Article Text
Abstract
Objective To examine trends in fireworks-related injuries (FRI) before and after enactment of an ordinance to limit access in the City and County of Honolulu (the island of Oahu).
Methods Surveillance of FRI treated in all emergency departments in the state, for 18 new year’s periods (31 December through 1 January) from 2004 to 2021. Prelaw (2004 to 2011) and postlaw (2012 to 2021) number of FRI were compared, by patient age and county.
Results The average annual number of FRI for all ages decreased significantly in Oahu, from 74 during the prelaw period to 27 during the postlaw period (p<0.01), but not in the remaining neighbour islands (p=0.07). Decreases were particularly evident for Oahu paediatric patients (under 18 years), among whom FRI declined from 42 to 10 per year (p<0.01). FRI were approximately halved for older Oahu patients and neighbour island paediatric patients.
Conclusions Legislation requiring permits for a specified number and type of fireworks, and limiting access to persons 18 years and older was associated with significant decreases in FRI in the City and County of Honolulu.
- policy
- public health
- regulation
- safe community
- blast/explosion
- child
Data availability statement
No data are available.
Statistics from Altmetric.com
Introduction
Although generally used in celebration, fireworks can lead to serious injuries and occasionally death to both users and bystanders, particularly among the paediatric population.1–3 Data from the US National Emergency Department Sample indicated increasing numbers and rates of injuries from fireworks over the 2008 through 2017 period.4 The authors of that study noted the concurrent increasing trend in national consumption of consumer fireworks, which may in turn reflect policy changes in many states, which have facilitated access to consumer fireworks.5 It is important to understand the effect of policy either enabling or restricting consumer access on the incidence of injuries from fireworks. However, existing literature is sparse, and studies are limited in duration and geographic scope or at an ecologic level, which impedes the examination of the association between fireworks-related injuries (FRI) and enacted policy.3 6 7
Consumer fireworks provide a popular form of celebration in Hawaii, with use allowed during specified times of New Year’s Eve and New Year’s Day, the Lunar New Year’s Day, the 4 July, and as expressly permitted on requested days for ‘cultural uses’ (eg, births, deaths, weddings, grand openings and blessings).8 Consumer fireworks are those primarily designed for retail sale to the public and produce their effects on or near the ground. Included in this definition are ‘firecrackers’, single paper cylinders less than one and a half inches in length, and containing a limited pyrotechnic charge. A state law passed in 2000 instituted a $25 permit requirement to use up to 5000 firecrackers, while the use of other consumer fireworks (eg, sparklers, fountains, spinners, etc) remained unregulated. Subsequently, the Council of the City and County of Honolulu passed Bill 34, which barred the sale and use of all consumer fireworks, except firecrackers, beginning 2 January 2011.9 This Bill further limited use of fireworks (firecrackers) to those 18 years of age and older. Usage of all types of consumer fireworks by minors remained permissible in the remaining three counties of the state, provided immediate adult supervision.9 The 2000 state law also mandated the reporting of serious injuries and fatalities caused by fireworks to the Hawaii Department of Health. Our study uses that surveillance system to describe FRI in Hawaii during the New Year’s holiday, the period of greatest fireworks use and examines associations between FRI and the 2011 legislative change.
Methods
The Hawaii Department of Health instituted an active surveillance system to capture hospital-attended FRI, in December 2000. Data were collected for two periods each year: from 31 December through 1 January and on 4 July; no attempt was made to collect data around the Lunar New Year or the individually permitted occasions. A blank logsheet of potential FRI was securely faxed to the emergency departments of all acute care hospitals in the state and two health centres in the days prior to the upcoming new year period (NYP) or 4 July. Hospital personnel reported individual patient data on date and time of the FRI, patient age and gender, type of injury and affected body part(s), patient mode of arrival (self-transport vs emergency medical services ambulance), disposition (discharged from emergency department vs hospital admission), type of firework and patient involvement (observer vs active user of the firework). All of the facilities completed the logsheets for each year of the study period.
Since surveillance shows FRI during the NYP outnumber those over the 4 July holiday by approximately 5-to-1, this study is limited to data collected around the NYP. Data collected from NYP2004 through NYP2021 (18 NYPs) were included in this report. (For convenience, this paper references the latter year of a given NYP, for example, the period of 31 December 2020 through 1 January 2021, is denoted ‘NYP2021’.) For some analyses, the study period was divided into NYP2004 to NYP2011 (prelaw), and NYP2012 to NYP2021 (postlaw). Other analyses were stratified by patient age group and the county of the reporting hospital. The island of Oahu constitutes the City and County of Honolulu, and as of 2019 is home to approximately 980 000 (69%) of the state’s 1.42 million estimated resident population.10 The remainder of the population resides in three other counties (Hawaii, Kauai and Maui), collectively referred to as the neighbour islands.
All statistical analyses for this report were performed using JMP software, V.14.2.0 (Cary, North Carolina). Data were analysed by χ2 for categorical and t test for continuous variables. Statistical contrasts described as ‘significant’ had an associated p value of less than 0.05. Paediatric patients were defined as those under 18 years of age. This study was approved by the Institutional Review Board.
Results
The surveillance documented 1142 FRI over the 18 year period, with most (75%, or 858) occurring in the City and County of Honolulu (the island of Oahu) (table 1).
Paediatric patients (those less than 18 years of age) comprised over 50% of the injured, on both Oahu and the neighbour islands. Most of the total patient population were men, including 72% (431) of the 596 paediatric patients. The most common injuries were burns, and hands were the most injured area of the body. About two-thirds (64.5%) of the patients were injured while setting off the firework, and this proportion was similar between paediatric patients (63.3%) and those over 17 years of age (66.0%). Information on the type of firework was missing for most (54.6%) of the FRI. Nearly all (91%) of the patients arrived by private transport. Eighty per cent (912) of the 1142 patients were discharged from the emergency department, 5% (63) were admitted as inpatients and less than 1% were transferred to another hospital. These proportions include 156 patients (14% of the total) for whom information on disposition was missing.
There was an abrupt decrease in the number of FRI in Hawaii in association with the enactment of the law after NYP2011 (figure 1). The average annual number more than halved from the prelaw to postlaw period (92 vs 41 FRI, respectively). The mean number of FRI on Oahu decreased from 74 injuries over the NYP2004–NYP2011 period to 27 from NYP2012–NYP2021 (p<0.0001), a decrease in 64% (table 2).
There was also a 21% decrease in FRI in the other three counties, from 18 during the prelaw period to 14 during the postlaw period (p=0.0651). There was some variation within the neighbour islands, however, with a pre-to-post law FRI decrease for only Maui County (8.1 vs 4.4 FRI, respectively). The annual total generally increased over the postlaw period of NYP2017 through NYP2021, for both Oahu and neighbour islands. There were postlaw decreases in the proportion of patients who were injured while setting off the firework, for both the paediatric and older age groups, on either Oahu or the neighbour islands. These decreases were greater for Oahu patients, however. Among paediatric patients, the proportion injured while setting off the firework on Oahu decreased from 65.8% in the prelaw period to 40.8% (a 38% decrease) postlaw, compared with 78.7% and 64.1% (a 19% decrease), respectively, for patients injured on neighbour islands.
FRI to children decreased significantly after enactment of the law in both neighbour islands and Oahu, but particularly in the latter (figure 2). Children under 18 years of age comprised 61% of the injured patients during the prelaw period, but 42% during the postlaw period (p<0.0001 for χ2 test). These changes in proportions were apparent on both Oahu and the neighbour islands. The average number of paediatric FRI patients decreased by more than fourfold from 42.2 in the prelaw period to 10.3 postlaw in the City and County of Honolulu. These averages were approximately halved in association with enactment of the law, from 11.8 to 6.4 injuries per NYP in neighbour islands. There were relatively high postlaw totals for paediatric FRI on Oahu in the three most recent three NYPs, although these were still well below the prelaw counts.
Discussion
We found a significant decrease in emergency department visits due to FRI in the City and County of Honolulu (the island of Oahu) in association with the enactment of legislation to restrict consumer access to fireworks. The mandate to limit usage to those 18 years of age and older appeared particularly impactful, with a fourfold reduction in the number of paediatric FRI between the prelaw and postlaw periods. A significant, nearly twofold decrease was also seen for FRI among adults on Oahu, possibly in association with the permit requirement, and the 2011 law’s ban of consumer fireworks other than firecrackers. An approximate twofold decrease in paediatric FRI was also seen for neighbour islands, while injuries among adults there did not significantly change.
There were an estimated 15 600 FRI treated in emergency departments in the USA in 2020.11 Studies using nationally representative data have shown increasing trends in FRI recent time periods.4 11 FRI in Hawaii were like those recorded nationally in a preponderance of male patients, the paediatric age group and type and anatomic location of the FRI. Although mortality from these injuries is low, they can result in significant morbidity and are associated with nearly $8 million annually in United States emergency department charges alone.12 Many studies have found that majority of those injured were male.1 2 12–15 Male may exhibit riskier behaviours when using fireworks, and public health efforts can be targeted to this specific group. Additionally, bystanders made up about one-quarter of FRI in Hawaii, suggesting that safety interventions should be applied to both firework users and spectators; even higher proportions of bystanders were reported from European studies.15 16
Increased access to fireworks has resulted in increased FRI in other states. For example, FRI increased in West Virginia after an expansion of legal access to consumer grade fireworks, but not to a statistically significant degree.6 However, that study was based on only 1-year pre and postlaw periods for FRI treated in a single healthcare system. A significant increase in FRI was noted in data collected from 11 counties in Washington state, again using 1-year pre and postcomparisons around a 1982 law liberalising access to fireworks during the 4 July period.7 Other studies of national data have shown ecological associations between increased access to fireworks and FRI.3 17 To our knowledge, ours is the first statewide evaluation of fireworks legislation over a multiyear period.
There are also few studies on this topic from other countries. A study from the Netherlands and Finland found that the incidence of FRI was approximately halved in association with increased regulations and public safety campaigns.16 Safety measures included limiting firework use to 8 hours, advocating for the use of safety glasses and preventing those younger than 18 years of age from accessing fireworks. The authors ultimately recommended a global ban on the use of consumer fireworks, which aligned with the message from many other studies.1 2 13 18
The position of the American Academy of Pediatrics is that adult supervision and excluding the use by children is not sufficient to prevent FRI; they recommend families attend public firework displays rather than purchase and use fireworks.18 While a complete ban on fireworks might further decrease the rate of FRI, this might be politically unpopular in Hawaii. Passage of Bill 34 was contentious, and the balance of public safety and cultural traditions was an important consideration when lawmakers decided on the extent of the Oahu fireworks law.19 In addition to legislative approaches, some authors have advocated for the use of protective equipment such as safety glasses and hand gloves.2 12 14 20 21 While multiple strategies of prevention are warranted, we believe that our study shows the efficacy of age-specific legislation prohibiting the use of fireworks among this vulnerable paediatric population. It is encouraging to observe the largest FRI decreases in children, as compliance with this component of the ordinance is dependent on public education and personal behaviour. Nevertheless, the FRI increases among Oahu children in the last three NYP suggest that the effectiveness of this component could be waning, and perhaps the need for ongoing public education activities. In contrast, the permit requirements and the elimination of consumer fireworks other than firecrackers are effectively enforced at the point of sale. However, similar to children, there have been recent increases in FRI for patients of all ages on Oahu. Neither of these concerning recent trends can be easily explained as due to population increases, as annual estimates for both children and residents of all ages on Oahu have trended down over the last several years.10 It is possible that the increases in FRI on Oahu over recent years reflect increased use of firecrackers, although we were unable to verify this assumption against the annual number of permits issued by the Honolulu Fire Department.
Limitations
Our study is limited to data collected from hospital emergency departments and two community health centres. Therefore, we were not able to include FRI treated in other healthcare settings or among those who did not seek medical attention. Another limitation is we were not able to validate the accuracy of the data. However, the data collection instrument and process were unchanged over the study period. Although we achieved complete reporting from all healthcare facilities, data were missing for some variables. As with any epidemiological study, our inferences of the effect of legislation on FRI are subjected to unmeasured confounders. It is possible that there was a underlying, statewide decreasing trend in firework use among children independent of the Oahu legislation, as decreased in FRI in this population were seen on both Oahu and the neighbour islands. The decrease in the former location, however, closely coincided with the enactment of the law and was of a much larger magnitude. Trends in FRI may have been influenced by the type of fireworks being used by the public, although there was too much missing data in our study to allow assessment. Decreased access to consumer fireworks on Oahu might have resulted in increased use of homemade devices, which would seem to impose greater risk of FRI, or access through black market sales, as was suggested during the deliberations around Bill 34.19
Public health implications
Legislation to make fireworks more difficult to obtain may decrease the incidence of FRI. Our study is one of the few reports showing a significant association between stricter firework legislation and a decrease in FRI over a multiyear period. Appealing aspects of our statute include public income from permit sales, and prohibiting use of fireworks among children, a susceptible population for whom legal safeguards are often more politically palatable. Our study suggests either statutory component merits consideration for communities concerned with injuries from fireworks.
What is already known on the subject
Fireworks can cause serious injury and mortality among the pediatric population.
Majority of states across our country do not have legislation to restrict use of fireworks.
What this study adds
Perhaps the first statewide, multiyear study to examine the potential effects of stricter fireworks legislation.
Reveals the benefits of age-specific fireworks legislation in our vulnerable pediatric population.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study does not involve human participants. Acknowledged IRB approval by DOH
Footnotes
Contributors DJG oversaw data collection, designed the study and conducted the analyses. DJG is the author acting as the guarantor. SSJK undertook the literature review and produced the first draft. All authors participated in reviewing and editing all drafts of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.