Discussion
Children and adolescents in the USA are at a greater risk of death from firearm-related injury than cancer, congenital abnormalities, pneumonia, or the influenza.1 In 2016, 43% (1101/2506) of suicides reported among young people were by firearms. Similarly, of the 2441 who were killed in 2016, 75% were by firearms.1 Due in part to unsafe storage, firearm thefts surpass 350 000 per year.19 The American Academy of Pediatrics recommends that parents store firearms, unloaded, in a separate location than ammunition and under lock and key20; yet, estimates suggest that these recommendations are followed by a small proportion of gun-owning parents, estimates ranging from 30% to 46%.21 22
As a method of suicide reduction, previous research offers some evidence on CAP legislations’ effectiveness.23 This conclusion was drawn mainly from a study done by Webster et al24 where they found a statistically significant decrease in suicides among children aged 14–17 in states that had CAP legislation. Similarly, Cummings et al12 reported a decline in youth suicides after CAP implementation. Taken together, these studies suggest that adoption of CAP legislation may reduce firearm suicide rates, but neither of these studies accounted for the language of CAP legislation.
CAP legislation may also reduce the rates of firearm-related injuries, including death.23 Using hospital admission data, DeSimone et al13 found a statistically significant reduction in all non-fatal gun injuries in states with CAP legislation. As another example, Schell et al25 estimated that if CAP legislations were implemented in all US states, within 6 years, there would be over 2500 fewer firearm-related deaths nationally than if no states had CAP laws.14 Similarly, Webster and Starnes26 stratified legislation by comparing states with felony CAP laws to misdemeanors and found statistically significant reduction in unintentional firearm deaths for children under age 14 in felony states, but the difference was not significant in misdemeanor states. The investigation by Webster and Starnes 26 is significant because it illustrated the importance of legislative stringency. Our results are consistent with Webster et al despite the different legal stratification criteria. Azad et al found that states with CAP legislation based on negligence had a 13% relative reduction in firearm fatalities, for children aged 0–14. They also found that from 1991 to 2016, approximately 3929 deaths were attributed to states not passing the most stringent form of CAP legislation.27
Our study has taken a nuanced approach to the analyses of CAP legislation. Results suggest a significant lower count of firearm injuries among states that have strong CAP legislation compared with states without CAP legislation, and the evidence presented highlights the importance of legal language in CAP legislations. Model 1 suggests that rates of firearm injuries in states with CAP legislation are 1% lower than states with no CAP legislation. Our data also suggest (model 2) that rates of firearm injuries per capita in states with strong or weak CAP legislation are lower than those in states with no CAP legislation. These findings mirror the previous work by Hamilton et al28 and DeSimone and colleagues.13 Both of these studies found a decrease in pediatric injury rates in states that had implemented CAP legislation, and concluded that CAP legislation might have an impact on pediatric firearm-related injury rates. The present study contributes to this literature by presenting additional evidence that strongly crafted CAP legislation is associated with lower pediatric firearm-related injury counts. Collectively, this evidence could guide further legislation at the state and federal levels.
There are several limitations to our study. The WISQARS data set is evolving, and data from all 50 states were not available. As the data set matures and as additional data become available, a more detailed and representative analysis will be possible, including an analysis of changes across time. Our results demonstrate an association between strong CAP legislation and lower pediatric injury rates, but our results do not establish a causal relationship. Furthermore, we do not account for other social factors that are known to influence crime and injury rates, such as state poverty levels, crime indices, neighborhood racial marginalization, policing and structural racism. Some of these state-level data are available in the US Social Explorer via census tracks; however, our data are based on state level and we cannot accurately pinpoint firearm injury location to match with census track data. Therefore, rather than enhancing our analyses, the use of census-derived data in combination with our state-level data would not have been appropriate.
Legislative measures are designed to influence human behavior, including implementation by law enforcement. Our study, however, did not evaluate CAP enforcement and it does not measure or account for enforcement irregularities. Some states that enact strong CAP legislation generally have a stronger firearm legislation. The individual and cumulative impacts of other types of firearm laws need to be evaluated as well.
Some of the limitations noted have been reported by other researchers.13 26 28 Decreases in research funding and legislation, such as the Dickey Amendment, a provision put in place in a 1996 federal spending omnibus,29 make studying US firearm-related morbidity and mortality difficult. The initial intent of the Dickey Amendment was to prevent the use of federal funding to advocate or promote gun control policies through the CDC, but the Amendment has resulted in the limitation of federal funding of virtually all firearm-related research through the CDC.30 Prior to 2020, firearm-related research received $2 million per year in federal funding, as opposed to cancer research, which received $4 billion per year. This amounts to only $2.70 per year of life loss and to pennies per injury.31 In March 2018, a memo from then Health and Human Services Secretary, Alex Azar, accompanied the 2018 spending bill. Although the Dickey Amendment was still present in the spending bill, ‘the CDC has the authority to conduct research on the causes of gun violence’.32 The authors hope that future studies of firearm-related research can receive increased federal attention and support.
The future holds promise. In December 2019, for the first time in over 20 years, the federal government allocated $25 million split evenly between the CDC and the National Institutes of Health for gun violence research.33 Support from medical professional associations has also gained visibility. The American Academy of Pediatrics34 and the Pediatric Trauma Society,35 for example, support the implementation of CAP legislation, and the Society of Adolescent Medicine supports increased research into CAP legislation.36 CAP legislation, however, is only one piece of the public health concern to reduce harm. Other measures, such as universal background checks, assault weapon bans, high-capacity magazine restrictions, and minimum purchase age policies, also can be used. These restrictions and policies also should be diligently studied with careful attention to language and legislative strength. As has been shown, language matters, and it is a relevant and influential factor to consider in research. Legislation alone will not be sufficient in reducing firearm injuries and death. The American Pediatric Surgical Association has recommended a multidimensional approach, and points to American success in reducing motor vehicle fatalities using a combination of ‘prevention, design, policy behavior and trauma care’.37
CAP legislation is not a cure-all for the problems Americans face regarding gun injuries, but as our work and previous work have shown, CAP legislation can be a piece of the puzzle. By limiting the access that minors have to guns, strong CAP legislation could decrease firearm injuries of minors.
In conclusion, data show that states that have legal liability for safe gun storage based on negligence report lower firearm injury rates for minors than states with no CAP legislation or those with liability relying on intentional or reckless storage. Additional data and studies are needed to assess the effectiveness and implementation of CAP legislation.