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Nancy L. Lewin, MPH, Jon S. Vernick, JD, MPH, Peter L. Beilenson, MD, MPH, Julie S. Mair, JD, MPH, Melisa M. Lindamood, MPA, Stephen P. Teret, JD, MPH and Daniel W. Webster, ScD, MPH

At the time of the intervention, Nancy L. Lewin was with the Center for Gun Policy and Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Jon S. Vernick, Stephen P. Teret, Daniel W. Webster, and Julie S. Mair are with the Center for Gun Policy and Research. Peter L. Beilenson and Melisa M. Lindamood are with the Baltimore City Health Department.

Correspondence: Requests for reprints should be sent to Jon S. Vernick, JD, MPH, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205 (e-mail: jvernick{at}jhsph.edu).

	ABSTRACT

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In 2002, the Baltimore City Health Department, in collaboration with the Baltimore Police Department and the Johns Hopkins Center for Gun Policy and Research, launched the Youth Ammunition Initiative. The initiative addressed Baltimore’s problem of youth gun violence by targeting illegal firearm ammunition sales to the city’s young people. The initiative included undercover "sting" investigations of local businesses and issuance of health department violation and abatement notices.

Intermediate results included the passage of 2 Baltimore city council ordinances regulating ammunition sales and reducing the number of outlets eligible to sell ammunition. Although it is too early to assess effects on violent crime, the intervention could theoretically reduce youth violence by interrupting one source of ammunition to youths.

More important, the initiative can serve as a policy model for health commissioners seeking to become more active in gun violence prevention efforts.

	INTRODUCTION

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BALTIMORE HAS A HIGHER rate of firearm homicides among young people than any other jurisdiction in the state of Maryland (Figure 1). In 2001, firearm homicide was the leading cause of death among residents of Baltimore aged 15 to 24 years.^1,2 Baltimore City Health Department data indicate that in the first 6 months of 2002, 34 youth younger than 18 years—predominantly male African Americans—were the victims of gun violence, resulting in 16 deaths (A. Spaccarelli, Office of the Commissioner, Baltimore City Health Department, written communication, June 2002) and substantial public concern.

View larger version (25K): [in this window] [in a new window]   FIGURE 1—— Firearm homicide rates among youths aged 0 to 19 years: Maryland counties, 1990–2000. Note. Total youth gun homicides in Maryland, 1990–2000 = 935; Maryland youth gun homicide rate, 1990–2000 = 6.1 deaths per 100000 population; Baltimore City youth gun homicide rate, 1990–2000 = 23.7 deaths per 100000 population.

	APPLYING LOCAL PUBLIC HEALTH AUTHORITY

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Baltimore’s health code gives the health commissioner broad authority to identify and abate risks to the public’s health.³ Typically, local health commissioners in the United States have used their authority for purposes such as food safety and prevention of communicable diseases. Fewer than one fifth of local health departments report involvement in gun violence prevention activities.⁴

In 2002, the health commissioner determined that the ongoing epidemic of youth gun violence in Baltimore qualified as a public health emergency and decided to use his powers innovatively (P. Beilenson, Office of the Commissioner, Baltimore City Health Department, oral communication, June 2002). Legal research conducted by the Center for Gun Policy and Research suggested that the same authority that allows the health department to prevent a restaurant from selling tainted food could also be used to prevent the illegal sale of ammunition.³ Local health powers therefore allowed the city to require abatement of the public nuisance of underage ammunition sales, not merely to arrest the violators. Therefore, the Youth Ammunition Initiative represented a preventive rather than a purely punitive approach.

	RELEVANT FIREARM LAWS IN MARYLAND

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Maryland law prohibits (a) the sale of handguns or handgun ammunition to anyone younger than 21 years and (b) the possession of guns and ammunition by such individuals.^5,6 Maryland also has a firearms preemption law that limits the ability of localities to implement their own gun control policies.⁷ The use of local public health powers for the purpose of gun violence prevention was potentially subject to this preemption law unless the initiative fell within one of the enumerated exceptions. Because the initiative was specifically targeted at young people, the exception permitting local firearm laws "with respect to minors" applied.⁸

KEY FINDINGS Local health commissioners can be advocates for gun policy and gun violence prevention. Collaboration between local police departments, health departments, and academic centers can lead to innovative gun policies at the local level that can potentially enhance public health and safety. Localities disproportionately affected by gun violence may be able to implement programs and pass local gun policies to regulate firearms and ammunition. Local legislation resulting from Baltimore’s Youth Ammunition Initiative reduced the number of eligible sales outlets for firearms and ammunition by 46% and mandated improvements in business practices for those outlets still permitted to sell ammunition. The Baltimore initiative may serve as a model for other cities seeking local strategies to address gun violence.

 

	SALE OF AMMUNITION IN BALTIMORE

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The public health risk posed by the large number of unregulated ammunition sales outlets in Baltimore, combined with police concerns about illegal sales to youth by local businesses, were important motivations for the initiative. Before the start of the initiative, information obtained by the police department suggested that young people were illegally buying handgun ammunition from a variety of unregulated sources.⁹ Although the sale of handgun ammunition to minors is prohibited under state and federal law, Maryland businesses selling ammunition are not subject to the same licensing requirements as those selling firearms. Furthermore, city zoning laws did not regulate local businesses—including neighborhood hardware stores and other storefronts unrelated to firearms—selling ammunition.¹⁰

	PROGRAM DESIGN AND IMPLEMENTATION

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Figure 2 illustrates the model for the Youth Ammunition Initiative. A key component of the effective planning and implementation of the initiative was the cooperation among the initiative’s partners: the city’s health department, its police department, and an academic center. After joint planning of the initiative, the Baltimore Police Department agreed to conduct "ammunition stings" in which a police cadet under the legal age for purchasing ammunition attempted to do so at various local businesses. The health department used police data, including information regarding rates of firearm violence in various Baltimore neighborhoods and anecdotal information about potentially problem ammunition sellers, to determine which ammunition sales outlets throughout the city to target for the stings.

View larger version (26K): [in this window] [in a new window]   FIGURE 2—— Conceptual model for the Baltimore Youth Ammunition Initiative.

The number of businesses subject to a "sting" represented only a small proportion of the hundreds of stores potentially able to sell ammunition. However, an additional component of the initiative involved cooperation between the police and health departments in raising the visibility of the initiative through the local media, potentially deterring other illegal sellers. This strategy led to substantial media attention.^9,11–14

	LEGISLATIVE FOLLOW-UP

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Figure 2 also illustrates the intermediate outcomes of the initiative. One important outcome was the legislative action that followed. In December 2002, at the urging of health department and other officials, the Baltimore City Council enacted 2 new ordinances. One, titled "Zoning—Firearm and Ammunition Sales" (Baltimore City Council Bill 02-0854, passed December 6, 2002), applied an environmental health approach to youth violence prevention, seeking to reduce juveniles’ risk of perpetrating or being victimized by gun violence by limiting the number of businesses permitted to sell firearms and ammunition in Baltimore. This ordinance, based on exceptions to the state firearms preemption law, reformed the local zoning code to limit firearm and ammunition sales within a certain distance from parks, churches, schools, public buildings, or other places of public assembly.

The second ordinance, titled "Ammunition—Sales to Minors" (Baltimore City Council Bill 02-0855, passed December 6, 2002), required that all businesses selling ammunition adopt new business practices designed to increase accountability. As a result, ammunition vendors must now register with the health department, implement age verification procedures using photo identification, post the city’s regulations for ammunition sales to minors, and maintain a log of each ammunition sale.

	DISCUSSION AND EVALUATION

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The Youth Ammunition Initiative highlighted the potential of involving local health officials in gun violence prevention efforts. In addition, the laws passed by the Baltimore City Council granted new authority to the health department to regulate ammunition sales. After enactment of these laws in 2002, the number of businesses eligible to sell ammunition in Baltimore decreased by 46% (Baltimore City Health Department, unpublished data, 2002; this figure refers to the reduction in the number of businesses eligible to sell ammunition because the precise number of outlets actually selling ammunition prior to the initiative is unknown). Since the conclusion of the initiative, the health department has proceeded with the implementation of the new ordinances, conducting inspections of ammunition sales outlets citywide.

View larger version (37K): [in this window] [in a new window]   Excerpt of Baltimore City Health Department violation notice for ammunition sales to minors and list of corrective steps required for violation abatement

There are also a number of limitations and challenges associated with the model represented by the initiative, including city agencies’ limited staff and financial resources, potentially competing priorities between health and police departments, lack of availability of data regarding firearm and ammunition use, and differences in the scope of the legal authority possessed by health commissioners to abate nuisances. In addition, it must be recognized that firearm violence is a multifaceted problem that no single intervention can solve.

	NEXT STEPS

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The Youth Ammunition Initiative can serve as an innovative policy model for other health commissioners, as well as localities adversely affected by youth gun violence but limited by state firearm preemption laws. The initiative demonstrates the promise of applying a combination of local interagency collaboration, public health authority, political will, and a thorough analysis of state and local gun regulations to exert local control for the purpose of gun violence prevention.

	Acknowledgments

 
We gratefully acknowledge the support of the Joyce Foundation and the Richard and Rhoda Goldman Fund.

We thank the assistance of Dr Shannon Frattaroli, Jerry Huffman, and Arianne Spaccarelli for their assistance.

	Footnotes

 
Peer Reviewed

Contributors
N.L. Lewin and J.S. Vernick wrote the first draft of the article. M.M. Lindamood provided the data for the figures. All of the authors helped to conceive and design the intervention and provided editorial and other substantive comments regarding the article.

Accepted for publication November 28, 2004.

	References

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1. CDC WONDER [database online]. Washington, DC: US Dept of Health and Human Services; 2004.

2. Injury-Related Deaths in Maryland: A Statewide Perspective, 2001. Baltimore, Md: Maryland Dept of Health and Mental Hygiene; 2003.

3. Health Code of Baltimore City (Revised). Baltimore, Md: City of Baltimore, 2000.

4. Price JH, Oden L. Reducing firearm injuries: the role of local public health departments. Public Health Rep. 1999;114:533–539.[CrossRef][ISI][Medline]

5. Annotated Code of Maryland, Article 27, 445(b)(2)(vi) (2002).

6. Annotated Code of Maryland, Article 27, 445(c) and 445(e)(1) (2002).

7. Teret SP, DeFrancesco S, Bailey LA. Gun deaths and home rule: a case for local regulation of a local public health problem. Am J Prev Med. 1993; 9(suppl 1):44–46.

8. Annotated Code of Maryland, Title 4, Subtitle 2, 4-209 (2002).

9. Briggs JE. Health chief, police seize bullets in raid: Beilenson used authority to initiate sting operation. Baltimore Sun. July 12, 2002:B1.

10. Zoning Code of Baltimore City—Compact Edition (2000). Baltimore, Md: City of Baltimore; 2000.

11. Haynes R. Officials to enforce law prohibiting ammunition sales to minors. Associated Press State and Local Wire. July 12, 2002.

12. Mitchell J. Mayor pledges more bullet sales scrutiny. Baltimore Sun. July 13, 2002:B4.

13. Webster DW, Lewin NL. Attack city gun violence at source. Baltimore Sun. July 19, 2002:A13.

14. Baltimore’s bullet mania [editorial]. Baltimore Sun. July 21, 2002:F4.

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This Article Abstract Figures Only Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lewin, N. L. Articles by Webster, D. W. Search for Related Content PubMed PubMed Citation Articles by Lewin, N. L. Articles by Webster, D. W. Related Collections Health Policy Adolescent Health Injury/Emergency Care/Violence Public Health Practice Government Urban Health