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Prevention of firearm-related injuries with restrictive licensing and concealed carry laws

An Eastern Association for the Surgery of Trauma systematic review

Crandall, Marie MD, MPH; Eastman, Alexander MD; Violano, Pina PhD, MSPH, RN-BC; Greene, Wendy MD; Allen, Steven MD; Block, Ernest MD; Christmas, Ashley Britton MD; Dennis, Andrew DO; Duncan, Thomas DO; Foster, Shannon MD; Goldberg, Stephanie MD; Hirsh, Michael MD; Joseph, D’Andrea MD; Lommel, Karen DO, MHA, MS; Pappas, Peter MD; Shillinglaw, William DO

Journal of Trauma and Acute Care Surgery: November 2016 - Volume 81 - Issue 5 - p 952–960
doi: 10.1097/TA.0000000000001251
Systematic Reviews
Editor's Choice
Press Release
EAST Journal Club

BACKGROUND In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the US Restrictive Licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons.

METHODS A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions.

RESULTS A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3,623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3,379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2.

CONCLUSION PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries.

PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries.

This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7% to 40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines.

LEVEL OF EVIDENCE Systematic review, level III.

From the University of Florida College of Medicine–Jacksonville, Department of Surgery, Jacksonville, Florida; University of Texas Southwestern Medical Center (A.E.), Department of Surgery, Dallas, Texas; Yale-New Haven Children's Hospital Injury Prevention Center (P.V.), New Haven, Connecticut; Emory University School of Medicine, Department of Surgery (W.G.), Atlanta, Georgia; Penn State Milton S. Hershey Medical Center, Department of Surgery (S.A), Hershey, Pennsylvania; University of Central Florida College of Medicine, Department of Surgery (E.B.), Orlando, Florida; Carolinas Health Care (A.B.C.) Department of Surgery, Charlotte, North Carolina; Cook County Hospital, Department of Trauma (A.D.), Chicago, Illinois; Ventura County Medical Center, Department of Surgery (T.D.), Ventura, California; University of Pennsylvania Reading Health System (S.F.) Department of Surgery, Reading, Pennsylvania; Virginia Commonwealth University (S.G.) Department of Surgery, Richmond, Virginia; University of Massachusetts (M.H.) Department of Surgery, Amherst, Massachusetts; University of Connecticut (D.J.) Department of Surgery, Hartford, Connecticut; University of Kentucky (K.L.) Department of Surgery, Lexington, Kentucky; University of Central Florida College of Medicine (P.P.) Department of Surgery, Orlando, Florida; and Mission Hospitals Asheville (W.S.) Department of Surgery, Asheville, North Carolina.

Submitted: August 8, 2016, Revised: August 14, 2016, Accepted: August 15, 2016, Published online: September 16, 2016.

Presentations: These data were presented at the Eastern Association for the Surgery of Trauma Annual Scientific Assembly in San Antonio, TX, January 2016.

Address for reprints: Marie Crandall, MD, MPH, FACS, University of Florida College of Medicine Jacksonville, 655W. 8th Street, Jacksonville, FL 32209; email:

© 2016 Lippincott Williams & Wilkins, Inc.