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

Relationships of State Alcohol Policy Environments With Homicides and Suicides

INTRODUCTION

Alcohol use is involved in a large proportion of homicides and suicides each year in the U.S., but there is limited evidence on how policies targeting alcohol influence violence in the U.S.

CONTEXT

Extant studies generally focus on individual policies in isolation of each other. This study examines the impacts of changes in states' alcohol policy restrictions on overall homicide and suicide rates and firearm-related homicide and suicide rates using a holistic measure of states' alcohol policy environments.

METHODS

Using a composite measure of state-level alcohol policies (Alcohol Policy Scale) and data from the National Vital Statistics System from 2002 to 2018, this study applied a Bayesian time series model to estimate the impacts of alcohol policy changes on overall and firearm-involved homicide and suicide rates. The analysis was performed in 2023 and 2024.

RESULTS

A 1 SD change in the Alcohol Policy Scale was associated with a 6% decline in homicide rates both overall (incident rate ratio=0.94; 95% credible interval = 0.89, 1.00) and for firearm homicides specifically (incident rate ratio=0.94, 95% CI=0.88, 1.01). There was no clear association of alcohol policy with suicides. The model predicts that a nationwide increase in alcohol restrictions equivalent to a shift from the 25th to 75th percentile of the scale's distribution would result in almost 1,200 fewer homicides annually.

CONCLUSIONS

Increases in the restrictiveness of state-level alcohol policies are associated with reductions in homicides. More restrictive alcohol policy environments may offer an opportunity to reduce homicides.

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.

The Diffusion of Punitive Firearm Preemption Laws Across U.S. States

INTRODUCTION

Firearm violence is a public health crisis. Most states prohibit local firearm laws, but some states have laws that allow for lawsuits and other penalties against local governments and lawmakers who pass firearm laws deemed preempted. These punitive firearm preemptive laws may reduce firearm policy innovation, discussion, and adoption beyond preemption alone. Yet, it is unknown how these laws spread from state to state.

METHODS

In 2022, using an event history analysis framework with state dyads, logistic regression models estimate the factors associated with adoption and diffusion of firearm punitive preemption laws, including state-level demographic, economic, legal, political, population, and state-neighbor factors.

RESULTS

As of 2021, 15 states had punitive firearm preemption laws. Higher numbers of background checks (AOR=1.50; 95% CI=1.15, 2.04), more conservative government ideology (AOR=7.79; 95% CI=2.05, 35.02), lower per capita income (AOR=0.16; 95% CI=0.05, 0.44), a higher number of permissive state firearm laws (AOR=2.75; 95% CI=1.57, 5.30), and neighboring state passage of the law (AOR=3.97; 95% CI=1.52, 11.51) were associated with law adoption.

CONCLUSIONS

Both internal and external state factors predict the adoption of punitive firearm preemption. This study may provide insight into which states are susceptible to adoption in the future. Advocates, especially in neighboring states without such laws, may want to focus their firearm safety policy efforts on opposing the passage of punitive firearm preemption.

Firearm injury survival is only the beginning: The impact of socioeconomic factors on unplanned readmission after injury

BACKGROUND

Firearm trauma remain a national crisis disproportionally impacting minority populations in the United States. Risk factors leading to unplanned readmission after firearm injury remain unclear. We hypothesized that socioeconomic factors have a major impact on unplanned readmission following assault-related firearm injury.

METHODS

The 2016-2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was used to identify hospital admissions in those aged >14 years with assault-related firearm injury. Multivariable analysis assessed factors associated with unplanned 90-day readmission.

RESULTS

Over 4 years, 20,666 assault-related firearm injury admissions were identified that resulted in 2,033 injuries with subsequent 90-day unplanned readmission. Those with readmissions tended to be older (31.9 vs 30.3 years), had a drug or alcohol diagnosis at primary hospitalization (27.1% vs 24.1%), and had longer hospital stays at primary hospitalization (15.5 vs 8.1 days) [all P<0.05]. The mortality rate in the primary hospitalization was 4.5%. Primary readmission diagnoses included: complications (29.6%), infection (14.5%), mental health (4.4%), trauma (15.6%), and chronic disease (30.6%). Over half of the patients readmitted with a trauma diagnosis were coded as new trauma encounters. 10.3% of readmission diagnoses included an additional 'initial' firearm injury diagnosis. Independent predictors of 90-day unplanned readmission were public insurance (aOR 1.21, P = 0.008), lowest income quartile (aOR 1.23, P = 0.048), living in a larger urban region (aOR 1.49, P = 0.01), discharge requiring additional care (aOR 1.61, P < 0.001), and discharge against medical advice (aOR 2.39, P < 0.001).

CONCLUSIONS

Here we present socioeconomic risk factors for unplanned readmission after assault-related firearm injury. Better understanding of this population can lead to improved outcomes, decreased readmissions, and decreased financial burden on hospitals and patients. Hospital-based violence intervention programs may use this to target mitigating intervention programs in this population.

"We know what's going on in our community": A qualitative analysis identifying community assets that deter gun violence

Communities of color are disproportionately impacted by gun violence. Unlocking potential community-led solutions could be the key to quelling the gun violence epidemic and its impact on these communities. In this qualitative study, we explored community perspectives on local assets that may prevent and mitigate gun violence. We conducted semi-structured, in-depth interviews (n = 45) among individuals not directly involved in gun violence (i.e., shooting victim or perpetrator) despite having a high probability of being involved in gun violence in New Haven, CT. Participants were asked to describe social structures that may deter local gun violence. Here, we report emergent themes to preventing gun violence across multiple levels, including role models (interpersonal), social cohesion and home ownership (neighborhood), and community-based organizations (organizational). Our findings suggest that investments in stable housing, efforts to build social cohesion, access to community-based mental health services, and youth activities are needed to curb the drivers of community gun violence.

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.

Income support policies and firearm violence prevention: A scoping review

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact.

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.

Worldwide suicide mortality trends by firearm (1990–2019): A joinpoint regression analysis

Introduction

Suicide by firearm is a major public health problem in many countries. But, studies that investigated the mortality of suicide by firearm on a global scale are still limited. The aim of this study was to assess the global, regional and national trends in mortality of suicide by firearm from 1990 to 2019.

Method

Mortality data of suicide by firearm was presented using the age-standardized rates (ASRs, expressed per 100,000). Joinpoint regression analysis was used to assess trends of mortality of suicide by firearm: the average annual percent change (AAPC) with the corresponding 95% confidence interval (95%CI) was calculated.

Results

A total of 52,694 (45,110 male and 7584 female) deaths of suicide by firearm were reported worldwide in 2019. The global ASR of suicide by firearm was six-fold higher in males than in females (1.15 per 100,000 and 0.19 per 100,000, respectively), and varied greatly across countries: the highest rates were in Greenland (24.52 per 100,000 and 2.69 per 100,000, respectively) and the United States of America (10.13 per 100,000 and 1.66 per 100,000, respectively), while the lowest rates (0.05 per 100,000 or less) were observed in China, Japan and Singapore. Globally, the mortality of suicide by firearm had a decreasing tendency from 1990 to 2019 in both sexes together (AAPC = -2.0% per year; 95%CI = -2.1 to -1.9).

Conclusion

Decreasing trends in mortality of suicide by firearm were observed in majority of countries across the world, but not in all. Future research should determine more effective ways to further reduce mortality of suicide by firearm.

Rural-urban, age, and gender disparities and trends in suicide and homicide: Multistate evidence across 12 years

PURPOSE

Few studies have simultaneously assessed age and gender trends in homicide and suicide across the rural-urban continuum. Herein, we examine geographic and demographic trends in suicide and homicide death rates by: (1) determining overall macro and disaggregated trends; (2) examining differences in trends based on rural-urban county classification; and (3) identifying differences in stratified trends among age and gender classifications.

METHODS

A retrospective study design used suicide and homicide data (n = 199,456) from years 2005to 2017 across 16 US states. Suicide and homicide deaths were grouped by age, gender, and rural-urban classification for descriptive analyses, and trends were analyzed using Joinpoint trend analysis software.

FINDINGS

Violence resulted in 142,470 suicide and 56,986 homicide deaths between 2005 and 2017. Among both males and females, overall macro trends of suicide and homicide rates generally increased with greater rurality, and trends in rural rates differed from those in nonrural areas. Joinpoint trend analysis revealed significant increases in male suicide rates in large metropolitan (1.66%), micropolitan (1.78%), and rural areas (1.77%); female suicide rates in large metropolitan (2.17%), small metropolitan (3.25%), and micropolitan areas (3.26%); male homicide rates in large metropolitan areas (10.19%); and female homicide rates in rural areas (8.29%). Finally, when stratified by age, several significant trends were found, including increases in suicide rates among females aged 64 and older in rural areas (11.71%).

CONCLUSIONS

Heterogeneous trends were found in suicide and homicide rates within specific rural-urban, age, and gender subgroups. Prevention efforts should proactively target those subgroups identified herein as most at-risk of violence.

The changing epidemiology of interpersonal firearm violence during the COVID-19 pandemic in Philadelphia, PA

Recent increases in firearm violence in U.S. cities are well-documented, however dynamic changes in the people, places and intensity of this public health threat during the COVID-19 pandemic are relatively unexplored. This descriptive epidemiologic study spanning from January 1, 2015 - March 31, 2021 utilizes the Philadelphia Police Department's registry of shooting victims, a database which includes all individuals shot and/or killed due to interpersonal firearm violence in the city of Philadelphia. We compared victim and event characteristics prior to the pandemic with those following implementation of pandemic containment measures. In this study, containment began on March 16, 2020, when non-essential businesses were ordered to close in Philadelphia. There were 331 (SE = 13.9) individuals shot/quarter pre-containment vs. 545 (SE = 66.4) individuals shot/quarter post-containment (p = 0.031). Post-containment, the proportion of women shot increased by 39% (95% CI: 1.21, 1.59), and the proportion of children shot increased by 17% (95% CI: 1.00, 1.35). Black women and children were more likely to be shot post-containment (RR 1.11, 95% CI: 1.02, 1.20 and RR 1.08, 95% CI: 1.03, 1.14, respectively). The proportion of mass shootings (≥4 individuals shot within 100 m within 1 h) increased by 53% post-containment (95% CI: 1.25, 1.88). Geographic analysis revealed relative increases in all shootings and mass shootings in specific city locations post-containment. The observed changes in firearm injury epidemiology following COVID-19 containment in Philadelphia demonstrate an intensification in firearm violence, which is increasingly impacting people who are likely made more vulnerable by existing social and structural disadvantage. These findings support existing knowledge about structural causes of interpersonal firearm violence and suggest structural solutions are required to address this public health threat.

Firearm laws and the network of firearm movement among US states

Background

The movement of firearm across state lines may decrease the effectiveness of state-level firearm laws. Yet, how state-level firearm policies affect cross-state movement have not yet been widely explored. This study aims to characterize the interstate movement of firearms and its relationship with state-level firearm policies.

Methods

We analyzed the network of interstate firearm movement using Bureau of Alcohol, Tobacco, Firearms, and Explosives firearm trace data (2010–2017). We constructed the network of firearm movement between 50 states. We used zero-inflated negative binomial regression to estimate the relationship between the number of a state’s firearm laws and number of states for which it was the source of 100 or more firearms, adjusting for state characteristics. We used a similar model to examine the relationship between firearm laws and the number of states for which a given state was the destination of 100 or more firearms.

Results

Over the 8-year period, states had an average of 26 (Standard Deviation [SD] 25.2) firearm laws. On average, a state was the source of 100 or more crime-related firearms for 2.2 (SD 2.7) states and was the destination of 100 or more crime-related firearms for 2.2 (SD 3.4) states. Greater number of firearm laws was associated with states being the source of 100 or more firearms to fewer states (Incidence Rate Ratio [IRR] 0.58 per SD, p < 0.001) and being the destination of 100 or more firearms from more states (IRR1.73 per SD, p < 0.001).

Conclusions

Restrictive state-level firearm policies are associated with less movement of firearms to other states, but with more movement of firearms from outside states. The effectiveness of state-level firearm-restricting laws is complicated by a network of interstate firearm movement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11772-y.

The impact of gun violence restraining order laws in the U.S. and firearm suicide among older adults: a longitudinal state-level analysis, 2012-2016

BACKGROUND

Older adults complete suicide at a disproportionately higher rate compared to the general population, with firearms the most common means of suicide. State gun laws may be a policy remedy. Less is known about Gun Violence Restricting Order (GVRO) laws, which allow for removal of firearms from people deemed to be a danger to themselves or others, and their effects on suicide rates among older adults. The purpose of this study was to examine the association of state firearm laws with the incidence of firearm, non-firearm-related, and total suicide among older adults, with a focus on GVRO laws.

METHODS

This is a longitudinal study of US states using data from 2012 to 2016. The outcome variables were firearm, non-firearm and total suicide rates among older adults. Predictor variables were [1] total number of gun laws to assess for impact of overall firearm legislation at the state level, and [2] GVRO laws.

RESULTS

The total number of firearm laws, as well as GVRO laws, were negatively associated with firearm-related suicide rate among older adults ages 55-64 and > 65 years-old (p < 0.001). There was a small but significant positive association of total number of firearm laws to non-firearm-related suicide rates and a negative association with total suicide rate. GVRO laws were not significantly associated with non-firearm-related suicide and were negatively associated with total suicide rate.

CONCLUSION

Stricter firearm legislation, as well as GVRO laws, are protective against firearm-relate suicides among older adults.