SPECIAL ARTICLE * ARTICLE SPECIAL

Firearm-related injuries in Canada: issues for prevention Antoine Chapdelaine, MD, MPH, FRCPC; Esther Samson, MD, FRCPC; M. Dennis Kimberley, MSW, PhD; Louise Viau, LIM We reviewed the available data on firearm-related injuries in Canada to suggest strategies for prevention in the context of the proposed amendments to the Criminal Code (Bill C-1 7) currently before Parliament. The risk of death from a firearm in Canada is equivalent to the risk of death from a motor vehicle crash. We discuss the risks associated with firearms with regard to suicides, homicides and "accidents." We also discuss the accessibility of firearms. This article builds upon a recently published update on the epidemiologic basis of the public health approach for the prevention of firearm-related injuries and deaths. The key to the etiologic approach to preventing such injuries and deaths is to view the incidents, regardless of their medicolegal circumstances, as having one factor in common: the discharge of a firearm.

Cet article est une revue des donnees disponibles sur les traumatismes relies aux armes a feu au Canada. Ceci aux fins de suggerer des strategies preventives dans le contexte des amendements au Code criminel (Projet de loi C-1 7) deposes a la Chambre des communes. Le risque de deces par la decharge d'une arme a feu au Canada est equivalent au risque de deces par collision de vehicule moteur. Nous discutons des risques relies aux armes a feu en ce qui a trait aux suicides, aux homicides et aux , ainsi que l'accessibilite des armes a feu. Cet article s'appuie sur une revue recemment publiee de la litterature sur les bases epidemiologiques de l'approche de sante publique pour la prevention des traumatismes relies aux armes a feu. La cle de cette approche etiologique et preventive revient a considerer que ces traumatismes resultent d'un facteur commun: la decharge d'une arme a feu. Et ceci peu importent les circonstances medico-legales de la survenue de tels traumatismes.

my mind is already second and third causes of potential years of life lost owing to injury, after motor vehicle crashes.2 Onethird of these intentional deaths were related to Anonymous politician firearms.3 The risk of death from a firearm discharge As quoted by Senator Jacques Flynn in Canada is almost equal to the risk of death from a motor vehicle crash (2.37 deaths per 10 000 firearms possessed v. 2.4 deaths per 10 000 registered motor B y 1988 in Canada injury was the leading cause c f potential years of life lost, ahead of vehicles in 19903-5), even though cars are used for cancer and cardiovascular disease.' From transportation far more frequently than firearms are 1986 to 198 8 suicides and homicides were the used for sports or leisure. From 1970 to 1989

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Dr. Chapdelaine is a consultant with the Departement de Sante communautaire, Sante publique et Environnement, and Dr. Samson is a clinical professor ofpsychiatry and head ofpsychogeriatric services, Hopital de l'Enfant-Jesus, Quebec, Que. Dr. Kimberley is associate professor, School of Social Work, Memorial University of Newfoundland, St. John's, Nfld. Ms. Viau is a barrister in Quebec and professor

of criminal law, Universite de Montreal, Montreal, Que.

Reprint requests to: Dr. Antoine Chapdelaine, Departement de Sante communautaire, Sante publique et Environnement, Hopital de l'Enfant Jesus, 1401-18th St., Quebec, PQ GIJ IZ4 CAN MED ASSOC J 1991; 145 (10)

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Statistics Canada registered more than 28 520 firearm-related deaths in Canada: 21 670 were suicides, 4055 homicides and 1683 "accidents"; 910 were of unknown intention, and 198 were related to legal interventions. These statistics highlight the magnitude of a problem that has so far not been considered a public health priority in Canada. We reviewed the Canadian data and linked them to the injury control approach in order to suggest public policy strategies for preventing firearm-related injuries. We will highlight some useful statistics for policy-making in the context of the proposed amendments to the Criminal Code (Bill C- 17) before Parliament. We will also summarize the epidemiologic basis of the public health approach for the prevention of firearm-related injuries, building on an update recently published.6 In an editorial in this issue (see pages 1211 to 1213) we suggest some strategies for preventing the inappropriate discharge and misuse of firearms. We will discuss the risks to the individual and the community with regard to intentional discharges (suicides and homicides), unintentional discharges and accessibility of firearms.

Intentional discharges Suicides In Canada suicides have accounted for 79% of firearm-related deaths.7 The overall increase by 200% in the suicide rate since 1960 has in part been attributable to Quebec, where the rate rose by 350%. In 1986 men 15 to 24 years of age and those more than 70 years had the highest rates of all age groups. That year 38% of the men who committed suicide used a firearm, as compared with 12% of the women. Women usually chose less effective means of attempting suicide, such as drugs (which accounted for 30% of suicides by women). In 1987 Quebec had a suicide rate that was 21% higher than the rates elsewhere in Canada. Of a total of 1179 suicides 30% involved guns.8 In a recent study conducted in the mostly urban region of Quebec City and the mostly rural region of Chaudiere-Appalaches 576 suicide records for 1987 to 1989 from the coroner's office were examined: 28% involved a firearm (a shotgun in 50%, a rifle in 40%, a handgun in 6% and unspecified in 4%) (Antoine Chapdelaine, Louise M. Bouchard and Gilles Mireault, H6pital de l'Enfant-Jesus, Quebec: unpublished data). Availability in the home and the likelihood that ammunition is kept close at hand may explain these findings. Remarkably, in half of the firearm-related suicides the most common calibres - a 22-gauge rifle or a 12-gauge shotgun - were used. 1218

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The problem is worst among native people.7'9 The total suicide rate was three times higher in the native Indian and Inuit population than in the total Canadian population. In 1986 native men 15 to 29 years old had the highest suicide rate (100 per 100 000 native people).7 As in the Canadian population the suicide rate in the native population is much higher among men than among women. The most frequent methods used by the native Indians were firearms and drugs and by the Inuit hanging and firearms.9 The number of firearm-related suicides has decreased, from more than 1200 per year (or about 37% of all suicides) before 1978 to about 1100 per year (or about 32% of all suicides) in 1989; however, suicides by young people are still of particular concern, since 20% of all suicides in Canada were committed by those 15 to 24 years of age, 37% of whom used a firearm (1988 data).3'5 Teen suicide is often impulsive, as demonstrated in reports of clustered suicides by adolescents.'0 Of particular interest is a study on the availability of firearms and the rates of suicide in King County, Wash., and Vancouver.'I The rate of suicide with firearms was higher in King County. The rate of suicide with a handgun was 6 times higher overall and almost 10 times higher among people 15 to 24 years old in King County. Handguns are far less available in Canada than in the United States. Interestingly, this difference in rates was not offset by higher rates of suicide by other means in the same age group in Vancouver. The authors concluded that a restriction of the access to handguns reduces the suicide rate in that age group. Further studies are needed to examine the effect of impulse and the proximity of firearms. Nevertheless, given the importance of the problem of suicides in Canada and the impulsive nature of teen suicides, further restriction to the most available and frequently used firearms should be implemented and evaluated to prevent suicides, especially by people 15 to 24 years of age. The method used in a suicide is closely related to the likelihood that the attempt will be "successful." Hospital statistics have shown that firearms are the most lethal method: death occurred in 92% of suicide attempts with a firearm, 78% with intentional exposure to carbon monoxide, 78% with hanging, 67% with drowning and 23% with an overdose of drugs. 12 More studies are needed to determine the outcome after impulsive acts of self-destruction, when the suicidal method permits salvage. In a review of 18 cases in which young men, mostly US native Indians, survived self-inflicted gunshot wounds to the face subsequent attempts were uncommon. I The survivors were found to be largely successful in LE 15 NOVEMBRE 1991

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employment and marriage and well adjusted after origin. The proportion of firearm-related homicides reconstructive surgery. However, firearms rarely in the native population is unknown. In a study comparing gun regulations, crime, offer these possibilities. assaults and homicides- in Seattle and Vancouver'7 the authors concluded the following. Homicides Between 1978 and 1987 shooting was the leading cause of homicidal death in Canada.'4 Firearms were implicated in 33% of the deaths: hunting rifles and shotguns accounted for 61%, handguns for 30% and illegal shotguns or rifles with barrels less than 46 cm long for 2%; in 7% of the deaths the firearm was unspecified. After shootings sharp instruments and blows were the leading causes of homicidal death, accounting for 28% and 21% of the deaths respectively. The remainder of deaths were caused by suffocation, strangulation, drowning and fire. Although homicide has long been regarded as a "crime" problem, only 19% of homicides in 1988 in Canada occurred during the commission of another criminal act (robbery, theft or break and enter in 65% of cases, sexual assault in 23% and miscellaneous criminal acts in 12%). Most often the victim knows the assailant, and the murder occurs during a dispute. For example, of spousal and common law homicides in Canada from 1980 to 1989, almost 40% involved firearms, and 84% of the victims were women. Furthermore, female victims of such homicides are much more likely than male victims to have been shot (43% v. 26%).'1 Even though firearms are the weapon most commonly used in homicides in Canada, there are noticeable differences between the male and female victims in terms of the methods used. Men are more likely than women to use a firearm (35.8% v. 28.5% respectively).5"14 Homicide is not just a problem in inner cities. Although the number of firearm-related homicides decreased from about 300 per year (or about 40% of all homicides) before 1978 to less than 200 per year (or about 30% of all homicides) on average for the period 1986-89, there have been more firearmrelated homicides in rural areas than in large cities.3,5 From 1980 to 1989, 848 such homicides occurred in rural areas, as compared with 523 in urban areas with a population greater than 500000. Of all homicides 41% involved firearms in rural areas, as compared with 28% in large cities. In addition, the homicide rates per 100 000 population were two times higher in rural areas than in cities. Native people are also at high risk for homicides.5"6 Although they account for less than 3% of the Canadian population, in 1988 they represented 17.6% and 22.2% of all homicide victims and suspects respectively. In other words about one in six people killed in a homicide and one in five people suspected of committing a homicide were of native NOVEMBER 15,1l991

The rate of assaults involving firearms was seven times higher in Seattle than in Vancouver. Despite similar overall rates of criminal activity and assault, the relative risk of death from homicide, adjusted for age and sex, was significantly higher in Seattle than in Vancouver.... Virtually all of this excess risk was explained by a 4.8-fold higher risk of being murdered with a handgun in Seattle as compared with Vancouver.

Gun control is more restrictive in Canada than in the United States. A European study suggested that increased firearm availability is associated with increased firearm-related homicide rates, with no evidence of displacement of choice to other murder weapons.'8 As with suicides the suggested association between firearm availability and violent death'9 needs to be studied further. For example, does a firearm in the home increase the likelihood of firearm-related death or lethal assault? Accurate measures of firearm ownership are urgently needed to answer such questions. As with suicides the type of weapon used substantially affects the probability that an assault will result in death. Gunshot wounds were found to be over 5 times more likely than knife wounds to result in death in an Australian study20 and 15 times more likely in a Danish study.2' Because of the quantity of energy transferred by a firearm to a human body such a weapon can cause far more damage than any other.6

Unintentional discharges Although each year in Canada only 4% of firearm-related deaths are classified as "accidents" and 3% as "undetermined as to intention" this adds up to 2593 deaths in two decades.5 Since 1978, when the current legislation on firearms in Canada was introduced, the number of firearm-related "accidental" deaths decreased by more than 50% among people less than 25 years old.3'5 Decreases in other age groups were less significant. From 1979 to 1988 the rate of "accidental" firearm-related deaths has been highest among young people: 25% among children under 15 years and about 30% among youths 15 to 24. Handguns were involved almost exclusively among those 15 to 44. Overall, the number of firearm-related deaths, including suicides, homicides and "accidents," are highest among people 15 to 34_3,5

Although unintentional discharges account for a CAN MED ASSOC J 1991; 145 (10)

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small proportion of firearm-related deaths they are responsible for a relatively large proportion of serious and disabling injuries. Of shootings necessitating hospital admission in Canada from 1983 to 1986, 53% were classified as "accidents," 21% as suicide attempts, 10% as intentional acts by another person, 1% as the result of a legal intervention and 14% as undetermined.3 In the native population firearm-related "accidents" have been prevalent.9 From 1980 to 1984 they accounted for 12.6% of all the deaths from injury or poisoning in this population in Alberta, 14.4% in Saskatchewan, 6.1% in Manitoba, 10.0% in Ontario, 8.3% in Quebec, 9.0% in Atlantic Canada, 11.2% in the Northwest Territories and 23.3% in the Yukon Territory. In a unique report of 68 nonhunting firearmrelated accidents from 1985 to 1990 in Manitoba22 91% were noted to be nonfatal; 62% were noted to be self-inflicted, mostly by those 12 to 40 years of age (in 71% of cases). In most (62%) of the shootings by another person the shooter was under 20 years of age and the victim under 12 years. In all, 61.7% involved a 22-calibre rifle, 11.8% a shotgun and 11.7% an airgun; in 14.8% the firearm was unspecified. The shooting occurred in a home in 45.6% of the cases and outdoors in 22.0%; the location was unspecified in the remainder. Graduates of a hunter safety course were responsible for 11.8% of the shootings. Almost two-thirds of the "accidental" shootings, including those involving hunter-safety graduates, resulted from careless storage or handling of the firearm about the home. In summary of Todd's study22 most unintentional injuries from shootings occur in or around the home, are associated with unsafe storage or handling of the firearm or involve 22-calibre rifles and 12-gauge shotguns or airguns (airguns are not defined as firearms in the Criminal Code and therefore are currently unregulated). Airguns cause more serious injuries than previously assumed.23 Self-inflicted injuries are also related to faulty firearm design and poor maintenance. For example, in a 22-calibre semiautomatic rifle the ammunition is fed into the rifle through a tube-feed system. The problem arises when a foreign object (grain or sand) obstructs the passage of live ammunition through the magazine tube. It is difficult to see if the rifle is still loaded, and the firearm can discharge unexpectedly (Ervin Heiman, Western Gun Parts, Edmonton: personal communication, 1991). "Accidental" injuries inflicted by someone else can be associated with play among small children24 or among impaired adults.

random events resulting from misfortune or fate and are, therefore, not preventable. . . Product design measures focussed on better engineering to prevent inadvertent discharge by children and adults may have a greater impact than years of firearm safety training.6

Accessibility of firearms

A recent po1125 of 10 103 households across Canada estimated that about 5.9 million firearms are owned privately; this excludes those owned by the armed forces, the police and other public or private institutions. Of the firearms 51% were rifles (24% semiautomatic), 39% shotguns (17% semiautomatic), 7% handguns (36% semiautomatic) and 3% some other type of firearm. It was estimated that 2.2 million (23%) of Canadian households owned at least one firearm for the following declared purposes: 67% for hunting, 13% for collecting, 12% for target shooting, 2% for employment and 5% unknown. Of the respondents 1% (representing an estimated 22 000 households) volunteered that the main reason for owning a firearm was for personal protection; 5% of the handgun owners (14% in Quebec) volunteered this reason. This disclosure is troubling, since guns seem rarely to offer effective personal protection during an assault or robbery. One study in the United States showed that guns kept in the home had been involved in 333 suicides, 41 homicides and 12 unintentional deaths.26 Even after the suicides were excluded a household member was killed 18 times more often than an intruder.26 This area needs further study in Canada to determine whether the risk of firearm-related injury outweighs the benefit of protection. Until the distribution of all firearms available in Canadian households is known and case-control or cohort studies can be conducted it is safe to assume that the safest home is one without a gun. Men account for 86% of the firearm owners.25 Of households with at least one firearm 45% have revenues of more than $40 000; 11% have revenues of less than $20 000, as compared with 17% in the Canadian population. Most important, the firearms in 50% of the households had not been used in the previous 12 months. In 51% of the households no member had received instruction in the safe care and handling of firearms within the past 5 years. Given the risk of suicide, homicide and unintentional shootings the accessibility of firearms in a quarter of Canadian homes, of which one in two households possibly treats the firearm or ammunition with somewhat "benign" neglect, is counterproUnintentional firearm injuries have long been dismissed as ductive to the goal of optimal public health and "accidents," which creates the impression that these are safety.

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Injury control

vention strategies will vary inversely with the effort required to keep people from being harmed, and with the to which people must make changes in their degree So that decision-makers (and physicians) are not behavior.29 . . . Providing automatic protection through "bothered" with too many facts to make up their environmental and product design [like airbags in cars, in minds the injury control approach is suggested to which sitting behind the wheel is all that is required for prevent firearm injuries. "The key to this approach compliance] is thus likely to be more effective than is to view these injuries, regardless of their medicole- requiring behavior change via laws or regulations [algal circumstances, as having one common factor though seat-belt laws and firearm legislation are effective], the discharge of a firearm."6 By viewing all injuries which in turn, is likely to be more effective than educating as the result of energy transfers to the body in persons at risk of injury and persuading them to change amounts or sequences that exceed its capability of their behavior. Based on this reasoning, injury control has tolerance without damage, we can analyse the causes deliberately focussed on modifying or eliminating dangerof these injuries and formulate strategies for preven- ous products rather than on persuading people to use these tion. This excess energy, caused in this case by the products more safely.30

discharge of a firearm, is the agent of injury in epidemiologic terms. For injury to occur this excess energy must be conveyed to the victim or host. Bullets, whether they are lethal or made of rubber, are the vehicles of firearm-related injuries. These agents, hosts and vehicles interact in a given physical or social environment, the nature of which can independently affect the probability or severity of a given injury.27 In injury control, as in disease management, prevention is more cost-effective than treatment and rehabilitation. Prevention is best accomplished by identifying and then breaking the chain of disease, or cause of injury, at its weakest link. This link can be the agent, the host, the vehicle or the environment. The host's behaviour is often the most obvious and closest link to injuries but not the most effective to act upon for prevention. In general, measures that modify the potential vehicle of injury or the environment in which injury occurs have proven more successful. . . . Passive countermeasures, which exert their beneficial effect without the need for any specific human action or cooperation, are usually much more effective than active measures, which require cooperation to be effective.... Safety programs, such as firearm education, focus on modifying human behavior but educational interventions of this sort are often expensive and rarely result in lasting behavioral change.6

Some programs, like those for drivers' education in high schools, have actually increased the probability of injury by increasing the number of high-risk teenagers exposed to driving.28 Three injury control strategies are recommended to break the weak links of injury caused by firearms: environmental, legislative or regulatory and educational. Environmental modification is demonstrably the most effective approach to injury control.... The injury control literature emphasizes that the effectiveness of injury pre-

NOVEMBER 15, 1991

There have been important advances in the prevention of many product related injuries based on this approach, e.g., through the use of home smoke-detectors, automobile redesign, childproof containers for medications, and lowering temperature settings on water heaters. This approach has been particularly effective when product related injuries result from impulsive behavior or when users are impaired because of age, intoxication, or mental or physical illness. Environmental interventions have also been successful in the prevention of intentional injuries in the limited realms in which they have been tried, e.g., fencing off of certain "target" sites for suicide jumping, and "target-hardening" of convenience stores. Guns are certainly a dangerous consumer product. Yet, with few exceptions, the well-established injury control precept of modifying or eliminating this dangerous consumer product has thus far not been effectively applied to the prevention of firearm violence.30

Conclusions The characteristics of a weapon are very important because they may affect the chances that a given firearm, if readily available, will be discharged intentionally or unintentionally.6'3' Restricting the accessibility of firearms will likely affect the violent incidents that would not have resulted in death had a firearm been unavailable. Physicians are often aware of suicidal ideation or spousal abuse. They have an important role to play with regard to firearms. For physicians to systematically investigate the accessibility of guns in a depressed patient's home, a home with family violence or even a home with children and have the firearms removed or made inoperable (e.g., with the use of gunlocks) is an act of medical prevention. Physicians prescribe nonlethal quantities of drugs to patients at risk of committing suicide or recommend the use of a safety seat in the car for a newborn's first trip home from the hospital. Preventing the inappropriate discharge of a firearm is as legitimate for the health and safety of Canadians as preventing injury and death from motor vehicle crashes. CAN MED ASSOC J 1991; 145 (10)

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In Canada the regulation of firearms as consumer products to make them safer to use correctly and harder to discharge by mistake requires injury surveillance data by type and class of firearm. Coroners' investigations and police files must categorize firearm-related deaths by class, calibre and manufacturer of the firearm. For outpatient surveillance the Canadian Children's Hospital Injury Research and Prevention Program (CHIRPP) has been established in 12 hospitals (including 2 adult hospitals) throughout Canada. To identify the weak links of injury causation, information is urgently needed on the distribution of firearms and ammunition across Canada by category, type and trademark for comparison with the category, type and trademark of firearms and bullets that cause injury. Although such information is available through the sellers' records and inventories, which must be maintained according to the Criminal Code, it is not currently being used for research. Unfortunately the records and inventories are not sent to the commissioner of the Royal Canadian Mounted Police and may be destroyed after 5 years. Over the past two decades in Canada some 50 000 "inappropriate" shootings have killed, injured or psychologically traumatized at least that

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many people (Le Soleil, Quebec, July 18, 1991: A- 11). Also, the risk of death from a firearm is equivalent to the risk of death from injuries suffered in a motor vehicle crash. The prevention of firearmrelated injuries in Canada is a feasible and worthwhile objective for the year 2000. Such a goal needs to be quantified and evaluated. We thank Kwing Hung, PhD, and Paul Hasselback, MD, for providing data and performing special tabulations, as well as Pierre Maurice, MD, for his encouragement.

References 1. Wilkins K, Mark E: Potential years of life lost, Canada, 19871988. Chronic Dis Can 1991; 12 (2): 12-15 2. Chapdelaine A, Gosselin P: Gun control: a public health concern. Chronic Dis Can 1990; 11 (6): 84-87

3. Hung CK: Firearm Statistics, Dept of Justice, Ottawa, 1990 4. Statistiques preliminaires de la mortalite sur les routes (rep TP-2436), Dept of Transport, Ottawa, 1991 5. Mortality: Summary List of Causes, 1970-88 (cat 84-203), Statistics Canada, Ottawa, 1990 6. Kellermann AL, Lee RK, Mercy JA et al: The epidemiologic basis for the prevention of firearm injuries. Annu Rev Public Health 1991; 12: 17-40 7. Beneteau R: Trends in suicide. Can Soc Trends 1988; winter: 22-24

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8. Beaulne G: Traumatismes au Qutbec. comprendre pour pre6enir, Les publications du Quebec, Quebec. 1991: 23 1-264 9. Health Status of Canadian Indians and Inuit, Update. Indian and Northern Health Services Directorate, Medical Services Branch, Dept of National Health and Welfare, Ottawa, 1987: 37-60 10. Recommendations for a community plan for the prevention and containment of suicide clusters. MMWR 1988; 37 (suppl 6): 1-12 11. Sloan JH, Rivara FP, Reay DT et al: Firearm regulations and rates of suicide: a comparison of two metropolitan areas. N Engl J Mled 1990; 322: 369-373 12. Card JJ: Lethality of suicidal methods and suicide risk: two distinct concepts. Omnega 1974; 5: 37-45 13. Shuck LW, Orgel MG, Vogel AV: Self-inflicted gunshot wounds to the face: a review of 18 cases. J Traumna 1980; 20: 370-377 14. Canadian Centre for Justice Statistics: Canadian Crime Statistics: Homicide Survey, Statistics Canada. Ottawa, 1988: app 1, Table 14, Fig XVII 15. Meredith C, Paquette C: An Exploratorv Study of Police ITse of Selected Criminal Code Sections Pertaining to Firearms in the Context of Domestic Violence, Dept of Justice, Ottawa, 1991: 2-3 16. Canadian Centre for Justice Statistics: Canadian Crime Statistics. Homicide Survey, Statistics Canada, Ottawa, 1988: app I, Table 24, Fig XXXI 17. Sloan JH, Kellerman AL, Reay DT et al: Handgun regulations, crime, assaults, and homicide: a tale of two cities. NEnglJ.Med 1988; 319: 1256-1262 18. Lester D: Crime as opportunity: a test of the hypothesis with European homicide rates. Br J Criminol 1991; 31: 186-188 19. Baker SP: Without guns, do people kill people? Am J Public Health 1985; 75: 587-588

20. Vinson T: Gun and knife attacks. Aust J Sci 1974; 7: 76-83 21. Hedeboe J, Charles AV, Neilson NJ et al: Interpersonal violence - patterns in a Danish community. Am J Public Health 1985; 75: 651-653 22. Todd AR: Report on a Background Paper Concerning Firearm Storage Standards and Firearm Safety Training for the Department of Justice, Vanitoba Natural Resources, Manitoba Firearm Accidents Reports, 1985-1990, Manitoba Natural Resources, Winnipeg, 1991: 70 23. Shanon A, Feldman W: Serious childhood injuries caused by air guns. Can Ved Assoc J 1991; 144: 723-725 24. Wintemute GJ, Teret SP, Kraus JF et al: When children shoot children: 88 unintended deaths in California. JAMA 1987; 257: 3107-3109 25. Angus Reid Group: Firearm Ownership in Canada, Dept of Justice, Ottawa, 1991: 23 26. Kellermann AL, Reay DT: Protection or peril? An analysis of firearm-related deaths in the home. N Engl J Med 1986; 314: 1557-1560 27. Haddon W: The changing approach to the epidemiology, prevention, and amelioration of trauma: the transition to approaches etiologically rather than descriptively based. Am J Public Health 1968; 58: 1431-1438 28. Robertson LS: Injuries: Causes, Control Strategies, and Public Policy, Lexington Bks, Lexington, Mass, 1983 29. National Research Council, Institute of Medicine: Injury in America: a Continuing Public Health Problem, Natl Acad Pr,

Washington, 1985 30. US Centers for Disease Control: Draft Position Paper on Violence Prevention, Public Health Service, US Dept of Health and Human Services, Washington, 1991: 1-23 31. Wintemute GJ, Teret SP, Kraus JF et al: The choice of weapons in firearm suicides. Am J Public Health 1988; 78: 824-826

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Firearm-related injuries in Canada: issues for prevention.

We reviewed the available data on firearm-related injuries in Canada to suggest strategies for prevention in the context of the proposed amendments to...
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