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Child Access Prevention Firearm Laws and Firearm Fatalities Among Children Aged 0 to 14 Years, 1991-2016 Open Access (recommended)


Resource type(s)
Masters Thesis
firearm fatalities
Attribution 4.0 International

Azad, Hooman Alexander
Monuteaux, Michael C.
Rees, Chris A.
Siegel, Michael
Mannix, Rebekah
Lee, Lois K.
Sheehan, Karen M
Fleegler, Eric W.
Public Health Relevance/Background: Firearm violence in the United States is a pressing public health issue. In children, firearm violence is less-often discussed, and there has been less research surrounding pediatric firearm fatalities compared to those in adults. Yet, there was a 38% increase in pediatric firearm fatalities from 2009 to 2016. Using a Haddon Matrix helps determine ways to curb firearm violence, and attempts to change the environment surrounding firearm storage are the cornerstone of firearm laws called Child Access Prevention (CAP) laws. Some pertain to adults giving firearms to children (recklessness laws), while others pertain to the improper storage of firearms in the home (negligence laws). Prior research on CAP laws has been lacking, given a small number of years after implementation of the laws, and only early post-implementation data. Understanding the effect of CAP laws on pediatric firearm fatalities in the United States is critically important in addressing injury prevention in children. Methods: This is a state-level, ecologic panel study using negative binomial regression to analyze differences in state pediatric firearm fatality rates performed on data from the United States on children ages 0-14 years between 1991 and 2016. The main exposure was implementation of two categories of state CAP laws: recklessness and negligence laws. Rates of firearm fatalities across all intents and by specific intent (homicide, suicide, unintentional) per 100,000 children ages 0-14 years was the primary outcome. A population-attributable fraction was calculated with respect to any negligence law and the most stringent form of negligence law. Results: Twenty-five states passed CAP laws between 1989 and 2000. Over the 26-year period, there were 13,967 firearm fatalities in children ages 0-14 years old. Recklessness laws were not associated with changes in pediatric firearm fatality rates. Negligence laws were associated with significant reductions in firearm fatalities in children 0-14 years old. Negligence laws were associated with a 13% reduction in all firearm fatalities (95% CI -18%, -7%), a 15% reduction in firearm homicides (95% CI -22%, -7%), a 12% reduction in firearm suicides (95% CI -20%, -2%), and a 13% reduction in unintentional firearm fatalities (95% CI -24%, -1%). The most stringent negligence laws were associated with unintentional firearm fatality reductions of 59% (95% CI -68%, -49%). 3,929 deaths (29% of all firearm deaths) could be attributed to states not having passed the most stringent form of negligence CAP laws. Discussion: Our study showed that recklessness laws were not associated with differences in firearm fatality rates, but that negligence laws were associated with lower overall rates of firearm fatalities, and lower rates of firearm homicides, suicides, and unintentional deaths. More stringent negligence laws were associated with larger reductions in fatality rate. Importantly, our study showed a reduction in pediatric firearm homicides with negligence CAP laws, the first study to show such a finding. Applying the Bradford-Hill criteria of causality to the existing evidence shows that the relationship between CAP laws and reduced pediatric firearm mortality has evidence for strength, biological gradient, specificity, consistency, and analogy, all of which argue in favor of a causal relationship. However, this is an observational study and we cannot determine causality from this form of study. A population-attributable fraction implied that up to 3,929 pediatric firearm fatalities could have been avoided with the passage of the strongest form of negligence law in all 50 states.
Original Bibliographic Citation
Azad HA, Monuteaux MC, Rees CA, et al. Child Access Prevention Firearm Laws and Firearm Fatalities Among Children Aged 0 to 14 Years, 1991-2016. JAMA Pediatr. 2020;174(5):463469. doi:10.1001/jamapediatrics.2019.6227
Related URL
DigitalHub. Galter Health Sciences Library & Learning Center
Date Created
Original Identifier
Subject: MESH
Child Mortality
Infant Mortality

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