American Society of Criminology. Miami, November 9 to 12, 1994.
  40. Himle MB, Miltenberger RG, Gatheridge BJ, Flessner CA. An evaluation of two procedures for training skills to prevent gun play in children. Pediatrics 2004;113:70-7.
  41. Hardy MS, Armstrong FD, Martin BL, Strawn KN. A firearm safety program for children: They just can’t say no. J Dev Behav Pediatr 1996;17:216-21.
  42. Hardy MS. Teaching firearm safety to children: Failure of a program. J Dev Behav Pediatr 2002;23:71-6.
  43. Fergusson DM, Horwood LJ, Beautrais AL, Shannon FT. A controlled field trial of a poisoning prevention method. Pediatrics 1982;69:515-20.
  44. Vernberg K, Culver-Dickinson P, Spyker DA. The deterrent effect of poison-warning stickers. Am J Dis Child 1984;138:1018-20.
  45. Robertson LS. Crash involvement of teenaged drivers when driver education is eliminated from high school. Am J Public Health 1980;70:599-603.
  46. Ploeg J, Ciliska D, Dobbins M, Hayward S, Thomas H, Underwood J. A systematic overview of adolescent suicide prevention programs. Can J Public Health 1996;87:319-24.

Appendix

 

Levels of evidence and strength of recommendations


Level of evidence

Description


I

Evidence obtained from at least one properly randomized controlled trial.

II-1

Evidence obtained from well-designed controlled trial without randomization.

II-2

Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group.

II-3

Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category.

III

Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Grade

Description


A

There is good evidence to recommend the clinical preventive action.

B

There is fair evidence to recommend the clinical preventive action.

C

The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making.

D

There is fair evidence to recommend against the clinical preventive action.

E

There is good evidence to recommend against the clinical preventive action.

F

There is insufficient evidence to make a recommendation; however, other factors may influence decision-making.


 

 

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.