Evidence to Assess Potential Policy-Oriented Solutions for Reducing Adolescent Firearm Carriage

Firearm injuries are the second leading cause of death among US children and adolescents from age 1 through 19 years of age, responsible for 3400 deaths and an estimated 18 000 nonfatal injuries annually.^1,2  Since 2013, there has been an increase in firearm-related fatalities, with homicides and suicides increasing 37% and 48%, respectively.²  Mass school shootings, although responsible for a small amount of the overall firearm-related deaths, have also been increasing in frequency, with significant psychosocial and emotional impacts on families and surrounding communities.^3,4  Economic costs for the acute care of pediatric firearm injuries are substantial, rising in recent analyses to nearly $400 million annually, before factoring in the costs for long-term medical care, lost wages, and legal proceedings.⁵  As a result of such trends, there has been greater societal awareness about this public health problem, especially as parents and policy makers now recognize that inaction on firearm safety has contributed to a situation in which high school students are now more likely to die of a firearm injury than any other cause of death.² 

Despite research results demonstrating that firearm access and carriage are 2 of the most significant risk factors for pediatric firearm injuries,^6–16  there has been little progress in developing effective evidence-based countermeasures to address the ease of adolescent firearm availability. This is due in large part to a lack of federal firearm research funding since the Dickey amendment was introduced in 1996.^17,18  Although not an outright ban, the amendment added language to the Centers for Disease Control and Prevention appropriations bill stipulating that research funding could not “be used to advocate or promote gun control.” The annual renewal of this amendment has had a chilling impact on efforts to advance the science of firearm injury prevention through federally funded research, leading to a significant discrepancy between the overall disease burden and the scientific output needed to achieve progress in reducing child and adolescent firearm injury and death.^19–21 

In the current issue of Pediatrics, Timsina et al²²  begin to unravel some of the key questions underlying how firearms policies might work as effective countermeasures for adolescent firearm availability and carriage. Researchers analyzed cross-sectional data from the Youth Risk Behavior Survey collected biennially between 1993 and 2017 to examine whether the 1998 nationwide implementation of the National Instant Criminal Background Check System (NICS) was associated with reduced adolescent firearm carriage and whether that association varied by state laws extending background checks to private firearm sales (ie, whether states had either point-of-sale background check requirements for private firearm sales or permit-to-purchase licensing requirements for firearm sales). Although not finding a reduction in carriage associated solely with NICS implementation, researchers identified that the combination of the NICS system with state laws extending background checks to private sales resulted in an estimated 25% reduction in the absolute risk of adolescent firearm carriage. Given that a key mechanism underlying adolescent firearm acquisition is the diversion of firearms from legal to illegal channels (eg, straw purchases),^9,23  the authors argue that these policies have the potential to affect adolescent firearm availability and downstream injury-related outcomes.

Findings from the Timsina et al²²  study, although a valuable addition to the literature, must be considered in the context of several limitations. Youth Risk Behavior Survey data, although representative of a national sample of school-aged adolescents, are not necessarily representative of statewide samples in pooled analyses and fail to capture data on nonenrolled students (ie, adolescents with illegal firearm possession are less likely to be attending school)⁹ , an important consideration when analyzing state law impacts on firearm carriage. In addition, examining laws requiring point-of-sale background checks for private sales and permit-to-purchase licensing laws as a unified policy variable precludes individual examination of the different state-level policies, which in previous analyses have demonstrated differential associations with outcomes. In studies of permit-to-purchase licensing policies, researchers found they were associated with reductions in firearm suicides and homicides^24–27  but not intimate partner homicide.²⁸  Conversely, in studies of point-of-sale background checks for private sales, researchers have generally not identified decreases in firearm mortality,^28–31  although background checks for private sales have been associated with reductions in firearm diversion.^32,33  Finally, given that states may differentially implement policies, analyzing state-level implementation methods is an important consideration for future studies.³⁴ 

Despite such limitations, Timsina et al²²  should be commended for beginning to address a key research question in this field: how do current firearm policy initiatives directly affect pediatric-specific firearm outcomes?³⁵  Although available research has examined the effects of policies overall, such research remains in the nascent stages when considered in the context of pediatric injury prevention. More focus is needed on understanding the effectiveness and mechanisms by which state and federal policy initiatives may impact adolescent firearm acquisition and the downstream behaviors of firearm carriage and use. In addition to policy, foundational research is needed to understand the contextual factors surrounding adolescent firearm carriage (eg, motives underlying carriage) as well as large-scale trials to examine the efficacy of individual-level behavioral interventions applied in school, health care, and community settings. In a recent research agenda³⁶  published by the Eunice Kennedy Shriver National Institute of Child Health and Human Development–funded Firearm Safety Among Children and Teens Consortium, authors highlight these knowledge deficits regarding adolescent firearm behaviors and outline a series of research priorities to build on this work. Central to expanding this knowledge is the pressing need to continue to increase federal sources of research funding. The sound application of rigorous scientific and public health methods has achieved marked success in other disciplines of injury prevention (eg, motor vehicle crash deaths, drowning), and parallel investments to advance the science of firearm injury prevention have the potential to reverse current trends in child and adolescent firearm deaths.