Discussion
There has been a significant shift in the USA with respect to the cause of trauma-related deaths as well as the epidemiology of populations affected. Death due to trauma yields a higher YPLL than most other causes of mortality as trauma patients are typically younger at time of death.1 Although the predominant cause of YPLL due to trauma deaths was previously attributed to MVC, the paradigm has shifted as we now see that firearms are the leading cause of YPLL since 2017. Although the total number of deaths in the black male population due to firearm homicide was significantly less than the total number of white male suicides during the study period (63 414 vs 170 388), the younger age of these black male homicide victims increases the overall YPLL. For each death, on average, black male homicides accounted for 50.5 YPLL, whereas white male suicides accounted for 29.1 YPLL.
Previous studies have shown that firearm ownership, mass shootings, injuries, and death are more of a problem in the USA as compared with other developed countries.3 Of more than 1 billion estimated firearms worldwide, 85% of the firearms are in civilian hands, whereas only 13% are in military arsenals.4 The USA alone is estimated to have 393.3 million firearms compared with 16.8 million in Mexico and 12.7 million in Canada.4 These numbers, however, may grossly underestimate the number of firearms as these are estimates and there is a significant number of unregistered firearms, many of which are acquired through illegal trafficking.5 6
Although the WHO states that suicides are preventable, it is not realistic that all suicides are preventable.7 The cause of suicide is multifactorial with mental illness often playing a major role in victims. Studies have shown that major depressive disorders are present in approximately 50% of the suicide victims, and that financial, relationship, and other outside stressors are frequently present in these individuals.8 These stress-inducing variables of life can accumulate, with many elderly adults reporting feelings of loneliness and isolation.9 Loss of a job or retirement with subsequent reliance on social security income has been cited as a major stressor in older adults as the loss of financial resources causes individuals to perceive themselves as a burden to family members and society.10 This is further compounded in individuals who identify themselves as their job, as the loss of their job further exacerbates lack of kinship and inclusion.10 The availability of firearms makes the impulsive behavior somewhat less reversible, and the effectiveness of firearms makes the attempts often successful. Studies investigating fatality rate by suicide method reveal that firearms are 89.6% effective compared with other methods of suicide.11 12 Up to 70% of suicides are based on impulsive behavior and suicide attempts are typically made after less than 3 hours of contemplation.12
Regionally, the South had the highest number of firearm deaths with 157 907 deaths during the 10-year period, whereas the Northeast had the lowest number of firearm deaths with 35 789 (figure 8). All regions had a higher total number of firearm deaths related to firearm suicide as opposed to homicide; however, despite 6856 more suicide deaths in the Northeast, the YPLL was higher for firearm homicides compared with suicides (700 639 YPLL vs 612 598 YPLL). The Bureau of Alcohol, Tobacco, Firearms, and Explosives releases an annual statistical update regarding firearms commerce in the USA which has consistently revealed that the Southern region of the USA has the most number of registered firearms.13 In 2018, there were over 3 million registered firearms in the South, with Texas and Florida as the two states with the highest number of registrations in the USA. Although the number of firearms within a state or region will not fully predict suicide, homicide, or violent crime rates, availability of firearms should be taken into account when discussing trauma and injury prevention strategies.
Figure 8YPLL by region, 2009–2018. YPLL, years of potential life lost.
The demand for total freedom and the second amendment have resulted in high access to firearms in this country and this is undisputable. The main argument is that the right to bear arms to prevent injury or to defend against aggressors may result in a small number of preventable deaths is a plausible theory, however, the data reveal that the resulting access to firearms has equated to magnitudes of death due to firearm suicides in the same individuals demanding access to firearms. Effective suicide prevention efforts should include limiting access to all methods of suicide—including firearms—for at-risk populations.
Limitations
Within the CDC WISQARS database, firearm deaths are currently only categorized into three different mechanisms: homicide, suicide, and legal firearm interventions. The legal firearm interventions remained constant throughout the study period and were not statistically significant in comparison with the YPLL secondary to homicide and suicide; therefore, it was only briefly mentioned in our article. Although the data obtained for this study are publicly available through the CDC website, there has been no previous systematic analysis and presentation of these data as has been performed in this study. This study summarizes the available data and therefore cannot fully determine the etiology behind the changes in YPLL caused by firearms without demonstrating bias.
