Evidence-based solutions to pediatric firearm deaths: The need for out-of-the-box answers

Pediatric firearm injury and mortality is a matter of national concern. The pediatric firearm mortality rate has increased by approximately 30% over the past decade, largely due to increases in both firearm homicide and suicide. Currently, firearm injury is the second leading cause of death for American youth (age 1–19).¹

The majority of pediatric firearm injuries and deaths occur with firearm(s) obtained from the home.^2,3 Safer firearm storage practices may decrease pediatric firearm injury or mortality by decreasing unauthorized access by youth. Recent surveys suggest, however, that only three out of ten firearm-owning homes in which children reside store their firearms in the manner that is most likely to prevent pediatric unauthorized access (i.e., storing the firearm unloaded, with a locking device, separate from ammunition). The question of how to increase safe firearm storage is of great importance to a range of stakeholders, including pediatric clinicians, public health professionals, firearm owners, youth, and parents. Numerous strategies (e.g., education, economic incentives, or gun-safe engineering) could be used to motivate safer firearm storage. Policy changes, such as Child Access Prevention (CAP) laws, may be an important component of these efforts.

In this issue, Azad and colleagues make an important contribution to knowledge about the associations between CAP laws and pediatric firearm mortality. They conducted a methodologically rigorous state-level panel study to test the association of different types of CAP laws with firearm mortality among youth aged 0 to 14 years in the United States over 26-years (1991–2016). Previous research has examined the association of CAP laws with pediatric firearm injury and mortality in a less nuanced manner, often only testing the presence or absence of a CAP law without considering great variations between CAP laws among states. Some of the ways in which CAP laws vary from state to state likely increase or decrease the laws’ likelihood of impacting pediatric firearm mortality. Two previous studies categorized CAP laws according to whether they assign liability for storing a firearm in a way that a child could or does gain access to it (i.e., negligent storage laws) or liability only for providing a gun to a child (i.e., reckless provision laws).^4,5 Azad et al. go further, analyzing three common thresholds by which a CAP law specifies that negligent storage of a firearm can expose an individual to possible criminal liability: 1) if a child accesses and uses a gun that was negligently stored; 2) if a child accesses a gun that was negligently stored (whether or not it was used); and 3) if a firearm is stored in a way that a child could access it (regardless of whether they do). This nuanced examination of CAP laws can aid stakeholders and legislators in considering what the standards for possible criminal liability should be in the formulation or amendment of their own state CAP laws.

The study’s results suggest that CAP laws that provide criminal liability based on negligent storage of a gun, particularly those that stipulate the most conservative definition of negligent storage (i.e., whether a child could gain unauthorized access to a gun), are associated with the greatest reductions in pediatric firearm mortality. While the level of disaggregation of CAP law types varies between studies, these findings are consistent with those of similarly designed studies,^4,6–8 adding to the mounting evidence that suggests that these laws may be associated with a reduction in pediatric firearm mortality.

As is common for quasi-experimental designs, however, and as acknowledged by the authors, the internal validity of this study is threatened by selection bias. States that passed CAP laws likely differ in important ways from those that did not. Indeed, Azad et al.’s sensitivity tests suggest that two types of CAP laws were statistically associated with reductions in non-firearm pediatric deaths, as well as firearm deaths. Thus, confounding is likely at least partially responsible for the estimated associations of CAP laws with firearm deaths. It is possible that states that passed CAP laws invested in additional strategies that reduced pediatric injury and mortality. CAP laws may serve as a proxy for prioritization of a range of injury prevention efforts and broader social determinants of health. This finding does not obviate the potential impact of CAP laws – but it does highlight that laws do not exist in a cultural vacuum. Other factors, such as the broader sociopolitical context of a state, are important considerations when interpreting these findings.

We would have greater confidence in the estimated associations if the intervening mechanism through which CAP laws may be related to pediatric firearm mortality - namely, safer storage of guns - were found to be affected by these laws. However, the field lacks knowledge on the relationship between CAP laws and actual firearm storage; to our knowledge, only one cross-sectional study has investigated this relationship; finding that CAP laws were associated with actual safer storage only in states that had a greater number of firearm safety laws, such as those related to background checks and domestic violence.⁹ Research that rigorously tests the mechanism through which the association between CAP laws and firearm storage is enacted is needed.

But Azad et al.’s greatest impact may be in highlighting important next steps.

First, because many states’ CAP laws do not impose criminal liability for reckless provision or negligent storage of guns to youth above the age of 15, this analysis tells us little about how to protect youth age 15–19 – those who are at highest risk of firearm homicide and suicide. Azad et al.’s decision to exclude this age group was methodologically appropriate, as it assures that the population in the dependent variable is largely covered by CAP laws. An analysis focusing on the states whose CAP laws cover older adolescents (age 15–17) would be helpful; we also suspect that other strategies may be needed to reduce injury and death among older adolescents.

Second, the authors investigate associations between CAP laws and pediatric firearm mortality, but not the associations between CAP laws and pediatric firearm injury. In 2017, over 18,000 American youth survived a firearm injury.¹ These injuries have long-lasting physical, emotional, and economic sequelae for both children, their family, and their community.¹⁰ Unfortunately, a data source that provides systematic national-level surveillance data on pediatric firearm injuries does not currently exist,¹¹ limiting researchers’ ability to conduct this research.

Third, this study was conducted without research funding. We commend the authors on leveraging the natural experiments that state CAP laws offer. In order to move forward, however, we must as a nation invest in funding and data infrastructure related to firearm injury and mortality. Our country has made minimal investment in understanding how to promote firearm safety in such a way that is respectful of Second Amendment rights and also keeps youth safe.¹²

Fourth, we cannot overstate the importance of thoughtful coalition-building – particularly side-by-side with firearm owners and community groups - to help promote safer storage of guns. Implementation of any public health program, firearm or not, can be challenging.¹³ Efforts to reduce youth unauthorized access to firearms can be particularly politically charged. While nationally representative scientific opinion polls have found that the majority of firearm-owning Americans support CAP laws,¹⁴ the passage of a law is only one element in successful injury prevention. Firearm owners must be leading and trusted voices in all aspects of firearm injury and mortality prevention, as illustrated by our and others’ work.^15,16

In conclusion, we commend Azad and colleagues on a well-done study that enhances the evidence base on the association between policy strategies and pediatric firearm mortality. However, further work is needed to elucidate the laws’ mechanism of action and to unearth potential confounders of the observed effect. We hope to see future work that allows for a more nuanced understanding of what it means to store firearms safely, how people interpret CAP laws and carry them out in their home, and the mechanism through which CAP laws exert their potential effect. In addition to encouraging evidence-based policies, we must also work to change cultural norms around safe storage, reduce stigma in discussions of storage options, and create out-of-the-box solutions that reduce harm.¹⁷

Without this work, we will continue to have more questions than answers, and more American youth suffering preventable firearm injuries and deaths.