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Public Awareness of and Personal Willingness to Use California's Extreme Risk Protection Order Law to Prevent Firearm-Related Harm

Public Awareness of and Personal Willingness to Use California's Extreme Risk Protection Order... Key Points Questions What does the public know IMPORTANCE Extreme risk protection order (ERPO) laws temporarily suspend firearm and about extreme risk protection orders ammunition access by individuals whom a judge has deemed to be at substantial risk of harming (ERPOs) and are people willing to use themselves or others. Despite widespread recent adoption of these laws, use of ERPOs has been these tools to prevent firearm-related limited. Barriers to ERPO uptake remain unclear. harm, both in general and when a family member is at risk? If they are not willing, OBJECTIVE To assess public awareness and perceived appropriateness of and willingness to use why not? ERPOs in various risk scenarios, and to identify reasons for being unwilling, overall and by firearm Findings In this state-representative ownership status, to inform efforts to improve ERPO implementation. cross-sectional survey study of 2870 adults in California, support for the DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional study using data from the 2020 appropriateness of and willingness to California Safety and Wellbeing Survey, a statewide internet survey on firearm ownership and use an ERPO at least some of the time exposure to violence and its consequences, conducted from July 14 to July 27, 2020. Adult was high (>70%) across selected risk respondents were recruited from the Ipsos KnowledgePanel using probability-based sampling scenarios, particularly among firearm methods. Responses were weighted to be representative of the adult population of California. owners and nonowners who live with owners. Approximately two-thirds of MAIN OUTCOMES AND MEASURES Awareness and perceived appropriateness of gun violence respondents cited a lack of awareness of restraining orders (GVROs; California’s official term for ERPOs), willingness to use a GVRO for a family ERPOs as a reason why they were member at risk of harm, and reasons for being not at all willing to use a GVRO in 1 or more risk unwilling to use an EPRO, followed by a scenarios, overall and by firearm ownership status. belief that the risk scenarios are private matters, and a distrust that the system RESULTS Of the 5018 panel members invited, 2870 (57%) completed the survey. Of these will be fair. respondents (mean [SD] age: 47.9 [16.9] years; 52.3% women; 41.9% White, 34.7% Latinx, 14.4% Asian, and 5.8% Black individuals), 65.6% (95% CI, 63.0%-68.1) had never heard of a GVRO or a red Meaning These findings on public flag law. Firearm owners were significantly more likely (20.5%; 95% CI, 15.9%-26.0%) than awareness and perceived nonowners who live with owners (6.1%; 95% CI, 3.7%-10.0%; P < .001) and nonowners (9.6%; 95% appropriateness of ERPOs, willingness CI, 7.8%-11.6%; P < .001) to have heard of both a GVRO and a red flag law. After reading a brief to use these tools to prevent firearm- description of California’s GVRO law, 72.9% (95% CI, 70.2%-75.4%) to 78.4% (95% CI, related harm, and areas of focus to 75.9%-80.8%) of respondents, depending on the risk scenario, indicated that GVROs were in general address barriers to EPRO uptake may be at least sometimes appropriate, while 73.2% (95% CI, 70.5%-75.6%) to 83.6% (95% CI, informative for EPRO implementation 81.2%-85.8%) said they would be somewhat or very willing to use a GVRO for a family member at risk in California and other jurisdictions. of harm. Firearm owners reported the highest levels of GVRO appropriateness in 4 of 5 risk scenarios (depending on the scenario, 80.0% [95% CI, 73.6%-85.1%] to 85.6% [95% CI, 79.9%-89.8%]). Supplemental content Nonowners who live with owners reported the highest levels of personal willingness to use a GVRO (depending on the scenario, 83.7% [95% CI, 74.7%-90.0%] to 94.7% [95% CI, 86.2%-98.1%]). The Author affiliations and article information are listed at the end of this article. most frequently cited reasons for being unwilling to use a GVRO were not knowing enough about GVROs (44.9%; 95% CI, 39.7%-50.3%), believing the risk scenarios are personal or family matters (26.6%; 95% CI, 22.2%-31.6%), and distrust that the system will be fair (23.1%; 95% CI, 19.1%-27.6%). (continued) Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 1/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Abstract (continued) CONCLUSIONS AND RELEVANCE In this cross-sectional survey study, public awareness of GVROs was low, but perceived appropriateness of and willingness to use these tools at least some of the time was high. Foci for efforts to address barriers to GVRO use in California were identified; similar challenges likely exist in other jurisdictions. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 Introduction Firearms are involved in more than half of suicides and approximately three-quarters of homicides in the US, accounting for nearly 39 000 violent deaths in 2018. While firearm violence is a vast public health problem, it is not inevitable. Policies and programs designed to prevent firearm-related harm are operating or are under consideration in jurisdictions across the country. Extreme risk protection order (ERPO) laws, sometimes referred to as “red flag” laws, have gained traction since the February 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, which many 3,4 stakeholders believed could have been prevented had an ERPO been available. Extreme risk protection orders are targeted, flexible, and proactive tools for temporarily suspending an individual’s access to firearms and ammunition when a judge has deemed the person to be at increased risk of firearm-related harm to themself or others and they are not otherwise prohibited from firearm ownership. Immediate family, household members, and law enforcement officers are 5,6 typically permitted to petition for an EPRO. Legislation on ERPOs has expanded rapidly. Of the 19 states and the District of Columbia with ERPO-type laws in effect as of February 2021, all but 2 were implemented since 2016. Yet early 7,8 evidence suggests that use of ERPOs remains relatively uncommon. There are various possible reasons for these lags in uptake. Central among these are questions about the extent to which the public is (1) aware of ERPOs, and (2) willing to use them in efforts to prevent firearm-related harm. Additionally, while ERPO laws have received greater bipartisan support and less pushback from gun rights organizations than many firearm violence prevention policies—eg, the National Rifle Association lobbied Congress to provide funding for states to adopt ERPO laws in the aftermath of the Parkland shooting—the perception that public support is deeply divided by gun ownership status has still been characterized as a speedbump on the road to ERPO implementation in many jurisdictions. The present study examines public awareness of and personal willingness to use an ERPO in specific risk scenarios, both in general and when a hypothetical family member is at risk, along with reasons for unwillingness to use such a tool, overall and by gun ownership status. We focused on California, which implemented the first ERPO law in January 2016 (2 states had related "risk warrant" laws in effect previously). In California, ERPOs are termed gun violence restraining orders (GVROs). As in other states, use of GVROs has increased over time in California, from 70 orders in 2016 to 700 in 2019; however, overall uptake of the law has been slow, with the increase driven primarily by law enforcement petitioners in 1 county. With renewed interest in short-term crisis interventions to prevent firearm injury and death amid the COVID-19 pandemic—at a time when firearm purchasing 11-15 has increased and conditions that elevate the risk of harm have worsened —this study is intended to identify opportunities to improve messaging and increase uptake of GVROs. As an early adopter and model for subsequent legislation in other states, we view the California experience as broadly informative for ERPO implementation in other jurisdictions. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 2/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Methods This was a cross-sectional survey study using data from the 2020 California Safety and Wellbeing Survey, a statewide survey on firearm ownership and exposure to violence and its consequences. The survey was designed by the University of California Firearm Violence Research Center and the Violence Prevention Research Program, both at the University of California, Davis, and administered online from July 14 to July 27, 2020, by Ipsos SA (Paris). The survey was approved by the University of California Davis Institutional Review Board. Respondents read informed consent language; study initiation constituted consent. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Survey respondents were recruited from the Ipsos KnowledgePanel, an online research panel 16-19 widely used in health-related research. Panel recruitment using probability-based sampling procedures has been described previously. All panel members who were 18 years or older and residents of California, except those currently serving in the US Armed Forces, were eligible to participate. Invitations were sent by email; automatic reminders were emailed to nonresponders 3 days later. Of 5018 members invited to participate, 2870 completed the survey (completion rate, 57%). The median completion time was 26 minutes. A final weight variable provided by Ipsos adjusted for the initial probability of panel selection and for survey-specific nonresponse and over-coverage or under-coverage using poststratification raking ratio adjustments based on cross-classifications of age, gender, race/ethnicity, education, household income, language proficiency, and California region. For race/ethnicity, respondents were asked if they consider themselves to be Latinx (Hispanic, Latino, or Spanish; yes/no) and to select their race(s): American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/other Pacific Islander, and/or White. Respondents tended to be older, male, non–Latinx, and have more years of education and higher income than nonrespondents. The sample was weighted to be statistically representative of the adult population of California, as reflected in the 2018 American Community Survey. Measures Respondents were asked whether they had ever heard of something called a GVRO, and subsequently, a red flag law. Next, respondents read a description of California’s GVRO law and were asked, “In general, do you think it would be appropriate for a judge to issue a GVRO” in each of 5 risk scenarios: when a person (1) is experiencing an emotional crisis, (2) has severe dementia or something like it, (3) has threatened to physically hurt themselves, (4) has threatened to physically hurt someone else, and (5) has threatened to physically hurt a group of people. Respondents could choose never, sometimes, usually, always, or don’t know. Those who answered “don’t know” were asked whether this was because they needed more information about GVROs. Respondents were then asked, “Would you personally be willing to ask a judge for a GVRO if a member of your family” was in each of the 5 risk scenarios. Respondents could choose not at all, somewhat, or very willing. A follow-up question asked whether respondents "would prefer to have the police ask a judge for a GVRO for you." Those who reported being “not at all” willing to ask a judge for a GVRO in 1 or more scenarios were asked about the reasons for their unwillingness. Respondents were grouped by firearm ownership status: firearm owners, nonowners who live with owners, and nonowners in households without firearms (hereafter, nonowners). Additional items of interest included whether respondents reported knowing anyone who had experienced or was at risk of harm to self or others, as well as sociodemographic information, which was collected separately as part of ongoing panel membership and was merged with study responses. Sociodemographic characteristics of respondents, overall and by firearm ownership status, are presented in Table 1. The original description of California’s GVRO law was followed by 1 of 3 randomized statements about the research evidence on EPRO effectiveness or by a no-statement control. No substantive JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 3/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Table 1. Sociodemographic Characteristics of Respondents, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Nonowners who live with owners Nonowners (n = 1989) Firearm owners (n = 529) (n = 219) Total (n = 2870) Characteristic No. (%) [95% CI] No. (%) [95% CI] No. (%) [95% CI] No. (%) [95% CI] Age, y 18-29 156 (17.3) [14.6-20.5] 12 (8.1) [4.4-14.6] 23 (24.6) [16.0-35.9] 200 (16.3) [14.0-18.9] 30-44 387 (31.2) [28.0-34.6] 54 (25.1) [18.6-33.0] 40 (20.4) [13.9-29.0] 511 (29.7) [27.0-32.5] 45-59 517 (26.4) [23.7-29.4] 130 (29.1) [23.5-35.5] 50 (23.7) [16.6-32.7] 738 (26.7) [24.4-29.2] 60+ 929 (25) [22.8-27.5] 333 (37.6) [32.1-43.5] 106 (31.3) [23.6-40.0] 1421 (27.3) [25.3-29.4] Sex Female 1010 (54.8) [51.5-58.1] 126 (26.5) [21.3-32.3] 166 (74.9) [64.8-82.9] 1364 (52.3) [49.5-55.0] Male 979 (45.2) [41.9-48.5] 403 (73.5) [67.7-78.7] 53 (25.1) [17.1-35.2] 1506 (47.7) [45.0-50.5] Race/ethnicity White 1035 (36.7) [33.7-39.8] 373 (60.2) [53.1-67.0] 141 (55.8) [45.7-65.3] 1615 (41.9) [39.3-44.6] Latinx 653 (38.1) [34.9-41.5] 97 (22.2) [16.6-29.0] 54 (22.9) [15.9-31.9] 849 (34.7) [32.0-37.4] Asian 169 (16.7) [14.1-19.7] 22 (10.4) [6.2-16.9] 7 (6.1) [2.6-13.9] 208 (14.4) [12.3-16.8 Black 86 (5.7) [4.3-7.5] 26 (6.0) [3.4-10.2] 7 (4.8) [1.7-12.8] 127 (5.8) [4.6-7.3] Multirace/other 46 (2.8) [1.8-4.2] 11 (1.2) [0.6-2.6] 10 (10.4) [4.9-20.9] 71 (3.2) [2.3-4.5] Education <High school 137 (18.6) [15.7-21.8] 6 (3.5) [1.4-8.1] 8 (10.3) [4.8-20.5] 158 (15.4) [13.1-18.0] High school degree 253 (19.4) [16.7-22.3] 64 (24.7) [18.5-32.1] 26 (20.6) [12.9-31.3] 364 (20.4) [18.1-23.0] Some college 581 (28.1) [25.3-31.0] 213 (44.6) [38.1-51.3] 80 (41.2) [32.0-51.0] 938 (32.7) [30.2-35.2] College degree 558 (18.7) [16.5-21.1] 137 (16.5) [12.3-21.7] 57 (14.6) [10.2-20.6] 775 (17.5) [15.7-19.4] Advanced degree 460 (15.3) [13.2-17.7] 109 (10.8) [8.3-14.1] 48 (13.4) [8.9-19.6] 635 (14.0) [12.4-15.8] Household income, $ <25 000 334 (16.8) [14.4-19.4] 52 (8.3) [5.3-12.8] 19 (8.4) [4.6-14.9] 431 (15.1) [13.2-17.2] 25 000-59 999 539 (26.0) [23.3-29.0] 128 (19) [14.8-24.0] 45 (17.8) [11.5-26.4] 744 (23.9) [21.7-26.3] 60 000-99 999 523 (23.1) [20.4-26.0] 132 (19.1) [14.8-24.2] 60 (20.9) [14.8-28.7] 757 (22.6) [20.4-24.9] ≥100 000 593 (34.1) [31.0-37.4] 217 (53.6) [46.9-60.1] 95 (52.9) [43.2-62.3] 938 (38.5) [35.8-41.3] Marital status Married or living with 1123 (59.2) [55.9-62.4] 344 (66.7) [60.1-72.7] 156 (64.3) [54.1-73.4] 1704 (61.0) [58.2-63.7] partner Widowed 150 (4.4) [3.5-5.5] 39 (5.7) [3.6-8.9] 9 (3.8) [1.6-8.9] 204 (4.4) [3.6-5.3] Divorced or separated 302 (10.8) [9.1-12.7] 89 (13.6) [9.7-18.8] 22 (7.3) [4.4-12.1] 432 (11.1) [9.6-12.7] Never married 414 (25.6) [22.6-28.8] 57 (13.9) [9.6-19.8] 32 (24.6) [16.3-35.3] 530 (23.5) [21.1-26.1] Political ideology Liberal 738 (34.2) [31.1-37.4] 109 (20.5) [15.6-26.4] 68 (31.3) [23.1-40.9] 940 (31.1) [28.6]-33.7 Moderate 551 (30.5) [27.5-33.7] 143 (28.5) [22.7-35.2] 69 (36.5) [27.5-46.6] 795 (30.8) [28.2-33.5] Conservative 511 (23.5) [20.9-26.4] 245 (43.3) [36.8-50.1] 66 (24.4) [17.5-33.0] 882 (27.3) [25.0-29.8] State region Superior California 142 (6.7) [5.2-8.5] 79 (15.2) [10.6-21.2] 20 (5.8) [3.2-10.3] 253 (8.1) [6.7-9.7] North Coast 47 (2.2) [1.3-3.5] 32 (4.8) [3.0-7.5] 9 (2.3) [1.1-4.9] 90 (2.5) [1.8-3.5] San Francisco Bay Area 396 (20.9) [18.1-24.1] 75 (11.8) [8.2-16.5] 25 (14.8) [8.7-24.1] 513 (18.5) [16.3-21.0] Northern San Joaquin 69 (3.6) [2.6-5.1] 35 (7.6) [4.8-11.8] 15 (4.4) [2.2-8.4] 129 (4.5) [3.5-5.7] Valley Central Coast 143 (6.0) [4.8-7.4] 38 (4.9) [3.2-7.4] 19 (13.3) [7.3-22.9] 204 (6.2) [5.1-7.5] Southern San Joaquin 116 (5.4) [4.2-7.0] 34 (7.1) [4.1-12.3] 20 (7.8) [4.3-13.6] 182 (6.0) [4.8-7.4] Valley Inland Empire 225 (10.4) [8.6-12.5] 74 (13.6) [9.7-18.6] 31 (8.5) [5.2-13.5] 358 (11.0) [9.5-12.8] Los Angeles County 500 (27.1) [24.4-30.1] 74 (18.1) [13.4-24.1] 50 (28) [20.1-37.5] 647 (25.9) [23.6-28.4] Orange County 137 (8.7) [6.9-10.8] 38 (7.5) [4.5-12.1] 10 (7.2) [2.9-16.7] 195 (8.3) [6.8-10.0] San Diego–Imperial 214 (9.0) [7.4-11.0] 50 (9.5) [6.0-14.7] 20 (8.0) [4.0-15.6] 299 (9.1) [7.7-10.8] Totals may not sum to 100% because refusals and “don't know” responses are Native, Asian, Black/African American, Native Hawaiian/other Pacific Islander, and not shown. White.” Among respondents who did not endorse Spanish, Hispanic, or Latino ethnicity, American Indian or Alaska Native (n = 10), Native Hawaiian or other Pacific Respondents were asked, “Are you Spanish, Hispanic, or Latino? Indicate what you Islander (n = 2), and those who selected more than 1 race (n = 59) were combined by consider your race to be. We appreciate your effort to describe your background using the authors into a multirace/other category. these US Census Bureau categories (select all that apply): American Indian/Alaska JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 4/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law differences were observed across the 4 conditions; therefore, results reflect the full sample, regardless of randomization. To align with GVRO statute language, questions about GVRO appropriateness and willingness included the qualifier: “Assume [the person/your family member] has or could get a gun and other options have failed or are not appropriate.” Detailed question phrasing and response options are provided in the eMethods section of the Supplement. Statistical Analysis We calculated weighted percentages and 95% CIs for each measure or cross-tabulation of measures in Stata, release 15.1 (StataCorp LLC) using the survey and weighting commands. Comparisons by firearm ownership status were conducted using the 2-sample t test within the framework of the weighted population. For ease of exposition and consistent with past research, we collapsed “sometimes,” “usually,” and “always” appropriate and “somewhat” and “very” willing into single response categories for primary analyses; analogous results with all response options are available in eTables 1A and 1B of the Supplement. Analyses were conducted from October 2020 to February 2021. All statistical tests were 2-tailed, and statistical significance was set at P < .05. Results Awareness Of 2870 respondents, (mean [SD] age was 47.9 [16.9] years and 52.3% were women; 49.1% were White, 34.7% Latinx, 14.4% Asian, and 5.8% Black individuals), 65.6% (95% CI, 63.0%-68.1%) reported that they had never heard of a GVRO or a red flag law; 11.0% (95% CI, 9.5%-12.8%) had heard of both; 13.9% (95% CI, 12.1%-15.8%) had heard of a GVRO only; and 8.8% (95% CI, 7.5%-10.4%) had heard of a red flag law only (Table 2). Firearm owners were significantly more likely (20.5%) than nonowners who live with owners (6.1%; P < .001) and nonowners (9.6%; P < .001) to have heard of both a GVRO and a red flag law, and significantly less likely to never have heard of either (51.6% vs 70.5% [P = .001] and 68.2% [P < .001], respectively) (Table 2). Firearm owners were also significantly more likely than nonowners (14.9% vs 7.3%; P = .004; Table 2) to have heard of a red flag law only. Appropriateness More than three-quarters of respondents indicated that, in general, it was at least sometimes appropriate for a judge to issue a GVRO when the at-risk person has threatened to physically hurt a Table 2. Public Awareness of Gun Violence Restraining Orders (GVROs) and “Red Flag” Laws Among California Adults, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Firearm ownership status Nonowners who live with owners Total (n = 2870) Nonowners (n = 1989) Firearm owners (n = 529) (n = 219) Awareness status No. % (95% CI) No. % (95% CI) P value No. % (95% CI) P value No. % (95% CI) P value Yes, GVRO only 464 13.9 (12.1-15.8) 322 14.4 (12.3-16.8) NS 88 13.0 (9.5-17.5) NS 39 15.0 (9.0-23.8) NS c d Yes, red flag law 275 8.8 (7.5-10.4) 162 7.3 (5.9-9.0) .004 75 14.9 (10.6-20.4) .004 20 8.4 (4.4-15.5) NS only c d c Yes, both GVRO 427 11.0 (9.5-12.8) 258 9.6 (7.8-11.6) <.001 128 20.5 (15.9-26.0) <.001 24 6.1 (3.7-10.0) <.001 and red flag law <.001 c d c Neither GVRO 1688 65.6 (63.0-68.1) 1238 68.2 (65.1-71.2) <.001 237 51.6 (44.8-58.3) <.001 136 70.5 (61.1-78.5) .001 nor red flag Abbreviation: NS, not significant. Significant difference from firearm owners. a d Percentages may not sum to 100% because refusals are not shown: 0.7% (95% CI, Significant difference from nonowners. 0.4-1.3) of respondents did not answer 1 or both questions (n = 16). e Significant difference from nonowners who live with owners. Respondents were asked, “Have you ever heard of something called a gun violence restraining order?” and “Have you ever heard of something called a 'red flag' law?” JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 5/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law group of people (78.4%; 95% CI, 75.9%-80.8%), someone else (78.1%; 95% CI, 75.5%-80.8%), or themselves (77.8%; 95% CI, 75.3%-80.2%) (Table 3). A slightly smaller share of respondents indicated that, in general, a GVRO is at least sometimes appropriate when the person is experiencing an emotional crisis (73.0%; 95% CI, 70.3%-75.4%) or has severe dementia or something like it (72.9%; 95% CI, 70.2%-75.4%). Of the 19.1% (95% CI, 16.9%-21.6%) of respondents who reported not knowing whether issuing a GVRO was appropriate in 1 or more scenarios, 48.5% (95% CI, 41.8%- 55.3%) said that this was because they needed more information about GVROs (eTable 2 in the Supplement). In 4 of 5 risk scenarios, firearm owners reported the highest levels of at least some support—80% or more—for the appropriateness of GVROs in general (Table 3). Firearm owners were significantly more likely than nonowners to indicate that, in general, it is at least sometimes appropriate for a judge to issue a GVRO when the at-risk person has severe dementia or something likeit(80.0%vs71.8%; P = .01); or has threatened to physically hurt themselves (84.1% vs 77.0%; P = .02), someone else (85.6% vs 76.5%; P = .002), or a group of people (85.3% vs 77.5%; P = .008). Nonowners who live with owners were significantly more likely than nonowners (82.2% vs 72.2%; P = .01) to report that, in general, GVROs are at least sometimes appropriate when the person is experiencing an emotional crisis. Willingness Most respondents indicated that they would be somewhat or very willing to ask a judge for a GVRO if a family member was experiencing an emotional crisis (73.2%; 95% CI, 70.5%-75.6%); had severe dementia or something like it (76.5%; 95% CI, 73.9%-78.9%); or had threatened to physically hurt Table 3. Perceived Appropriateness of a Judge Issuing a Gun Violence Restraining Orders (GVRO), in General, by Risk Scenario and Firearm Ownership Status, 2020 California Safety and Wellbeing Survey (n = 2870) Appropriate to issue GVRO Never Sometimes/usually/always Risk scenario and firearm P ownership status No. % (95% CI) No. % (95% CI) value Person experiencing an emotional crisis Total 296 11.5 (9.9-13.5) 2203 73.0 (70.3-75.4) NS Nonowners 182 11.3 (9.3-1.7) 1546 72.2 (69.0-75.2) .01 Firearm owners 76 15.0 (10.9-20.3) 410 75.2 (68.8-80.6) NS Nonowners who live with owners 15 6.7 (2.9-14.7) 178 82.2 (73.6-88.4) .01 Person with severe dementia or something like it Total 286 12.2 (10.4-14.2) 2253 72.9 (70.2-75.4) NS Nonowners 198 12.3 (10.2-14.8) 1559 71.8 (68.5-74.8) .01 Firearm owners 50 10.7 (7.2-15.6) 440 80.0 (73.6-85.1) .014 Nonowners who live with owners 19 13.4 (7.1-23.6) 180 76.3 (66.2-84.1) NS Person who threatened to physically hurt themself Total 235 11.3 (9.5-13.3) 2396 77.8 (75.3-80.2) NS Nonowners 162 11.2 (9.2-13.7) 1661 77.0 (73.8-79.8) .02 Firearm owners 40 11.8 (7.8-17.4) 466 84.1 (78.4-88.6) .02 Nonowners who live with owners 16 9.4 (4.5-18.8) 187 80.7 (71.0-87.7) NS Abbreviation: NS, not significant. Person who threatened to physically hurt someone else a Percentages may not sum to 100% because refusals Total 235 11.3 (9.5-13.3) 2413 78.1 (75.5-80.5) NS and “don't know” responses are not shown. Nonowners 169 11.9 (9.8-14.4) 1662 76.5 (73.3-79.5) .002 Respondents were asked, “In general, do you think it Firearm owners 36 9.5 (6.2-14.3) 474 85.6 (79.9-89.8) .002 would be appropriate for a judge to issue a GVRO in the following scenarios? Assume the person has or Nonowners who live with owners 15 8.9 (4.1-18.4) 190 83.4 (73.9-89.8) NS could get a gun and other options have failed or are Person who threatened to physically hurt a group of people not appropriate.” Total 238 11.7 (9.9-13.8) 2415 78.4 (75.9-80.8) NS Significant difference from nonowners who live Nonowners 172 12.4 (10.2-15.0) 1669 77.5 (74.4-80.3) .008 with owners. Firearm owners 36 9.8 (6.2-15.2) 471 85.3 (79.6-89.6) .008 Significant difference from nonowners. Nonowners who live with owners 15 9.3 (4.4-18.7) 190 81.5 (71.8-88.4) NS Significant difference from firearm owners. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 6/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law themself (82.8%; 95% CI, 80.4%-85.0%), someone else (83.8%; 95% CI, 81.4%-85.9%), or a group of people (83.6%; 95% CI, 81.2%-85.8%) (Table 4). Knowing someone who had experienced or was at risk of harm to self was associated with significantly higher levels of at least some willingness to use a GVRO in the harm-to-self scenario; however, knowing someone who had experienced or was at risk of interpersonal harm was not associated with differences in willingness in the harm-to-others scenarios (eTables 3A-3F in the Supplement). Nonowners who live with owners reported the highest levels of at least some willingness to ask a judge for a GVRO across all risk scenarios, ranging from 83.7% (95% CI, 74.7%-90.0%) who were somewhat or very willing if a family member were experiencing an emotional crisis to 94.7% (95% CI, 86.2%-98.1%) if a family member had threatened to physically hurt someone else (Table 4). Differences in willingness between nonowners who live with owners and both firearm owners and nonowners were statistically significant (P < .05; Table 4) in all scenarios except dementia and mass harm, where only the contrast with nonowners was significant (P < .01; Table 4). Lack of Willingness In all, 29.9% (95% CI, 27.3%-32.5%) of respondents reported that they were not at all willing to ask a judge for a GVRO if a family member were in 1 or more risk scenarios. The most frequently cited reason for being unwilling was not knowing enough about GVROs (44.9%; 95% CI, 39.7%-50.3%; Table 4. Willingness to Ask a Judge for a Gun Violence Restraining Order (GVRO) for a Family Member, by Risk Scenario and Firearm Ownership Status, 2020 California Safety and Wellbeing Survey (n = 2870) Willingness to ask for a GVRO Not at all Somewhat/very Risk scenario and firearm P ownership status No. % (95% CI) No. % (95% CI) value Family member experiencing an emotional crisis Total 651 24.4 (22.0-27.0) 2168 73.2 (70.5-75.6) NS Nonowners 406 24.2 (21.3-27.3) 1548 73.1 (69.9-76.1) .01 Firearm owners 161 29.8 (23.9-36.4) 365 69.8 (63.2-75.7) .006 Nonowners who live with 38 16.3 (10.0-25.3) 181 83.7 (74.7-90.0) .01 owners Family member with severe dementia or something like it Total 515 20.6 (18.4-23.1) 2290 76.5 (73.9-78.9) NS Nonowners 348 20.9 (18.2-23.9) 1597 76.1 (73.0-79.0) NS Firearm owners 103 21.5 (16.27-27.9) 421 78.0 (71.6-83.2) NS Nonowners who live with 25 15.3 (8.9-25.0) 193 84.5 (74.9-90.9) NS owners Family member who threatened to physically hurt themselves Total 318 14.3 (12.3-16.5) 2493 82.8 (80.4-85.0) NS Nonowners 207 14.3 (11.9-17.0) 1740 82.4 (79.5-85.0) <.001 Firearm owners 68 16.6 (12.0-22.6) 458 83.0 (77.0-87.7) .003 Nonowners who live with 9 5.4 (1.9-14.5) 210 94.6 (85.5-98.1) <.001 owners Family member who threatened to physically hurt you or someone else Abbreviation: NS, not significant. Total 280 13.4 (11.4-15.6) 2529 83.8 (81.4-85.9) NS c Percentages may not sum to 100% because refusals Nonowners 188 14.1 (11.7-16.9) 1758 82.6 (79.7-85.2) <.001 are not shown. Firearm owners 57 14.2 (9.8-20.1) 470 85.6 (79.7-90.0) .02 Respondents were asked, “Would you personally be Nonowners who live with 9 5.1 (1.8-13.8) 209 94.7 (86.2-98.1) <.001 willing to ask a judge for a GVRO if a member of your owners family was in one of the following scenarios? Assume Family member who threatened to physically hurt a group of people the person has or could get a gun and other options Total 284 13.7 (11.7-16.0) 2533 83.6 (81.2-85.8) NS have failed or are not appropriate.” c c Nonowners 192 14.4 (12.0-17.3) 1761 82.6 (79.6-85.2) .002 Significant difference from nonowners who live with owners. Firearm owners 55 14.0 (9.8-20.0) 470 85.4 (79.4-89.9) NS Significant difference from nonowners. Nonowners who live with 11 7.0 (2.9-15.8) 208 93.0 (84.2-97.1) .002 owners Significant difference from firearm owners. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 7/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Table 5); it was followed by the belief that these risk scenarios are personal or family matters (26.6%; 95% CI, 22.2%-31.6%), distrust that the system will be fair (23.1%; 95% CI, 19.1%-27.6%), worry about due process rights (18.6%; 95% CI, 15.3%-22.3%), not wanting to involve the court (16.4%; 95% CI, 12.7%-20.8%), the notion that it is never appropriate for the government to take a person’s guns (13.7%; 95% CI, 10.4%-17.9%), and worry about retaliation (11.3%; 95% CI, 8.4%-15.0%). Firearm owners were significantly less likely than nonowners (33.9% vs 47.8%; P = .04) to endorse not knowing enough about GVROs and significantly more likely than nonowners (27.7% vs 14.5%; P = .006) to endorse worry about due process rights, to distrust that the system will be fair (34.0% vs 20.1%; P = .02), and the notion that it is never appropriate for the government to take a person’s guns (22.9% vs 11.3%; P = .02) as reasons for their unwillingness to use a GVRO (Table 5). When all respondents, regardless of willingness to ask a judge for a GVRO in specific risk scenarios, were asked whether they would prefer to have the police ask a judge for a GVRO for them, 35.4% (95% CI, 32.8%-38.1%) said yes, 38.6% (95% CI, 35.9%-41.4%) said they did not know, and 24.7% (95% CI, 22.4%-27.1%) said no (eTable 4 in the Supplement). Firearm owners (33.5%) were significantly more likely than both nonowners who live with owners (21.2%; P = .02) and nonowners (23.3%; P = .004) to report that no, they did not prefer to have the police ask a judge for a GVRO for them and significantly less likely than nonowners to report that they did not know (30.3% vs 39.6%; P = .01). Discussion Extreme risk protection orders temporarily suspend access to firearms and ammunition by individuals whom a judge has deemed to be at substantial risk of harming themselves or others. This California-based study documents widespread public support—more than 70% across various risk scenarios—for the use of GVROs (California’s term for ERPOs) at least some of the time, both in general and when the at-risk person is a hypothetical family member. Firearm owners, even those without preexisting awareness of GVROs (results not shown), reported the highest levels of at least some support for the appropriateness of GVROs, in general, in 4 of 5 risk scenarios, while non–gun- owning respondents who live with owners reported the highest levels of at least some willingness to ask a judge for a GVRO for a family member, across all 5 risk scenarios. Table 5. Reasons Not At All Willing to Ask a Judge for a Gun Violence Restraining Order (GVRO) for a Family Member, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Nonowners who live with owners Total (n = 799) Nonowners (n = 518) Firearm owners (n = 181) (n = 43) P P P Reason No. % (95% CI) No. % (95% CI) value No. % (95% CI) value No. % (95% CI) value c d Do not know enough about 322 44.9 (39.7-50.3) 240 47.8 (41.4-54.3) .04 43 33.9 (23.4-46.3) .04 16 46.4 (25.4-68.7) NS GVROs These are personal/family 233 26.6 (22.2-31.6) 148 25.5 (20.4-31.5) NS 57 29.2 (19.7-41.0) NS 17 47.1 (26.1-69.2) NS matters c d Do not trust the system will 218 23.1 (19.1-27.6) 119 20.1 (15.6-25.4) .02 71 34.0 (24.6-45.0) .02 9 23.0 (8.0-50.9) NS be fair c d Worried about due process 201 18.6 (15.3-22.3) 109 14.5 (11.1-18.6) .006 65 27.7 (19.9-37.2) .006 11 35.3 (16.9-59.3) NS rights Do not want to involve the 119 16.4 (12.7-20.8) 78 17.6 (12.9-23.4) NS 30 16.4 (10.2-25.4) NS 7 9.9 (4.0-22.6) NS court c d Never appropriate for 106 13.7 (10.4-17.9) 46 11.3 (7.5-16.6) .02 45 22.9 (15.2-33.0) .02 3 9.3 (1.8-36.1) NS government to take guns Worried about retaliation 88 11.3 (8.4-15.0) 60 11.6 (8.2-16.3) NS 17 9.4 (4.5-18.6) NS 7 17.0 (6.3-38.5) NS Other reason 101 10.7 (7.8-14.4) 59 8.5 (5.8-12.4) NS 30 18.2 (9.9-31.1) NS 5 8.7 (2.9-23.3) NS Abbreviation: NS, not significant. Significant difference from firearm owners. a d Percentages of respondents who did not endorse each reason or refused to respond Significant difference from nonowners. are not shown. Respondents were asked, “You mentioned that you were not at all willing to ask a judge for a GVRO in 1 or more situations. Please choose the reasons why. Select all that apply.” JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 8/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Although uptake of ERPOs, especially by non–law-enforcement petitioners, has been slow in California and across the country, these findings suggest that resistance from individuals most likely to be affected by the law (eg, firearm owners, those with social proximity to owners, and individuals who know someone at risk of harm) does not account for such lags. These findings are consistent with national studies indicating that many firearm violence prevention policies have broad public support, and that general consensus exists between firearm owners and nonowners; although notably, greater support among gun owners vs nonowners in California is unique relative to prior national estimates. These findings also align with expert guidance and past research that found higher levels of public support, especially among owners, when firearm violence prevention efforts, including firearm safety conversations between health care professionals and patients, are implemented in the context of risk reduction. Extreme risk protection order laws exemplify a targeted, risk-based approach to preventing harm before it occurs, leveraging the knowledge of those who are often the first to recognize that someone they care about is in crisis or behaving dangerously, and providing a tool for proactive intervention. Studies document that ERPOs have been used in efforts to prevent mass harm, and that they may be particularly effective in preventing suicide because access to a firearm during what is often an impulsive act of self-harm can mean the difference between death and survival. These findings suggest that most adults in California are receptive to this characterization of firearm- related harm as preventable rather than inevitable, and when provided with a mechanism to intervene before violence occurs, a large share of the population—including gun owners and those who live with owners—not only think it is at least sometimes appropriate but are somewhat or very willing to take action personally on behalf of someone who is at increased risk. Nonetheless, GVRO awareness levels are low. Approximately two-thirds of respondents had never heard of a GVRO or a red flag law, and pluralities of respondents within the subsets of those who did not know whether a GVRO was appropriate (19%) and who were not at all willing to ask a judge for a GVRO (30%) in 1 or more risk scenarios said they needed more information about GVROs. This lack of awareness represents a substantial barrier to GVRO implementation at the population level and presents a clear opportunity for improvement. We recommend further research to assess what additional information would amplify public understanding and use of GVROs and how such 24,25 messaging can be disseminated in ways that are relevant, accurate, and effective. These findings provide several insights for addressing hesitancy to use GVROs. First, among the subset of those who were not at all willing to ask a judge for a GVRO in 1 or more scenarios of increased risk, the perception that these are personal or family matters was cited by more than 1 of 4 respondents. Similar to the shifts in the public’s understanding of intimate partner violence, it will be important to normalize the process of intervening to reduce an at-risk individual’s access to guns as an issue affecting society as a whole (including mass harm and domestic terrorism), rather than only as a private problem. Second, among firearm owners in particular, it will be essential to address concerns about due process and the notion that it is never appropriate for the government to regulate a person’s access to guns. While the latter may require more sustained investments in shifting cultural paradigms about private firearm ownership, the former may be more readily addressed through targeted messaging efforts to emphasize that ERPO-type laws have built in due process protections, including a timely hearing before a judge at which petitioners must meet a standard of proof and counter evidence can be presented. Finally, it will also be necessary to address distrust of the mainstream criminal legal system, which has systematically oppressed and disenfranchised Asian, Black, and Latinx communities through historical and present policies and practices. More than 20% of respondents who were not at all willing to use a GVRO in 1 or more risk scenarios cited distrust in the fairness of the system and 16% said they did not want to involve the court. A separate analysis that is not yet published will examine whether responses fell along any specific or expected racial-ethnic lines. As recently argued, it will be essential to include assessment of social inequities associated with ERPO implementation and future evaluation—including possible consequences of unequal enforcement JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 9/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law and benefits of reduced harm—so that the use of these tools does not perpetuate the uneven burden of structurally rooted trauma and injustice within marginalized communities. Limitations This study has several limitations. First, we relied on self-reported data, which is subject to nonresponse and social desirability biases; however, nonresponse rates were low in the study sample, and evidence suggests that completion rates are higher and social desirability bias is lower in online panel surveys than in random-digit-dial telephone surveys. Second, although we think these findings can inform understandings of EPRO implementation in other states, California is unique. Geographic variations in firearm ownership and the cultural acceptability of firearms, firearm violence, and firearm regulations should be considered when attempting to generalize these results. Third, primary analyses that collapse response categories (eg, somewhat, usually, and always appropriate; somewhat and very willing) may mask more nuanced differences in the extent of support for GVRO appropriateness and willingness overall and by firearm ownership status. However, given the polarizing nature of gun policy discourse, we posit that any indication of support for the appropriateness of or willingness to use an EPRO is not only noteworthy, but may also be valuable for changing behavior via subjective norms—ie, beliefs that an important person or group of people will approve and support a particular behavior. Finally, although we measured the public’s perceived appropriateness of GVROs in general and their personal willingness to use these tools, the extent to which such support translates into real-world action is unclear. Conclusions This cross-sectional study found that ERPOs are promising tools for reducing firearm-related harm. Although we found widespread public support (including among firearm owners and nonowners who live with owners) for using ERPOs at least some of the time across a range of risk scenarios, public awareness levels are low. Attention to concerns regarding unjust implementation of ERPOs is warranted. This study identifies concrete areas of focus for efforts to address ERPO uptake and implementation challenges in California and other states with similar laws in effect or under consideration. ARTICLE INFORMATION Accepted for Publication: April 15, 2021. Published: June 4, 2021. doi:10.1001/jamahealthforum.2021.0975 Open Access: This is an open access article distributed under the terms of the CC-BY License.©2021 Kravitz-Wirtz N et al. JAMA Health Forum. Corresponding Author: Nicole Kravitz-Wirtz, PhD, MPH, University of California Firearm Violence Research Center and Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA 95817 (nkravitzwirtz@ucdavis.edu). Author Affiliations: University of California Firearm Violence Research Center and Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento. Author Contributions: Dr Kravitz-Wirtz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kravitz-Wirtz, Aubel, Wintemute. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Kravitz-Wirtz, Aubel. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kravitz-Wirtz, Aubel. Obtained funding: Wintemute. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 10/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Administrative, technical, or material support: Pallin. Supervision: Kravitz-Wirtz, Wintemute. Conflict of Interest Disclosures: None reported. Funding/Support: This research was supported by the University of California Firearm Violence Research Center at UC Davis, with funds from the State of California, the California Wellness Foundation (Award No. 2017-0447), and the Heising-Simons Foundation (Award No. 2019-1728). 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. REFERENCES 1. US Centers for Disease Control and Prevention. Fatal injury reports. Web-based Injury Statistics Query and Analysis System (WISQARS). Accessed August 31, 2020. https://www.cdc.gov/injury/wisqars/index.html 2. Rivara FP, Vars FE, Rowhani-Rahbar A. Three interventions to address the other pandemic–firearm injury and death. JAMA. 2021;325(4):343-344. doi:10.1001/jama.2020.24206 3. Laqueur HS, Wintemute GJ. Identifying high-risk firearm owners to prevent mass violence. Criminol Public Policy. 2020;19(1):109-127. doi:10.1111/1745-9133.12477 4. Pane LM. Parkland attack fueled big shift in America’s gun politics. Associated Press. 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Social desirability bias in CATI, IVR, and web surveys: the effects of mode and question sensitivity. Public Opinion Quarterly. 2008;72(5):847-865. doi:10.1093/poq/nfn063 SUPPLEMENT. eMethods. Detailed question wording and response options, 2020 California Safety and Wellbeing Survey eTable 1A. Perceived appropriateness of a judge issuing a GVRO, in general, by risk scenario and firearm ownership status, 2020 California Safety and Wellbeing Survey eTable 1B. Willingness to ask a judge for a GVRO for a family member, by risk scenario and firearm ownership status, 2020 California Safety and Wellbeing Survey eTable 2. Need more information about GVROs, respondents who did not know if a GVRO is appropriate in1 risk scenarios (n = 449) eTable 3A. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm someone else, by number of known others who have been shot by someone else on purpose eTable 3B. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm a group of people, by number of known others who have been shot by someone else on purpose eTable 3C. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm themselves, by number of known others who have shot themselves on purpose eTable 3D. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm someone else, by concern a known other might physically hurt another person on purpose eTable 3E. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm a group of people, by concern a known other might physically hurt another person on purpose eTable 3F. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm themselves, by concern a known other might physically hurt themselves on purpose eTable 4. Prefer to have the police ask a judge for a GVRO for you, by firearm ownership status (n = 2870) JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 12/12 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AM AM A A A A A A A A A A A A AM AM A A A A A A AM AM http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Health Forum American Medical Association

Public Awareness of and Personal Willingness to Use California's Extreme Risk Protection Order Law to Prevent Firearm-Related Harm

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American Medical Association
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Copyright 2021 Kravitz-Wirtz N et al. JAMA Health Forum.
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2689-0186
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10.1001/jamahealthforum.2021.0975
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Abstract

Key Points Questions What does the public know IMPORTANCE Extreme risk protection order (ERPO) laws temporarily suspend firearm and about extreme risk protection orders ammunition access by individuals whom a judge has deemed to be at substantial risk of harming (ERPOs) and are people willing to use themselves or others. Despite widespread recent adoption of these laws, use of ERPOs has been these tools to prevent firearm-related limited. Barriers to ERPO uptake remain unclear. harm, both in general and when a family member is at risk? If they are not willing, OBJECTIVE To assess public awareness and perceived appropriateness of and willingness to use why not? ERPOs in various risk scenarios, and to identify reasons for being unwilling, overall and by firearm Findings In this state-representative ownership status, to inform efforts to improve ERPO implementation. cross-sectional survey study of 2870 adults in California, support for the DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional study using data from the 2020 appropriateness of and willingness to California Safety and Wellbeing Survey, a statewide internet survey on firearm ownership and use an ERPO at least some of the time exposure to violence and its consequences, conducted from July 14 to July 27, 2020. Adult was high (>70%) across selected risk respondents were recruited from the Ipsos KnowledgePanel using probability-based sampling scenarios, particularly among firearm methods. Responses were weighted to be representative of the adult population of California. owners and nonowners who live with owners. Approximately two-thirds of MAIN OUTCOMES AND MEASURES Awareness and perceived appropriateness of gun violence respondents cited a lack of awareness of restraining orders (GVROs; California’s official term for ERPOs), willingness to use a GVRO for a family ERPOs as a reason why they were member at risk of harm, and reasons for being not at all willing to use a GVRO in 1 or more risk unwilling to use an EPRO, followed by a scenarios, overall and by firearm ownership status. belief that the risk scenarios are private matters, and a distrust that the system RESULTS Of the 5018 panel members invited, 2870 (57%) completed the survey. Of these will be fair. respondents (mean [SD] age: 47.9 [16.9] years; 52.3% women; 41.9% White, 34.7% Latinx, 14.4% Asian, and 5.8% Black individuals), 65.6% (95% CI, 63.0%-68.1) had never heard of a GVRO or a red Meaning These findings on public flag law. Firearm owners were significantly more likely (20.5%; 95% CI, 15.9%-26.0%) than awareness and perceived nonowners who live with owners (6.1%; 95% CI, 3.7%-10.0%; P < .001) and nonowners (9.6%; 95% appropriateness of ERPOs, willingness CI, 7.8%-11.6%; P < .001) to have heard of both a GVRO and a red flag law. After reading a brief to use these tools to prevent firearm- description of California’s GVRO law, 72.9% (95% CI, 70.2%-75.4%) to 78.4% (95% CI, related harm, and areas of focus to 75.9%-80.8%) of respondents, depending on the risk scenario, indicated that GVROs were in general address barriers to EPRO uptake may be at least sometimes appropriate, while 73.2% (95% CI, 70.5%-75.6%) to 83.6% (95% CI, informative for EPRO implementation 81.2%-85.8%) said they would be somewhat or very willing to use a GVRO for a family member at risk in California and other jurisdictions. of harm. Firearm owners reported the highest levels of GVRO appropriateness in 4 of 5 risk scenarios (depending on the scenario, 80.0% [95% CI, 73.6%-85.1%] to 85.6% [95% CI, 79.9%-89.8%]). Supplemental content Nonowners who live with owners reported the highest levels of personal willingness to use a GVRO (depending on the scenario, 83.7% [95% CI, 74.7%-90.0%] to 94.7% [95% CI, 86.2%-98.1%]). The Author affiliations and article information are listed at the end of this article. most frequently cited reasons for being unwilling to use a GVRO were not knowing enough about GVROs (44.9%; 95% CI, 39.7%-50.3%), believing the risk scenarios are personal or family matters (26.6%; 95% CI, 22.2%-31.6%), and distrust that the system will be fair (23.1%; 95% CI, 19.1%-27.6%). (continued) Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 1/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Abstract (continued) CONCLUSIONS AND RELEVANCE In this cross-sectional survey study, public awareness of GVROs was low, but perceived appropriateness of and willingness to use these tools at least some of the time was high. Foci for efforts to address barriers to GVRO use in California were identified; similar challenges likely exist in other jurisdictions. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 Introduction Firearms are involved in more than half of suicides and approximately three-quarters of homicides in the US, accounting for nearly 39 000 violent deaths in 2018. While firearm violence is a vast public health problem, it is not inevitable. Policies and programs designed to prevent firearm-related harm are operating or are under consideration in jurisdictions across the country. Extreme risk protection order (ERPO) laws, sometimes referred to as “red flag” laws, have gained traction since the February 2018 mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, which many 3,4 stakeholders believed could have been prevented had an ERPO been available. Extreme risk protection orders are targeted, flexible, and proactive tools for temporarily suspending an individual’s access to firearms and ammunition when a judge has deemed the person to be at increased risk of firearm-related harm to themself or others and they are not otherwise prohibited from firearm ownership. Immediate family, household members, and law enforcement officers are 5,6 typically permitted to petition for an EPRO. Legislation on ERPOs has expanded rapidly. Of the 19 states and the District of Columbia with ERPO-type laws in effect as of February 2021, all but 2 were implemented since 2016. Yet early 7,8 evidence suggests that use of ERPOs remains relatively uncommon. There are various possible reasons for these lags in uptake. Central among these are questions about the extent to which the public is (1) aware of ERPOs, and (2) willing to use them in efforts to prevent firearm-related harm. Additionally, while ERPO laws have received greater bipartisan support and less pushback from gun rights organizations than many firearm violence prevention policies—eg, the National Rifle Association lobbied Congress to provide funding for states to adopt ERPO laws in the aftermath of the Parkland shooting—the perception that public support is deeply divided by gun ownership status has still been characterized as a speedbump on the road to ERPO implementation in many jurisdictions. The present study examines public awareness of and personal willingness to use an ERPO in specific risk scenarios, both in general and when a hypothetical family member is at risk, along with reasons for unwillingness to use such a tool, overall and by gun ownership status. We focused on California, which implemented the first ERPO law in January 2016 (2 states had related "risk warrant" laws in effect previously). In California, ERPOs are termed gun violence restraining orders (GVROs). As in other states, use of GVROs has increased over time in California, from 70 orders in 2016 to 700 in 2019; however, overall uptake of the law has been slow, with the increase driven primarily by law enforcement petitioners in 1 county. With renewed interest in short-term crisis interventions to prevent firearm injury and death amid the COVID-19 pandemic—at a time when firearm purchasing 11-15 has increased and conditions that elevate the risk of harm have worsened —this study is intended to identify opportunities to improve messaging and increase uptake of GVROs. As an early adopter and model for subsequent legislation in other states, we view the California experience as broadly informative for ERPO implementation in other jurisdictions. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 2/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Methods This was a cross-sectional survey study using data from the 2020 California Safety and Wellbeing Survey, a statewide survey on firearm ownership and exposure to violence and its consequences. The survey was designed by the University of California Firearm Violence Research Center and the Violence Prevention Research Program, both at the University of California, Davis, and administered online from July 14 to July 27, 2020, by Ipsos SA (Paris). The survey was approved by the University of California Davis Institutional Review Board. Respondents read informed consent language; study initiation constituted consent. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline. Survey respondents were recruited from the Ipsos KnowledgePanel, an online research panel 16-19 widely used in health-related research. Panel recruitment using probability-based sampling procedures has been described previously. All panel members who were 18 years or older and residents of California, except those currently serving in the US Armed Forces, were eligible to participate. Invitations were sent by email; automatic reminders were emailed to nonresponders 3 days later. Of 5018 members invited to participate, 2870 completed the survey (completion rate, 57%). The median completion time was 26 minutes. A final weight variable provided by Ipsos adjusted for the initial probability of panel selection and for survey-specific nonresponse and over-coverage or under-coverage using poststratification raking ratio adjustments based on cross-classifications of age, gender, race/ethnicity, education, household income, language proficiency, and California region. For race/ethnicity, respondents were asked if they consider themselves to be Latinx (Hispanic, Latino, or Spanish; yes/no) and to select their race(s): American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/other Pacific Islander, and/or White. Respondents tended to be older, male, non–Latinx, and have more years of education and higher income than nonrespondents. The sample was weighted to be statistically representative of the adult population of California, as reflected in the 2018 American Community Survey. Measures Respondents were asked whether they had ever heard of something called a GVRO, and subsequently, a red flag law. Next, respondents read a description of California’s GVRO law and were asked, “In general, do you think it would be appropriate for a judge to issue a GVRO” in each of 5 risk scenarios: when a person (1) is experiencing an emotional crisis, (2) has severe dementia or something like it, (3) has threatened to physically hurt themselves, (4) has threatened to physically hurt someone else, and (5) has threatened to physically hurt a group of people. Respondents could choose never, sometimes, usually, always, or don’t know. Those who answered “don’t know” were asked whether this was because they needed more information about GVROs. Respondents were then asked, “Would you personally be willing to ask a judge for a GVRO if a member of your family” was in each of the 5 risk scenarios. Respondents could choose not at all, somewhat, or very willing. A follow-up question asked whether respondents "would prefer to have the police ask a judge for a GVRO for you." Those who reported being “not at all” willing to ask a judge for a GVRO in 1 or more scenarios were asked about the reasons for their unwillingness. Respondents were grouped by firearm ownership status: firearm owners, nonowners who live with owners, and nonowners in households without firearms (hereafter, nonowners). Additional items of interest included whether respondents reported knowing anyone who had experienced or was at risk of harm to self or others, as well as sociodemographic information, which was collected separately as part of ongoing panel membership and was merged with study responses. Sociodemographic characteristics of respondents, overall and by firearm ownership status, are presented in Table 1. The original description of California’s GVRO law was followed by 1 of 3 randomized statements about the research evidence on EPRO effectiveness or by a no-statement control. No substantive JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 3/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Table 1. Sociodemographic Characteristics of Respondents, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Nonowners who live with owners Nonowners (n = 1989) Firearm owners (n = 529) (n = 219) Total (n = 2870) Characteristic No. (%) [95% CI] No. (%) [95% CI] No. (%) [95% CI] No. (%) [95% CI] Age, y 18-29 156 (17.3) [14.6-20.5] 12 (8.1) [4.4-14.6] 23 (24.6) [16.0-35.9] 200 (16.3) [14.0-18.9] 30-44 387 (31.2) [28.0-34.6] 54 (25.1) [18.6-33.0] 40 (20.4) [13.9-29.0] 511 (29.7) [27.0-32.5] 45-59 517 (26.4) [23.7-29.4] 130 (29.1) [23.5-35.5] 50 (23.7) [16.6-32.7] 738 (26.7) [24.4-29.2] 60+ 929 (25) [22.8-27.5] 333 (37.6) [32.1-43.5] 106 (31.3) [23.6-40.0] 1421 (27.3) [25.3-29.4] Sex Female 1010 (54.8) [51.5-58.1] 126 (26.5) [21.3-32.3] 166 (74.9) [64.8-82.9] 1364 (52.3) [49.5-55.0] Male 979 (45.2) [41.9-48.5] 403 (73.5) [67.7-78.7] 53 (25.1) [17.1-35.2] 1506 (47.7) [45.0-50.5] Race/ethnicity White 1035 (36.7) [33.7-39.8] 373 (60.2) [53.1-67.0] 141 (55.8) [45.7-65.3] 1615 (41.9) [39.3-44.6] Latinx 653 (38.1) [34.9-41.5] 97 (22.2) [16.6-29.0] 54 (22.9) [15.9-31.9] 849 (34.7) [32.0-37.4] Asian 169 (16.7) [14.1-19.7] 22 (10.4) [6.2-16.9] 7 (6.1) [2.6-13.9] 208 (14.4) [12.3-16.8 Black 86 (5.7) [4.3-7.5] 26 (6.0) [3.4-10.2] 7 (4.8) [1.7-12.8] 127 (5.8) [4.6-7.3] Multirace/other 46 (2.8) [1.8-4.2] 11 (1.2) [0.6-2.6] 10 (10.4) [4.9-20.9] 71 (3.2) [2.3-4.5] Education <High school 137 (18.6) [15.7-21.8] 6 (3.5) [1.4-8.1] 8 (10.3) [4.8-20.5] 158 (15.4) [13.1-18.0] High school degree 253 (19.4) [16.7-22.3] 64 (24.7) [18.5-32.1] 26 (20.6) [12.9-31.3] 364 (20.4) [18.1-23.0] Some college 581 (28.1) [25.3-31.0] 213 (44.6) [38.1-51.3] 80 (41.2) [32.0-51.0] 938 (32.7) [30.2-35.2] College degree 558 (18.7) [16.5-21.1] 137 (16.5) [12.3-21.7] 57 (14.6) [10.2-20.6] 775 (17.5) [15.7-19.4] Advanced degree 460 (15.3) [13.2-17.7] 109 (10.8) [8.3-14.1] 48 (13.4) [8.9-19.6] 635 (14.0) [12.4-15.8] Household income, $ <25 000 334 (16.8) [14.4-19.4] 52 (8.3) [5.3-12.8] 19 (8.4) [4.6-14.9] 431 (15.1) [13.2-17.2] 25 000-59 999 539 (26.0) [23.3-29.0] 128 (19) [14.8-24.0] 45 (17.8) [11.5-26.4] 744 (23.9) [21.7-26.3] 60 000-99 999 523 (23.1) [20.4-26.0] 132 (19.1) [14.8-24.2] 60 (20.9) [14.8-28.7] 757 (22.6) [20.4-24.9] ≥100 000 593 (34.1) [31.0-37.4] 217 (53.6) [46.9-60.1] 95 (52.9) [43.2-62.3] 938 (38.5) [35.8-41.3] Marital status Married or living with 1123 (59.2) [55.9-62.4] 344 (66.7) [60.1-72.7] 156 (64.3) [54.1-73.4] 1704 (61.0) [58.2-63.7] partner Widowed 150 (4.4) [3.5-5.5] 39 (5.7) [3.6-8.9] 9 (3.8) [1.6-8.9] 204 (4.4) [3.6-5.3] Divorced or separated 302 (10.8) [9.1-12.7] 89 (13.6) [9.7-18.8] 22 (7.3) [4.4-12.1] 432 (11.1) [9.6-12.7] Never married 414 (25.6) [22.6-28.8] 57 (13.9) [9.6-19.8] 32 (24.6) [16.3-35.3] 530 (23.5) [21.1-26.1] Political ideology Liberal 738 (34.2) [31.1-37.4] 109 (20.5) [15.6-26.4] 68 (31.3) [23.1-40.9] 940 (31.1) [28.6]-33.7 Moderate 551 (30.5) [27.5-33.7] 143 (28.5) [22.7-35.2] 69 (36.5) [27.5-46.6] 795 (30.8) [28.2-33.5] Conservative 511 (23.5) [20.9-26.4] 245 (43.3) [36.8-50.1] 66 (24.4) [17.5-33.0] 882 (27.3) [25.0-29.8] State region Superior California 142 (6.7) [5.2-8.5] 79 (15.2) [10.6-21.2] 20 (5.8) [3.2-10.3] 253 (8.1) [6.7-9.7] North Coast 47 (2.2) [1.3-3.5] 32 (4.8) [3.0-7.5] 9 (2.3) [1.1-4.9] 90 (2.5) [1.8-3.5] San Francisco Bay Area 396 (20.9) [18.1-24.1] 75 (11.8) [8.2-16.5] 25 (14.8) [8.7-24.1] 513 (18.5) [16.3-21.0] Northern San Joaquin 69 (3.6) [2.6-5.1] 35 (7.6) [4.8-11.8] 15 (4.4) [2.2-8.4] 129 (4.5) [3.5-5.7] Valley Central Coast 143 (6.0) [4.8-7.4] 38 (4.9) [3.2-7.4] 19 (13.3) [7.3-22.9] 204 (6.2) [5.1-7.5] Southern San Joaquin 116 (5.4) [4.2-7.0] 34 (7.1) [4.1-12.3] 20 (7.8) [4.3-13.6] 182 (6.0) [4.8-7.4] Valley Inland Empire 225 (10.4) [8.6-12.5] 74 (13.6) [9.7-18.6] 31 (8.5) [5.2-13.5] 358 (11.0) [9.5-12.8] Los Angeles County 500 (27.1) [24.4-30.1] 74 (18.1) [13.4-24.1] 50 (28) [20.1-37.5] 647 (25.9) [23.6-28.4] Orange County 137 (8.7) [6.9-10.8] 38 (7.5) [4.5-12.1] 10 (7.2) [2.9-16.7] 195 (8.3) [6.8-10.0] San Diego–Imperial 214 (9.0) [7.4-11.0] 50 (9.5) [6.0-14.7] 20 (8.0) [4.0-15.6] 299 (9.1) [7.7-10.8] Totals may not sum to 100% because refusals and “don't know” responses are Native, Asian, Black/African American, Native Hawaiian/other Pacific Islander, and not shown. White.” Among respondents who did not endorse Spanish, Hispanic, or Latino ethnicity, American Indian or Alaska Native (n = 10), Native Hawaiian or other Pacific Respondents were asked, “Are you Spanish, Hispanic, or Latino? Indicate what you Islander (n = 2), and those who selected more than 1 race (n = 59) were combined by consider your race to be. We appreciate your effort to describe your background using the authors into a multirace/other category. these US Census Bureau categories (select all that apply): American Indian/Alaska JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 4/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law differences were observed across the 4 conditions; therefore, results reflect the full sample, regardless of randomization. To align with GVRO statute language, questions about GVRO appropriateness and willingness included the qualifier: “Assume [the person/your family member] has or could get a gun and other options have failed or are not appropriate.” Detailed question phrasing and response options are provided in the eMethods section of the Supplement. Statistical Analysis We calculated weighted percentages and 95% CIs for each measure or cross-tabulation of measures in Stata, release 15.1 (StataCorp LLC) using the survey and weighting commands. Comparisons by firearm ownership status were conducted using the 2-sample t test within the framework of the weighted population. For ease of exposition and consistent with past research, we collapsed “sometimes,” “usually,” and “always” appropriate and “somewhat” and “very” willing into single response categories for primary analyses; analogous results with all response options are available in eTables 1A and 1B of the Supplement. Analyses were conducted from October 2020 to February 2021. All statistical tests were 2-tailed, and statistical significance was set at P < .05. Results Awareness Of 2870 respondents, (mean [SD] age was 47.9 [16.9] years and 52.3% were women; 49.1% were White, 34.7% Latinx, 14.4% Asian, and 5.8% Black individuals), 65.6% (95% CI, 63.0%-68.1%) reported that they had never heard of a GVRO or a red flag law; 11.0% (95% CI, 9.5%-12.8%) had heard of both; 13.9% (95% CI, 12.1%-15.8%) had heard of a GVRO only; and 8.8% (95% CI, 7.5%-10.4%) had heard of a red flag law only (Table 2). Firearm owners were significantly more likely (20.5%) than nonowners who live with owners (6.1%; P < .001) and nonowners (9.6%; P < .001) to have heard of both a GVRO and a red flag law, and significantly less likely to never have heard of either (51.6% vs 70.5% [P = .001] and 68.2% [P < .001], respectively) (Table 2). Firearm owners were also significantly more likely than nonowners (14.9% vs 7.3%; P = .004; Table 2) to have heard of a red flag law only. Appropriateness More than three-quarters of respondents indicated that, in general, it was at least sometimes appropriate for a judge to issue a GVRO when the at-risk person has threatened to physically hurt a Table 2. Public Awareness of Gun Violence Restraining Orders (GVROs) and “Red Flag” Laws Among California Adults, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Firearm ownership status Nonowners who live with owners Total (n = 2870) Nonowners (n = 1989) Firearm owners (n = 529) (n = 219) Awareness status No. % (95% CI) No. % (95% CI) P value No. % (95% CI) P value No. % (95% CI) P value Yes, GVRO only 464 13.9 (12.1-15.8) 322 14.4 (12.3-16.8) NS 88 13.0 (9.5-17.5) NS 39 15.0 (9.0-23.8) NS c d Yes, red flag law 275 8.8 (7.5-10.4) 162 7.3 (5.9-9.0) .004 75 14.9 (10.6-20.4) .004 20 8.4 (4.4-15.5) NS only c d c Yes, both GVRO 427 11.0 (9.5-12.8) 258 9.6 (7.8-11.6) <.001 128 20.5 (15.9-26.0) <.001 24 6.1 (3.7-10.0) <.001 and red flag law <.001 c d c Neither GVRO 1688 65.6 (63.0-68.1) 1238 68.2 (65.1-71.2) <.001 237 51.6 (44.8-58.3) <.001 136 70.5 (61.1-78.5) .001 nor red flag Abbreviation: NS, not significant. Significant difference from firearm owners. a d Percentages may not sum to 100% because refusals are not shown: 0.7% (95% CI, Significant difference from nonowners. 0.4-1.3) of respondents did not answer 1 or both questions (n = 16). e Significant difference from nonowners who live with owners. Respondents were asked, “Have you ever heard of something called a gun violence restraining order?” and “Have you ever heard of something called a 'red flag' law?” JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 5/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law group of people (78.4%; 95% CI, 75.9%-80.8%), someone else (78.1%; 95% CI, 75.5%-80.8%), or themselves (77.8%; 95% CI, 75.3%-80.2%) (Table 3). A slightly smaller share of respondents indicated that, in general, a GVRO is at least sometimes appropriate when the person is experiencing an emotional crisis (73.0%; 95% CI, 70.3%-75.4%) or has severe dementia or something like it (72.9%; 95% CI, 70.2%-75.4%). Of the 19.1% (95% CI, 16.9%-21.6%) of respondents who reported not knowing whether issuing a GVRO was appropriate in 1 or more scenarios, 48.5% (95% CI, 41.8%- 55.3%) said that this was because they needed more information about GVROs (eTable 2 in the Supplement). In 4 of 5 risk scenarios, firearm owners reported the highest levels of at least some support—80% or more—for the appropriateness of GVROs in general (Table 3). Firearm owners were significantly more likely than nonowners to indicate that, in general, it is at least sometimes appropriate for a judge to issue a GVRO when the at-risk person has severe dementia or something likeit(80.0%vs71.8%; P = .01); or has threatened to physically hurt themselves (84.1% vs 77.0%; P = .02), someone else (85.6% vs 76.5%; P = .002), or a group of people (85.3% vs 77.5%; P = .008). Nonowners who live with owners were significantly more likely than nonowners (82.2% vs 72.2%; P = .01) to report that, in general, GVROs are at least sometimes appropriate when the person is experiencing an emotional crisis. Willingness Most respondents indicated that they would be somewhat or very willing to ask a judge for a GVRO if a family member was experiencing an emotional crisis (73.2%; 95% CI, 70.5%-75.6%); had severe dementia or something like it (76.5%; 95% CI, 73.9%-78.9%); or had threatened to physically hurt Table 3. Perceived Appropriateness of a Judge Issuing a Gun Violence Restraining Orders (GVRO), in General, by Risk Scenario and Firearm Ownership Status, 2020 California Safety and Wellbeing Survey (n = 2870) Appropriate to issue GVRO Never Sometimes/usually/always Risk scenario and firearm P ownership status No. % (95% CI) No. % (95% CI) value Person experiencing an emotional crisis Total 296 11.5 (9.9-13.5) 2203 73.0 (70.3-75.4) NS Nonowners 182 11.3 (9.3-1.7) 1546 72.2 (69.0-75.2) .01 Firearm owners 76 15.0 (10.9-20.3) 410 75.2 (68.8-80.6) NS Nonowners who live with owners 15 6.7 (2.9-14.7) 178 82.2 (73.6-88.4) .01 Person with severe dementia or something like it Total 286 12.2 (10.4-14.2) 2253 72.9 (70.2-75.4) NS Nonowners 198 12.3 (10.2-14.8) 1559 71.8 (68.5-74.8) .01 Firearm owners 50 10.7 (7.2-15.6) 440 80.0 (73.6-85.1) .014 Nonowners who live with owners 19 13.4 (7.1-23.6) 180 76.3 (66.2-84.1) NS Person who threatened to physically hurt themself Total 235 11.3 (9.5-13.3) 2396 77.8 (75.3-80.2) NS Nonowners 162 11.2 (9.2-13.7) 1661 77.0 (73.8-79.8) .02 Firearm owners 40 11.8 (7.8-17.4) 466 84.1 (78.4-88.6) .02 Nonowners who live with owners 16 9.4 (4.5-18.8) 187 80.7 (71.0-87.7) NS Abbreviation: NS, not significant. Person who threatened to physically hurt someone else a Percentages may not sum to 100% because refusals Total 235 11.3 (9.5-13.3) 2413 78.1 (75.5-80.5) NS and “don't know” responses are not shown. Nonowners 169 11.9 (9.8-14.4) 1662 76.5 (73.3-79.5) .002 Respondents were asked, “In general, do you think it Firearm owners 36 9.5 (6.2-14.3) 474 85.6 (79.9-89.8) .002 would be appropriate for a judge to issue a GVRO in the following scenarios? Assume the person has or Nonowners who live with owners 15 8.9 (4.1-18.4) 190 83.4 (73.9-89.8) NS could get a gun and other options have failed or are Person who threatened to physically hurt a group of people not appropriate.” Total 238 11.7 (9.9-13.8) 2415 78.4 (75.9-80.8) NS Significant difference from nonowners who live Nonowners 172 12.4 (10.2-15.0) 1669 77.5 (74.4-80.3) .008 with owners. Firearm owners 36 9.8 (6.2-15.2) 471 85.3 (79.6-89.6) .008 Significant difference from nonowners. Nonowners who live with owners 15 9.3 (4.4-18.7) 190 81.5 (71.8-88.4) NS Significant difference from firearm owners. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 6/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law themself (82.8%; 95% CI, 80.4%-85.0%), someone else (83.8%; 95% CI, 81.4%-85.9%), or a group of people (83.6%; 95% CI, 81.2%-85.8%) (Table 4). Knowing someone who had experienced or was at risk of harm to self was associated with significantly higher levels of at least some willingness to use a GVRO in the harm-to-self scenario; however, knowing someone who had experienced or was at risk of interpersonal harm was not associated with differences in willingness in the harm-to-others scenarios (eTables 3A-3F in the Supplement). Nonowners who live with owners reported the highest levels of at least some willingness to ask a judge for a GVRO across all risk scenarios, ranging from 83.7% (95% CI, 74.7%-90.0%) who were somewhat or very willing if a family member were experiencing an emotional crisis to 94.7% (95% CI, 86.2%-98.1%) if a family member had threatened to physically hurt someone else (Table 4). Differences in willingness between nonowners who live with owners and both firearm owners and nonowners were statistically significant (P < .05; Table 4) in all scenarios except dementia and mass harm, where only the contrast with nonowners was significant (P < .01; Table 4). Lack of Willingness In all, 29.9% (95% CI, 27.3%-32.5%) of respondents reported that they were not at all willing to ask a judge for a GVRO if a family member were in 1 or more risk scenarios. The most frequently cited reason for being unwilling was not knowing enough about GVROs (44.9%; 95% CI, 39.7%-50.3%; Table 4. Willingness to Ask a Judge for a Gun Violence Restraining Order (GVRO) for a Family Member, by Risk Scenario and Firearm Ownership Status, 2020 California Safety and Wellbeing Survey (n = 2870) Willingness to ask for a GVRO Not at all Somewhat/very Risk scenario and firearm P ownership status No. % (95% CI) No. % (95% CI) value Family member experiencing an emotional crisis Total 651 24.4 (22.0-27.0) 2168 73.2 (70.5-75.6) NS Nonowners 406 24.2 (21.3-27.3) 1548 73.1 (69.9-76.1) .01 Firearm owners 161 29.8 (23.9-36.4) 365 69.8 (63.2-75.7) .006 Nonowners who live with 38 16.3 (10.0-25.3) 181 83.7 (74.7-90.0) .01 owners Family member with severe dementia or something like it Total 515 20.6 (18.4-23.1) 2290 76.5 (73.9-78.9) NS Nonowners 348 20.9 (18.2-23.9) 1597 76.1 (73.0-79.0) NS Firearm owners 103 21.5 (16.27-27.9) 421 78.0 (71.6-83.2) NS Nonowners who live with 25 15.3 (8.9-25.0) 193 84.5 (74.9-90.9) NS owners Family member who threatened to physically hurt themselves Total 318 14.3 (12.3-16.5) 2493 82.8 (80.4-85.0) NS Nonowners 207 14.3 (11.9-17.0) 1740 82.4 (79.5-85.0) <.001 Firearm owners 68 16.6 (12.0-22.6) 458 83.0 (77.0-87.7) .003 Nonowners who live with 9 5.4 (1.9-14.5) 210 94.6 (85.5-98.1) <.001 owners Family member who threatened to physically hurt you or someone else Abbreviation: NS, not significant. Total 280 13.4 (11.4-15.6) 2529 83.8 (81.4-85.9) NS c Percentages may not sum to 100% because refusals Nonowners 188 14.1 (11.7-16.9) 1758 82.6 (79.7-85.2) <.001 are not shown. Firearm owners 57 14.2 (9.8-20.1) 470 85.6 (79.7-90.0) .02 Respondents were asked, “Would you personally be Nonowners who live with 9 5.1 (1.8-13.8) 209 94.7 (86.2-98.1) <.001 willing to ask a judge for a GVRO if a member of your owners family was in one of the following scenarios? Assume Family member who threatened to physically hurt a group of people the person has or could get a gun and other options Total 284 13.7 (11.7-16.0) 2533 83.6 (81.2-85.8) NS have failed or are not appropriate.” c c Nonowners 192 14.4 (12.0-17.3) 1761 82.6 (79.6-85.2) .002 Significant difference from nonowners who live with owners. Firearm owners 55 14.0 (9.8-20.0) 470 85.4 (79.4-89.9) NS Significant difference from nonowners. Nonowners who live with 11 7.0 (2.9-15.8) 208 93.0 (84.2-97.1) .002 owners Significant difference from firearm owners. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 7/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Table 5); it was followed by the belief that these risk scenarios are personal or family matters (26.6%; 95% CI, 22.2%-31.6%), distrust that the system will be fair (23.1%; 95% CI, 19.1%-27.6%), worry about due process rights (18.6%; 95% CI, 15.3%-22.3%), not wanting to involve the court (16.4%; 95% CI, 12.7%-20.8%), the notion that it is never appropriate for the government to take a person’s guns (13.7%; 95% CI, 10.4%-17.9%), and worry about retaliation (11.3%; 95% CI, 8.4%-15.0%). Firearm owners were significantly less likely than nonowners (33.9% vs 47.8%; P = .04) to endorse not knowing enough about GVROs and significantly more likely than nonowners (27.7% vs 14.5%; P = .006) to endorse worry about due process rights, to distrust that the system will be fair (34.0% vs 20.1%; P = .02), and the notion that it is never appropriate for the government to take a person’s guns (22.9% vs 11.3%; P = .02) as reasons for their unwillingness to use a GVRO (Table 5). When all respondents, regardless of willingness to ask a judge for a GVRO in specific risk scenarios, were asked whether they would prefer to have the police ask a judge for a GVRO for them, 35.4% (95% CI, 32.8%-38.1%) said yes, 38.6% (95% CI, 35.9%-41.4%) said they did not know, and 24.7% (95% CI, 22.4%-27.1%) said no (eTable 4 in the Supplement). Firearm owners (33.5%) were significantly more likely than both nonowners who live with owners (21.2%; P = .02) and nonowners (23.3%; P = .004) to report that no, they did not prefer to have the police ask a judge for a GVRO for them and significantly less likely than nonowners to report that they did not know (30.3% vs 39.6%; P = .01). Discussion Extreme risk protection orders temporarily suspend access to firearms and ammunition by individuals whom a judge has deemed to be at substantial risk of harming themselves or others. This California-based study documents widespread public support—more than 70% across various risk scenarios—for the use of GVROs (California’s term for ERPOs) at least some of the time, both in general and when the at-risk person is a hypothetical family member. Firearm owners, even those without preexisting awareness of GVROs (results not shown), reported the highest levels of at least some support for the appropriateness of GVROs, in general, in 4 of 5 risk scenarios, while non–gun- owning respondents who live with owners reported the highest levels of at least some willingness to ask a judge for a GVRO for a family member, across all 5 risk scenarios. Table 5. Reasons Not At All Willing to Ask a Judge for a Gun Violence Restraining Order (GVRO) for a Family Member, by Firearm Ownership Status, 2020 California Safety and Wellbeing Survey Nonowners who live with owners Total (n = 799) Nonowners (n = 518) Firearm owners (n = 181) (n = 43) P P P Reason No. % (95% CI) No. % (95% CI) value No. % (95% CI) value No. % (95% CI) value c d Do not know enough about 322 44.9 (39.7-50.3) 240 47.8 (41.4-54.3) .04 43 33.9 (23.4-46.3) .04 16 46.4 (25.4-68.7) NS GVROs These are personal/family 233 26.6 (22.2-31.6) 148 25.5 (20.4-31.5) NS 57 29.2 (19.7-41.0) NS 17 47.1 (26.1-69.2) NS matters c d Do not trust the system will 218 23.1 (19.1-27.6) 119 20.1 (15.6-25.4) .02 71 34.0 (24.6-45.0) .02 9 23.0 (8.0-50.9) NS be fair c d Worried about due process 201 18.6 (15.3-22.3) 109 14.5 (11.1-18.6) .006 65 27.7 (19.9-37.2) .006 11 35.3 (16.9-59.3) NS rights Do not want to involve the 119 16.4 (12.7-20.8) 78 17.6 (12.9-23.4) NS 30 16.4 (10.2-25.4) NS 7 9.9 (4.0-22.6) NS court c d Never appropriate for 106 13.7 (10.4-17.9) 46 11.3 (7.5-16.6) .02 45 22.9 (15.2-33.0) .02 3 9.3 (1.8-36.1) NS government to take guns Worried about retaliation 88 11.3 (8.4-15.0) 60 11.6 (8.2-16.3) NS 17 9.4 (4.5-18.6) NS 7 17.0 (6.3-38.5) NS Other reason 101 10.7 (7.8-14.4) 59 8.5 (5.8-12.4) NS 30 18.2 (9.9-31.1) NS 5 8.7 (2.9-23.3) NS Abbreviation: NS, not significant. Significant difference from firearm owners. a d Percentages of respondents who did not endorse each reason or refused to respond Significant difference from nonowners. are not shown. Respondents were asked, “You mentioned that you were not at all willing to ask a judge for a GVRO in 1 or more situations. Please choose the reasons why. Select all that apply.” JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 8/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Although uptake of ERPOs, especially by non–law-enforcement petitioners, has been slow in California and across the country, these findings suggest that resistance from individuals most likely to be affected by the law (eg, firearm owners, those with social proximity to owners, and individuals who know someone at risk of harm) does not account for such lags. These findings are consistent with national studies indicating that many firearm violence prevention policies have broad public support, and that general consensus exists between firearm owners and nonowners; although notably, greater support among gun owners vs nonowners in California is unique relative to prior national estimates. These findings also align with expert guidance and past research that found higher levels of public support, especially among owners, when firearm violence prevention efforts, including firearm safety conversations between health care professionals and patients, are implemented in the context of risk reduction. Extreme risk protection order laws exemplify a targeted, risk-based approach to preventing harm before it occurs, leveraging the knowledge of those who are often the first to recognize that someone they care about is in crisis or behaving dangerously, and providing a tool for proactive intervention. Studies document that ERPOs have been used in efforts to prevent mass harm, and that they may be particularly effective in preventing suicide because access to a firearm during what is often an impulsive act of self-harm can mean the difference between death and survival. These findings suggest that most adults in California are receptive to this characterization of firearm- related harm as preventable rather than inevitable, and when provided with a mechanism to intervene before violence occurs, a large share of the population—including gun owners and those who live with owners—not only think it is at least sometimes appropriate but are somewhat or very willing to take action personally on behalf of someone who is at increased risk. Nonetheless, GVRO awareness levels are low. Approximately two-thirds of respondents had never heard of a GVRO or a red flag law, and pluralities of respondents within the subsets of those who did not know whether a GVRO was appropriate (19%) and who were not at all willing to ask a judge for a GVRO (30%) in 1 or more risk scenarios said they needed more information about GVROs. This lack of awareness represents a substantial barrier to GVRO implementation at the population level and presents a clear opportunity for improvement. We recommend further research to assess what additional information would amplify public understanding and use of GVROs and how such 24,25 messaging can be disseminated in ways that are relevant, accurate, and effective. These findings provide several insights for addressing hesitancy to use GVROs. First, among the subset of those who were not at all willing to ask a judge for a GVRO in 1 or more scenarios of increased risk, the perception that these are personal or family matters was cited by more than 1 of 4 respondents. Similar to the shifts in the public’s understanding of intimate partner violence, it will be important to normalize the process of intervening to reduce an at-risk individual’s access to guns as an issue affecting society as a whole (including mass harm and domestic terrorism), rather than only as a private problem. Second, among firearm owners in particular, it will be essential to address concerns about due process and the notion that it is never appropriate for the government to regulate a person’s access to guns. While the latter may require more sustained investments in shifting cultural paradigms about private firearm ownership, the former may be more readily addressed through targeted messaging efforts to emphasize that ERPO-type laws have built in due process protections, including a timely hearing before a judge at which petitioners must meet a standard of proof and counter evidence can be presented. Finally, it will also be necessary to address distrust of the mainstream criminal legal system, which has systematically oppressed and disenfranchised Asian, Black, and Latinx communities through historical and present policies and practices. More than 20% of respondents who were not at all willing to use a GVRO in 1 or more risk scenarios cited distrust in the fairness of the system and 16% said they did not want to involve the court. A separate analysis that is not yet published will examine whether responses fell along any specific or expected racial-ethnic lines. As recently argued, it will be essential to include assessment of social inequities associated with ERPO implementation and future evaluation—including possible consequences of unequal enforcement JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 9/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law and benefits of reduced harm—so that the use of these tools does not perpetuate the uneven burden of structurally rooted trauma and injustice within marginalized communities. Limitations This study has several limitations. First, we relied on self-reported data, which is subject to nonresponse and social desirability biases; however, nonresponse rates were low in the study sample, and evidence suggests that completion rates are higher and social desirability bias is lower in online panel surveys than in random-digit-dial telephone surveys. Second, although we think these findings can inform understandings of EPRO implementation in other states, California is unique. Geographic variations in firearm ownership and the cultural acceptability of firearms, firearm violence, and firearm regulations should be considered when attempting to generalize these results. Third, primary analyses that collapse response categories (eg, somewhat, usually, and always appropriate; somewhat and very willing) may mask more nuanced differences in the extent of support for GVRO appropriateness and willingness overall and by firearm ownership status. However, given the polarizing nature of gun policy discourse, we posit that any indication of support for the appropriateness of or willingness to use an EPRO is not only noteworthy, but may also be valuable for changing behavior via subjective norms—ie, beliefs that an important person or group of people will approve and support a particular behavior. Finally, although we measured the public’s perceived appropriateness of GVROs in general and their personal willingness to use these tools, the extent to which such support translates into real-world action is unclear. Conclusions This cross-sectional study found that ERPOs are promising tools for reducing firearm-related harm. Although we found widespread public support (including among firearm owners and nonowners who live with owners) for using ERPOs at least some of the time across a range of risk scenarios, public awareness levels are low. Attention to concerns regarding unjust implementation of ERPOs is warranted. This study identifies concrete areas of focus for efforts to address ERPO uptake and implementation challenges in California and other states with similar laws in effect or under consideration. ARTICLE INFORMATION Accepted for Publication: April 15, 2021. Published: June 4, 2021. doi:10.1001/jamahealthforum.2021.0975 Open Access: This is an open access article distributed under the terms of the CC-BY License.©2021 Kravitz-Wirtz N et al. JAMA Health Forum. Corresponding Author: Nicole Kravitz-Wirtz, PhD, MPH, University of California Firearm Violence Research Center and Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA 95817 (nkravitzwirtz@ucdavis.edu). Author Affiliations: University of California Firearm Violence Research Center and Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento. Author Contributions: Dr Kravitz-Wirtz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Kravitz-Wirtz, Aubel, Wintemute. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Kravitz-Wirtz, Aubel. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kravitz-Wirtz, Aubel. Obtained funding: Wintemute. JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 10/12 JAMA Health Forum | Original Investigation Awareness and Use of California’s Extreme Risk Protection Order Law Administrative, technical, or material support: Pallin. Supervision: Kravitz-Wirtz, Wintemute. Conflict of Interest Disclosures: None reported. Funding/Support: This research was supported by the University of California Firearm Violence Research Center at UC Davis, with funds from the State of California, the California Wellness Foundation (Award No. 2017-0447), and the Heising-Simons Foundation (Award No. 2019-1728). 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Social desirability bias in CATI, IVR, and web surveys: the effects of mode and question sensitivity. Public Opinion Quarterly. 2008;72(5):847-865. doi:10.1093/poq/nfn063 SUPPLEMENT. eMethods. Detailed question wording and response options, 2020 California Safety and Wellbeing Survey eTable 1A. Perceived appropriateness of a judge issuing a GVRO, in general, by risk scenario and firearm ownership status, 2020 California Safety and Wellbeing Survey eTable 1B. Willingness to ask a judge for a GVRO for a family member, by risk scenario and firearm ownership status, 2020 California Safety and Wellbeing Survey eTable 2. Need more information about GVROs, respondents who did not know if a GVRO is appropriate in1 risk scenarios (n = 449) eTable 3A. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm someone else, by number of known others who have been shot by someone else on purpose eTable 3B. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm a group of people, by number of known others who have been shot by someone else on purpose eTable 3C. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm themselves, by number of known others who have shot themselves on purpose eTable 3D. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm someone else, by concern a known other might physically hurt another person on purpose eTable 3E. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm a group of people, by concern a known other might physically hurt another person on purpose eTable 3F. Willingness to ask a judge for a GVRO for a family member who has threatened to physically harm themselves, by concern a known other might physically hurt themselves on purpose eTable 4. Prefer to have the police ask a judge for a GVRO for you, by firearm ownership status (n = 2870) JAMA Health Forum. 2021;2(6):e210975. doi:10.1001/jamahealthforum.2021.0975 (Reprinted) June 4, 2021 12/12 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A AM AM A A A A A A A A A A A A AM AM A A A A A A AM AM

Journal

JAMA Health ForumAmerican Medical Association

Published: Jun 4, 2021

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