Impact on Nonfirearm Deaths of Firearm Laws Affecting Firearm Deaths: A Systematic Review and Meta-Analysis

Background. There is debate whether policies that reduce firearm suicides or homicides are offset by increases in non–firearm-related deaths. Objectives. To assess the extent to which changes in firearm homicides and suicides following implementation of various gun laws affect nonfirearm homicides and suicides. Search Methods. We performed a literature search on 13 databases for studies published between 1995 and October 31, 2018 (PROSPERO CRD42019120105). Selection Criteria. We included studies if they (1) estimated an effect of 1 of 18 included classes of gun policy on firearm homicides or suicides, (2) included a control group or comparison group and evaluated time series data to establish that policies preceded their purported effects, and (3) provided estimated effects of the policy and inferential statistics for either total or nonfirearm homicides or suicides. Data Collection and Analysis. We extracted data from each study, including study timeframe, population, and statistical methods, as well as point estimates and inferential statistics for the effects of firearm policies on firearm deaths as well as either nonfirearm or overall deaths. We assessed quality at the estimate (study–policy–outcome) level by using prespecified criteria to evaluate the validity of inference and causal identification. For each estimate, we derived the mortality multiplier (i.e., the ratio of the policy’s effect on total homicides or suicides; expressed as a change in the number of deaths) as a proportion of its effect on firearm homicides or suicides. Finally, we performed a meta-analysis to estimate overall mortality multipliers for suicide and homicide that account for both within- and between-study heterogeneity. Main Results. We identified 16 eligible studies (study timeframes spanning 1977–2015). All examined state-level policies in the United States, with most estimating effects of multiple policies, yielding 60 separate estimates of the mortality multiplier. From these, we estimated that a firearm law’s effect on homicide, expressed as a change in the number of total homicide deaths, is 0.99 (95% confidence interval = 0.76, 1.22) times its effect on the number of firearm homicides. Thus, on average, changes in the number of firearm homicides caused by gun policies are neither offset nor compounded by second-order effects on nonfirearm homicides. There is insufficient evidence in the existing literature on suicide to indicate the extent to which the effects of gun