Associations between state gun policies and firearm-related deaths in the United States: A mixed-effects analysis from 2003 to 2022

22/01/2026

Surgery. 2026 Jan 20:109911. doi: 10.1016/j.surg.2025.109911. Online ahead of print.

ABSTRACT

BACKGROUND: Firearm-related deaths are prevalent in the United States, with the second greatest total recorded in 2022. Data associating handgun policies with firearm-related crude death rates by all intentions and crude suicide rates remain inconclusive. We aimed to identify associations between handgun policies and crude death rates and crude suicide rates over time.

METHODS: We queried the Centers for Disease Control and Prevention database for adult crude death rates and crude suicide rates in the United States and the Research and Development Firearm Database to identify state-specific handgun policies. We analyzed data from 2003 to 2022 using 2 mixed-effects models: crude death rates and crude suicide rates. Linear and quadratic interaction terms captured changes in policy effectiveness over time. Robust standard errors accounted for heteroscedasticity, improving estimate reliability.

RESULTS: Safety training requirements reduced crude death rates by 29.0% (P < .01), followed by possession restrictions (12.2%; P < .01), registration requirements (8.9%; P < .05), and tracing requirements (6.1%; P < .05). Permit requirements reduced crude suicide rates by 15.9% (P < .05), followed by extreme risk protection orders (6.7%; P < .001), untraceable firearms restrictions 5.9%; P < .05), tracing requirements (4.3%; P < .05), and trafficking policies (4.2%; P < .05). Preemption of local policies increased crude suicide rates by 9.8% (P < .01). The effect of tracing requirements increased from 2003-2022 for both crude death rates (6.1% to 30.6%; P < .01) and crude suicide rates (4.3% to 22.5%; P < .05). The effect of preemption of select local policies initially weakened from 2003-2012, (+12.2% to +9.7%), then strengthened to +15.3% in 2022 (P < .01).

CONCLUSION: Safety training, possession requirements, handgun registration, and tracing policies are associated with lower crude death rates. Permit requirements, extreme risk protection orders, untraceable firearm restrictions, tracing, and trafficking policies are associated with lower crude suicide rates. Implementation of these policies nationwide may reduce crude death rates and crude suicide rates.

PMID:41565543 | DOI:10.1016/j.surg.2025.109911

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