Firearm injury and mortality is a major public health concern that has taken a devastating toll on young Americans for decades. In 2018, 3335 young people (aged 1–19) died of firearm injuries, specifically homicide (55%), suicide (39%), and unintentional injury (3%).1 In a recent article, the Firearm Safety Among Children and Teens Consortium2 recommended increased attention to safe firearm storage in the home and other places (eg, cars) where individuals <18 years of age may have unauthorized access to prevent firearm injury and mortality, specifically suicide and unintentional injury. Such efforts draw on robust empirical findings that suggest that safer firearm storage will save lives.3 A simulation study revealed that a modest increase in safe firearm storage would result in a 32% decrease in lives lost.4
One setting ripe for delivering anticipatory guidance paired with safe storage devices, such as cable locks or lockboxes, is the pediatric health care setting. In this Pediatrics Perspectives, we offer suggestions for needed research to allow pediatric clinicians to offer recommendations that reflect effective and acceptable ways to safely store firearms to keep youth safe and that incorporate the voices of firearm stakeholders.
What does it mean to store firearms safely from the perspective of parents and legal guardians (hereinafter referred to as parents) with children <18 years of age in the home? There is no universally agreed on recommendation that accounts for the nuanced reasons that parents own firearms.
Specifically, major national organizations, depending on guild, offer different recommendations. The position of the American Academy of Pediatrics (AAP), the largest organization of pediatric physicians, is as follows: “The AAP affirms that the most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes.”5 If firearms are in the home, the AAP recommends that they be stored locked (eg, in a lockbox), unloaded (ie, ammunition not in the firearm), and with ammunition stored in a separate locked location. The National Shooting Sporting Foundation, a national trade association that includes manufacturers, distributors, firearms retailers, shooting ranges, and sportsperson organizations and publishers in the United States, offers storage recommendations similar to those of the AAP (ie, triple-safe storage) but does not recommend the absence of firearms in homes. The recommendation to have no firearms in the home may be unacceptable to some families. As a field, we must research how best to broaden our definition of safe storage while maintaining effectiveness.
A Harm Reduction Strategy
To advance current knowledge on how best to deliver anticipatory guidance in routine pediatric health care settings, we make the following suggestions.
First, we argue that the field ought to consider harm reduction approaches to safe firearm storage to prevent access by those, including youth, who might use firearms to harm themselves, either intentionally or unintentionally. These approaches seek to maximize individual rights while trying to minimize the potential for negative effects and promote positive health outcomes. Thus, they are highly applicable to parental safe firearm storage practices. Recommendations that promote the absence of firearms in the home may be ineffective for some families given that the right to keep and bear arms is a part of the US Constitution. This perspective may alienate potential partners and firearm stakeholders with whom we have a shared mission (to keep young people safe and to prevent unauthorized access to firearms). Recent efforts by the AAP and researchers to engage firearm stakeholders suggest that future research will importantly include the voices of firearm stakeholders. One particularly noteworthy example of such a partnership comes from the Gun Shop Project in New Hampshire. This work included a group of mental health and public health experts, firearm retailers, firearm range owners, and firearm rights advocates who developed materials to support firearm retailers and range owners on how best to prevent suicide.6 In taking this type of approach, questions regarding how we define safe storage become germane. Currently, this is conceptualized as safely storing all firearms, yet safety may have different meanings depending on reasons for ownership and use. Imagine a home with children and two firearms, one for sport and one for protection. If the parent stores the unloaded sporting firearm in a lockbox with the ammunition stored separately but keeps the one for protection loaded in a lockbox, does this constitute safe storage? Empirical study of whether flexible storage recommendations result in greater uptake, as well as quantifying the relationship of these recommendations with the risk of pediatric firearm injury and mortality, is needed.
Second, recent studies with firearm stakeholders, including parents, reveal that firearm storage behaviors are dynamic and individualized, thus requiring a personalized approach.7 Some current recommendations for parents around firearm safe storage may be unrealistic on the basis of what we have learned from decades of injury science research. There are major gaps in our understanding of how to make evidence-informed recommendations that take into account stakeholder preferences and contextual variation. In the absence of research evidence, we have to draw on our personal experiences. We have found that taking a nonjudgmental stance toward firearm storage practices when discussing safe storage is the most effective and appropriate way to share our knowledge and to come to an agreement with parents about a solution that is most likely to keep their child safe. This is the basis for shared decision-making. It is likely better that some of the firearms in the home are stored as safely as possible than to have all stored unsafely.
We call for research examining innovative and effective ways to store firearms safely that may be more acceptable to firearm stakeholders, particularly given the desire to have quick access to firearms for protection.7 These can include new strategies to store firearms safely, development of more preferred storage devices, and policies to increase safe storage. New strategies to store firearms safely require empirical attention. Potential existing and overlooked solutions may include removing the firing pin, bolt, fire control group, or other critical functional components from firearms in the home and storing them securely and separately to ensure that the firearms are disabled and not functional should unauthorized access occur. To develop more preferred storage devices, it will be necessary to work in interdisciplinary teams to develop acceptable and cost-effective storage approaches. A federal policy mandate, the Child Safety Lock Act of 2005, requires all handguns to be sold with a safety device, typically cable locks. Mandates like this one are likely to be most effective if they incorporate owner preferences; we have learned in informal conversations that these cable locks are often left behind at retailers because of their perceived lack of utility. Offering keyed lockboxes rather than cable locks may be more acceptable. This research is critical to inform clinician and major national organization recommendations.
If we are to make progress, we must partner with a range of stakeholders, including parent firearm owners, and be flexible in how we think about safe storage as it relates to unauthorized pediatric access. This will allow us to identify and test approaches that have the greatest likelihood of widespread adoption by parents of youth.
We thank the following individuals for their input on an earlier version of this article: Gene Ananiev, PhD; Brett Bass; Molly Davis, PhD; Benjamin Hoffman, MD, CPST-I, FAAP; Cheryl King, PhD; Ken Lewis, MBA; Amy Pettit, PhD; and Courtney Benjamin Wolk, PhD.
All authors jointly conceptualized and drafted this perspective piece, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: Supported by the National Institutes of Health (R24 HD087149). Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: Dr Beidas reported receiving grants from the National Institutes of Health. She receives royalties from Oxford University Press and has served as a consultant for Merck and the Camden Coalition of Healthcare Providers. Dr Rowhani-Rahbar reported receiving grants from the National Institutes of Health, the US Department of Justice, and Arnold Ventures and contracts from the City of Seattle and the State of Washington. Dr Rivara reported receiving grants from the National Institutes of Health, the US Department of Justice, and Arnold Ventures and contracts from the City of Seattle and the State of Washington.