Elsevier

The Lancet

Volume 387, Issue 10030, 30 April–6 May 2016, Pages 1847-1855
The Lancet

Articles
Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study

https://doi.org/10.1016/S0140-6736(15)01026-0Get rights and content

Summary

Background

In an effort to reduce firearm mortality rates in the USA, US states have enacted a range of firearm laws to either strengthen or deregulate the existing main federal gun control law, the Brady Law. We set out to determine the independent association of different firearm laws with overall firearm mortality, homicide firearm mortality, and suicide firearm mortality across all US states. We also projected the potential reduction of firearm mortality if the three most strongly associated firearm laws were enacted at the federal level.

Methods

We constructed a cross-sectional, state-level dataset from Nov 1, 2014, to May 15, 2015, using counts of firearm-related deaths in each US state for the years 2008–10 (stratified by intent [homicide and suicide]) from the US Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, data about 25 firearm state laws implemented in 2009, and state-specific characteristics such as firearm ownership for 2013, firearm export rates, and non-firearm homicide rates for 2009, and unemployment rates for 2010. Our primary outcome measure was overall firearm-related mortality per 100 000 people in the USA in 2010. We used Poisson regression with robust variances to derive incidence rate ratios (IRRs) and 95% CIs.

Findings

31 672 firearm-related deaths occurred in 2010 in the USA (10·1 per 100 000 people; mean state-specific count 631·5 [SD 629·1]). Of 25 firearm laws, nine were associated with reduced firearm mortality, nine were associated with increased firearm mortality, and seven had an inconclusive association. After adjustment for relevant covariates, the three state laws most strongly associated with reduced overall firearm mortality were universal background checks for firearm purchase (multivariable IRR 0·39 [95% CI 0·23–0·67]; p=0·001), ammunition background checks (0·18 [0·09–0·36]; p<0·0001), and identification requirement for firearms (0·16 [0·09–0·29]; p<0·0001). Projected federal-level implementation of universal background checks for firearm purchase could reduce national firearm mortality from 10·35 to 4·46 deaths per 100 000 people, background checks for ammunition purchase could reduce it to 1·99 per 100 000, and firearm identification to 1·81 per 100 000.

Interpretation

Very few of the existing state-specific firearm laws are associated with reduced firearm mortality, and this evidence underscores the importance of focusing on relevant and effective firearms legislation. Implementation of universal background checks for the purchase of firearms or ammunition, and firearm identification nationally could substantially reduce firearm mortality in the USA.

Funding

None.

Introduction

Firearm violence in the USA is an issue of substantial public health concern.1 Mortality due to firearms is endemic, characterised by stable but high national fatality rates since 2000.2 More than 90 people are killed every day by firearms in the USA.3 This burden of fatal firearm injuries varies widely between states and by race or ethnic origin, with higher firearm mortality rates occurring among black people than white people.2, 3 Firearm mortality mainly occurs among young adults aged 17 to 25 years and accounts for 80% of all homicides and 45% of all suicides within this age group.3, 4

Firearms are ubiquitous in the USA, and the high level of firearm ownership has been directly associated with an increased risk of firearm-related mortality.5, 6 Firearm violence prevention strategies have produced a small amount of success in the form of a federal law—the “Brady Handgun Violence Prevention Act” (enacted Nov 30, 1993)—often called the Brady Law.7 The Brady Law requires background checks to be undertaken for individuals before they can purchase a firearm from a federally licensed dealer, manufacturer, or importer—unless an exception applies. However, the loopholes to this statute allow unfettered sales from unlicensed dealers. To offset the limitations of the Brady Law, several states have instituted separate laws intended to fill these gaps.8, 9 States have implemented firearm laws in an effort to reduce firearm access to children (child-access prevention [CAP] laws) and to regulate firearm storage practices.10, 11 Conversely, many states have also enacted laws aimed to further deregulate the carrying of firearms through so-called stand-your-ground laws (where an individual may use deadly force in self-defence without the duty to retreat when faced with a reasonable perceived threat).10 These state regulations have been implemented either as amendments to an existing firearm law or as a separate legislation.

Some preliminary evidence exists regarding the effectiveness of the different state laws in reducing firearm mortality.8, 11, 12 However, this evidence has focused on assessments of either the cumulative effect of several firearm laws or an arbitrary legislative strength score1 and the effect of a select few laws such as stand-your-ground or CAP.11, 12 To our knowledge, no studies have assessed several firearm laws together with all relevant state-level characteristics. In view of the many firearm laws in different states, we aimed to build on the available evidence to determine the independent effect of different firearm laws on firearm mortality, taking into account relevant firearm laws and state-specific characteristics.

Research in context

Evidence before this study

We searched PubMed with the terms “gun” OR “firearm”, AND “policy” OR “law” OR “legislation” OR “legislature” OR “laws” OR “policies”, for articles published in any language before May 1, 2015. We identified 1154 articles, of which 1008 remained after adding the restriction term “humans”. Several articles assessed the effect of one or few firearm laws or policies, but we identified only six articles that studied the effect of several laws on firearm deaths in the USA, and only two that deemed all firearm laws as a score.

Added value of this study

Our findings showed that of the laws we surveyed, only a few were associated with reduced firearm mortality, whereas most were either associated with increased mortality or had no conclusive association. We showed that federal-level implementation of the three most strongly associated laws—universal background checks for firearm purchase, background checks for ammunition, and requiring firearm identification by either microstamping or ballistic fingerprinting—would substantially reduce overall national firearm mortality.

Implications of all the available evidence

Implementation of background checks for firearm or ammunition purchase and firearm identification nationally could substantially reduce firearm mortality in the USA. However, very few of the existing state-specific firearm laws are associated with reduced firearm mortality, and this evidence underscores the importance of focusing on relevant and effective firearms legislation.

Section snippets

Study design

We did a cross-sectional, state-level study from Nov 1, 2014, to May 15, 2015, to assess the effect of different firearm legislation on firearm mortality in the USA, taking into account state-specific firearm legislation, unemployment, non-firearm homicides, firearm exports, and firearm ownership rates based on previous studies (appendix).8, 9, 11, 13 The Columbia University Ethics Review Board deemed the study exempt from federal regulations for the protection of human research participants.

Data sources

We

Results

31 672 firearm-related deaths occurred in 2010 (10·1 per 100 000) in the USA, with a mean state-specific count of 631·5 events (SD 629·1). Analysed by state, Hawaii had the lowest rate (n=45; 3·31 per 100 000) and Alaska had the highest (n=144; 20·3 per 100 000). 25 laws existed in 2009 that either controlled firearms or were permissive.

The figure shows the crude and adjusted analysis to assess the independent effect of each firearm law on firearm-related deaths. Predicted probabilities of

Discussion

Using a comprehensive dataset including all state-specific firearm laws, we showed nine laws to be associated with reduced overall firearm mortality, nine to be associated with increased mortality, and seven to be inconclusive. The three laws most strongly associated with reduced firearm mortality were universal background checks for firearm purchase, background checks for ammunition, and requiring firearm identification by either microstamping or ballistic fingerprinting. We showed that

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