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State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United StatesA Cross-sectional Analysis of Data by County

Educational Objective
To determine whether counties located closer to states with lenient firearm policies have higher firearm death rates.
1 Credit CME
Key Points

Question  Are state firearm laws associated with increases in interstate firearm deaths from homicide and suicide?

Findings  In this cross-sectional study, strong firearm laws in a state were associated with lower firearm suicide rates and lower overall suicide rates in the state regardless of the strength of the laws in other states. Strong firearm laws in a state were associated with lower rates of firearm homicide. Counties in states with weak laws had lower rates of firearm homicide only when surrounding states had strong laws.

Meaning  Strengthening firearm policies at the state level could help to reduce the incidence of both firearm suicide and homicide, with benefits that extend across state lines.


Importance  Firearm laws in one state may be associated with increased firearm death rates from homicide and suicide in neighboring states.

Objective  To determine whether counties located closer to states with lenient firearm policies have higher firearm death rates.

Design, Setting, and Participants  This cross-sectional study of firearm death rates by county for January 2010 to December 2014 examined data from the US Centers for Disease Control and Prevention for firearm suicide and homicide decedents for 3108 counties in the 48 contiguous states of the United States.

Exposures  Each county was assigned 2 scores, a state policy score (range, 0-12) based on the strength of its state firearm laws, and an interstate policy score (range, −1.33 to 8.31) based on the sum of population-weighted and distance-decayed policy scores for all other states. Counties were divided into those with low, medium, and high home state and interstate policy scores.

Main Outcomes and Measures  County-level rates of firearm, nonfirearm, and total homicide and suicide. With multilevel Bayesian spatial Poisson models, we generated incidence rate ratios (IRR) comparing incidence rates between each group of counties and the reference group, counties with high home state and high interstate policy scores.

Results  Stronger firearm laws in a state were associated with lower firearm suicide rates and lower overall suicide rates regardless of the strength of the other states’ laws. Counties with low state scores had the highest rates of firearm suicide. Rates were similar across levels of interstate policy score (low: IRR, 1.34; 95% credible interval [CI], 1.11-1.65; medium: IRR, 1.36, (95% CI, 1.15-1.65; and high: IRR, 1.43; 95% CI, 1.20-1.73). Counties with low state and low or medium interstate policy scores had the highest rates of firearm homicide. Counties with low home state and interstate scores had higher firearm homicide rates (IRR, 1.38; 95% CI, 1.02-1.88) and overall homicide rates (IRR, 1.32; 95% CI, 1.03-1.67). Counties in states with low firearm policy scores had lower rates of firearm homicide only if the interstate firearm policy score was high.

Conclusions and Relevance  Strong state firearm policies were associated with lower suicide rates regardless of other states’ laws. Strong policies were associated with lower homicide rates, and strong interstate policies were also associated with lower homicide rates, where home state policies were permissive. Strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that may extend beyond state lines.

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Article Information

Corresponding Author: Elinore J. Kaufman, MD, MSHP, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065 (

Accepted for Publication: January 9, 2018.

Correction: This article was corrected on March 12, 2018, for a typographical error in the Importance paragraph in the abstract.

Published Online: March 5, 2018. doi:10.1001/jamainternmed.2018.0190

Author Contributions: Dr Kaufman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kaufman.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kaufman, Morrison.

Obtained funding: Branas.

Administrative, technical, or material support: Morrison, Branas, Wiebe.

Study supervision: Branas, Wiebe.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Morrison was supported by a grant from the National Center for Injury Control and Prevention, Centers for Disease Control and Prevention (grant No. R49CE002474).

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors thank Jon Vernick, JD, of Johns Hopkins Bloomberg School of Public Health for his input on the components of the policy score; Dr Vernick was not compensated.

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