eAppendix. Selected BRFSS Questions
eTable 1. Firearm Ownership and Storage Practices in Households With Children in Washington State by Child and Household Characteristics, 2013 and 2016
eTable 2. Prevalence of Household Unlocked Firearm by Reported Alcohol Misuse of Adults in the Home and Selected Characteristics Among Children Residing in Firearm-Owning Households
eTable 3. Prevalence of Household Loaded Firearm by Reported Alcohol Misuse of Adults in the Home and Selected Characteristics Among Children Residing in Firearm-Owning Households
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Morgan ER, Gomez A, Rivara FP, Rowhani-Rahbar A. Firearm Storage and Adult Alcohol Misuse Among Washington State Households With Children. JAMA Pediatr. 2019;173(1):37–43. doi:10.1001/jamapediatrics.2018.3624
What proportion of children in Washington State live in firearm-owning households, and what is the association between unsafe firearm storage and exposure to adult alcohol misuse?
In this cross-sectional analysis of survey data from 5241 respondents to Behavioral Risk Factor Surveillance System surveys, it was found that 30% of children in Washington State lived in firearm-owning households, an estimated 55% of whom lived with an unsafely stored firearm. Firearms were 20% more likely to be stored unsafely in homes with an adult who misused alcohol.
Many children in Washington live in firearm-owning households; those who live with an adult who reports alcohol misuse may also be more likely to be exposed to unsafely stored firearms.
Firearm injuries and fatalities among children are an important public health problem. Children living with an adult misusing alcohol may be at a heightened risk for self-harm or unintentional injury, highlighting the need to investigate the association between household firearm storage and adult alcohol misuse.
To characterize household firearm presence among children by various sociodemographic characteristics, and to assess the association between children living in a home with an unsafely stored firearm and an adult reporting alcohol misuse.
Design, Setting, and Participants
This cross-sectional investigation uses data from the 2013 and 2016 Behavioral Risk Factor Surveillance System in the state of Washington, a program that administers a telephone survey statewide to randomly selected noninstitutionalized adults at least 18 years of age about their health-related risk behaviors, chronic health conditions, and use of preventive services. The 2013 and 2016 data included 5241 responses to the firearm ownership and storage module and the Random Child Selection module (intended for a randomly selected child younger than age 18 years and reported by an adult living in the same household). Data for this study were collected from January 1 through December 31, 2013, and January 1 through December 31, 2016. Data were analyzed from March through May 2018.
Main Outcomes and Measures
The primary outcomes were a child’s residence in a firearm-owning home, the manner in which household firearms were stored, and the adult respondent’s alcohol consumption.
Among the 3443 children living in a non–firearm-owning household, 50.7% were male (all values given as a percentage only are weighted); among those reporting specific age, the weighted mean age was 9.3 years (unweighted mean [SD], 10.1 [5.2] years). In the 1756 children living in a firearm-owning household, 52.5% were male; among those reporting specific age, the weighted mean age was 9.1 years (unweighted mean [SD], 9.8 [5.4] years). An estimated 470 000 children (29.4%; 95% CI, 27.3%-31.7%) in the state resided in a firearm-owning household. Among them, 258 000 children (54.6%; 95% CI, 51.5%-57.6%) lived with at least 1 firearm that was not stored safely (ie, not locked and unloaded). Firearms were more likely to be stored unsafely in homes in which an adult reported alcohol misuse (prevalence ratio: 1.20; 95% CI, 1.07-1.35).
Conclusions and Relevance
Children living in a household with an adult who misuses alcohol may be more likely to live with an unsafely stored firearm, which is concerning given the association between adult alcohol misuse and children’s risk for sustaining injury.
In 2016 in the United States, 9350 firearm injuries occurred among youth younger than 18 years of age, and 18% of these injuries were fatal.1 Approximately 45% of these deaths were unintentional or self-inflicted. In an estimated 85% of youth firearm suicides and unintentional injuries, the firearm used originated from the home of the decedent, a friend, or a relative.2,3
The presence of a firearm in the home is a risk factor for suicide and unintentional injury among children and adolescents.4 However, the risk for firearm injury among children in firearm-owning households is not uniform. Among those who lived in such a home and died by firearm suicide or unintentional firearm injury, the likelihood that the firearm was unsafely stored (ie, not locked and unloaded) was higher.5 A recent national study found that an estimated 34% of US households with children younger than 18 years of age have at least 1 firearm, and an estimated 71% of those firearms are stored unsafely.6 Evidence suggests that firearms are equally accessible to young people, regardless of whether they have a history of mental illness or substance abuse.7,8 This finding may indicate that parents or guardians often do not take sufficient measures to restrict access to firearms by their children, even those at high risk for self-harm.
Mental illness is only one of the many factors in suicidal behavior among youth. Previous studies have found that, in addition to a child’s mental health, several interpersonal and environmental factors are associated with youth suicide attempt or death.9-12 Surveys of young people with a prior suicide attempt and family members of youth who died by suicide have revealed that physical and sexual abuse as well as interpersonal conflict with parents, other family members, friends, or romantic partners were events that preceded some suicide attempts or fatalities. Suicide attempts were also more common among children with a parent who abused alcohol.10-12 In addition to the direct association between parental alcohol misuse and a youth suicide attempt or death, children with parents who misuse alcohol are also more likely to perpetrate or be subjected to bullying.13 Youth involved in bullying are more likely to attempt suicide,14 suggesting an additional pathway by which alcohol misuse by a parent or guardian may increase a child’s risk for suicide. In addition, young people left in the care of adults who misuse alcohol are at greater risk for unintentional injury.15-17 Guardian or parental alcohol abuse is associated with increased injury-related emergency department visits among children.18
Current knowledge of the association between exposure to adult alcohol misuse and access to firearms among children is limited. Using data from the Behavioral Risk Factor Surveillance System (BRFSS) in Washington State, we sought to (1) characterize children by their household firearm ownership status, (2) determine the firearm-storage practice in households with children, and (3) examine associations between household firearm storage practices and children’s exposure to adult alcohol misuse at home. Our goal was to add contemporary information to the extant literature about the accessibility of firearms among children and the variability in firearm storage by adult alcohol misuse. Findings from this study can inform policy and offer insight on potential points of intervention critical in youth firearm-injury prevention.
This study used data from the 2013 and 2016 (each covering January 1 to December 31) Washington BRFSS surveys. The Washington State and University of Washington institutional review boards determined that use of BRFSS data is exempt from review and approval because the data are deidentified. The surveys were organized by and administered through the Washington State Department of Health.
The BRFSS uses random-digit dialing to survey noninstitutionalized adults at least 18 years of age about their health-related risk behaviors, chronic health conditions, and use of preventive services. Selected information on alcohol consumption is collected in all states. Washington intermittently applies state-added sections to the survey to acquire additional information about household firearm ownership and storage practices.
Washington (and other states) also periodically adds in a Random Child Selection module to collect demographic information about 1 child residing in the household. These data are used to estimate the prevalence of various household characteristics among children. Because all behavioral questions of interest are asked of adult respondents, prevalence estimates should be interpreted as the proportion of children in Washington living with an adult who engages in that behavior.
We were interested in studying children living with an adult who reported misusing alcohol. To do so, we first characterized the alcohol consumption of the adult respondent. Chronic or excessive drinking was defined as alcohol consumption in 1 week of 8 or more servings for women and 15 or more servings for men.19Binge drinking was defined as alcohol consumption at 1 time of 4 or more servings for women and 5 or more servings for men.19 Children were considered exposed if the respondent reported either type of alcohol misuse (ie, binge or chronic drinking).
Firearm ownership and storage practice were assessed through a 4-question module. Survey participants were first asked, “Are any firearms now kept in or around your home?” Those who reported the presence of a firearm were further asked about their storage practice. The follow-up questions were, “Is there a firearm in or around your home that is now loaded?” and “Is there a firearm in or around your home that is now unlocked? By unlocked, we mean that you do not need a key or combination to get the firearm or to fire it. We don’t count a safety as a lock.” If participants reported having at least 1 loaded firearm, they were subsequently asked, “Are any of the loaded firearms also unlocked? By unlocked, we mean you do not need a key or combination to get the firearm or to fire it. We don’t count a safety as a lock.” Questions in BRFSS are ordered such that individuals reporting at least 1 unlocked and loaded firearm can be distinguished from respondents reporting the presence of a firearm that was locked and loaded in addition to the presence of at least 1 unlocked and unloaded firearm. The latter 2 categories are not mutually exclusive. The specific questions used to ascertain information about adult alcohol consumption and characteristics of the child are in the eAppendix in the Supplement.
We used multivariable Poisson regression models to obtain prevalence ratios and their 95% CIs, with which we compared the prevalence of unsafe household firearm storage practices between children living with an adult who reported alcohol misuse and children living with an adult who did not report this behavior. Model covariates were selected a priori and included the child’s age, race/ethnicity, annual household income, and urbanicity as well as respondent characteristics such as age, sex, and marital status as potential confounders. Urbanicity and age of the child were identified a priori as potential effect measure modifiers and were assessed using interaction terms in the regression models that examined the association between firearm storage practices and exposure to adult alcohol misuse after controlling for potential confounders.
Data were weighted using iterative proportional fitting or raking. This methodology seeks to minimize bias, make estimates more generalizable to the state population, and accommodate the growing use of cell phones and the decline in landline usage. Raking methods were introduced to BRFSS in 2011, making the data collected before and after the 2011 change not directly comparable; thus, the Centers for Disease Control and Prevention advises against using both sets of data in the same analysis.20 After the 2011 change, 2013 and 2016 were the only years in which Washington added both the firearms module and the Random Child Selection module to the BRFSS survey. We conducted all analyses in Stata, version 15.1 (StataCorp LLC) from March through May 2018.
In the 2013 and 2016 BRFSS surveys, a total of 5530 participants responded to the Random Child Selection module. Of the 5530 respondents, 5241 (94.8%) were included in our analysis and 289 (5.2%) were eliminated for not providing an answer to the household firearm ownership question. In the analysis of storage practice, a total of 1756 of 5241 respondents (33.5%) were included, 3443 (65.7%) from non–firearm-owning households were excluded, and 42 (0.8%) from firearm-owning homes who did not provide information on firearm storage method were excluded. Among the 3443 children living in a non–firearm-owning household, 50.7% were male (all values given as a percentage only are weighted); among those reporting specific age, the weighted mean age was 9.3 years (unweighted mean [SD], 10.1 [5.2] years). In the 1759 children living in a firearm-owning household, 52.5% were male; among those reporting specific age, the weighted mean age was 9.1 years (unweighted mean [SD], 9.8 [5.4] years).
Overall, an estimated 29.4% (95% CI, 27.3%-31.7%) of children in Washington (approximately 470 000 children) lived in a firearm-owning home. More children in firearm-owning homes than those in non–firearm-owning households were non-Hispanic white (71.0% [95% CI, 67.8%-74.0%] vs 49.1% [95% CI, 47.0%-51.1%]), lived in a household with an annual income higher than $75 000 (53.4% [95% CI, 50.3%-56.5%]) vs 40.6% [95% CI, 38.5%-42.7%]), and resided in a rural area (18.4% [95% CI, 16.3%-20.7%] vs 12.3% [95% CI, 11.0%-13.7%]) (Table 1). Household firearm ownership did not vary meaningfully by child age or sex. Information on household firearm ownership by subgroup is available in eTable 1 in the Supplement.
Among all children in Washington, an estimated 13.2% (95% CI, 12.1%-14.4%) lived with locked and unloaded firearms, 5.9% (95% CI, 5.1%-6.7%) with at least 1 locked and loaded firearm, 7.9% (95% CI, 7.0%-8.8%) with at least 1 unlocked and unloaded firearm, and 3.1% (95% CI, 2.6%-3.7%) with at least 1 unlocked and loaded firearm. In firearm-owning households with children, the prevalence of unsafely stored firearms (ie, anything other than locked and unloaded) was 54.6% (95% CI, 51.5%-57.6%), indicating that approximately 258 000 children lived with an unsafely stored firearm. Compared with children in households in which all firearms were safely stored, children in households with at least 1 unsafely stored firearm tended to be younger (aged 4 years or younger) (24.6% [95% CI, 21.1%-28.6%]) vs 30.2% [95% CI, 26.6%-34.0%]), to be female (44.3% [95% CI, 39.8%-48.9%]) vs 49.6% [95% CI, 45.5%-53.7%]), and to have the questionnaire answered by a relative other than a parent or grandparent (4.0% [95% CI, 2.8%-5.7%]) vs 6.7% [95% CI, 4.8%-9.2%]); a smaller proportion of these children were non-Hispanic white (73.9% [95% CI, 68.8%-78.3%]) vs 68.4% [95% CI, 64.0%-72.5%]), while a greater proportion were of another race/ethnicity (12.9% [95% CI, 9.8%-16.7%]) vs 17.3% [95% CI, 14.0%-21.2%]) (Table 1). The prevalence of unsafe firearm storage defined differently (ie, unlocked or loaded) is available in eTables 2 and 3 in the Supplement.
In addition, children from firearm-owning homes were also characterized by whether the respondent, an adult in their household, reported alcohol misuse (Table 2). The prevalence of unsafe firearm storage practice was greater in households of children living with an adult who misused alcohol than in households of children without an adult reporting alcohol misuse (Table 3). In firearm-owning homes, 67.1% of children living with an adult who reported misusing alcohol were exposed to at least 1 unlocked and unloaded firearm, compared with 50.9% of children living with an adult who reported no alcohol abuse (prevalence ratio, 1.20; 95% CI, 1.07-1.35). At least 1 firearm was stored unlocked in the homes of 46.9% of children living with an adult who reported alcohol misuse, compared with 33.8% of children living with an adult who did not report alcohol misuse (prevalence ratio, 1.27; 95% CI, 1.06-1.51). No statistically significant association was observed between adult-reported alcohol misuse and loaded firearm storage, ignoring the locked status. No evidence of interaction was found between child urbanicity or age and adult alcohol misuse for any of the storage practice categories.
To our knowledge, this study is among the first to quantify the association between presence of an adult reporting alcohol misuse and children’s living in a home with an unsafely stored firearm among a statewide representative sample. In this study, 3 in 10 children in Washington State resided in a home with a firearm. Among those in firearm-owning homes, approximately 1 in 2 children lived with unsafely stored firearms.
Previous research has indicated that alcohol misuse is associated with unsafe firearm storage in the general population.21,22 We found that firearms were more likely to be stored unsafely among homes with children in which an adult reported alcohol misuse. This is concerning because these children are at heightened risk for suicide and unintentional injury.10-12,15 The increased risk for unintentional injury is thought to be partially attributable to a greater prevalence of risk factors for injury in the homes of children living with a guardian misusing alcohol, such as decreased use of seatbelts, absence of a smoke detector, or an unlocked firearm.23-25 In addition, previous research suggests that adult alcohol misuse is associated with more lax supervision of children,26 which can in turn lead to unintentional injury. The combination of more lax supervision and decreased safety of the home environment puts children living in homes with adults who misuse alcohol at increased risk for unintentional injury. Because safe firearm storage can prevent self-inflicted and unintentional firearm injury among children, screening for alcohol misuse within the home may help identify families for whom counseling and intervention on safe firearm storage may be particularly important.5
In addition, the association between inappropriate firearm storage and presence of an adult who misuses alcohol has implications for youth interpersonal violence. Considering the known associations between parental alcohol misuse and bullying13 and bullying and firearm access or carrying,27,28 living with unsafely stored firearms and an alcohol-misusing adult may contribute to an increased risk of violence perpetration, initiation, or escalation in young people. Longitudinal research has also indicated that parental alcohol use is associated with youth deviancy and rebellion29 as well as youth aggression.30 A young person at risk for deviancy and aggression may be more likely to be involved in violence. If these children and adolescents reside in a home with an unsafely stored firearm, that firearm could potentially be used for perpetration or escalation of interpersonal violence.
This investigation is strengthened by complex sampling methodology and subsequent weighting of BRFSS data.20 Washington State uses disproportionate stratified sampling. This sampling scheme results in the oversampling of rural residents that would not have been well represented in simple random sampling. The subsequent reweighting of data ensures that these oversampled populations are not overrepresented in final estimates but are sufficiently sampled so that more robust estimates can be generated for these subpopulations. These methods create robust and representative estimates of the prevalence of firearm ownership and various storage practices for states that include a firearms module on their surveys. Reinstating questions about firearm safety on the nationwide questionnaire would provide clinicians, public health agencies, researchers, and policy makers with the data to generate better informed interventions for the prevention of firearm injuries.
As with other analyses of survey data, our investigation has some limitations. Ascertainment of firearm ownership and storage methods can be difficult as it is a sensitive topic subject to social desirability bias. The characteristics of survey respondents are factors in self-reporting of household firearm ownership and storage practices.31 One of the primary variables associated with this reporting is the self-identified gender of the respondent. Estimates of firearm prevalence from the General Social Survey varied by a median of 7 percentage points in married households, with men more likely than women to report ownership.32 For this reason, we adjusted for the gender of the respondent and included the child’s gender in the model. Respondent characteristics are also factors in self-reported storage practices. Previous investigations have found that individuals who reported never having used household firearms tended to report safe storage more frequently; they were less likely to indicate that firearms were sometimes or always stored loaded and that firearms were stored loaded and unlocked some or all of the time.33 Questions about firearm use, specific firearm owner, or reasons for firearm ownership are not included on the current Washington BRFSS questionnaires. Because of the variation in use of household firearms33 and social desirability bias, unsafe storage practices are likely underreported. In addition, respondents may be only 1 of the potentially multiple adults in the household. One adult reporting no alcohol misuse does not necessarily indicate that no other adults in the household were misusing alcohol.
Another limitation of this study is the lack of further information about children in the home. The Random Child Selection module only ascertains demographic data. This information allows for extrapolation about household characteristics but does not provide information about a child’s potential risk factors for unintentional injury or suicide (eg, mental or substance use disorder). Previous studies suggest that household firearm storage practices do not differ greatly with regard to risk factors, such as a child’s mental health.7,8 However, children’s access to firearms does vary by bullying history.27 Childhood bullying is also associated with living with an adult who misuses alcohol13; nonetheless, data on this component of the relationship between adult alcohol misuse, unsafe storage of household firearms, and youth suicide risk factors were not available through BRFSS.
Because questions regarding firearm ownership and storage have not been included in BRFSS surveys in every state since 2004, research on this topic in representative samples has been limited in recent years. To our knowledge, our findings provide one of the most recent characterizations of children living in firearm-owning households and in homes practicing unsafe firearm storage practices using BRFSS data. This information can be used to inform future safe-storage campaigns and help tailor the messaging for families of youth who are most likely to be exposed to unsafely stored firearms. This investigation can also inform community-based safe firearm storage promotions as they continue to grow. A safe-storage intervention in King County, Washington, successfully improved storage habits among attendees but found that not all methods of safe storage were universally appealing, indicating the value in targeted intervention.34 The effectiveness of safe-storage campaigns has also recently been addressed by the US Government Accountability Office.35 Firearm safety practices may be improved on a larger scale with the expansion of safe-storage programs, which will help reduce children’s access to firearms. Research has found that parents who misuse alcohol are less likely to improve their firearm storage behavior after an intervention,36 indicating that this group may need further attention to effect change. In addition, in these populations, it may be valuable to pair safe firearm storage counseling and interventions with tools and resources for reducing alcohol consumption, as this pairing may improve adherence to safe firearm storage recommendations.
Our findings also have clinical implications. It is recommended that providers engage patients in discussions about firearm ownership and storage practices. A nationally representative survey of adults in the United States found that 2 in 3 adults agree that it is sometimes appropriate for clinicians to discuss firearm safety with patients.37 Because unintentional injury rates and emergency department usage are higher among children who live with an adult who misuses alcohol,18 our findings of increased prevalence of unsafely stored firearms among this already high-risk group suggest that conversations about safe firearm storage between clinicians and guardians are particularly important.
Accepted for Publication: August 21, 2018.
Corresponding Author: Erin R. Morgan, MS, Department of Epidemiology, University of Washington, PO Box 357236, Seattle, WA 98195 (email@example.com).
Published Online: November 19, 2018. doi:10.1001/jamapediatrics.2018.3624
Author Contributions: Ms Morgan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Acquisition, analysis, or interpretation of data: Morgan, Gomez, Rowhani-Rahbar.
Drafting of the manuscript: Morgan, Rivara.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Morgan.
Obtained funding: Gomez.
Administrative, technical, or material support: Morgan, Gomez.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded in part by Grandmothers Against Gun Violence. The firearms-related state-added questions were funded by Clark County Public Health, Kitsap Public Health District, Public Health–Seattle & King County, Snohomish Health District, Spokane Regional Health District, Tacoma-Pierce County Health Department, and Washington State Department of Health. The Behavioral Risk Factor Surveillance System data used were made available by Washington State Department of Health, Center for Health Statistics, and Behavioral Risk Factor Surveillance System and were supported in part by Cooperative Agreements U58/SO000047-3 (2013) and NU58/DP006066-02-02 (2016) from the Centers for Disease Control and Prevention.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.