Associations Between Gun Laws and Suicides

How firearm legislation impacts firearm mortality internationally: A scoping review

Background

The literature on gun violence is broad and variable, describing multiple legislation types and outcomes in observational studies. Our objective was to document the extent and nature of evidence on the impact of firearm legislation on mortality from firearm violence.

Methods

A scoping review was conducted under PRISMA-ScR guidance. A comprehensive peer-reviewed search strategy was executed in several electronic databases from inception to March 2024. Grey literature was searched for unpublished sources. Data were extracted on study design, country, population, type of legislation, and overall study conclusions on legislation impact on mortality from suicide, homicide, femicide, and domestic violence. Critical appraisal for a sample of articles with the same study design (ecological studies) was conducted for quality assessment.

Findings

5057 titles and abstracts and 651 full-text articles were reviewed. Following full-text review and grey literature search, 202 articles satisfied our eligibility criteria. Federal legislation was identified from all included countries, while state-specific laws were only reported in studies from the U.S. Numerous legislative approaches were identified including preventative, prohibitive, and more tailored strategies focused on identifying high risk individuals. Law types had various effects on rates of firearm homicide, suicide, and femicide. Lack of robust design, uneven implementation, and poor evaluation of legislation may contribute to these differences.

Interpretation

We found that national, restrictive laws reduce population-level firearm mortality. These findings can inform policy makers, public health researchers, and governments when designing and implementing legislation to reduce injury and death from firearms.

Funding

Funding is provided by the Strategy for Patient-Oriented Research (SPOR) Evidence Alliance and in part by St. Michael's Hospital, University of Toronto.

Scoping review registration

Open Science Framework (OSF): https://osf.io/sf38n.

Gunshot injuries in Central Europe - Epidemiology and outcome in Germany, Switzerland and Austria - an analysis based on the TraumaRegister DGU®

BACKGROUND

Firearms are of special interest in trauma research due to high lethality and criminal value. Strong correlation between guns per capita and fire-arm related deaths has been shown. Most of existing literature regarding gun-shot fatalities are from the U.S. and data for Central Europe is lacking. Thus, the aim of this study was to assess the legal frameworks regarding gun-ownership in Germany (DE), Austria (A) and Switzerland (CH), and to retrospectively analyze data from the TraumaRegister DGU® regarding the epidemiology, injury severity, intention and outcome of gunshot-related deaths in these countries.

METHODS

All patients from TR-DGU who sustained a gunshot injury in the time period from 1st January 2009 to 31st December 2019 were considered for analysis. Only cases admitted to level 1 or 2 trauma center in Germany, Switzerland, or Austria were included. Predicted mortality was calculated using the RISC-II. Further, the legal framework for firearm posession were explored.

RESULTS

The legal frameworks do not differ significantly between the countries. However, only ex-military men from Switzerland are allowed to keep their automatic (military) weapon at home. We assessed 1312 gunshot fatalities (DE 1,099, A 111, CH 102) of which most were due to suspected suicide (A 72.1 %, CH 64.7 %, and DE 56.6 %, p = 0.003). Act of suspected violent crime or accidental gunshots were rare in all three countries. Amongst all gunshot fatalities, Austria showed the highest mean age (57.6 years), followed by DE (53.4 years) and CH (49.4 years; p < 0.01). Gunshot fatalities amongst all assessed countries due to suspected suicide showed a peak at the age of 60 years and above, whereas suspected violent crime delicts with gunshots were mainly seen in younger age groups. The highest mortality was found in suspected suicide cases, showing a mortality of 82.1 % (predicted 65.2 %) in Switzerland, 75.3 % (predicted 65.8 %) in Austria and 63.7 % (predicted 56.2 %) in Germany.

CONCLUSION

Gunshot wounds are still rare in central Europe, but gunshot-related suicide rates are high. Gun ownership laws may have an impact on gunshot wounds due to suspected suicide. Injury patterns differ compared to countries where a high incidence of gun ownership is seen.

Institutional Failures as Structural Determinants of Suicide: The Opioid Epidemic and the Great Recession in the United States

We investigate recent trends in U.S. suicide mortality using a "structural determinants of health" framework. We access restricted-use multiple cause of death files to track suicide rates among U.S. Black, White, American Indian/Alaska Native, and Latino/a men and women between 1990 and 2017. We examine suicide deaths separately by poisonings and nonpoisonings to illustrate that (1) women's suicide rates from poisonings track strongly with increases in prescription drug availability and (2) nonpoisoning suicide rates among all adult Americans track strongly with worsening economic conditions coinciding with the financial crash and Great Recession. These findings suggest that institutional failures elevated U.S. suicide risk between 1990 and 2017 by increasing access to more lethal means of self-harm and by increasing both exposure and vulnerability to economic downturns. Together, these results support calls to scale up to focus on the structural determinants of U.S. suicide.

Effectiveness of a Suicide Prevention Lethal Means Training Program for the General Public

To evaluate the effectiveness of Conversations on Access to Lethal Means for the General Public (CALM-GP), a training for the public focusing on reducing access to lethal means during a crisis. The program adapted Counseling on Access to Lethal Means (CALM), developed for mental health practitioners and physicians. Participants completed pre/post surveys and follow-up surveys three months afterward. Measures included comfort and confidence in talking to a suicidal individual about access to lethal means, the likelihood of follow-up, and the number of lethal means conversations before and after the program. Surveys showed improvement in comfort and confidence talking about safely storing firearms and other lethal means and the likelihood of follow-up with that individual regarding access to lethal means. Results also indicated increased conversations participants had regarding suicide and lethal means at three-month follow-up. This evaluation suggests that CALM-GP is an effective suicide prevention and lethal means program for the public.

State Firearm Legislation and Youth/Young Adult Handgun Carrying in the United States

PURPOSE

To examine the association between state firearm legislation and youth/young adult handgun carrying in the United States and to identify policy priority areas for intervention.

METHODS

We linked person-level gun carrying data from a nationally representative sample of U.S. youth and young adults with state-level gun policies over a 15-year period. Cross-classified mixed effects logistic regressions estimated the associations between state gun policies and handgun carrying and explored whether the associations varied by person-level demographic characteristics.

RESULTS

Youth and young adults in states with a greater number of gun policies were less likely to carry a handgun than youth and young adults in states with fewer gun policies. Regulations on gun purchasing, concealed carrying permitting, and domestic violence-related laws were particularly important in reducing youth/young adult gun-carrying behavior. In addition, these associations varied by gender and race/ethnicity.

DISCUSSION

State firearm legislation may be an effective mechanism to reduce youth and young adult gun carrying and ultimately mitigate gun-related mortality and morbidity.

Suicide Rates and Differences in Rates Between Non-Hispanic Black and Non-Hispanic White Populations in the 30 Largest US Cities, 2008-2017

OBJECTIVES

Suicide is a leading cause of death in the United States, and rates vary by race and ethnicity. An analysis of suicide across large US cities is absent from the literature. The objective of this study was to examine suicide rates among the total population, non-Hispanic Black population, and non-Hispanic White population in the United States and in the 30 largest US cities.

METHODS

We used data from the National Vital Statistics System to calculate non-Hispanic White, non-Hispanic Black, and total age-adjusted suicide rates for the 30 largest US cities and for the entire nation during 2 periods: 2008-2012 and 2013-2017. We also examined absolute and relative differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations in each city.

RESULTS

The overall age-adjusted suicide rate per 100 000 population in the United States increased significantly from 12.3 in 2008-2012 to 13.5 in 2013-2017. Total suicide rates were stable in most cities; rates increased significantly in only 1 city (Louisville), and rates decreased significantly in 2 cities (Boston and Memphis). The non-Hispanic White suicide rate was significantly higher-1.3 to 4.3 times higher-than the non-Hispanic Black suicide rate in 24 of 26 study cities during 2013-2017. From 2008-2012 to 2013-2017, non-Hispanic White suicide rates decreased significantly in 3 cities and increased significantly in 3 cities; non-Hispanic Black suicide rates increased significantly in 5 cities and decreased in none. Absolute differences in suicide rates among non-Hispanic White populations and non-Hispanic Black populations increased significantly in 1 city (Louisville) and decreased significantly in 2 cities (Memphis and Boston).

CONCLUSIONS

Our study may inform the use of evidence-based programs and practices to address population-level risk factors for suicide.

The Revolution Will Be Hard to Evaluate: How Co-Occurring Policy Changes Affect Research on the Health Effects of Social Policies

Extensive empirical health research leverages variation in the timing and location of policy changes as quasi-experiments. Multiple social policies may be adopted simultaneously in the same locations, creating co-occurrence that must be addressed analytically for valid inferences. The pervasiveness and consequences of co-occurring policies have received limited attention. We analyzed a systematic sample of 13 social policy databases covering diverse domains including poverty, paid family leave, and tobacco use. We quantified policy co-occurrence in each database as the fraction of variation in each policy measure across different jurisdictions and times that could be explained by covariation with other policies. We used simulations to estimate the ratio of the variance of effect estimates under the observed policy co-occurrence to variance if policies were independent. Policy co-occurrence ranged from very high for state-level cannabis policies to low for country-level sexual minority-rights policies. For 65% of policies, greater than 90% of the place-time variation was explained by other policies. Policy co-occurrence increased the variance of effect estimates by a median of 57-fold. Co-occurring policies are common and pose a major methodological challenge to rigorously evaluating health effects of individual social policies. When uncontrolled, co-occurring policies confound one another, and when controlled, resulting positivity violations may substantially inflate the variance of estimated effects. Tools to enhance validity and precision for evaluating co-occurring policies are needed.

What to Do When Everything Happens at Once: Analytic Approaches to Estimate the Health Effects of Co-Occurring Social Policies

Social policies have great potential to improve population health and reduce health disparities. Increasingly, those doing empirical research have sought to quantify the health effects of social policies by exploiting variation in the timing of policy changes across places. Multiple social policies are often adopted simultaneously or in close succession in the same locations, creating co-occurrence that must be handled analytically for valid inferences. Although this is a substantial methodological challenge for researchers aiming to isolate social policy effects, only in a limited number of studies have researchers systematically considered analytic solutions within a causal framework or assessed whether these solutions are being adopted. We designated 7 analytic solutions to policy co-occurrence, including efforts to disentangle individual policy effects and efforts to estimate the combined effects of co-occurring policies. We used an existing systematic review of social policies and health to evaluate how often policy co-occurrence is identified as a threat to validity and how often each analytic solution is applied in practice. Of the 55 studies, only in 17 (31%) did authors report checking for any co-occurring policies, although in 36 studies (67%), at least 1 approach was used that helps address policy co-occurrence. The most common approaches were adjusting for measures of co-occurring policies; defining the outcome on subpopulations likely to be affected by the policy of interest (but not other co-occurring policies); and selecting a less-correlated measure of policy exposure. As health research increasingly focuses on policy changes, we must systematically assess policy co-occurrence and apply analytic solutions to strengthen studies on the health effects of social policies.

Firearm laws and the network of firearm movement among US states

Background

The movement of firearm across state lines may decrease the effectiveness of state-level firearm laws. Yet, how state-level firearm policies affect cross-state movement have not yet been widely explored. This study aims to characterize the interstate movement of firearms and its relationship with state-level firearm policies.

Methods

We analyzed the network of interstate firearm movement using Bureau of Alcohol, Tobacco, Firearms, and Explosives firearm trace data (2010–2017). We constructed the network of firearm movement between 50 states. We used zero-inflated negative binomial regression to estimate the relationship between the number of a state’s firearm laws and number of states for which it was the source of 100 or more firearms, adjusting for state characteristics. We used a similar model to examine the relationship between firearm laws and the number of states for which a given state was the destination of 100 or more firearms.

Results

Over the 8-year period, states had an average of 26 (Standard Deviation [SD] 25.2) firearm laws. On average, a state was the source of 100 or more crime-related firearms for 2.2 (SD 2.7) states and was the destination of 100 or more crime-related firearms for 2.2 (SD 3.4) states. Greater number of firearm laws was associated with states being the source of 100 or more firearms to fewer states (Incidence Rate Ratio [IRR] 0.58 per SD, p < 0.001) and being the destination of 100 or more firearms from more states (IRR1.73 per SD, p < 0.001).

Conclusions

Restrictive state-level firearm policies are associated with less movement of firearms to other states, but with more movement of firearms from outside states. The effectiveness of state-level firearm-restricting laws is complicated by a network of interstate firearm movement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11772-y.

Increasing Rate of Unintentional Firearm Deaths in Youngest Americans: Firearm Prevalence and Covid-19 Pandemic Implication

BACKGROUND

The United States has had, by far, the world's greatest civilian ownership of firearms. An even greater ownership occurred during the Covd-19 pandemic, mostly of handguns and including many new owners. The U.S. has also had the least progress of the 41 highest sociodemographic countries ranked by the Institute for Health Metrics and Evaluation in reducing the unintentional firearm mortality rate in young children. This study characterized the unintentional firearm mortality trends in American 1-4 year-olds by sex and race/ethnicity and evaluated the trends in the context of firearm prevalence in the U.S.

METHODS

Mortality data for 1999-2018 were obtained from the U.S. Centers for Disease Control and Prevention and the Institute for Health Metrics and Evaluation, firearm injury and mortality data for 2016-2020 from Everytown for Gun Safety #NotAnAccident database, firearm background check data for 1999-2020 from the National Instant Criminal Background Check System, and civilian firearm prevalence for 2017 from the Small Arms Survey.

RESULTS

In American 1-4 year-olds, the rate of unintentional firearm deaths during 1999-2018 increased exponentially at an average annual percent rate of 4.9 (p < 0.001) and was greatest in non-Hispanic black children. Unintentional firearm deaths had the most rapid increase of all evaluable causes of death in the age group. The unintentional firearm death rate increase was correlated with the concurrent rate of firearm background checks and handgun permits issued (each p < 0.001) and in non-Hispanic white children with handgun prevalence in their families (p = 0.03). Globally, the unintentional firearm death rate was also correlated with firearm prevalence (p = 0.02).

CONCLUSIONS

An increase in fatal firearm accidents in the United States death rate among 1-4 year-olds is directly associated with the steadily increasing prevalence of firearms. The acceleration of firearm deaths and injuries among young Americans, especially among non-Hispanic black children, requires urgent solutions to address firearm prevalence and access. The problem is expected to become even more urgent as a result of the record high firearm sales that occurred in the United States during the 2020 coronavirus pandemic.

The impact of gun violence restraining order laws in the U.S. and firearm suicide among older adults: a longitudinal state-level analysis, 2012-2016

BACKGROUND

Older adults complete suicide at a disproportionately higher rate compared to the general population, with firearms the most common means of suicide. State gun laws may be a policy remedy. Less is known about Gun Violence Restricting Order (GVRO) laws, which allow for removal of firearms from people deemed to be a danger to themselves or others, and their effects on suicide rates among older adults. The purpose of this study was to examine the association of state firearm laws with the incidence of firearm, non-firearm-related, and total suicide among older adults, with a focus on GVRO laws.

METHODS

This is a longitudinal study of US states using data from 2012 to 2016. The outcome variables were firearm, non-firearm and total suicide rates among older adults. Predictor variables were [1] total number of gun laws to assess for impact of overall firearm legislation at the state level, and [2] GVRO laws.

RESULTS

The total number of firearm laws, as well as GVRO laws, were negatively associated with firearm-related suicide rate among older adults ages 55-64 and > 65 years-old (p < 0.001). There was a small but significant positive association of total number of firearm laws to non-firearm-related suicide rates and a negative association with total suicide rate. GVRO laws were not significantly associated with non-firearm-related suicide and were negatively associated with total suicide rate.

CONCLUSION

Stricter firearm legislation, as well as GVRO laws, are protective against firearm-relate suicides among older adults.