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Accident Analysis and Prevention 42 (2010) 1184–1188

Contents lists available at ScienceDirect

Accident Analysis and Prevention

journa l homepage: www.e lsev ier .com/ locate /aap

nintentional firearm deaths: A comparison of other-inflictednd self-inflicted shootings

avid Hemenway ∗, Catherine Barber, Matthew Millerarvard Injury Control Research Center, Harvard School of Public Health, 677 Huntington Ave., 3rd Fl., Boston, MA 02115, USA

r t i c l e i n f o

rticle history:eceived 5 October 2009eceived in revised form2 December 2009

a b s t r a c t

This study compares other-inflicted and self-inflicted unintentional firearm fatalities. Data come fromthe National Violent Death Reporting System, a new surveillance system from the Centers for DiseaseControl and Prevention. Data are currently available from 16 states and parts of California for various years2003–2006. Of the 363 unintentional firearm fatalities, about half (49%) were other-inflicted, ranging from

ccepted 13 January 2010

eywords:irearmunsccidental shootings

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 deathswere primarily friends (43%) or family (47%); brothers were the most common family shooter. To learnhow to prevent unintentional injuries, it is critical to have information not only on the victim, but alsoon the person who inflicted the injury.

ther-inflictedational Violent Death Reporting System

. Introduction

Between 1965 and 2006, over 64,000 Americans died from unin-entional firearm shootings, more Americans than were killed inur wars during the same period (Hemenway, 2006). Except forhe age and gender distribution of these decedents, surprisinglyittle else is known about the circumstances of these deaths. Whats known is largely based on a few studies, usually focused on chil-ren and adolescents with data often limited to a specific countyDowd et al., 1994; Grossman et al., 1999; Schaechter et al., 2003),ity (Ranney et al., 2009) or state (Cherry et al., 2001; Martin et al.,991; Zavoski et al., 1995).

Data on the circumstances of unintentional firearm fatalities inhe United States have recently become available from the Nationaliolent Death Reporting System (NVDRS) of the Centers for Dis-ase Control and Prevention (Hemenway et al., 2009; Karch et al.,008; Steenkamp et al., 2006). The NVDRS includes data relatedo the circumstances of unintentional firearm fatalities for all ageroups across 16 states. Before the creation of NVDRS, there wereo systematically collected data that allowed for the comparison of

nintentional shootings that were other-inflicted (i.e., getting acci-entally shot by someone else) vs. self-inflicted (i.e., accidentallyhooting oneself).

∗ Corresponding author. Tel.: +1 617 432 4493; fax: +1 617 432 3699.E-mail addresses: hemenway@hsph.harvard.edu (D. Hemenway),

barber@hsph.harvard.edu (C. Barber), mmiller@hsph.harvard.edu (M. Miller).

001-4575/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.oi:10.1016/j.aap.2010.01.008

© 2010 Elsevier Ltd. All rights reserved.

National data on unintentional firearm fatalities previouslycame from death certificates (e.g. tabulated in WISQARS, the Web-based Injury Statistics Query and Reporting System) (CDC, 2009).Such mortality data are victim-based, but it is the shooter who isusually the more relevant target for prevention. This paper usesdata from the NVDRS to describe the circumstances of uninten-tional firearm deaths in the United States and to compare andcontrast shootings that are other-inflicted with those that areself-inflicted. The characteristics of cases in which the shooter issomeone other than the victim have not previously been examinedin a large cross-state dataset of fatal firearm accidents.

2. Methods

2.1. Data

The NVDRS is a federally funded, state-based surveillance sys-tem that links data from the death certificate, police report, crimelab, and coroner/medical examiner records on all deaths that occurfollowing a suicide, homicide, legal intervention, unintentionalfirearm injury, and injuries of unknown intent. Data cover a censusof all deaths that were classified on the death certificate as a suicide,homicide, legal intervention, unintentional firearm injury, or injuryof unknown intent. Data are linked into a single data repository at

the CDC and are incident-based, covering information on the per-sons (victims and suspects), weapons, and circumstances involved.The information is gathered by trained abstracters who usuallywork for the state health department or in some cases the medicalexaminer’s office or a subcontracted entity. Data may be extracted

D. Hemenway et al. / Accident Analysis an

Table 1Participating US States and California Counties, 2003–2006, NVDRS RestrictedAccess Dataset.

NVDRS jurisdiction Data years

Alaska, Maryland, Massachusetts, New Jersey,Oregon, South Carolina, Virginia

2003–2006

Colorado, Georgia, North Carolina, Oklahoma,Rhode Island, Wisconsin

2004–2006

Kentucky, New Mexico, Utah, Oakland CA, SanFrancisco County CA, Santa Clara County CA

2005–2006

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Victims of unintentional shootings were overwhelmingly male.

Alameda County CA, Los Angeles County CA,Riverside County CA

2006

anually or imported electronically and are coded in accordanceith a detailed coding manual (CDC, 2004). For quality control pur-oses, 10% of all narratives are reviewed by staff at the CDC to assessow accurately the abstractors apply the coding definitions for typef death and precipitating circumstances. CDC staff send correc-ions to the states on an ongoing basis to improve coding. NVDRSas been described in further detail elsewhere (Steenkamp et al.,006). Data for this study are from the NVDRSs Restricted Accessataset (RAD) for the years 2003–2006, released in January 2009.ixteen states and parts of California submitted data (Table 1).

Use of the data in this study was approved by the Harvard Schoolf Public Health’s Institutional Review Board.

.2. Case definition

NVDRS defines unintentional firearm injuries as “A death result-ng from a penetrating injury or gunshot wound from a weaponhat uses a powder charge to fire a projectile when there was areponderance of evidence that the shooting was not intention-lly directed at the victim.” Examples include a hunter mistakingnother hunter for an animal, a man shooting himself or anothererson with a gun he believed was unloaded, a child under age 6hooting a person (even if “intentionally”), and a criminal unin-entionally shooting himself during the commission of a crime.irearm-related deaths that do not meet the case definition arehose that occur to another person during the commission of arime or assault or when a gun is used to intentionally harm, con-rol or frighten another person, even if the person who dies was annintended target. So, for example, if during a robbery a passer-by

s shot unintentionally, the death is classified as a homicide, notn accident. If, on the other hand, the shooter stumbles and shootsimself, the death is classified as an accident. Russian roulette (fir-

ng a revolver at oneself after spinning a cylinder that the shooternows is partially loaded) is classified as suicide in NVDRS.

One of the authors (CB) reviewed the incident narrative forach firearm-related death that met any of the following criteria toetermine whether it met the NVDRS case definition for an unin-entional firearm incident: it was classified as an accident by thebstractor, death certificate, or coroner/medical examiner report; itas assigned an underlying cause of death code of W32, W33, W34

r Y86; or it was classified by the Supplementary Homicide Reports a “negligent manslaughter.” A second author (DH) reviewedll cases in which the NVDRS abstractor and author disagreed toesolve disagreements. A total of 398 deaths met the NVDRS caseefinition. These included 391 that were classified by the NVDRSbstractor as accidents and 7 that were classified by the abstractors homicides (2 were hunting accidents and 5 involved children ordolescents playing with guns). Another 10 deaths that were clas-

ified by the NVDRS abstractor as accidents were excluded becausehey involved a BB gun injury (1 case), Russian roulette (4 cases),egal intervention (3 cases), or assault (2 cases).

d Prevention 42 (2010) 1184–1188 1185

2.3. Data hierarchies

If more than one suspect or weapon was identified in an inci-dent, we used the one that was listed first. Firearm type andrelationship of victim to suspect were reported according to mul-tiple data sources in NVDRS. When more than one data sourcesupplied substantive information, we applied a hierarchy basedon the assumed reliability of that source. For firearm type thehierarchy was crime laboratory, law enforcement, coroner/medicalexaminer; for relationship the hierarchy was law enforcement,coroner/medical examiner, Supplementary Homicide Report. In 14cases, relationship was not coded but was stated in the narrativeand was therefore assigned by the authors based on that descrip-tion.

The NVDRS abstractor coded the context in which a firearmaccident occurred, coding as many as applied from among thecategories of hunting, playing/fooling around, self-defense, targetshooting, celebratory firing, loading/unloading, cleaning, showingto others, and other. In 20% of cases no context was selected. Wereviewed narratives for all cases to identify whether contexts couldbe further characterized, adding categories for exiting/entering amotor vehicle, suicide play (e.g., pointing a gun believed to beunloaded at oneself and pulling the trigger), threats/assault (i.e.self-inflicted accident during a threat or assault with a gun), suicideattempt (e.g., accidental shooting while swatting a gun away froma suicide attempter), and miscellaneous carrying/handling. Weexpanded the definition of “cleaning” to include repairing or assem-bling/disassembling a gun and “self-defense” to include carrying agun for protection. Unknowns were reduced to 12%. For analyticpurposes, we assigned contexts to a collapsed, mutually exclusivelist using the following hierarchy: hunting, playing (also includescelebratory 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 associ-ations between the proportion of shootings that were other- (vs.self-) inflicted and characteristics of the victim and incident. Wealso ran a multivariate logistic regression examining which factorsexplained why shootings were self-inflicted vs. other-inflicted. Wecollapsed some of the context and firearm type variables since thenumbers were small.

3. Results

A total of 398 people died from unintentional firearm injuries inthe NVDRS jurisdictions over the 4-year period. In 35 cases (9%), itwas 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 anotherperson (Table 2).

The younger the victim, the more likely the decedent was shotby someone else. For children aged 0–14, over three quarters (78%)of the deaths were other-inflicted. This percentage fell with the vic-tim’s age; for older adult victims aged 55+, less than one-fifth (19%)were other-inflicted. The relationship between age and whetheror not the shooting was self-inflicted also held in the multivariateanalysis (Table 3).

So were the shooters. Ninety-two percent (92%) of the shooterswho killed another person were male (Table 4). The few femaleswho died were usually (73%) shot by another person (almost alwaysmale) (Table 2).

1186 D. Hemenway et al. / Accident Analysis and Prevention 42 (2010) 1184–1188

Table 2Unintentional firearm fatalities by proportion other-inflicted (vs. self-inflicted), selected states, 2003–2006, National Violent Death Reporting System.

N Column % % Other-inflicted pa

Total 363b 100 49

Age of victim0–14 72 19 78 ***15–24 121 33 60 ***25–54 127 35 3355+ 43 12 19 –

Gender of victimMale 330 91 47 –Female 33 9 73 **

Place of incidentHome of victim 150 41 36 –Other home 89 25 66 ***Elsewhere 124 34 53 **

ContextPlaying 140 39 61 **Hunting 77 21 62 **Cleaning/loading 39 11 36Carrying/handling 18 5 22 –Showing 13 4 62 *Target shooting 10 3 50Self-defense 9 2 0 NAOther 30 8 27Unknown 27 7 22

Firearm typeHandgun 187 52 39 –Rifle 76 21 66 ***Shotgun 68 19 59 **Unknown 32 9 50

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a Asterisks refer to the probability that the proportion of cases that were other-ieference 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 sh

Most unintentional firearm victims were young; in this data set

he median victim was under 25 years old (Table 2). Most shoot-rs were also young: 81% of shooters who unintentionally killednother person were under age 25 (Fig. 1).

able 3djusted odds ratios for other-inflicted (vs. self-inflicted) among unintentionalrearm fatalities, selected states, 2003–2006, National Violent Death Reportingystem.

Adjusted OR (95% CI)a pb

Age (years) .96 (.94–.97) ***

Gender of victimMale – –Female 6.1 (2.2–17.2) ***

Place of incidentHome of victim – –Other home 3.7 (1.9–7.1) ***Elsewhere 2.1 (1.0–4.2) *

Collapsed contextPlaying 2.1 (1.1–4.0) *Hunting/target shooting 2.1 (0.9–4.6)All other –

Collapsed firearm typeHandgun –Long gun 5.2 (2.6–10.2) ***Unknown 3.0 (1.2–7.4) *

ote: This model excludes the 9 incidents involving a self-inflicted defensive actbecause these by definition cannot be other-inflicted).

a Adjusted odds ratio with 95% confidence intervals report the ratio of the oddshat the fatality was other-inflicted (vs. self-inflicted) in the listed group comparedith the reference group (“–”) in a multivariate logistic regression controlling for

ll other listed variables.b Probability: *p ≤ .05; **p ≤ .01; ***p ≤ .001.

d (vs. self-inflicted) varied significantly in the listed subgroup compared with the

g was self- or other-inflicted.

Most firearm deaths occurred in the context of someone playingwith the gun, hunting, cleaning or loading the gun (Table 2). Most(over 60%) of both the hunting and playing fatalities were other-inflicted.

In more than half (58%) of all unintentional firearm fatalities,the shooting occurred away from the victim’s home. In shootingsaway from home, another person shot the victim 60% of the time(Table 2).

Handguns rather than long guns caused most of the uninten-tional firearm deaths (Table 2). While accidental handgun deathswere more likely than long gun deaths to be self-inflicted, 39% of

victims killed accidentally with a handgun were shot by anotherperson.

Comparing other- and self-inflicted deaths, the shooters andvictims in other-inflicted incidents were much younger. Whereas81% of shooters who killed another person were under age 25,

Table 4The shooter in other-inflicted unintentional firearm fatalities.

Percent (n = 179)

Shooter age (n = 141)0–14 3515–24 4625–54 1455+ 4

Shooter gender (n = 165)Male 92Female 8

Relationship to victim (n = 171)Family 47Friend 43Acquaintance 9Stranger 1

D. Hemenway et al. / Accident Analysis and Prevention 42 (2010) 1184–1188 1187

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Fig. 1. Percentage by age category of shooters and victims

nly 35% of shooters in self-inflicted deaths were under age 25Fig. 1). For example, among the 62 hunting incidents for whichhe shooter’s age was known, the shooter was under 25 in 55% ofhe other-inflicted incidents vs. 14% of the self-inflicted incidentsnot shown).

As with the shooters, victims in other-inflicted deaths wereounger than victims in self-inflicted deaths. Seventy-two percent72%) of victims in other-inflicted shootings were under age 25,ompared with the 35% of victims in self-inflicted shootings (Fig. 1).n over 70% of other-inflicted incidents, both parties were under age5 (not shown).

Even though most other-inflicted deaths occurred outside theome, shooters were likely to be family (including intimate part-ers) (47%) or friends (43%). In fewer than 2% of the cases washe other person a stranger (Table 4). Among family members,usbands, fathers, grandfathers, uncles and in-laws were all rep-esented. But by far the most common shooter among the relativesere siblings (45% of family shootings), nearly always brothers (not

hown).

. Discussion

Outside of motor vehicle injuries, surprisingly little is knownbout self-inflicted vs. other-inflicted unintentional injuries (seeevy et al., 2002 for one of the rare articles that makes theistinction). Very few surveys ask about the person who mayave unintentionally injured another or even make a distinctionetween self-inflicted and other-inflicted unintentional injuries.or example, the World Health Organization (2004) “Guidelines foronducting Community Surveys on Injuries and Violence” includesuestions about the perpetrators of intentional injury, but for unin-entional injuries, there are no questions even about whether thenjury was self-inflicted or inflicted by someone else.

The current article focuses on the issue of self-inflicted vs. other-nflicted unintentional firearm fatalities. For most unintentionalnjuries, there are often gray areas about the extent of others’nvolvement in the injury (e.g., a driver swerves to avoid another

otorist and runs off the road). One of the features of uninten-ional firearm deaths is that there is usually little question aboutho pulled the trigger.

We find that in almost half of all unintentional firearm fatal-ties, someone other than the victim fired the shot. In the large

ajority of the unintentional shooting deaths of children, some-ne else shot them; by contrast the large majority of the shootingeaths of older adults were self-inflicted. A study of unintentional

rearms deaths in North Carolina, using medical examiner data,lso found that younger victims were likely to be shot by some-ne else, whereas most older victims shot themselves (Cherry etl., 2001). By contrast, for nonfatal unintentional firearm injuries,national study exclusively of children using data from hospital

er-inflicted and self-inflicted unintentional firearm deaths.

emergency departments found that more of the injuries were self-inflicted (48%) rather than other-inflicted (40%), with 12% unknown(Eber et al., 2004).

In our study, for other-inflicted deaths, the shooter is almostalways a male and almost half the time is from the same family asthe victim, often a brother. The most common type of circumstancein unintentional gun deaths is someone playing with the gun, andin these instances, most of the time the injury is other-inflicted.

Our results show that the danger to children and adolescentsis largely from being shot by others—typically friends or siblings.These findings lend credence to programmatic and policy proposalsto improve gun storage, and to make it normative for parents to askabout the availability of guns in the homes visited by their children.

The real costs of unintentional firearm death are not borneexclusively by the victim and his family, but also include the guiltand grief of the shooter and his family. In half of all other-inflictedunintentional fatal firearm incidents—a quarter of all unintentionalshooting deaths—the shooter was a friend or acquaintance. Usually,both shooter and victim are young, with many expected years of lifeahead of them.

The current study has important limitations. The fact that theNVDRS is not currently a national system limits its value. Althougha third of the states are included in the system, these are not a rep-resentative or random sample of all fifty states. Our results certainlymay not be generalizable outside the United States.

Another limitation is that the NVDRS does not provide the levelof detailed information about the shooter or the victim that acase–control study might provide. One case–control study (Wallerand Whorton, 1973), which looked exclusively at other-inflictedunintentional shootings, obtained information about the shooter in34 shootings (both fatal and nonfatal) in Vermont. The study foundthat these shooters were more likely than the victim (or than thetypical licensed motorist) to misuse alcohol, to have been investi-gated or arrested for acts of violence, and to be involved in highwaycrashes.

Despite these limitations the information provided by this studyis a marked advance over death certificate data. Mortality datasetslike WISQARS that rely solely on death certificate data only haveinformation about the victim. In addition, the intent of the shooteris not always easily determined, and medical examiners are notuniform in their classifications (Barber et al., 2002; Hanzlick andGoodin, 1997). A strength of the National Violent Death Report-ing System is that it uses information from multiple sources totry to consistently and accurately distinguish unintentional fromintentional firearm deaths. In addition, for this article, where therewere discrepancies among primary sources, we carefully read the

information provided from NVDRS sites to increase uniformity inclassification.

By using NVDRS data, the current study provides basic descrip-tive information about the circumstances of unintentional firearmdeaths across a wide range of states. By dividing unintentional

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atalities into other-inflicted and self-inflicted injuries, our studynderscores the need to examine another party along with theictim—the shooter—and suggests that prevention of accidentalrearm fatalities, like prevention of intentional firearm fatalities,hould focus on influencing the shooter as well as the victim.

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