Mortality Trends in Gunshot and Firearm-related Assault Victims: A CDC Wonder Database Analysis from 1999 to 2020

Mortality Trends in Gunshot and Firearm-related Assault Victims: A CDC Wonder Database Analysis from 1999 to 2020 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mortality Trends in Gunshot and Firearm-related Assault Victims: A CDC Wonder Database Analysis from 1999 to 2020 Fatima Kaleem Ahmed, Amna Kaleem Ahmed, Moiz- Ul-Haq Hashmi, Laibah Arshad Khan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6574590/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Firearm violence in the U.S.A. is an epidemic that is rapidly spreading, with a 25-fold higher rate of firearm homicides among comparable developed countries. Methods: Death certificates from the CDC WONDER for Epidemiologic Research database were examined from 1999 to 2020 for firearm-related mortality. The AAMR per 100,000 persons and the APC were calculated and stratified by year, sex, race/ethnicity, and geographic region. Results: The AAMR for men decreased from 7.1 in 1999 to 6.4 in 2014 (APC: -0.75; 95% CI: -2.5-0.2), after which it increased to 10.9 in 2020 (APC: 6.6; 95% CI: 3.3-15.3). Men had consistently higher AAMRs than women did: from 1999 (AAMR men: 7.1 vs. women: 1.5) to 2020 (AAMR men: 10.9 vs. women: 1.9). African American individuals had the highest overall AAMR (16.4), followed by American Indian/Alaskan Native (3.5), White (2.4), and Asian/Pacific Islander individuals, who had the lowest AAMR of 1.3. Discussion: Men are biologically predisposed to displaying hostile conduct and are more likely to express overt physical aggression. Black communities disproportionately impacted by poverty and unemployment often serve as perfect breeding grounds for crime, where interpersonal conflicts are more likely to escalate into violent encounters, contributing to increased gun-related crime. The consumption of violent media such as arcade games involving firearms has been at an all-time high level in the last decade and can be linked to more gun-related deaths. The hysteria surrounding the COVID-19 pandemic, socioeconomic chaos, and mental health conditions led to an exponential rise. firearm assault homicide mortality Background Firearm violence in the United States is spreading rapidly across the nation. From 2006 to 2014, more than 700,000 emergency department (ED) visits in the United States were related to firearm violence. [1] The burden of fatal firearm injuries varies significantly across states and racial or ethnic groups, with black individuals experiencing higher rates than white individuals do. Mortality from firearm violence is particularly pronounced among those aged 17–25 years, accounting for up to 80% of all homicides and 45% of all suicides within this age group. [2] The United States has the highest rate of firearm homicides among developed nations, with a rate 25 times higher than that of comparable countries such as Australia, Austria, Belgium, and Canada. Over the past decade, 82% of all firearm-related deaths in high-income countries have occurred in the United States. [3] Remarkably, the rates of firearm fatalities have recently surpassed those of motor vehicle fatalities. The direct and indirect costs of firearm violence in the U.S. are estimated at $ 229 billion annually. [4] Hospital readmissions are a significant contributor to the long-term healthcare costs associated with firearm-related injuries. [5] These costs are particularly influenced by state-specific firearm policies, which often have effects that spill over into neighboring states. [6] The goal of this study was to evaluate trends in firearm-related mortality across different demographic groups in the United States, including gender, race, and geographical regions. The Centers for Disease Control and Prevention (CDC) categorizes firearm-related injuries into several groups: intentionally self-inflicted injuries (such as suicide and nonfatal self-harm), unintentional injuries (accidental discharges during handling or play), interpersonal violence (including firearm homicides and assaults), legal interventions (injuries resulting from law enforcement actions), and injuries of undetermined intent. [7] In this research, we concentrate on all categories except self-inflicted injuries. Materials and methods Study setting and population In this descriptive study, data from death certificates were retrieved from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging ONline Data for Epidemiologic Research) database and examined from 1999 to 2020 for Firearm-related mortality in people of all ages via the following codes from the International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10: W32, W33, W34, X93, X94, X95, Y22, Y23, and Y24. The ICD codes mentioned above have previously been used to identify firearm-related injuries. [8][9] This dataset includes causes of death from death certificates for the 50 states and the District of Columbia and has been previously used in studies to determine trends in mortality due to firearms. Multiple cause-of-death public use record death certificates were studied to select firearm-related deaths, which were identified as those with firearms reported anywhere on the death certification either as contributing or underlying causes of death. This study was exempt from local institutional review board approval because it used a de-identified government-issued public use dataset and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting. Data abstraction Data for year, demographics, region, and states were extracted. Demographics included sex, age, and race/ethnicity. Race/ethnicity was classified as non-Hispanic (NH) White, NH Black or African American, Hispanic or Latino, NH American Indian or Alaskan Native, and NH Asian or Pacific Islander. This information relies on reported data on death certificates and has been used in previous analyses of the WONDER database. [10] Regions were classified into Northeast, Midwest, South, and West Regions according to the U.S. Census Bureau definitions. [11] Statistical analysis National trends in Firearm-related mortality were examined by calculating crude and age-adjusted mortality rates (AAMRs) per 100,000 populations from 1999 to 2020 by year, sex, race/ethnicity, state, and region with 95% CIs. Crude mortality rates were determined by dividing the number of Firearm-related deaths by the corresponding U.S. population of that year. AAMRs were calculated by standardizing Firearm-related deaths to the year 2000 U.S. population. To quantify national annual trends in Firearm-related mortality, the Joinpoint Regression Program (Joinpoint Regression Program, Version 5.2.0.0) was used to determine the annual percent change (APC) with 95% CI in the AAMR. This method identifies significant changes in the AAMR over time by fitting log-linear regression models where temporal variation occurs. APCs were considered increasing or decreasing if the slope describing the change in mortality was significantly different from zero via 2-tailed t-tests. A value of P < 0.05 was considered statistically significant. Results Annual trends for the Firearm-related AAMR A total of 278,505 firearm-related deaths occurred among all ages between 1999 and 2020. The AAMR in 1999 was 4.27, with a steady decline until 2014 to an AAMR of 3.79 and an APC of -0.750 (95% CI: -2.31-0.19). There was a subsequent increase in the AAMR to 6.51, with an APC of 6.51 (95% CI: 3.28–14.20). [Supplementary Tables 1, 2, and 3] [Supplementary Fig. 1] Firearm-related AAMR stratified by sex The AAMR for firearm-related deaths in men was 7.08 in 1999 and 10.94 in 2020. The overall AAMR declined from 1999 to 2014 (APC: −0.75; 95% CI: −2.48 − 0.24), followed by an increase from 2014 to 2020 (APC: 6.56; 95% CI: 3.25–15.27). The AAMR for firearm-related deaths in females was 1.45 in 1999, declined to 1.19 in 2014 (APC: -0.96; 95% CI: -1.69- -0.36), and then increased to 1.95 in 2020 (APC: 6.66; 95% CI: 4.54–10.13). Men had consistently higher AAMRs than women did: from 1999 (AAMR men: 7.1 vs. women: 1.5) to 2020 (AAMR men: 10.9 vs. women: 1.9). [Supplementary Tables 1, 2, and 3] [Supplementary Fig. 1] Firearm-related AAMR stratified by ethnicity The AAMR for the Hispanic population steadily declined from 5.28 in 1999 to 5.05 in 2006 (APC: −0.37; 95% CI: −2.13–3.19), followed by a steep decline to 3.16 in 2013 (APC: −7.11; 95% CI: −12.97 to − 5.18), which was followed by an increase to an AAMR of 4.76 until the end of the study period (APC: 5.49; 95% CI: 3.37–8.36). The AAMR for non-Hispanic individuals followed a steady rate from 4.09 in 1999 to 3.95 in 2014 (APC − 0.12; 95% CI:-1.26-0.75), followed by a sharp increase in the AAMR to 6.93 in 2020 (APC 7.41; 95% CI: 4.67–14.96). [Supplementary Tables 1, 2, and 4] [Supplementary Fig. 2] Firearm-related AAMR stratified by race In 1999, African American individuals had the highest overall AAMR (14.98), followed by American Indian/Alaskan Native (4.17), White (2.55), and Asian/Pacific Islander individuals, who had the lowest AAMR of 1.95. In 2020, the racial trends were in a similar order, with African American individuals having the highest overall AAMR (25.5), followed by American Indian/Alaskan Native (5.47), White (3.13), and Asian/Pacific Islander individuals having the lowest AAMR of 1.16. In descending order of APC, African American had an APC of 1.67 (95% CI: 0.81–2.48), Americans Indian had an APC of 1.58 (95% CI: 0.85–2.41), and whites had an APC of 0.58 (95% CI: 0.17–1.10). Asian was the only race with an overall negative APC of -2.24 (95% CI: -3.20 to -0.83). [Supplementary Tables 1, 5, and 6] [Supplementary Fig. 3] Firearm-related AAMR stratified by geographic region On average, over the course of the study period, the highest mortality was observed in the southern region (AAMR: 5.73; 95% CI: 5.70–5.76), followed by the mid-western region (AAMR: 4.37; 95% CI: 4.34–4.41), the western region (AAMR: 3.69; 95% CI: 3.66–3.72), and the northeastern region (AAMR: 2.89; 95% CI: 2.86–2.92). A significant difference in the AAMR was observed in different states, with the lowest AAMR in Massachusetts of 1.99 (95% CI: 1.65–2.33), and the highest in District of Columbia at AAMR of 20.44 (95% CI: 17.12–23.75). [Supplementary Tables 7 and 8] [Supplementary Figs. 4 and 5] Discussion We comprehensively examined firearm-related mortality trends in the United States from 1999 to 2020, focusing particularly on gender, racial, and geographic variations. Our findings reveal a disturbing landscape of gun-related mortality rates, marked by a significant increase in recent years, especially since 2014. This trend emphasizes the complex interaction of socioeconomic, cultural, and policy factors driving gun violence in the country. During the 2000s and early 2010s, many U.S. cities implemented stronger law enforcement and crime prevention strategies, including community policing and focused deterrence, which may have contributed to the decrease in firearm-related deaths during this era. [12] The sharp rise in firearm-related deaths after 2014 can be linked to worsening economic deprivation and socioeconomic conditions, particularly in the aftermath of the Great Recession (2007–2009). Communities disproportionately impacted by poverty and unemployment often serve as perfect breeding grounds for crime, where interpersonal conflicts are more likely to escalate into violent encounters, contributing to increased gun-related crime. [13] The consumption of violent media such as arcade games involving firearms has been at an all-time high in the last decade. This can be linked to the varied attitudes toward firearms in real-world scenarios and, hence, more gun-related deaths. [14] When this trend increased between 2019 and 2020, the COVID-19 pandemic was an inevitable factor. The global hysteria surrounding the pandemic, socioeconomic chaos, and ever-increasing death tolls had substantial effects on human psychology and society as a whole. This social disarray led to a higher prevalence of mental health conditions. These statistics explain why more people are likely to experience feelings of mistrust and frustration. [15] These emotions serve as a prerequisite in the setting stage for crime and violence. Consequently, this period was marked by record-high firearm purchases and incidents of gun violence, such as mass shootings, across the United States, and hence, a greater number of deaths attributable to firearms. [16] When the data on firearm-related deaths were analyzed for sex variations, we observed that the number of deaths among males was significantly greater than that among women. This can be attributed to the fact that men are biologically predisposed to displaying hostile conduct and are more likely to express overt physical aggression. [17] The involvement of men in crime syndicates is far more common than the opposite sex; in addition, gang males are more frequently involved in crime and victimization than gang females are. [18] To make matters worse, societal norms and traditional notions of masculinity emphasize toughness and competitiveness in males, potentially leading to greater engagement of men in violent firearm-related crimes, either as victims or perpetrators. [19] All of these factors adequately explain why males constitute a greater proportion of deaths linked with firearms. The findings of the study underscore long-standing and substantial racial inequalities in firearm lethality. African Americans remain the most affected by gun violence, as evidenced by higher mortality rates by a considerable margin. The rise in AAMRs among African Americans could be attributed to socioeconomic disparities and racism. [13][20] A 2020 study revealed that black Americans were three times more likely to be shot by police than their white counterparts were. [21] Furthermore, African American youth are exposed to areas with substantially higher levels of violence. Proximity to violence inevitably exposes them to gun-related crimes and possibly explains the high prevalence of firearm-related deaths in this ethnicity. [22] The data also present trends in which firearm mortality rates were higher among American Indian and Alaskan Native populations as well as Whites but not to the same extent as those of the African American population. On the other hand, a decrease in AAMRs among Asians and Pacific Islanders suggests that this category of people is less vulnerable to firearm deaths, given cultural reasons, stronger family systems, less adoption of firearms, and their settlement in areas with fewer gun-friendly laws. [23] The mortality rate of the Hispanic population initially decreased but then rapidly increased toward the end of the study period. The age-adjusted mortality rates (AAMRs) for firearms in the United States exhibit geographical variability that is influenced by gun law differences, cultural attitudes, and socioeconomic factors. In states such as Mississippi, Louisiana, and Alabama which have the highest AAMRs, more permissive gun laws, including fewer restrictions on ownership and carrying, are observed. In these states, there may be weaker background check systems, less stringent storage rules, and lenient conceal carry regulations, all of which contribute to the increased mortality rates associated with guns. [23] Conversely, some states, such as Massachusetts, Idaho, or Utah, generally enforce strict measures against arms. Research has consistently established links between stringent arms legislation and reduced fatalities due to guns, suggesting that legal frameworks are responsible for spatial inequalities. [24] Cultural attitudes toward firearms also significantly influence these trends. In southern states where higher mortality rates occur among gun users, there is a strong cultural emphasis on private ownership of weapons for personal protection purposes or on hunting, which leads to an increase in individuals who possess guns as well as their application. The Northeast Region, meanwhile, has a low rate of AAMRs, reflecting a less significant acceptance of guns within its society. Furthermore, southern states often face a higher level of poverty and lower access to healthcare and education, [25] conditions that can exacerbate frustration and increase the likelihood of a higher prevalence of crime and firearm-related deaths. The complex interplay of legal, cultural, and economic factors helps explain the pronounced regional differences in firearm-related mortality across the United States. Conclusion In conclusion, this study highlights a troubling increase in firearm-related mortality rates in the United States from 1999 to 2020, particularly since 2014. The rising trends in firearm-related deaths reflect a complex interplay of socioeconomic, cultural, and policy factors. Men consistently experience higher mortality rates than women do, driven by biological predispositions and societal norms. Racial disparities constitute one of the most stark factors, with African Americans facing the highest mortality rates, reflecting broader socioeconomic inequalities and systemic issues. The geographic variability in firearm-related deaths underscores the significant impact of state-specific gun laws, cultural attitudes toward firearms, and socioeconomic conditions. States with more permissive gun laws and higher poverty rates have been shown to report higher mortality rates, whereas those with stricter regulations and better socioeconomic conditions have lower rates. These findings emphasize the need for targeted interventions that address both the immediate and underlying causes of firearm violence; some of these interventions include implementing stricter gun control measures, socioeconomic support, and community-based strategies to reduce gun violence and its devastating impact across diverse demographics and regions. Statements and declarations Availability of data and material: Publicly available data were used, the sources of which are included in the reference list of this article. Conflict of interest disclosure: On behalf of all authors, the corresponding author states that there is no conflict of interest. Funding: The authors declare that no funds, grants, or other support was received during the preparation of this manuscript. Clinical trial number : not applicable. Ethics, Consent to Participate, and Consent to Publish declarations: not applicable. Credit author statement: F.K.A. conceptualized the study, supervised the process, and conducted the CDC website analysis. A.K.A. worked on the methodology and did the JoinPoint analysis. M.U.H.H. did the graphic representation of data and proofread the manuscript. L.A.K. was involved in the proofreading of the manuscript. A.K., R.F.S., O.K.A., & R.R. were involved in the main manuscript writing. References Walker GN, Dekker AM, Hampton DA, Akhetuamhen A, Moore PQ. A Case for Risk Stratification in Survivors of Firearm and Interpersonal Violence in the Urban Environment. West J Emerg Med. 2020 Oct 16;21(6):132-140. doi: 10.5811/westjem.2020.8.45041. PMID: 33207158; PMCID: PMC7673864. Kalesan B, Mobily ME, Keiser O, Fagan JA, Galea S. Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study. Lancet. 2016 Apr 30;387(10030):1847-55. doi: 10.1016/S0140-6736(15)01026-0. Epub 2016 Mar 11. PMID: 26972843. Grinshteyn E, Hemenway D. 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The Annals of the American Academy of Political and Social Science , 669 (1), 41–62. https://doi.org/10.1177/0002716216678167 Michael Siegel, Molly Pahn, Ziming Xuan, Craig S. Ross, Sandro Galea, Bindu Kalesan, Eric Fleegler, and Kristin A. Goss, 2017:Firearm-Related Laws in All 50 US States, 1991–2016 12AmericanJournalofPublicHealth 107, 1122_1129, https://doi.org/10.2105/AJPH.2017.303701 Liu Y, Siegel M, Sen B. Association of State-Level Firearm-Related Deaths With Firearm Laws in Neighboring States. JAMA Netw Open. 2022;5(11):e2240750. doi:10.1001/jamanetworkopen.2022.40750 Baker, Regina Smalls (2015). Poverty and Place in the Context of the American South . Dissertation,Duke University. Retrieved from https://hdl.handle.net/10161/10511. Additional Declarations No competing interests reported. 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From 2006 to 2014, more than 700,000 emergency department (ED) visits in the United States were related to firearm violence. [1] The burden of fatal firearm injuries varies significantly across states and racial or ethnic groups, with black individuals experiencing higher rates than white individuals do. Mortality from firearm violence is particularly pronounced among those aged 17\u0026ndash;25 years, accounting for up to 80% of all homicides and 45% of all suicides within this age group. [2]\u003c/p\u003e \u003cp\u003eThe United States has the highest rate of firearm homicides among developed nations, with a rate 25 times higher than that of comparable countries such as Australia, Austria, Belgium, and Canada. Over the past decade, 82% of all firearm-related deaths in high-income countries have occurred in the United States. [3] Remarkably, the rates of firearm fatalities have recently surpassed those of motor vehicle fatalities. The direct and indirect costs of firearm violence in the U.S. are estimated at \u003cspan\u003e$\u003c/span\u003e229\u0026nbsp;billion annually. [4] Hospital readmissions are a significant contributor to the long-term healthcare costs associated with firearm-related injuries. [5] These costs are particularly influenced by state-specific firearm policies, which often have effects that spill over into neighboring states. [6] The goal of this study was to evaluate trends in firearm-related mortality across different demographic groups in the United States, including gender, race, and geographical regions.\u003c/p\u003e \u003cp\u003eThe Centers for Disease Control and Prevention (CDC) categorizes firearm-related injuries into several groups: intentionally self-inflicted injuries (such as suicide and nonfatal self-harm), unintentional injuries (accidental discharges during handling or play), interpersonal violence (including firearm homicides and assaults), legal interventions (injuries resulting from law enforcement actions), and injuries of undetermined intent. [7] In this research, we concentrate on all categories except self-inflicted injuries.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting and population\u003c/h2\u003e \u003cp\u003eIn this descriptive study, data from death certificates were retrieved from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging ONline Data for Epidemiologic Research) database and examined from 1999 to 2020 for Firearm-related mortality in people of all ages via the following codes from the International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10: W32, W33, W34, X93, X94, X95, Y22, Y23, and Y24. The ICD codes mentioned above have previously been used to identify firearm-related injuries. [8][9] This dataset includes causes of death from death certificates for the 50 states and the District of Columbia and has been previously used in studies to determine trends in mortality due to firearms. Multiple cause-of-death public use record death certificates were studied to select firearm-related deaths, which were identified as those with firearms reported anywhere on the death certification either as contributing or underlying causes of death. This study was exempt from local institutional review board approval because it used a de-identified government-issued public use dataset and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData abstraction\u003c/h3\u003e\n\u003cp\u003eData for year, demographics, region, and states were extracted. Demographics included sex, age, and race/ethnicity. Race/ethnicity was classified as non-Hispanic (NH) White, NH Black or African American, Hispanic or Latino, NH American Indian or Alaskan Native, and NH Asian or Pacific Islander. This information relies on reported data on death certificates and has been used in previous analyses of the WONDER database. [10] Regions were classified into Northeast, Midwest, South, and West Regions according to the U.S. Census Bureau definitions. [11]\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eNational trends in Firearm-related mortality were examined by calculating crude and age-adjusted mortality rates (AAMRs) per 100,000 populations from 1999 to 2020 by year, sex, race/ethnicity, state, and region with 95% CIs. Crude mortality rates were determined by dividing the number of Firearm-related deaths by the corresponding U.S. population of that year. AAMRs were calculated by standardizing Firearm-related deaths to the year 2000 U.S. population. To quantify national annual trends in Firearm-related mortality, the Joinpoint Regression Program (Joinpoint Regression Program, Version 5.2.0.0) was used to determine the annual percent change (APC) with 95% CI in the AAMR. This method identifies significant changes in the AAMR over time by fitting log-linear regression models where temporal variation occurs. APCs were considered increasing or decreasing if the slope describing the change in mortality was significantly different from zero via 2-tailed t-tests. A value of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eAnnual trends for the Firearm-related AAMR\u003c/h2\u003e \u003cp\u003eA total of 278,505 firearm-related deaths occurred among all ages between 1999 and 2020. The AAMR in 1999 was 4.27, with a steady decline until 2014 to an AAMR of 3.79 and an APC of -0.750 (95% CI: -2.31-0.19). There was a subsequent increase in the AAMR to 6.51, with an APC of 6.51 (95% CI: 3.28\u0026ndash;14.20). [Supplementary Tables\u0026nbsp;1, 2, and 3] [Supplementary Fig.\u0026nbsp;1]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFirearm-related AAMR stratified by sex\u003c/h2\u003e \u003cp\u003eThe AAMR for firearm-related deaths in men was 7.08 in 1999 and 10.94 in 2020. The overall AAMR declined from 1999 to 2014 (APC: \u0026minus;0.75; 95% CI: \u0026minus;2.48\u0026thinsp;\u0026minus;\u0026thinsp;0.24), followed by an increase from 2014 to 2020 (APC: 6.56; 95% CI: 3.25\u0026ndash;15.27). The AAMR for firearm-related deaths in females was 1.45 in 1999, declined to 1.19 in 2014 (APC: -0.96; 95% CI: -1.69- -0.36), and then increased to 1.95 in 2020 (APC: 6.66; 95% CI: 4.54\u0026ndash;10.13). Men had consistently higher AAMRs than women did: from 1999 (AAMR men: 7.1 vs. women: 1.5) to 2020 (AAMR men: 10.9 vs. women: 1.9). [Supplementary Tables\u0026nbsp;1, 2, and 3] [Supplementary Fig.\u0026nbsp;1]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFirearm-related AAMR stratified by ethnicity\u003c/h3\u003e\n\u003cp\u003eThe AAMR for the Hispanic population steadily declined from 5.28 in 1999 to 5.05 in 2006 (APC: \u0026minus;0.37; 95% CI: \u0026minus;2.13\u0026ndash;3.19), followed by a steep decline to 3.16 in 2013 (APC: \u0026minus;7.11; 95% CI: \u0026minus;12.97 to \u0026minus;\u0026thinsp;5.18), which was followed by an increase to an AAMR of 4.76 until the end of the study period (APC: 5.49; 95% CI: 3.37\u0026ndash;8.36). The AAMR for non-Hispanic individuals followed a steady rate from 4.09 in 1999 to 3.95 in 2014 (APC \u0026minus;\u0026thinsp;0.12; 95% CI:-1.26-0.75), followed by a sharp increase in the AAMR to 6.93 in 2020 (APC 7.41; 95% CI: 4.67\u0026ndash;14.96). [Supplementary Tables\u0026nbsp;1, 2, and 4] [Supplementary Fig.\u0026nbsp;2]\u003c/p\u003e\n\u003ch3\u003eFirearm-related AAMR stratified by race\u003c/h3\u003e\n\u003cp\u003eIn 1999, African American individuals had the highest overall AAMR (14.98), followed by American Indian/Alaskan Native (4.17), White (2.55), and Asian/Pacific Islander individuals, who had the lowest AAMR of 1.95. In 2020, the racial trends were in a similar order, with African American individuals having the highest overall AAMR (25.5), followed by American Indian/Alaskan Native (5.47), White (3.13), and Asian/Pacific Islander individuals having the lowest AAMR of 1.16. In descending order of APC, African American had an APC of 1.67 (95% CI: 0.81\u0026ndash;2.48), Americans Indian had an APC of 1.58 (95% CI: 0.85\u0026ndash;2.41), and whites had an APC of 0.58 (95% CI: 0.17\u0026ndash;1.10). Asian was the only race with an overall negative APC of -2.24 (95% CI: -3.20 to -0.83). [Supplementary Tables\u0026nbsp;1, 5, and 6] [Supplementary Fig.\u0026nbsp;3]\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFirearm-related AAMR stratified by geographic region\u003c/h2\u003e \u003cp\u003eOn average, over the course of the study period, the highest mortality was observed in the southern region (AAMR: 5.73; 95% CI: 5.70\u0026ndash;5.76), followed by the mid-western region (AAMR: 4.37; 95% CI: 4.34\u0026ndash;4.41), the western region (AAMR: 3.69; 95% CI: 3.66\u0026ndash;3.72), and the northeastern region (AAMR: 2.89; 95% CI: 2.86\u0026ndash;2.92). A significant difference in the AAMR was observed in different states, with the lowest AAMR in Massachusetts of 1.99 (95% CI: 1.65\u0026ndash;2.33), and the highest in District of Columbia at AAMR of 20.44 (95% CI: 17.12\u0026ndash;23.75). [Supplementary Tables\u0026nbsp;7 and 8] [Supplementary Figs.\u0026nbsp;4 and 5]\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe comprehensively examined firearm-related mortality trends in the United States from 1999 to 2020, focusing particularly on gender, racial, and geographic variations. Our findings reveal a disturbing landscape of gun-related mortality rates, marked by a significant increase in recent years, especially since 2014. This trend emphasizes the complex interaction of socioeconomic, cultural, and policy factors driving gun violence in the country.\u003c/p\u003e \u003cp\u003eDuring the 2000s and early 2010s, many U.S. cities implemented stronger law enforcement and crime prevention strategies, including community policing and focused deterrence, which may have contributed to the decrease in firearm-related deaths during this era. [12] The sharp rise in firearm-related deaths after 2014 can be linked to worsening economic deprivation and socioeconomic conditions, particularly in the aftermath of the Great Recession (2007\u0026ndash;2009). Communities disproportionately impacted by poverty and unemployment often serve as perfect breeding grounds for crime, where interpersonal conflicts are more likely to escalate into violent encounters, contributing to increased gun-related crime. [13] The consumption of violent media such as arcade games involving firearms has been at an all-time high in the last decade. This can be linked to the varied attitudes toward firearms in real-world scenarios and, hence, more gun-related deaths. [14] When this trend increased between 2019 and 2020, the COVID-19 pandemic was an inevitable factor. The global hysteria surrounding the pandemic, socioeconomic chaos, and ever-increasing death tolls had substantial effects on human psychology and society as a whole. This social disarray led to a higher prevalence of mental health conditions. These statistics explain why more people are likely to experience feelings of mistrust and frustration. [15] These emotions serve as a prerequisite in the setting stage for crime and violence. Consequently, this period was marked by record-high firearm purchases and incidents of gun violence, such as mass shootings, across the United States, and hence, a greater number of deaths attributable to firearms. [16]\u003c/p\u003e \u003cp\u003eWhen the data on firearm-related deaths were analyzed for sex variations, we observed that the number of deaths among males was significantly greater than that among women. This can be attributed to the fact that men are biologically predisposed to displaying hostile conduct and are more likely to express overt physical aggression. [17] The involvement of men in crime syndicates is far more common than the opposite sex; in addition, gang males are more frequently involved in crime and victimization than gang females are. [18] To make matters worse, societal norms and traditional notions of masculinity emphasize toughness and competitiveness in males, potentially leading to greater engagement of men in violent firearm-related crimes, either as victims or perpetrators. [19] All of these factors adequately explain why males constitute a greater proportion of deaths linked with firearms.\u003c/p\u003e \u003cp\u003eThe findings of the study underscore long-standing and substantial racial inequalities in firearm lethality. African Americans remain the most affected by gun violence, as evidenced by higher mortality rates by a considerable margin. The rise in AAMRs among African Americans could be attributed to socioeconomic disparities and racism. [13][20] A 2020 study revealed that black Americans were three times more likely to be shot by police than their white counterparts were. [21] Furthermore, African American youth are exposed to areas with substantially higher levels of violence. Proximity to violence inevitably exposes them to gun-related crimes and possibly explains the high prevalence of firearm-related deaths in this ethnicity. [22] The data also present trends in which firearm mortality rates were higher among American Indian and Alaskan Native populations as well as Whites but not to the same extent as those of the African American population. On the other hand, a decrease in AAMRs among Asians and Pacific Islanders suggests that this category of people is less vulnerable to firearm deaths, given cultural reasons, stronger family systems, less adoption of firearms, and their settlement in areas with fewer gun-friendly laws. [23] The mortality rate of the Hispanic population initially decreased but then rapidly increased toward the end of the study period.\u003c/p\u003e \u003cp\u003eThe age-adjusted mortality rates (AAMRs) for firearms in the United States exhibit geographical variability that is influenced by gun law differences, cultural attitudes, and socioeconomic factors. In states such as Mississippi, Louisiana, and Alabama which have the highest AAMRs, more permissive gun laws, including fewer restrictions on ownership and carrying, are observed. In these states, there may be weaker background check systems, less stringent storage rules, and lenient conceal carry regulations, all of which contribute to the increased mortality rates associated with guns. [23] Conversely, some states, such as Massachusetts, Idaho, or Utah, generally enforce strict measures against arms. Research has consistently established links between stringent arms legislation and reduced fatalities due to guns, suggesting that legal frameworks are responsible for spatial inequalities. [24] Cultural attitudes toward firearms also significantly influence these trends. In southern states where higher mortality rates occur among gun users, there is a strong cultural emphasis on private ownership of weapons for personal protection purposes or on hunting, which leads to an increase in individuals who possess guns as well as their application. The Northeast Region, meanwhile, has a low rate of AAMRs, reflecting a less significant acceptance of guns within its society. Furthermore, southern states often face a higher level of poverty and lower access to healthcare and education, [25] conditions that can exacerbate frustration and increase the likelihood of a higher prevalence of crime and firearm-related deaths. The complex interplay of legal, cultural, and economic factors helps explain the pronounced regional differences in firearm-related mortality across the United States.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study highlights a troubling increase in firearm-related mortality rates in the United States from 1999 to 2020, particularly since 2014. The rising trends in firearm-related deaths reflect a complex interplay of socioeconomic, cultural, and policy factors. Men consistently experience higher mortality rates than women do, driven by biological predispositions and societal norms. Racial disparities constitute one of the most stark factors, with African Americans facing the highest mortality rates, reflecting broader socioeconomic inequalities and systemic issues. The geographic variability in firearm-related deaths underscores the significant impact of state-specific gun laws, cultural attitudes toward firearms, and socioeconomic conditions. States with more permissive gun laws and higher poverty rates have been shown to report higher mortality rates, whereas those with stricter regulations and better socioeconomic conditions have lower rates. These findings emphasize the need for targeted interventions that address both the immediate and underlying causes of firearm violence; some of these interventions include implementing stricter gun control measures, socioeconomic support, and community-based strategies to reduce gun violence and its devastating impact across diverse demographics and regions.\u003c/p\u003e"},{"header":"Statements and declarations ","content":"\u003cp\u003e\u003cem\u003eAvailability of data and material:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePublicly available data were used, the sources of which are included in the reference list of this article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of interest disclosure:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support was received during the preparation of this manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical trial number\u003c/em\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics, Consent to Participate, and Consent to Publish declarations:\u003c/em\u003e not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCredit author statement:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eF.K.A. conceptualized the study, supervised the process, and conducted the CDC website analysis. A.K.A. worked on the methodology and did the JoinPoint analysis. M.U.H.H. did the graphic representation of data and proofread the manuscript. L.A.K. was involved in the proofreading of the manuscript. A.K., R.F.S., O.K.A., \u0026amp; R.R. were involved in the main manuscript writing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalker GN, Dekker AM, Hampton DA, Akhetuamhen A, Moore PQ. A Case for Risk Stratification in Survivors of Firearm and Interpersonal Violence in the Urban Environment. West J Emerg Med. 2020 Oct 16;21(6):132-140. doi: 10.5811/westjem.2020.8.45041. PMID: 33207158; PMCID: PMC7673864.\u003c/li\u003e\n\u003cli\u003eKalesan B, Mobily ME, Keiser O, Fagan JA, Galea S. Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study. Lancet. 2016 Apr 30;387(10030):1847-55. doi: 10.1016/S0140-6736(15)01026-0. Epub 2016 Mar 11. PMID: 26972843.\u003c/li\u003e\n\u003cli\u003eGrinshteyn E, Hemenway D. 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PMID: 33093328; PMCID: PMC7708450. \u003c/li\u003e\n\u003cli\u003eCenters for Disease Control and Prevention. Firearm Violence. [Internet]. 2024 [cited 2024 Aug 10]. Available from: https://www.cdc.gov/firearm-violence/about/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/firearms/fastfact.html\u003c/li\u003e\n\u003cli\u003eToigo S, Pollock NJ, Liu L, Contreras G, McFaull SR, Thompson W. Fatal and non-fatal firearm-related injuries in Canada, 2016-2020: a population-based study using three administrative databases. Inj Epidemiol. 2023 Feb 14;10(1):10. doi: 10.1186/s40621-023-00422-z. PMID: 36788597; PMCID: PMC9930327.\u003c/li\u003e\n\u003cli\u003eMagee LA, Ranney ML, Fortenberry JD, Rosenman M, Gharbi S, Wiehe SE. Identifying nonfatal firearm assault incidents through linking police data and clinical records: Cohort study in Indianapolis, Indiana, 2007-2016. Prev Med. 2021 Aug;149:106605. doi: 10.1016/j.ypmed.2021.106605. Epub 2021 May 13. 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Retrieved from https://hdl.handle.net/10161/10511.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"firearm, assault, homicide, mortality","lastPublishedDoi":"10.21203/rs.3.rs-6574590/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6574590/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eIntroduction:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFirearm violence in the U.S.A. is an epidemic that is rapidly spreading, with a 25-fold higher rate of firearm homicides among comparable developed countries.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMethods:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDeath certificates from the CDC WONDER for Epidemiologic Research database were examined from 1999 to 2020 for firearm-related mortality. The AAMR per 100,000 persons and the APC were calculated and stratified by year, sex, race/ethnicity, and geographic region.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe AAMR for men decreased from 7.1 in 1999 to 6.4 in 2014 (APC: -0.75; 95% CI: -2.5-0.2), after which it increased to 10.9 in 2020 (APC: 6.6; 95% CI: 3.3-15.3). Men had consistently higher AAMRs than women did: from 1999 (AAMR men: 7.1 vs. women: 1.5) to 2020 (AAMR men: 10.9 vs. women: 1.9). African American individuals had the highest overall AAMR (16.4), followed by American Indian/Alaskan Native (3.5), White (2.4), and Asian/Pacific Islander individuals, who had the lowest AAMR of 1.3.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDiscussion:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMen are biologically predisposed to displaying hostile conduct and are more likely to express overt physical aggression. Black communities disproportionately impacted by poverty and unemployment often serve as perfect breeding grounds for crime, where interpersonal conflicts are more likely to escalate into violent encounters, contributing to increased gun-related crime. The consumption of violent media such as arcade games involving firearms has been at an all-time high level in the last decade and can be linked to more gun-related deaths. The hysteria surrounding the COVID-19 pandemic, socioeconomic chaos, and mental health conditions led to an exponential rise.\u003c/p\u003e","manuscriptTitle":"Mortality Trends in Gunshot and Firearm-related Assault Victims: A CDC Wonder Database Analysis from 1999 to 2020","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-29 11:14:25","doi":"10.21203/rs.3.rs-6574590/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8d80043-8452-4177-b5f1-0bae57e74521","owner":[],"postedDate":"May 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T12:25:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-29 11:14:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6574590","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6574590","identity":"rs-6574590","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}