State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County

An introduction to bayesian spatial smoothing methods for disease mapping: modeling county firearm suicide mortality rates

This article introduces bayesian spatial smoothing models for disease mapping-a specific application of small area estimation where the full universe of data is known-to a wider audience of public health professionals using firearm suicide as a motivating example. Besag, York, and Mollié (BYM) Poisson spatial and space-time smoothing models were fitted to firearm suicide counts for the years 2014-2018. County raw death rates in 2018 ranged from 0 to 24.81 deaths per 10 000 people. However, the highest mortality rate was highly unstable, based on only 2 deaths in a population of approximately 800, and 80.5% of contiguous US counties experienced fewer than 10 firearm suicide deaths and were thus suppressed. Spatially smoothed county firearm suicide mortality estimates ranged from 0.06 to 4.05 deaths per 10 000 people and could be reported for all counties. The space-time smoothing model produced similar estimates with narrower credible intervals as it allowed counties to gain precision from adjacent neighbors and their own counts in adjacent years. bayesian spatial smoothing methods are a useful tool for evaluating spatial health disparities in small geographies where small numbers can result in highly variable rate estimates, and new estimation techniques in R software have made fitting these models more accessible to researchers.

Reporting and Description of Research Methodology in Studies Estimating Effects of Firearm Policies

BACKGROUND

Evidence about which firearm policies work, to what extent, and for whom is hotly debated, perhaps partly because variation in research methodology has produced mixed and inconclusive effect estimates. We conducted a scoping review of firearm policy research in the health sciences in the United States, focusing on methodological considerations for causal inference.

METHODS

We identified original, empirical articles indexed in PubMed from 1 January 2000 to 1 September 2021 that examined any of 18 prespecified firearm policies. We extracted key study components, including policy type(s) examined, policy operationalization, outcomes, study setting and population, study approach and design, causal language, and whether and how authors acknowledged potential sources of bias.

RESULTS

We screened 7733 articles and included 124. A plurality of studies used a legislative score as their primary exposure (n = 39; 32%) and did not examine change in policies over time (n = 47; 38%). Most examined firearm homicide (n = 51; 41%) or firearm suicide (n = 40; 32%) as outcomes. One-third adjusted for other firearm policies (n = 41; 33%). Three studies (2%) explicitly mentioned that their goal was to estimate causal effects, but over half used language implying causality (n = 72; 58%). Most acknowledged causal identification assumptions of temporality (n = 91; 73%) and exchangeability (n = 111; 90%); other assumptions were less often acknowledged. One-third of studies included bias analyses (n = 42; 34%).

CONCLUSIONS

We identified a range of methodologic approaches in firearm policy research in the health sciences. Acknowledging the imitations of data availability and quality, we identify opportunities to improve causal inferences about and reporting on the effects of firearm policies on population health.

Bullet holes: A novel model to identify the most impactful gaps in the firearm homicide prevention laws of each state

BACKGROUND

Firearm homicides (FH) are a major cause of mortality in the United States. Firearm law implementation is variable across states, and legislative gaps may represent opportunities for FH prevention. For each state, we sought to identify which firearm law category would have been most effective if implemented and how effective it would have been.

METHODS

We conducted a retrospective cohort study examining the effects of firearm laws on FH rates in the 48 contiguous US states 2010 to 2019. Data were obtained from the CDC WONDER and FBI UCR databases, State Firearm Law Database, and US Census. Firearm laws were grouped into 14 categories. We assessed the association between the presence of each law category and FH rate as an incidence rate ratio (IRR) using a Poisson regression accounting for state population characteristics and laws of surrounding states. We estimated the IRR for each state that did not have a given law category present and determined which of these missing law categories would have been associated with the greatest reduction in FH rate.

RESULTS

FH rates varied widely across states and increased from a mean of 3.2 (SD = 1.7) to 4.2 (SD = 2.9) FH per 100,000. All law categories were significantly associated with decreased FH rate ( p < 0.05), with IRR ranging from 0.25 to 0.85. The most effective missing law category differed between states but was most commonly child access prevention (34.09% of states), assault weapons and large-capacity magazines (15.91%), preemption (15.91%), and concealed carry permitting (13.64%). In total across 2010 to 2019, we estimated that 129,599 fewer FH would have occurred with enactment of the most effective missing law category in each state.

CONCLUSION

Modeling firearm law prevention of FH with regard to state legislative and population characteristics can identify the highest impact missing law categories in each state. These results can be used to inform efforts to reduce FH.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Association Between Marijuana Laws and Suicide Among 12- to 25-Year-Olds in the United States From 2000 to 2019

OBJECTIVE

Cannabis use is associated with suicide-related outcomes in both adolescents and adults, and may be increasing amid shifting cannabis policies. However, little is known about the impact of medical marijuana legalization (MML) and recreational marijuana legalization (RML) policies on youth suicide. Using 20 years of national data, we examined associations between MML, RML, and suicide-related mortality among US individuals aged 12 to 25 years, and assessed whether they varied based on age and sex.

METHOD

Suicide deaths (N = 113,512) from the 2000-2019 National Vital Statistics System Multiple Cause of Death files for age groups 12 to 13, 14 to 16, 17 to 19, 20 to 22, and 23 to 25 years were examined in relation to time-varying cannabis law status using a staggered adoption difference-in-difference (DiD) approach with a negative binomial regression to determine associations between MML, RML, and suicide rates, controlling for individual- and state-level covariates and accounting for the varying effective dates of MML and RML by state.

RESULTS

The overall unadjusted annual suicide rate was 10.93/100,000, varying from 9.76 (states without marijuana laws (ML)) to 12.78 (MML states) to 16.68 (RML states). In multivariable analysis, both MML (incidence rate ratio [IRR] = 1.10, 95% CI: 1.05-1.15) and RML (IRR = 1.16, 95% CI: 1.06-1.27) were associated with higher suicide rates among female youth compared to those in states without ML. Youth aged 14 to 16 years had higher rates of suicide in states with RML compared to states with MML (IRR = 1.14, 95% CI: 1.00-1.30) and states without ML (IRR = 1.09, 95% CI: 1.00-1.20). Findings were consistent across sensitivity analyses.

CONCLUSION

MML and RML were associated with increased suicide-related mortality in female youth and 14- to- 16-year-old individuals of both sexes. Mechanisms through which cannabis policies are related to increased youth suicide warrant further study and should inform legislative reform.

Modification of Firearm Law-Firearm Injury Association by Economic Disadvantage

INTRODUCTION

Firearm-related injuries in the U.S. have risen 37% since 2015. Understanding how the association between firearm incidents and state-level firearm restrictiveness is modified by community-level distress and economic connectedness (EC) may inform upstream injury prevention efforts.

METHODS

A national cross-sectional study of firearm incidents (interpersonal and unintentional firearm events) occurring between 1/2015 and 12/2021 was performed using the Gun Violence Archive. The exposures were community distress (Distressed Communities Index, DCI), EC, and year-state-level firearm restrictiveness. The primary outcome was mean annual urban firearm incidence rate per ZIP Code Tabulation Area. Generalized linear mixed models were fit to evaluate the modification of the firearm law-firearm incident association by DCI and EC. Data analyses took place in 2022.

RESULTS

About 266,020 firearm incidents were included. The mean rate was higher with each DCI tertile, with a RR of 3.18 (95% CI: 3.06, 3.30) in high versus low distress communities. Low EC was associated with over 1.8 times greater rate of firearm-related injury. The least restrictive firearm laws were associated with 1.20 times higher risk of firearm incidents (95% CI: 1.12, 1.28). The association between restrictive laws and lower incidence rates was strongest in low and medium distress and high EC communities.

CONCLUSIONS

Stricter firearm laws are associated with lower rate of firearm incidents. The magnitude of this association is smallest for communities experiencing the greatest economic disadvantage.

Impact of Medicaid Expansion and Firearm Legislation on Cost of Firearm Injuries

INTRODUCTION

Firearm injury-related hospitalizations in the U.S. cost $900 million annually. Before the Affordable Care Act, government insurance programs covered 41% of the costs. This study describes the impact of Affordable Care Act Medicaid expansion and state-level firearm legislation on coverage and costs for firearm injuries.

METHODS

This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. The impact of the Affordable Care Act expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses.

RESULTS

The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted ($11,550; p=0.02) injuries; there were no state-level differences in assault or total per capita firearm-related hospitalization costs. Affordable Care Act expansion increased government coverage of costs by 15 percentage points (95% CI=3, 29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI=6, 21). In 2016, states with weak firearm legislation and no Affordable Care Act expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI=15, 34).

CONCLUSIONS

Affordable Care Act expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had the highest proportion of uninsured/self-pay patients.

Colleges and Crime-Comparing Homicide and Suicide Rates Among College Towns and Their Counterparts

INTRODUCTION

To investigate differences in homicide and suicide rates across college town status and determine whether college towns were predisposed to changes in rates over time.

METHODS

We analyzed county-level homicide and suicide rates (total and by firearm) across college town status using 2015-2019 CDC death certificate data and data from the American Communities Project.

RESULTS

Population-level homicide rates were similar across college town status, but younger age groups were at increased risk for firearm homicide and total homicide in college towns. College town status was associated with lower population-level firearm suicide rates, but individuals aged less than 18 y were at increased risk for total and firearm suicide. Finally, college towns were not classified as outliers for changes in either firearm homicide or suicide rates over time.

CONCLUSIONS

College towns had similar homicide rates and significantly lower firearm suicide rates than other counties; however, individuals aged less than 18 y were at increased risk for both outcomes. The distinctive demographic, social, economic, and cultural features of college towns may contribute to differing risk profiles among certain age groups, thus may also be amenable to focused prevention efforts.

Funding the war in America: A look in the mirror

BACKGROUND

Health care political action committees (HPACs) historically contribute more to candidates opposing firearm restrictions (FRs), clashing with their affiliated medical societies. These societies have increasingly emphasized the prevention of firearm violence and it is not known if recent contributions by their HPACs have aligned with their stated goals. We hypothesized that such HPACs still contribute similar amounts toward legislators up for reelection opposing FR.

METHODS

We identified HPACs of medical societies endorsing one or both calls-to-action against firearm violence published in the Annals of Internal Medicine (2015, 2019). House of Representatives (HOR) votes on H.R.8, a background checks bill, were characterized from GovTrack. We compiled HPAC contributions between the H.R.8 vote and election to HOR members up for re-election from the National Institute on Money in Politics. Our primary outcome was total campaign contributions by H.R.8 stance. Secondary outcomes included percentage of politicians funded and total contributions.

RESULTS

Nineteen societies endorsed one or both call-to-action articles. Three hundred eighty-five of 430 HOR members ran for reelection in 2020. Those endorsing H.R.8 (n = 226, 59%) received $2.8 M for $4,750 (interquartile range [IQR], $1000-$15,500) per candidate. Those opposing (n = 159, 41%) received $1.5 M for $2,500 (IQR, $0-$11,000) per candidate ( p = 0.0057). Health care political action committees donated toward a median of 20% (IQR, 7-28) of candidates endorsing H.R.8 and 9% (IQR, 4-22) of candidates opposing H.R.8 ( p = 0.0014). Those endorsing H.R.8 received 1,585 total contributions for a median of 3 (IQR, 1-10) contributions per candidate, while those opposing received 834 total contributions for a median of 2 (IQR, 0-7) contributions per candidate ( p = 0.0029).

CONCLUSION

Politicians voting against background checks received substantial contributions toward reelection from the HPACs of societies advocating for firearm restrictions. However, this is the first study to suggest that HPAC's contributions have become more congruent with their respective societies. Further alignment of medical society goals and their HPAC political contributions could have a profound impact on firearm violence.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

How have firearm laws changed in states with unexpected decreases or increases in firearm homicide, 1990-2019?

Background

Firearm violence is one of the leading preventable causes of death and injury in the United States and is on the rise. While policies regulating access to firearms offer opportunities to prevent firearm-related deaths, an understanding of the holistic impact of changing state firearm policies on firearm homicide rates over the last 30 years is limited.

Objectives

To identify US states that showed unexpected decreases and increases in firearm homicide rates and summarise their firearm policy changes in the last three decades.

Methods

We analysed changes in firearm homicide rates by US state and county from 1990 to 2019. We triangulated across three estimation approaches to derive state rankings and identify the top and bottom three states which consistently showed unexpected decreases (low outliers) and increases (high outliers) in firearm homicide rates. We summarised firearm policy changes in state outliers using the RAND State Firearm Law Database.

Results

We identified New York, District of Columbia, and Hawaii as low state outliers and Delaware, New Jersey, and Missouri as high state outliers. Low state outliers made more restrictive firearm policy changes than high state outliers, which covered a wider range of policy types. Restrictive changes in high state outliers primarily targeted high-risk populations (e.g., prohibited possessors, safe storage). Specific legislative details, such as the age threshold (18 vs 21 years old) for firearm minimum age requirements, also emerged as important for differentiating low from high state outliers.

Conclusions

While no firearm law change emerged as necessary or sufficient, an accumulation of diverse restrictive firearm policies may be key to alleviating the death toll from firearm homicide.

Self-inflicted craniomaxillofacial gunshot wounds by handguns are more deadly than those by shotguns: an NIS study

PURPOSE

The purpose of the present study is to determine whether handguns discharged at the craniomaxillofacial region are associated with greater fatality in suicide attempts relative to shotguns.

METHODS

The following retrospective cohort study was completed using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) database. The primary predictor variable was the type of firearm (handguns vs. shotguns). The primary outcome variable was prognosis (fatality vs. no fatality). A binary logistic regression was performed to determine the risk of mortality of all predictor variables.

RESULTS

Our final sample consisted of 223 patients. Handguns (85.2%) were the most popular firearm. Relative to black patients, white patients were over three times more likely to die (p < 0.05). Compared to patients who were transferred in, patients not transferred in were eight times more likely to die (p = 0.000). Relative to patients who were admitted electively, patients who were not admitted electively were 16.7 times more likely to die (p < 0.01). Finally, relative to patients who used shotguns, patients who used handguns were 3.4 times more likely to die (p = 0.002).

CONCLUSION

Self-inflicted gunshot wounds to the maxillofacial region by handguns were more lethal than shotguns.

Long gun suicides in the state of Maryland following the firearm safety act of 2013

OBJECTIVES

In 2013, the state of Maryland passed the Firearms Safety Act limiting the private sales of handguns, which did not apply to long guns often used for hunting (e.g., rifles and shotguns). This decreased the accessibility of handguns relative to long guns. We assessed the frequency of long gun suicides in the years before and after the policy change during winter season, which encompasses hunting season in Maryland.

METHODS

We performed a retrospective analysis on all 4107 well-characterized adult suicides caused by firearms in Maryland from 2003 through 2019. Logistic regression was performed, stratifying by decedent sex, race, and age.

RESULTS

While handgun suicides decreased in the period after 2013's Firearm Safety Act (p < 0.008), wintertime long gun suicides increased after 2013 (p < 0.004). Caucasian race (p < 0.006), male sex (p < 0.005), and middle age (p < 0.001) were significantly associated with wintertime long gun suicides after 2013.

CONCLUSION

Our findings suggest that while the 2013 Firearms Safety Act decreased handgun suicides significantly, it did not reduce long gun suicides and there may even have been replacement with long guns during hunting season, when rifles are out and accessible. This association was most prominent among the demographics most likely to hunt (Caucasian, middle-aged, and male).

Preventing the most common firearm deaths: Modifiable factors related to firearm suicide

BACKGROUND

More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates.

METHODS

We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates.

RESULTS

In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (β, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases.

CONCLUSIONS

During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.

State Firearm Legislation and Youth/Young Adult Handgun Carrying in the United States

PURPOSE

To examine the association between state firearm legislation and youth/young adult handgun carrying in the United States and to identify policy priority areas for intervention.

METHODS

We linked person-level gun carrying data from a nationally representative sample of U.S. youth and young adults with state-level gun policies over a 15-year period. Cross-classified mixed effects logistic regressions estimated the associations between state gun policies and handgun carrying and explored whether the associations varied by person-level demographic characteristics.

RESULTS

Youth and young adults in states with a greater number of gun policies were less likely to carry a handgun than youth and young adults in states with fewer gun policies. Regulations on gun purchasing, concealed carrying permitting, and domestic violence-related laws were particularly important in reducing youth/young adult gun-carrying behavior. In addition, these associations varied by gender and race/ethnicity.

DISCUSSION

State firearm legislation may be an effective mechanism to reduce youth and young adult gun carrying and ultimately mitigate gun-related mortality and morbidity.

Association of State-Level Firearm-Related Deaths With Firearm Laws in Neighboring States

IMPORTANCE

Firearms are easily transported over state borders; hence permissive firearm laws in one state may have an interstate association with firearm-related deaths in nearby states.

OBJECTIVES

To examine whether certain firearm laws have an interstate association with firearm-related deaths in nearby states.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional observational study used data on state firearm-related deaths in the 48 contiguous states of the US between January 1, 2000, and December 31, 2019. A spatial autoregressive model with fixed effects for state and year was used to evaluate within-state, interstate, and overall associations between firearm laws and firearm-related deaths. Analyses were performed during January 2022.

EXPOSURES

The following 9 types of laws were evaluated: universal background checks for all firearms purchase, background checks for handgun sales at gun shows, license requirement to purchase all firearms, state dealer license requirement for handgun sales, requirement of retaining records of handgun sales, ban on purchasing a handgun on behalf of another, prohibition of firearm possession by persons who committed violent misdemeanors, required relinquishment of firearms for persons becoming prohibited from possessing them, and discretion in granting a concealed carry permit.

MAIN OUTCOMES AND MEASURES

State-level total firearm-related death rates, suicide rates, and homicide rates.

RESULTS

In sum, the study period included 662 883 firearm-related deaths of all intents. License requirement for firearm purchase had a within-state association (effect size, -1.79 [95% CI, -2.73 to -0.84]), interstate association (effect size, -10.60 [95% CI, -17.63 to -3.56]), and overall association (effect size, -12.38 [95% CI, -19.93 to -4.83]) per 100 000 population decrease in total firearm-related deaths. This law also had within-state association (effect size, -1.26 [95% CI, -1.72 to -0.80]), interstate association (effect size, -9.01 [95% CI, -15.00 to -3.02]), and overall association (effect size, -10.27 [95% CI, -16.53 to -4.01]) per 100 000 population decrease in firearm-related homicide.

CONCLUSIONS AND RELEVANCE

The findings of this pooled cross-sectional analysis suggest that certain firearm laws in one state were associated with other states' firearm-related deaths. Synergic legislative action in adjacent states, federal firearm legislation, and measures that reduce migration of firearms across state borders should be part of the overarching strategy to prevent firearm-related deaths.

A Closer Look at the Rising Epidemic of Mass Shootings in the United States and Its Association With Gun Legislation, Laws, and Sales

INTRODUCTION

Mass shootings pose a considerable threat to public safety and significantly cost the United States in terms of lives and expenses. The following are the specific aims of this study: (1) to assess US mass shootings, firearm-related sales, laws, and regional differences from 2015 to 2021 and (2) to investigate changes in mass shootings and firearm sales before and during the Coronavirus Disease 2019 pandemic.

METHODS

A retrospective review was conducted of mass shootings, gun sales, and laws regarding the minimum age required to purchase a firearm within the United States from 2015 to 2021. The 10 states/regions with the greatest mean mass shootings/capita from 2015 to 2021 were selected for further analysis.

RESULTS

Mass shootings correlated significantly with firearm sales from 2015 to 2021 nationwide (P < 0.02 for all). The growth in mass shootings, the number killed/injured, and gun sales were greater in 2020 and 2021 compared to the years prior. The 10 states with the highest mean mass shooting/capita over the study period were Alabama, Arkansas, the District of Columbia, Illinois, Louisiana, Maryland, Mississippi, Missouri, South Carolina, and Tennessee. No significant correlation was found between the number of mass shootings/capita and the minimum age to purchase a firearm.

CONCLUSIONS

Firearm sales correlated significantly with mass shootings from 2015 to 2021. Mass shootings and gun sales increased at greater rates during the Coronavirus Disease 2019 pandemic compared to the years before the pandemic. Mass shootings exhibited inconsistent trends with state gun laws regarding the minimum age to purchase a firearm. Future studies may consider investigating the methods by which firearms used in mass shootings are obtained to further identify targets for prevention.

Achieving health equity in US suicides: a narrative review and commentary

Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.

The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51–85 + years old for both sexes. Of all US suicides from 1999–2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71–85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2–4 times higher suicide rates than women, despite having only 1/4—1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.

To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.

The Association Between Repealing the 48-Hour Mandatory Waiting Period on Handgun Purchases and Suicide Rates in Wisconsin

IMPORTANCE

Suicide is a significant public health burden in the United States. There is little understanding how policies regarding gun purchasing affects suicide rates. Wisconsin state legislature rescinded a 48-hour waiting period for handgun purchases, which took effect in June 2015.

OBJECTIVE

To determine whether firearm-related suicide increased with the repeal of the 48-hour waiting period for handgun purchases in 2015.

METHOD

We obtained data through the Wisconsin Department of Health Services via the Wisconsin Interactive Statistics on Health Query System. Suicide rates were compared by Comparative Mortality Figures (CMF).

RESULTS

We reviewed all suicides in Wisconsin between 2012-2014 and 2016-2018. The rate ratios (R) and second generation P values (p_δ) comparing deaths between 2012-2014 and 2016-2018 indicate significant increases in firearm-related suicide among people of color (R = 1.927; p_δ = 0.0) and among Wisconsinites residing in urban counties (R = 1.379, p_δ = 0.0). There was no significant increase in non-firearm-related suicide (R = 1.117, p_δ = 0.092), nor in firearm-related suicide among White non-Hispanics (R = 1.107, p_δ = 0.164) or Wisconsinites residing in rural counties (R = 1.085, p_δ = 0.500).

CONCLUSION

Our findings suggest that the repeal of the 48-hour waiting period on handgun purchases in 2015 is correlated with the increase of firearm-related suicides among Wisconsin residents of color and Wisconsinites residing in urban counties.Key Messages:Firearm policies are associated with changes in suicide rates.

County-Level Variation in Changes in Firearm Mortality Rates Across the US, 1989 to 1993 vs 2015 to 2019

IMPORTANCE

Firearm violence remains a critical public health challenge, disproportionately impacting some US regions. County-level variation may hold key insights into how firearm mortality rates vary across the US.

OBJECTIVE

To model county-level changes in firearm mortality rates (total, homicide, and suicide) from 1989 to 1993 vs 2015 to 2019 and identify and characterize hot spots showing unexpected changes over time.

DESIGN, SETTING, AND PARTICIPANTS

This is a cross-sectional study with 2 time points using a novel small area estimation method to analyze restricted access mortality microdata by cause of death and US county. The analysis included 3111 US counties from 49 states and the District of Columbia from January 1, 1989, to December 31, 2019. Bayesian spatial models were fitted to map geographical variation in changes in age-standardized firearm mortality rates (per 100 000 person-years) from 1989 to 1993 vs 2015 to 2019. County outliers (or hot spots) were defined as having observed rates that fell outside the 95% credible intervals of their expected posterior predictive distribution. These counties were characterized using visualization and descriptive statistics of their characteristics. Data were analyzed from June to December 2021.

EXPOSURES

County of residence.

MAIN OUTCOMES AND MEASURES

Five-year age-standardized mortality rates by US county, age, and cause of death for 1989 to 1993 and 2015 to 2019.

RESULTS

Between 1989 and 2019, 1 036 518 firearm deaths were recorded in counties across the US. Suicide was the most common cause of firearm mortality (589 285 deaths) followed by homicide (412 231 deaths). Age-standardized rates (deaths per 100 000 individuals) for firearm deaths and suicides increased from 1989 to 1993 vs 2015 to 2019 (mean [SD] change, 0.16 [8.78] for firearm deaths and 1.21 [6.91] for suicides), while firearm homicides decreased (mean [SD] change, -0.39 [3.96]). However, these national trends were not homogeneous across counties and often varied by geographical region. The West and Midwest showed the most pronounced increases in firearm suicide rates, whereas the Southeast showed localized increases in firearm homicide rates, despite the national decreasing trend. Critical hot spots were identified in urban counties of Alabama, and firearm homicide rates (per 100 000) in Baltimore City, Maryland, almost doubled from 29.71 to 47.43, and by 2015 to 2019 it accounted for 66.7% of all firearm homicide in Maryland. By contrast, District of Columbia showed promising improvements over time, decreasing from 56.5 firearm homicides per 100 000 in 1989 to 1993 to 14.45 in 2015 to 2019.

CONCLUSIONS AND RELEVANCE

There was substantial variation in rates and changes in firearm deaths among US counties. Geographical hot spots may be useful to inform targeted prevention efforts and local policy responses.

Suicide mortality among psychiatric patients in Northeast Italy: a 10-year cohort study

AIMS

The present study investigated the relationship between suicide mortality and contact with a community mental health centre (CMHC) among the adult population in the Veneto Region (northeast Italy, population 4.9 million). Specifically, it estimated the effects of age, gender, time elapsed since the first contact with a CMHC, calendar year of diagnosis and diagnostic category on suicide mortality and modality.

METHODS

The regional mortality archive was linked to electronic medical records for all residents aged 18-84 years who had been admitted to a CMHC in the Veneto Region in 2008. In total, 54 350 subjects diagnosed with a mental disorder were included in the cohort and followed up for a period of 10 years, ending in 2018. Years of life lost (YLL) were computed and suicide mortality was estimated as a mortality rate ratio (MRR).

RESULTS

During the follow-up period, 4.4% of all registered deaths were from suicide, but, given the premature age of death (mean 52.2 years), suicide death accounted for 8.7% of YLL; this percentage was particularly high among patients with borderline personality disorder (27.2%), substance use disorder (12.1%) and bipolar disorder (11.5%) who also presented the highest suicide mortality rates. Suicide mortality rates were halved in female patients (MRR 0.45; 95% CI 0.37-0.55), highest in patients aged 45-54 years (MRR 1.56; 95% CI 1.09-2.23), and particularly elevated in the 2 months following first contact with CMHCs (MRR 10.4; 95% CI 5.30-20.3). A sensitivity analysis restricted to patients first diagnosed in 2008 confirmed the results. The most common modalities of suicide were hanging (47%), jumping (18%), poisoning (13%) and drowning (10%), whereas suicide from firearm was rare (4%). Gender, age at death and time since first contact with CMHCs influenced suicide modality.

CONCLUSIONS

Suicide prevention strategies must be promptly initiated after patients' first contact with CMHCs. Patients diagnosed with borderline personality disorder, substance use disorder and bipolar disorder may be at particularly high risk for suicide.

State firearm laws and nonfatal firearm injury-related inpatient hospitalizations: A nationwide panel study

BACKGROUND

Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period.

METHODS

In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law.

RESULTS

Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates.

CONCLUSION

State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

State firearm laws, gun ownership, and K-12 school shootings: Implications for school safety

Limited research has been conducted on the state-level factors that may be associated with intentional school shootings. We obtained school shooting data from the Washington Post that identified any act of intentional interpersonal gunfire in a K-12 school over the course of two decades. We also compiled new data on active school shootings during the same twenty-year time period, which identified any attempted mass shooting incident in a K-12 school. We conducted a time-series analysis to measure the association of permissiveness of state firearm laws and state gun ownership with K-12 school shootings and active shootings. More permissive firearm laws and higher rates of gun ownership were associated with higher rates of both school shootings and active school shootings after controlling for critical covariates. Specific recommendations for K-12 schools to consider as they seek to prevent acts of intentional gunfire on school grounds are presented.

Permissiveness of firearm laws, pro-gun culture, and suicides by firearm in the U.S., 2000–2016

Objectives

Stricter firearm policies correlate with lower suicides by firearm in the US. However, much work examines policies in isolation and does not investigate firearm policies as they relate to US pro-gun culture. We examine the relation between permissiveness of state firearm laws, gun culture, and suicides by firearm.

Study design

Panel longitudinal study.

Methods

The count of suicides by firearm for 50 US states from 2000 to 2016 served as the outcome. Permissiveness of multiple state firearm laws, based on ratings from the Traveler's Guide to the Firearm Laws of the Fifty States, served as the exposure. These ratings, measured at the state-year, capture not only the overall policy environment but also the extent to which the state exhibits a pro-gun culture. We applied a fixed effects negative binomial count model, which controls for the population-at-risk, to examine suicides overall and by race/ethnicity and gender.

Results

A 10-unit increase in permissiveness of state firearm laws corresponds with 2% greater suicides by firearm overall (Incidence rate ratio [IRR] = 1.02; 95% CI: 1.01–1.03) and among non-Hispanic white males ([IRR] = 1.02, 95% CI: 1.01–1.02).

Conclusions

Findings, if replicated, indicate that states enacting more restrictive firearm policies, and lessening a pro-gun culture, may lead to reductions in suicide by firearm.

•

Firearms persist as the most common method of suicide in the US.

•

Firearm policies and the broader pro-gun culture may correspond with suicides.

•

Permissiveness of state firearm laws precede increases in suicides by firearm.

•

A restrictive suite of firearm policies may reduce suicides by firearm.

Bang for the buck: The impact of political financial contributions on firearm law

BACKGROUND

One hundred thousand Americans are shot annually, and 39,000 die. State laws restricting firearm sales and use have been shown to decrease firearm deaths, yet little is known about what impacts their passage or repeal. We hypothesized that spending by groups that favor firearm restrictive legislation would increase new state firearm restrictive laws (FRLs) and that states increasing these laws would endure fewer firearm deaths.

METHODS

We acquired 2013 to 2018 state data on spending by groups against firearm restrictive legislation and for firearm restrictive legislation regarding lobbying, campaign, and independent and total expenditures from the National Institute on Money in State Politics. State-level political party representation data were acquired from the National Conference of State Legislatures. Mass shooting data were obtained from the Mass Shooter Database of the Violence Project, and firearm death rates were obtained from Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research and Federal Bureau of Investigation Uniform Crime Reporting databases. Firearm restrictive laws were obtained from the State Firearms Law Database. A univariate panel linear regression with fixed effect for state was performed with change in FRLs from baseline as the outcome. A final multivariable panel regression with fixed effect for state was then used. Firearm death rates were compared by whether states increased, decreased, or had no change in FRLs.

RESULTS

Twenty-two states gained and 13 lost FRLs, while 15 states had no net change (44%, 26%, and 30%; p = 0.484). In multivariable regression accounting for partisan control of state government, for-firearm restrictive legislation groups outspending against-firearm restrictive legislation groups had the largest association with increased FRLs (β = 1.420; 95% confidence interval, 0.63-2.21; p < 0.001). States that gained FRLs had significantly lower firearm death rates (p < 0.001). Relative to states with no change in FRLs, states that lost FRLs had an increase in overall firearm death of 1 per 100,000 individuals. States that gained FRLs had a net decrease in median overall firearm death of 0.5 per 100,000 individuals.

CONCLUSION

Higher political spending by groups in favor of restrictive firearm legislation has a powerful association with increasing and maintaining FRLs. States that increased their FRLs, in turn, showed lower firearm death rates.

LEVEL OF EVIDENCE

Epidemiological, level I.

The mitigating effect of low firearm background check requirements on firearm homicides in border states

BACKGROUND

Firearm-related violence is a significant public health issue in the US. Research has found an increase in guns used in crimes sourced from low gun law states into high gun law states. The purpose of this study is to evaluate the effect of distance from states without universal background checks (UBC), background checks at shows (BCS), or permit to purchase (PTP) laws on firearm homicide rates in states with them.

METHODS

States were identified based on their enactment of laws that are designed to prevent the private sale of firearms to criminals. Demographic data for each county were obtained for the years 2014 through 2017. The border distance from a county in a state with the evaluated gun laws to the nearest border state without the gun laws was obtained using Google Maps. Multiple regression analyses were performed to test the relationship between border distance and firearm homicide rates.

RESULTS

The regression model evaluating all formats found the border distance was negatively associated with firearm homicides (p=.009). The parameter estimate indicated as border distance increased, the firearm homicide rate decreased. When counties with UBC or PTP on all guns were evaluated separately from all formats model, the statistical significance was lost (p=.62). In counties where all handgun sales either require a background check or a PTP is required, the distance was also not statistically significant (p=.11).

CONCLUSIONS

This study provides evidence that there may be a mitigating effect on the reduction of firearm homicides in states that require background checks or PTP on private sales when there is a state in close proximity that did not have these laws. Limited counties at certain distances may have contributed to the insignificant findings in other models.

Demographics and Incident Location of Gunshot Wounds at a Single Level I Trauma Center

Introduction

Kansas has seen a steady increase in the rate of firearm deaths and injuries. Little is known surrounding the demographic and geospatial factors of these firearm-related traumas. The purpose of this study was to describe the overall incidence of firearm-related traumas, identify high injury locations, and examine any racial/ethnic disparities that may exist.

Methods

A retrospective review was conducted of all patients 14 years or older who were admitted with a gunshot wound (GSW) to a Level I trauma center between 2016 and 2017.

Results

Forty-nine percent of patients were Caucasian, 26.5% African American, and 19.6% Hispanic/Latino. Hispanic/Latino patients were the youngest (25.8 ± 8.8 years) and Caucasians were the oldest (34.3 ± 14.1 years, p = 0.002). Compared to Caucasian patients, African American (42.0%) and Hispanic/Latino (54.1%) patients were more likely to be admitted to the intensive care unit (ICU; p = 0.034) and experienced longer ICU lengths of stay (2.5 ± 6.3 and 2.4 ± 4.7 days, p = 0.031, respectively). African American patients (96.0%) experienced more assaults, while Caucasians were more likely to receive gunshot wounds accidentally (26.9%, p = 0.001). More African American (86.0%) and Hispanic/Latino (89.2%) patients were injured with a handgun and Caucasians sustained the highest percentage of shotgun/rifle related injuries (16.1%, p = 0.012). Most GSWs occurred in zip codes 67202, 67203, 67213, 67211, and 67214. Geographical maps indicated that GSWs occur in neighborhoods with low-income and high minority residents and in the downtown and nightclub areas of the city.

Conclusions

Most GSW victims were older Caucasian males. Racial differences were noted and injury locations concentrated in certain locations.

Firearm Suicides in the Elderly: A Narrative Review and Call for Action

Firearm suicides are one of the leading causes of death for older Americans. The purpose of this review is to explore the risk factors associated with suicides in the elderly, provide an overview of the epidemiology of firearm-related suicides in older Americans, and explore methods of preventing firearm suicides in the elderly. The vast majority (70 %) of elderly suicides in the U.S were committed using a firearm. Elderly firearm suicides have increased by 49 % between 2010 and 2018, disproportionately affecting white males. Yearly firearm suicides in the elderly ranged from 4,276 in 2010 to 6,375 in 2018. In 2018, the rate of elderly male firearm suicides was 24.96/100,000 compared to a rate of 1.92/100,000 for elderly females, a rate ratio of 13 to 1 for males compared to females. The primary risk factors for elderly firearm suicides seem to be physical illnesses, mental illnesses, and social factors. Older Americans engage in suicidal behaviors with greater planning and lethality of intent than do young adults. Of all the strategies to prevent suicides with firearms, the most efficacious measures based on current research seem to be state firearm legislation and improving mental healthcare, but these effects are not specific to the elderly. Strengthening state firearm laws and improving mental healthcare for the elderly may have promise in preventing elderly firearm-related suicides. Additional implications for practice and research are discussed in this review.

Firearm Homicide Incidence, Within-state Firearm Laws, and Interstate Firearm Laws in US Counties

BACKGROUND

Firearm homicides occur less frequently in US states with more firearm control laws. However, firearms are easily transported across state lines, and laws in one location may affect firearm violence in another. This study examined associations between within-state firearm laws and firearm homicide while accounting for interference from laws in other nearby states.

METHODS

The units of analysis were 3,107 counties in the 48 contiguous US states, arrayed in 15 yearly panels for 2000 to 2014 (n = 46,605). The dependent measure was firearm homicides accessed from the Centers for Disease Control and Prevention (CDC) Compressed Mortality Data. The main independent measures were counts of firearm laws and the proportion of laws within categories (e.g., background checks, child access prevention laws). We calculated these measures for interstate laws using a geographic gravity function between county centroids. Bayesian conditional autoregressive Poisson models related within-state firearm laws and interstate firearm laws to firearm homicides.

RESULTS

There were 172,726 firearm homicides in the included counties over the 15 years. States had between 3 and 100 firearm laws. Within-state firearm laws (incidence rate ratio [IRR] = 0.995, 95% confidence interval [CI] = 0.992, 0.997) and interstate firearm laws (IRR = 0.993, 95% CI = 0.990, 0.996) were independently associated with fewer firearm homicides, and associations for within-state laws were strongest where interstate laws were weakest.

CONCLUSIONS

Additional firearm laws are associated with fewer firearm homicides both within the states where the laws are enacted and elsewhere in the United States. Interference from interstate firearm laws may bias associations for studies of within-state laws and firearm homicide.

Association of Minimum Age Laws for Handgun Purchase and Possession With Homicides Perpetrated by Young Adults Aged 18 to 20 Years

IMPORTANCE

Laws mandating a minimum age to purchase or possess firearms are viewed as a potentially effective policy tool to reduce homicide by decreasing young adults' access to firearms.

OBJECTIVE

To evaluate whether state laws that raised the minimum age to purchase and/or possess a handgun to 21 years were associated with lower rates of firearm homicide perpetrated by young adults aged 18 to 20 years.

DESIGN, SETTING, AND PARTICIPANTS

In this difference-in-differences analysis of a national cohort, young adult-perpetrated homicide rates were compared between states that did and did not implement stricter minimum age laws than the 1994 federal statute, adjusting for state-level factors. Under 1994 US federal law, the minimum age to purchase a handgun from a licensed dealer is 21 years; to purchase a handgun from an unlicensed dealer, 18 years; and to possess a handgun, 18 years. The 12 states that raised the minimum ages to purchase and/or possess a handgun beyond those set by federal law before 1994 were excluded from the stricter implementation group. Data were collected from January 1, 1995, to December 31, 2017, and analyzed from November 7, 2019, to June 23, 2020.

EXPOSURES

Implementation of state law to raise the minimum age to purchase and/or possess a handgun beyond federal minimum age laws. During the study period, Massachusetts, Maryland, New Jersey, New York, and Wyoming raised the minimum age from 18 to 21 years to purchase a handgun from all dealers. With the exception of Wyoming, these states also increased the minimum age from 18 to 21 years to possess a handgun.

MAIN OUTCOMES AND MEASURES

Firearm homicides perpetrated by young adults aged 18 to 20 years. Homicide data were obtained from the Supplementary Homicide Reports.

RESULTS

During the study period, 35 960 firearm homicides were perpetrated by young adults aged 18 to 20 years. There was no statistically significant change in the rates of homicide perpetrated by this age group in the 5 states that imposed stricter age limits compared with the 32 that did not (crude incidence rate ratio, 1.10; 95% CI, 0.86-1.40). The adjusted incidence rate ratio was 1.14 (95% CI, 0.89-1.45) in states that implemented stricter minimum age laws compared with those that did not.

CONCLUSIONS AND RELEVANCE

This study found that stricter state minimum age laws were not associated with significantly lower rates of young adult-perpetrated homicide in states that adopted them compared with states that did not, and policy makers should reassess their use.

Neighbors Do Matter: Between-State Firearm Laws and State Firearm-Related Deaths in the U.S., 2000-2017

INTRODUCTION

Firearm injury is a major U.S. public health concern. This study aims to evaluate whether the relationship between state firearm laws and state firearm deaths are affected by comparatively lenient firearm laws in neighboring states.

METHODS

This observational study used 2000‒2017 data on firearm deaths and firearm laws of the 48 contiguous states of the U.S. (Alaska, Hawaii, and the District of Columbia excluded). The associations among state firearm deaths, state firearm laws, and presence of neighboring states with more lenient laws were analyzed using negative binomial regression models with state- and year-fixed effects. Analyses were conducted in 2019‒2020.

RESULTS

There were 578,022 firearm deaths of all intents during the study period or 11.1 firearm deaths (IQR=8.5-14.0) per 100,000 population. The presence of more state firearm laws was associated with decreased firearm deaths (incident rate ratio=0.991, 95% CI=0.987, 0.996). However, weaker firearm laws in neighboring states correlated with more firearm deaths within a state (incident rate ratio=1.016, 95% CI=1.004, 1.028). Failing to account for weaker laws in neighboring states led to the underestimation of the impact of 1 additional law on state's own firearm deaths (incident rate ratio=0.994, 95% CI=0.989, 0.998 vs 0.991, 95% CI=0.987, 0.996) by approximately 20%.

CONCLUSIONS

Weaker firearm laws in neighboring states may undermine the effectiveness of a state's own firearm laws in curbing firearm deaths. Coordinated legislative action across neighboring states may be more effective than an individual state taking legislative action.

Universal background checks for handgun purchases can reduce homicide rates of African Americans

BACKGROUND

Federal law requires background checks for firearms purchased from licensed dealers, but states can extend requirements to private sales of handguns and purchases at gun shows (universal background checks for handguns [UBC-HG]). Although firearm homicide disproportionately affects African Americans, little is known about how UBG-HG impacts African Americans. We hypothesized that implementation of UBC-HG would reduce rates of firearm homicide of African Americans.

METHODS

We collected Centers for Disease Control firearm homicide counts for African American and white populations in the 50 states, 1999 to 2017. Laws were drawn from the State Firearm Laws Database. The exposure and outcome of interest were UBC-HG adoption and firearm homicide. We included non-Hispanic African American and non-Hispanic white populations. We used Poisson regression to perform a differences-in-differences analysis. A categorical variable for state accounted for time-stable state characteristics. We controlled for year to account for trends over time unrelated to policy. We controlled for state-specific, time-variable factors, including median household income, population younger than 25 years or 65 years or older, alcohol consumption, and count of firearm laws (UBC-HG excluded). Standard errors were adjusted for clustering at the state level.

RESULTS

The firearm homicide rate among whites was 1.8 per 100,000 (interquartile range, 1.2-2.7) ranging from 1.4 in 2011 to 1.8 in 2016. The firearm homicide rate was 15.6 per 100,000 (interquartile range, 11.6-21.0) among African Americans, ranging from 14.0 in 2009 to 19.6 in 2017. While no significant difference in firearm homicides among whites (incidence rate ratio, 0.93; 95% confidence interval, 0.73-1.20) was appreciated, the passage of UBC-HG was associated with an 19% decrease in African Americans firearm homicides (incidence rate ratio, 0.81; 95% confidence interval, 0.70-0.94; p = 0.006).

CONCLUSION

Implementing UBC-HG was associated with decreased firearm homicides among African Americans-the population most at risk. Expanding UBC-HG may be an effective approach to reducing racial disparities in firearm homicides.

LEVEL OF EVIDENCE

Epidemiological, level III.

Beyond Band-Aids for Bullet Holes: Firearm Violence As a Public Health Priority

OBJECTIVES

To review the public health approach to preventing and treating firearm violence.

DATA SOURCES

Peer-reviewed, published scholarship and federal data systems.

STUDY SELECTION

English-language, indexed research articles on the epidemiology, risk, prevention, and consequences of firearm violence.

DATA EXTRACTION

This narrative review includes findings related to the epidemiology and impact of firearm violence, focusing on short- and long-term outcomes. Evidence supporting interventions at the individual, agent, and environmental level to reduce firearm-related harm was examined.

DATA SYNTHESIS

Firearm violence is a major public health challenge in the Unites States. The consequences of firearm violence reach beyond the nearly 40,000 firearm-related deaths and 90,000 firearm-related injuries each year. Firearm violence, including self-harm, assault, and unintentional injury, affects the health of individuals, families, communities, and health systems. Data sources remain inadequate, however, to fully capture these impacts. Treating firearm violence as a disease and taking a public health approach to prevention and treatment is key to reducing the harms of firearm violence. Using a public health framework not only recognizes the physical and mental consequences of firearm violence but also focuses our attention on underlying causes and on innovative, multi-level interventions to reduce the harms of firearm violence.

CONCLUSIONS

The public health approach positions clinicians to change the conversation from political diatribe of pro-gun and anti-gun to systematically reducing injury and death. To achieve comparable success, we must design, test, and implement effective interventions at the environmental, policy, technological, and individual levels to prevent firearm violence. We must collect robust data on firearm violence and its consequences. And we must reckon with the conditions of inequality and disadvantage that feed violence through all means.

Firearm suicide mortality among emergency department patients with physical health problems

PURPOSE

Individuals with poor physical and mental health may face elevated risk for suicide, particularly suicide by firearm.

METHODS

This retrospective cohort study used statewide, longitudinally linked emergency department (ED) patient record and mortality data to examine 12-month incidence of firearm suicide among ED patients presenting with a range of physical health problems. Participants included all residents presenting to a California ED in 2009-2013 with nonfatal visits for somatic diagnoses hypothesized to increase suicide risk, including myocardial infarction, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, cancer, back pain, headache, joint disorder, and injuries. For each patient diagnostic group, we calculated rates of firearm suicide per 100,000 person-years and standardized mortality ratios (SMRs) relative to the demographically matched California population.

RESULTS

Firearm suicide rates per 100,000 person-years ranged from 9.6 (among patients presenting with unintentional injury) to 55.1 (patients with cancer diagnoses), with SMRs from 1.48 to 7.45 (all p < 0.05). SMRs for patients with cardiovascular conditions ranged from 2.45 to 5.10. Men and older individuals had higher firearm suicide rates, and there was substantial between-group variability in the proportion of suicide decedents who used a firearm.

CONCLUSIONS

ED patients presenting with deliberate self-harm injuries, substance use, and cancer were especially at risk for firearm suicide. To avoid missed suicide prevention opportunities, EDs should implement evidence-based suicide interventions as a best practice for their patients.

Ecological factors associated with suicide mortality among non-Hispanic whites

BACKGROUND

In this paper, we examine the ecological factors associated with death rates from suicide in the United States in 1999 and 2017, a period when suicide mortality increased in the United States. We focus on Non-Hispanic Whites, who experienced the largest increase in suicide mortality. We ask whether variation in suicide mortality among commuting zones can be explained by measures of the social and economic environment and access to lethal means used to kill oneself in one's area of residence.

METHODS

We use vital statistics data on deaths and Census Bureau population estimates and define area of residence as one of 704 commuting zones. We estimate separate models for men and women at ages 20-64 and 65 and above. We measure economic environment by percent of the workforce in manufacturing and the unemployment rate and social environment by marital status, educational attainment, and religious participation. We use gun sellers and opioid prescriptions as measures of access to lethal means.

RESULTS

We find that the strongest contextual predictors of higher suicide mortality are lower rates of manufacturing employment and higher rates of opiate prescriptions for all age/sex groups, increased gun accessibility for men, and religious participation for older people.

CONCLUSIONS

Socioeconomic characteristic and access to lethal means explain much of the variation in suicide mortality rates across commuting zones, but do not account for the pervasive national-level increase in suicide mortality between 1999 and 2017.

Trends in Mortality From Drug Poisonings, Suicide, and Alcohol-Induced Deaths in the United States From 2000 to 2017

IMPORTANCE

Life expectancy has decreased in the US, driven largely by increases in drug poisoning, suicide, and alcohol-induced deaths. Assessing whether patterns of these causes differ is required to inform public health interventions.

OBJECTIVE

To compare patterns and trends in drug poisoning, suicide, and alcohol-induced death rates by geography and demographic characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study used national vital statistics data from the entire US population from January 1, 2000, to December 31, 2017, among US residents aged 20 to 64 years. Data were analyzed from January through August 2019.

EXPOSURES

Age, sex, race/ethnicity, county-level percentage of unemployment, rurality, and geography.

MAIN OUTCOMES AND MEASURES

Deaths were categorized as due to drug poisoning, suicide, or alcohol-induced causes based on underlying cause of death. Age-standardized incidence rates and annual percentage changes (APCs) in rates were estimated. Clusters of high-rate counties were identified with hot spot analysis. Excess deaths during 2001 to 2017 were estimated for each cause as the difference between the number of deaths observed and expected if rates had remained stable starting in 2000.

RESULTS

During 2000 to 2017, 1 446 177 drug poisoning, suicide, and alcohol-induced premature deaths occurred in the US, including 563 765 drug poisoning deaths (age-standardized rate: 17.6 per 100 000 person-years [PYs]), 517 679 suicides (age-standardized rate: 15.8 per 100 000 PYs), and 364 733 alcohol-induced deaths (age-standardized rate: 10.5 per 100 000 PYs), totaling 451 596 more deaths than expected based on 2000 rates. High drug poisoning death rates were clustered in the Northeast through Appalachia, yet rates of suicide and alcohol-induced deaths were highest in the West. Only suicide death rates were highest in rural areas. Drug poisoning death rates were highest among people aged 35 to 49 years (age-standardized rate: 23.7 per 100 000 PYs), whereas suicide and alcohol-induced death rates peaked among people aged 50 to 64 years (suicide age-standardized rate: 19.6 per 100 000 PYs; alcohol-induced age-standardized death rate: 26.8 per 100 000 PYs). Increases occurred over time across racial/ethnic groups, although trajectories and inflection years varied. Drug poisoning (2013-2017 APC, 15.0% [95% CI, 11-8%-18.3%] per year) and alcohol-induced death rates (2012-2017 APC, 4.1% [95% CI, 3.3%-4.9%] per year) have accelerated recently, while increases in suicide death rates have largely increased at a constant trajectory (2000-2017 APC, 1.8% [95% CI, 1.7%-1.9%] per year).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that demographic characteristics and geographic patterns varied by cause of death, suggesting that increasing death rates from these causes were not concentrated in 1 group or region. Specialized interventions tailored for the underlying drivers of each cause of death are urgently needed.

Longitudinal Associations Between Healthcare Resources, Policy, and Firearm-Related Suicide and Homicide from 2012 to 2016

BACKGROUND

Firearm-related violence is a leading cause of mortality in the United States (US). Prior research suggests that public policy plays a role in firearm mortality, but the role of healthcare resources (physicians, insurance coverage) within the US policy context has not yet been studied.

OBJECTIVE

To examine how healthcare resources and social/firearm policy affect firearm-related suicide and homicide rates in the US.

DESIGN

Longitudinal, ecological study.

SETTING

US.

PARTICIPANTS

US states from 2012 to 2016 (N = 242).

MEASUREMENT

The outcome variables were age-adjusted, firearm-related suicide and homicide rates. Predictor variables were healthcare resources (physicians, Medicaid benefits generosity) and policy context (social policy, firearm policy) with covariates for sociodemographic factors.

RESULTS

Healthcare provider variables did not have significant associations to firearm-related suicide or homicide. In fully saturated models, more worker protection laws, greater average population density, more alcohol regulation, and more firearm prohibition policies were associated with fewer firearm-related suicides. Higher generosity of Medicaid benefits was associated with fewer firearm-related homicides. Poverty rate was a predictor of both outcomes.

LIMITATIONS

This state-level study cannot make individual-level inferences. Only proxy variables were available for measuring gun ownership and actual gun ownership rates may not have been ideally captured at the state level.

CONCLUSIONS

At the state level, there are protective associations of certain social, healthcare, and firearm policies to firearm-related suicide and homicide rates. Healthcare resources play a role in population-level firearm outcomes but alone are not sufficient to decrease firearm-related homicide or suicide.

Firearm laws and illegal firearm flow between US states

BACKGROUND

Considerable variation in firearm legislation exists. Prior studies show an association between stronger state laws and fewer firearm deaths. We hypothesized that firearms would flow from states with weaker laws to states with stronger laws based on proximity and population.

METHODS

Crime gun trace data from 2015 to 2017 was accessed from the Bureau of Alcohol, Tobacco, Firearms and Explosives and compared with the count and composition of firearm legislation in 2015 among the contiguous 48 states. Additional independent variables included population, median household income, distance, and presence or absence of a shared border. We used Exponential Random Graph Models to identify predictors of traced firearm transfers between origin and destination states.

RESULTS

After controlling for network structure, firearm laws in origin states were associated with fewer traced firearm transfers (incidence rate ratio [IRR], 0.88; 95% confidence interval [CI], 0.83-0.93; p < 0.001). Conversely, more firearm laws in destination states were associated with more traced firearm transfers (IRR, 1.10; 95% CI, 1.06-1.15; p < 0.001). Larger population at the origin was associated with increased transfers (IRR, 1.38; 95%CI, 1.27-1.50; p < 0.001), as was larger population at the destination state (IRR, 1.45; 95% CI, 1.35-1.56; p < 0.001). Greater distance was associated with fewer transfers (for each 1,000 km; IRR, 0.35; 95% CI, 0.27-0.46; p < 0.001), and transfers were greater between adjacent states (IRR, 2.49; 95% CI, 1.90-3.27; p < 0.001).

CONCLUSION

State firearm legislation has a significant impact on gun trafficking even after controlling for network structure. States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state.

LEVEL OF EVIDENCE

Epidemiologic, level III.

American firearm homicides: The impact of your neighbors

BACKGROUND

Restrictive firearm legislation has correlated with decreased overall firearm fatality rates, but not with firearm-related homicide or firearm mortality among Black Americans. We hypothesized that firearm trafficking from states with less restrictive firearm legislation to neighboring states with more restrictive firearm legislation increases firearm homicide rates in those restrictive states.

METHODS

For years 2011-2015, state firearm legislation Brady Campaign to Prevent Gun Violence scorecards were analyzed in relation to firearms traced by the Bureau of Alcohol, Tobacco, and Firearms and Center for Disease Control and Prevention firearm mortality rates. States were ranked by Brady score and arranged by quintile to establish the Standardized Brady Score. The effect of less-restrictive neighboring states on the 10 most-restrictive firearm legislation states was modeled by averaging the 10 most-restrictive states with their bordering states to create a Border Adjustment Score. Firearm fatality rates were calculated for each quintile and Poisson regression models were created for each score and outcome. Model fit was compared using Akaike Information Criterion (AIC).

RESULTS

There were 169,396 firearm fatalities including 57,885 firearm homicides. Comparing top and bottom quintile firearm legislation states, 65% vs. 44% of firearms traced by the Bureau of Alcohol, Tobacco, Firearms and Explosives originated in other states respectively. The Border Adjustment Score generated a more linear relationship than the Standardized Brady Score for all firearm fatality categories as firearm legislation scores decreased. The Border Adjustment Score minimized the AIC with respect to the Standardized Brady Score for black (AIC, 4443 vs. 4680) and white firearm homicide rates (3243 vs. 4319), indicating improved model fit after adjustment for neighboring state firearm legislation.

CONCLUSION

Our results suggest that firearm movement across states plays an important role in firearm homicides. Accounting for firearm legislation in both individual and neighboring states may improve our understanding of the relationship between firearm legislation and homicide.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level IV.

Child Access Prevention Firearm Laws and Firearm Fatalities Among Children Aged 0 to 14 Years, 1991-2016

IMPORTANCE

Firearms caused more than 500 pediatric fatalities in 2017-a 50% increase from 2009. Laws regulating firearms are one approach to reducing pediatric firearm fatalities.

OBJECTIVE

To evaluate the association between state child access prevention (CAP) firearm laws and pediatric firearm fatalities.

DESIGN, SETTING, AND PARTICIPANTS

A state-level, cross-sectional study of CAP firearm laws throughout the United States, 1991-2016, was conducted using negative binomial regression to analyze differences in state fatality rates in children aged 0 to 14 years. Data analysis was performed from November 21, 2018, to October 18, 2019.

EXPOSURES

Implementation of 2 categories of state CAP firearm laws: recklessness laws, which pertain to providing a firearm to a child, and negligence laws, which pertain to accessibility of a firearm within the home.

MAIN OUTCOMES AND MEASURES

Rates of firearm fatalities across all intents and by specific intent (homicide, suicide, and unintentional) per 100 000 children aged 0 to 14 years.

RESULTS

Twenty-five states passed CAP laws between 1989 and 2000. Between 1991 and 2016, 13 697 firearm fatalities occurred in children aged 0 to 14 years. Recklessness laws were not associated with changes in pediatric firearm fatality rates. Negligence laws overall were associated with significant reductions in firearm fatalities in children aged 0 to 14 years, with a 13% relative reduction in all firearm fatalities (95% CI, -18% to -7%), a 15% relative reduction in firearm homicides (95% CI, -22% to -7%), a 12% relative reduction in firearm suicides (95% CI, -20% to -2%), and a 13% relative reduction in unintentional firearm fatalities (95% CI, -24% to -1%). The most stringent negligence laws were associated with unintentional firearm fatality reductions of 59% (95% CI, -68% to -49%). A total of 3929 deaths (29% of all firearm deaths) were associated with states not having passed the most stringent form of negligence CAP laws.

CONCLUSIONS AND RELEVANCE

In this study, negligence laws were associated with relative reductions in firearm fatality rates in children aged 0 to 14 years. The most stringent negligence laws were associated with the largest reductions in unintentional firearm fatalities. Recklessness laws were not associated with reduced firearm fatality rates. The passage of negligence CAP laws may have the potential to reduce firearm fatalities in children.

The relationship of nursing practice laws to suicide and homicide rates: a longitudinal analysis of US states from 2012 to 2016

BACKGROUND

Nursing resources can have a protective effect on patient outcomes, but nurses and nursing scope of practice have not been studied in relation to injury outcomes. The purpose of this study was to examine whether scope of practice and ease of practice laws for nurse practitioners and registered nurses are associated with suicide and homicide rates in the United States.

METHODS

This state-level analysis used data from 2012 to 2016. The outcome variables were age-adjusted suicide and homicide rates. The predictor variables were NP scope of practice by state (limited, partial, or full) and RN ease of practice (state RN licensure compact membership status). Covariates were state sociodemographic, healthcare, and firearm/firearm policy context variables that have a known relationship with the outcomes.

RESULTS

Full scope of practice for NPs was associated with lower rates of suicide and homicide, with stronger associations for suicide. Likewise, greater ease of practice for RNs was associated with lower suicide and homicide rates.

CONCLUSIONS

Findings suggest that nurses are an important component of the healthcare ecosystem as it relates to injury outcomes. Laws supporting full nursing practice may have a protective effect on population health in the area of injuries and future studies should explore this relationship further.

Prevalence of long gun use in Maryland firearm suicides

Background

Firearms account for the majority of US suicides, largely due to lethality and accessibility. Under Federal and Maryland law, long guns are less regulated than handguns which is a concern for increased suicide risk. This study uses Maryland data to ascertain the impact of long guns on suicides in the state. We hypothesize that the prevalence of long gun use among firearm suicides will be increased in rural and young populations.

Methods

This is a cross sectional study using police and medical examiner narratives to identify firearm type involved in all 3931 Maryland gun suicides from 2003 to 2018. Proportions of firearm suicides utilizing long guns were calculated. Urban-rural differences were determined using the National Center for Health Statistics’ classification system. Logistic regression was used to calculate odds ratios of long gun to handgun suicides across the urban-rural spectrum, controlling for decedent demographics.

Results

From 2003 to 2018, 28.4% of Maryland gun suicides used long guns. The proportion of long guns used was highest in the most rural counties, where 51.6% of firearm suicides were by long gun, compared to 16.8% in the most urban counties. Long guns were disproportionately used by the young. For decedents 18 or younger, 44.6% used long guns, compared to 20.2% in those 65 or older. Compared to the most urban counties, firearm suicide decedents in the most rural counties were 3.74x more likely to use long guns (OR = 3.74; 95% CI 2.19, 6.40; p < .001) after adjusting for demographics, intoxication, and hunting season.

Conclusions

Long guns are used in a large proportion of Maryland firearm suicides, particularly in rural areas and disproportionately in youth suicides. Long guns must be considered as part of access to lethal means or policy strategies in efforts to reduce the burden of firearm suicide.

The relationship between alcohol consumption and the desire to own a firearm: an empirical study on citizens of São Paulo city, Brazil

OBJECTIVE

The main objective of this study was to investigate the association between alcohol consumption (use and bingeing) and the desire to own a firearm for protection.

STUDY DESIGN

We used data from three random cross-sectional victimisation surveys conducted in São Paulo city, Brazil, in 2003, 2008 and 2013 with people aged ≥16 years.

METHODS

We performed tests for equality of proportions. Our analysis was performed separately for each victimisation survey to check the robustness of the results. We also used probit models, estimated by the maximum likelihood method, to analyse the relationship between desire to own a firearm and alcohol consumption, controlling for many other variables.

RESULTS

In 2013, although only 1.5% of the population surveyed reported living in a household with a firearm, 15.7% report that they would possess a firearm if they could, and 13.0% believed they would be safer/more protected from violence if they had a firearm. The desire to own a firearm is higher among people who consume alcoholic beverages than among those who do not and is higher as alcohol binge frequency increases.

CONCLUSION

In São Paulo city, alcohol consumption and binge drinking are positively associated with the desire to own a firearm.

Suicide

Throughout the world, approximately 800,000 people die by suicide every year, accounting for 1.5% of all deaths. Suicide is the 10th leading cause of death in North America and the foremost cause of death worldwide among persons 15 to 24 years of age.

Austrian firearm legislation and its effects on suicide and homicide mortality: A natural quasi-experiment amidst the global economic crisis

Background:

Restriction of access to suicide methods has been shown to effectively reduce suicide mortality rates.

Aims:

To examine how the global economic crisis of 2008 and the firearm legislation reform of 1997 affected suicide and homicide mortality rate within Austria.

Methods:

Official data for the years 1985–2016 for firearm certificates, suicide, homicide, unemployment rates and alcohol consumption were examined using auto regressive error and Poisson regression models.

Results:

Firearm certificates, total suicide mortality rate, suicide and homicides by firearms, and the fraction of firearm suicides/homicides among all suicides/homicides decreased after the firearm legislation reform in 1997. However, significant trend changes can be observed after 2008. The availability of firearm certificates significantly increased and was accompanied by significant changes in trends of firearm suicide and homicide rates. Concurrently, the total suicide mortality rate in 2008, for the first time since 1985, stopped its decreasing trend. While the total homicide rate further decreased, the fraction of firearm homicides among all homicides significantly increased.

Conclusion:

The initially preventative effect of the firearm legislation reform in Austria in 1997 seems to have been counteracted by the global economic downturn of 2008. Increased firearm availability was associated with corresponding increases in both firearm suicide and firearm homicide mortality. Restrictive firearm legislation should be an imperative part of a country’s suicide prevention programme. Although firearm legislation reform may have long-lasting effects, societal changes may facilitate compensatory firearm acquisitions and thus counteract preventive efforts, calling in turn again for adapted counter-measures.

What I have is what I am: Differences in demographics, suicidal thoughts and behaviors, and firearm behavior and beliefs between firearm owners who do and do not primarily identify as firearm owners

Non-legislative forms of means safety (i.e., safe firearm storage practices) have been promoted as a way to reduce elevated suicide risk found among firearm owners. However, evidence suggests that some firearm owners are less willing than others to engage in these practices. The current study aimed to understand factors that differentiate firearm owners' beliefs and behaviors that are relevant to suicide risk by examining differences between individuals for whom firearm ownership represents a central aspect of identity (i.e., primary firearm owners) versus firearm owners who primarily identify with some other demographic or occupational characteristic. Results of main analyses revealed that primary firearm owners were more likely to be male, were less likely to have experienced suicidal ideation, were less likely to store their firearms safely across a number of storage methods, and were less open to means safety across all storage methods. These findings highlight demographically which firearm owners may be more likely to view firearm ownership as central to their identity and also suggest that this identification may be associated with beliefs and behaviors that increase suicide risk. Future firearm suicide prevention efforts should focus on culturally competent discussions and messaging to find common ground with firearm owners and to increase the salience of suicide among firearm owners.