Easiness of Legal Access to Concealed Firearm Permits and Homicide Rates in the United States

How firearm legislation impacts firearm mortality internationally: A scoping review

Background

The literature on gun violence is broad and variable, describing multiple legislation types and outcomes in observational studies. Our objective was to document the extent and nature of evidence on the impact of firearm legislation on mortality from firearm violence.

Methods

A scoping review was conducted under PRISMA-ScR guidance. A comprehensive peer-reviewed search strategy was executed in several electronic databases from inception to March 2024. Grey literature was searched for unpublished sources. Data were extracted on study design, country, population, type of legislation, and overall study conclusions on legislation impact on mortality from suicide, homicide, femicide, and domestic violence. Critical appraisal for a sample of articles with the same study design (ecological studies) was conducted for quality assessment.

Findings

5057 titles and abstracts and 651 full-text articles were reviewed. Following full-text review and grey literature search, 202 articles satisfied our eligibility criteria. Federal legislation was identified from all included countries, while state-specific laws were only reported in studies from the U.S. Numerous legislative approaches were identified including preventative, prohibitive, and more tailored strategies focused on identifying high risk individuals. Law types had various effects on rates of firearm homicide, suicide, and femicide. Lack of robust design, uneven implementation, and poor evaluation of legislation may contribute to these differences.

Interpretation

We found that national, restrictive laws reduce population-level firearm mortality. These findings can inform policy makers, public health researchers, and governments when designing and implementing legislation to reduce injury and death from firearms.

Funding

Funding is provided by the Strategy for Patient-Oriented Research (SPOR) Evidence Alliance and in part by St. Michael's Hospital, University of Toronto.

Scoping review registration

Open Science Framework (OSF): https://osf.io/sf38n.

Levels and Changes in Defensive Firearm Use by US Crime Victims, 1987‒2021

Objectives. To examine levels and temporal changes in the frequency of defensive gun use by US crime victims. Methods. We computed national-level counts of criminal incidents involving firearm defense during 3 periods: 1993 to 2005, 2007 to 2015, and 2016 to 2021. We also considered earlier national estimates for 1987 to 1990. The data came from the US Bureau of Justice Statistics National Crime Victimization Survey (NCVS). We counted firearm defenses as incidents in which victims used a gun to threaten or attack an offender. Results. Over the 4 periods, for all crimes, victims reported gun defenses in an average range of between 61 000 and 65 000 incidents per year. This included between 38 000 and 53 000 personal (violent) incidents and between 12 000 and 23 000 household (property) incidents. Conclusions. Firearm defenses occurred at a relatively low and nearly constant level over the 35-year period. Although some victims use guns for defense, these uses are infrequent compared with the incidence of crime. Public Health Implications. The continuing relative rarity of NCVS armed defenses suggests that claims about the protective benefits of widespread firearm ownership may be overstated. (Am J Public Health. 2024;114(12):1384-1387. https://doi.org/10.2105/AJPH.2024.307838).

Examining the Impact of Minimum Handgun Purchase Age and Background Check Legislation on Young Adult Suicide in the United States, 1991-2020

Objectives. To examine the independent and joint effects of state legislation on minimum age for purchasing handguns and background checks on the suicide of young adults aged 18 to 20 years. Methods. We used negative binomial regressions with fixed effects for year and generalized estimating equations for state to estimate the effects of state legislation on annual counts of firearm, nonfirearm, and total young adult suicides in all 50 US states from 1991 to 2020. Results. Minimum age laws decreased the incidence rate of firearm suicide among young adults, an effect that was amplified in states with permit to purchase laws; there was no effect on the nonfirearm or total suicide rate. Permit to purchase laws significantly decreased the young adult firearm suicide incidence rate by 39% (incidence rate ratio [IRR] = 0.61; 95% confidence interval [CI] = 0.51, 0.74) and the overall suicide incidence rate by 14% (IRR = 0.86; 95% CI = 0.75, 0.99), with no effect on the nonfirearm suicide rate. Conclusions. Permit to purchase laws are a more promising avenue for reducing young adult suicides than are age-based restrictions. (Am J Public Health. 2024;114(8):805-813. https://doi.org/10.2105/AJPH.2024.307689).

Concealed Handgun License Laws and Concealed Handgun License Adoption, 2002-2019

INTRODUCTION

National-level data suggest that gun owners in the U.S. carry concealed weapons in public at growing rates. This research investigates whether these trends are associated with state adoption of more permissive concealed carry-licensing laws between 2002 and 2019.

METHODS

Data were obtained from 31 U.S. states from 2002 to 2019. State-level rates of licenses issued, denied, and newly issued per 100,000 residents were calculated and compared across 3 state legal categories: (1) states that banned carrying-concealed weapons and adopted a shall-issue law, (2) states with a may-issue law that adopted a shall-issue law, and (3) states that made no changes to concealed carry-licensing laws. Difference-in-differences methods were used to compare the rate of licenses newly issued and denied in ban to shall-issue states relative to those in states with no concealed carry-licensing law change during the study timeframe. Data were analyzed in 2022-2023.

RESULTS

States that transitioned from a ban on concealed weapons carrying to shall-issue laws were positively associated (2%-6%, SE=0.11-0.13) with additional new licenses relative to states that did not enact concealed carry-licensing law changes. Ban to shall-issue law changes were also associated with denial of substantially more licenses (75%-85%, SE=0.24-0.23). Furthermore, states that transitioned from may-issue to shall-issue laws awarded fewer licenses than those transitioning from a concealed weapons ban to shall-issue laws.

CONCLUSIONS

State-level concealed carry licensing may inform public health and safety policies as large restrictive U.S. states transition to more permissive concealed carry-licensing laws.

Why did US urban homicide spike in 2020? A cross-sectional data analysis for the largest American cities

Working with data about homicide victims and perpetrators from 50 of America's largest cities, we investigate the explanatory power of some familiar explanations for why murder in those cities rose sharply in 2020. The analysis reveals that the distribution of risk by race was essentially the same in 2020 as in 2019. That empirical finding challenges some theories of how racial tensions after the death of George Floyd may have driven homicide increases. Similarly, homicide growth was not concentrated in those cities with the greatest availability in 2020 of new and older guns, or among the cities that suffered the most from the COVID-19 pandemic. At a minimum, the cross-city outcomes should reduce confidence that some combination of "race, guns, and COVID-19" explains all of the most important aspects of what happened in 2020.

Historical Redlining and Present-Day Nonsuicide Firearm Fatalities

BACKGROUND

Redlining began in the 1930s with the Home Owners' Loan Corporation (HOLC); this discriminatory practice limited mortgage availability and reinforced concentrated poverty that still exists today. It is important to understand the potential health implications of this federally sanctioned segregation.

OBJECTIVE

To examine the relationship between historical redlining policies and present-day nonsuicide firearm fatalities.

DESIGN

Maps from the HOLC were overlaid with incidence of nonsuicide firearm fatalities from 2014 to 2022. A multilevel negative binomial regression model tested the association between modern-day firearm fatalities and HOLC historical grading (A ["best"] to D ["hazardous"]), controlling for year, HOLC area-level demographics, and state-level factors as fixed effects and a random intercept for city. Incidence rates (IRs) per 100 000 persons, incidence rate ratios (IRRs), and adjusted IRRs (aIRRs) for each HOLC grade were estimated using A-rated areas as the reference.

SETTING

202 cities with areas graded by the HOLC in the 1930s.

PARTICIPANTS

Population of the 8597 areas assessed by the HOLC.

MEASUREMENTS

Nonsuicide firearm fatalities.

RESULTS

From 2014 to 2022, a total of 41 428 nonsuicide firearm fatalities occurred in HOLC-graded areas. The firearm fatality rate increased as the HOLC grade progressed from A to D. In A-graded areas, the IR was 3.78 (95% CI, 3.52 to 4.05) per 100 000 persons per year. In B-graded areas, the IR, IRR, and aIRR relative to A areas were 7.43 (CI, 7.24 to 7.62) per 100 000 persons per year, 2.12 (CI, 1.94 to 2.32), and 1.42 (CI, 1.30 to 1.54), respectively. In C-graded areas, these values were 11.24 (CI, 11.08 to 11.40) per 100 000 persons per year, 3.78 (CI, 3.47 to 4.12), and 1.90 (CI, 1.75 to 2.07), respectively. In D-graded areas, these values were 16.26 (CI, 16.01 to 16.52) per 100 000 persons per year, 5.51 (CI, 5.05 to 6.02), and 2.07 (CI, 1.90 to 2.25), respectively.

LIMITATION

The Gun Violence Archive relies on media coverage and police reports.

CONCLUSION

Discriminatory redlining policies from 80 years ago are associated with nonsuicide firearm fatalities today.

PRIMARY FUNDING SOURCE

Fred Lovejoy Housestaff Research and Education Fund.

Gun Laws, Stay-at-Home Orders, and Poverty: Surges in Pandemic Firearm Violence in Large US Cities

INTRODUCTION

The COVID-19 pandemic heralded a surge in firearm homicides (FH) in many, but not all, urban centers. We aimed to determine the relationship of firearm restrictive legislation, stay-at-home orders (SaHOs), and FH during the height of the COVID-19 pandemic in US cities.

METHODS

Demographics and socioeconomic data were captured from the 2020 US Census for large (population ≥250,000) cities. FH data were captured from the Gun Violence Archive. We retrieved firearm recovery estimates from the Bureau of Alcohol, Tobacco, and Firearms Firearms Trace Database. Firearm restrictive legislation was gathered from the State Firearm Laws Database. SaHO durations were found from press releases and government sources. Variables with P ≤ 0.200 in univariate linear regression were entered into a final multivariable model.

RESULTS

A median of 7.5 FH per 100,000 people occurred in the 85 included US cities across 32 states in 2020 (range, 0.35-69.80 per 100,000). In multivariable regression, longer SaHOs (β: 0.033, 95% confidence interval [CI]: 0.014-0.053, P = 0.001) and higher poverty (β: 0.471, 95% CI: 0.280-0.670, P < 0.001) were associated with increases in FH. Handgun-specific laws (β: -0.793, 95% CI: -1.430 to -0.160, P = 0.015) were associated with lower FH.

CONCLUSIONS

We found that poverty and longer SaHOs were associated with increased FH in large US cities during the height of the pandemic, while handgun-specific laws were associated with a decrease. Reducing poverty, mitigating the negative effects of SaHOs, and expanding handgun-specific legislation may protect from surges in FH during future crises.

Association Between the New York SAFE Act and Firearm Suicide and Homicide: An Analysis of Synthetic Controls, New York State, 1999‒2019

Objectives. To assess the association between the New York Secure Ammunition and Firearms Enforcement Act (NY SAFE Act) and firearm suicide and homicide rates. Methods. We employed a synthetic controls approach to investigate the impact of the NY SAFE Act on firearm suicide and firearm homicide rates. We collected state-level data on firearm mortality from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER) database for the period 1999-2019. We derived statistical inference by using a permutation-based in-place placebo test. Results. The implementation of the NY SAFE Act was associated with a significant reduction in firearm homicide rates, demonstrating a decrease of 63%. This decrease corresponds to an estimated prevention of 1697 deaths between 2013 and 2019. However, there was no association between the NY SAFE Act and firearm suicide rates. Conclusions. As the responsibility for enacting firearm policies increasingly falls on states instead of the federal government, this study provides valuable information that can assist states in making evidence-based decisions regarding the development and implementation of firearm policies that prioritize public safety and aim to prevent firearm-related fatalities. (Am J Public Health. 2023;113(12):1309-1317. https://doi.org/10.2105/AJPH.2023.307400).

The Relationship between Concealed Carry Licenses and Firearm Homicide in the US: A Reciprocal County-Level Analysis

This study investigates the reciprocal county-level relationship between the number of concealed carry weapon (CCW) licenses issued and homicides between 2010 and 2019 in a sample of eleven states. We utilize a random intercept cross-lagged panel model (RI-CLPM) approach accounting for reciprocal effects over time between homicide and concealed carry licenses, providing a robust methodological approach to the study of concealed carry and homicide. The results of the RI-CLPM found that increases in the number of CCWs in 2010-2017 were statistically associated with increases in total gun homicide in 2011-2018. Reciprocally, we found some limited evidence that increases in gun homicide were associated with changes in the number of CCWs issued in subsequent years during the early part of our study period. Far from concealed carry making people safer, our model finds acute safety risks associated with expansion of legal firearm carrying. As the right to carry firearms expands in many states, we emphasize the importance of responsible gun ownership practices, and draw attention to the need to implement preventive laws that keep guns out of the hands of people with prior violent histories and from places where violence risk is amplified.

Invited Commentary: Concealed Carrying of Firearms, Public Policy, and Opportunities for Mitigating Harm

In the last 30 years, 25 US states have relaxed laws regulating the concealed carrying of firearms (concealed-carry weapons (CCW) laws). These changes may have substantial impacts on violent crime. In a recent study, Doucette et al. (Am J Epidemiol. 2023;192(3):342-355) used a synthetic control approach to assess the effects of shifting from more restrictive "may/no-issue" CCW laws to less restrictive "shall-issue" CCW laws on homicides, aggravated assaults, and robberies involving a gun or committed by other means. The study adds to the evidence that more permissive CCW laws have probably increased rates of firearm assault in states adopting these laws. Importantly, this study is the first to identify that specific provisions of shall-issue CCW laws-including denying permits to persons with violent misdemeanor convictions, a history of dangerous behavior, or "questionable character" and live-fire training requirements-may help mitigate harms associated with shall-issue CCW laws. These findings are timely and salient given the recent Supreme Court ruling striking down a defining element of may-issue laws. This thorough study offers actionable results and provides a methodological model for state firearm policy evaluations. Its limitations reflect the needs of the field more broadly: greater focus on racial/ethnic equity and within-state variation, plus strengthening the data infrastructure on firearm violence and crime.

FOREWORD Finding Balance in the Fight Against Gun Violence

The United States is distinct among high-income countries for its problem with gun violence, with Americans 25 times more likely to be killed by gun homicide than people in other high-income countries.1 Suicides make up a majority of annual gun deaths - though that gap is closing as homicides are on the rise - and the U.S. accounts for 35% of global firearm suicides despite making up only 4% of the world's population.2 More concerning, gun deaths are only getting worse. In 2021, firearm fatalities approached 50,000, the highest we have seen in at least 40 years.3 The increase in homicides in conjunction with lower crime overall further suggests an problem specifically with guns.4 As devastating as these deaths are, it does not come close to encompassing the mass toll of America's gun violence epidemic - a toll that disproportionately impacts people of color, with the Black community suffering at the highest rates. A broader and more accurate view of what constitutes gun violence must become a part of the national discourse if we are going to develop effective strategies to combat this crisis.5.

Impact of Changes to Concealed-Carry Weapons Laws on Fatal and Nonfatal Violent Crime, 1980-2019

The United States faces rapidly rising rates of violent crime committed with firearms. In this study, we sought to estimate the impact of changes to laws that regulate the concealed carrying of weapons (concealed-carry weapons (CCW) laws) on violent crimes committed with a firearm. We used augmented synthetic control models and random-effects meta-analyses to estimate state-specific effects and the average effect of adopting shall-issue CCW permitting laws on rates of 6 violent crimes: homicide with a gun, homicide by other means, aggravated assault with a gun, aggravated assault with a knife, robbery with a gun, and robbery with a knife. The average effects were stratified according to the presence or absence of several shall-issue permit provisions. Adoption of a shall-issue CCW law was associated with a 9.5% increase in rates of assault with a firearm during the first 10 years after law adoption and was associated with an 8.8% increase in rates of homicide by other means. When shall-issue laws allowed violent misdemeanants to acquire CCW permits, the laws were associated with higher rates of gun assaults. It is likely that adoption of shall-issue CCW laws has increased rates of nonfatal violent crime committed with firearms. Harmful effects of shall-issue laws are most clear when provisions intended to reduce risks associated with civilian gun-carrying are absent.

USA Suicides Compared to Other Western Countries in the 21st Century: Is there a Relationship with Gun Ownership?

OBJECTIVES

Causes of suicide are complex indicating a nation's psycho-socio-economic well-being hence this population-based study explores whether USA suicides worsened compared to nineteen Other Western Countries (OWC) being possibly related to gun ownership in the 21st Century.

METHODS

Total suicide data are drawn from the latest WHO Age-Standardised-Death-Rates per million (pm) controlled for age, sex, and population, along with suicides in the five age- bands 15-34 years to 75 + years. National gun ownership data from the international Small Arms Survey. Chi-square tests any significant difference between American and OWC suicides during the century. Spearman Rank Order correlations are used to determine comparability of suicides and gun ownership per thousand person rates over the period 2000-15.

RESULTS

USA had the highest gun ownership, treble the rate of the next highest country. American Total suicides rose 27%, significantly more than eight other countries (p < 0.05). The USA had significantly worse suicide outcomes for Older (75+) people than three OWC; eleven for Mature Adults 55-74; eight for Adults 34-54 and for ten countries for Young Adults 15-34. Young Adult suicides numbered 12,438, 6,702 gun-related in 2015, exceeding recent USA military losses. Only Young Adult suicides positively correlated with gun ownership (<0.025).

CONCLUSIONS

The key finding is whilst most countries reduced suicides American rates rose substantially this century, raising questions about US society. Importantly the easy access to firearms in the USA makes Young Adult suicide more likely when facing psycho-social stress. This study exposes the vulnerability of distressed young American adults in a permissive gun culture, with its sequel, life-long grieving parents.HighlightsDuring 21st Century USA suicides rose substantially more than other Western nations.Only USA suicides rose >20% amongst Total suicides and in those aged 15-to-74years.USA Young Adult suicides 150,099 in 21st century, 12,438 in 2015, 6,702 were gun-related.

Public opinion on laws regulating public gun carrying

This study sought to examine public support for gun carrying-related policies from 2019 to 2021, a period encompassing the COVID-19 pandemic and increasing calls for racial and social justice. We conducted the National Survey of Gun Policy in January 2019 and 2021. The surveys were fielded using the NORC AmeriSpeak panel. Respondents indicated support for six policies regulating civilian gun carrying. Analyses, conducted in 2021, incorporated survey weights for nationally representative estimates. There were significant declines in support from 2019 to 2021 for two policies that would expand where civilians can lawfully carry guns: allowing concealed carry when on K-12 school grounds (23% in 2021 vs 31% in 2019) and college/university campuses (27% vs 36%). Support was also significantly lower for requiring concealed carry applicants to pass a test demonstrating safe and lawful use (74% in 2021 vs 81% in 2019). For the two new policies in the 2021 survey, more than half of respondents overall supported prohibiting open carry at demonstrations/rallies (54%) and prohibiting the carry of guns into government buildings (69%). There was lower support among gun owners (39% and 57%, respectively). Since 2019, there has been a decline in support for expanding locations for civilian gun carrying. Support remains high among U.S. adults, including the two-thirds of gun owners, for requiring concealed carry applicants to demonstrate competence in safe and lawful gun use. Our findings in support of a more regulated approach to concealed carry are in direct contrast to state-level shifts eliminating concealed gun carrying regulations.

Officer-Involved Shootings and Concealed Carry Weapons Permitting Laws: Analysis of Gun Violence Archive Data, 2014-2020

About 1,000 civilians are killed every year by a law enforcement officer in the USA, more than 90% by firearms. Most civilians who are shot are armed with a firearms. Higher rates of officer-involved shootings (OIS) are positively associated with state-level firearm ownership. Laws relaxing restrictions on civilians carrying concealed firearms (CCW) have been associated with increased violent crime. This study examines associations between CCW laws and OIS. We accessed counts of fatal and nonfatal OIS from the Gun Violence Archive (GVA) from 2014-2020 and calculated rates using population estimates. We conducted legal research to identify passage years of CCW laws. We used an augmented synthetic control models with fixed effects to estimate the effect of Permitless CCW law adoption on OIS over fourteen biannual semesters. We calculated an inverse variance weighted average of the overall effect. On average, Permitless CCW adopting states saw a 12.9% increase in the OIS victimization rate or an additional 4 OIS victimizations per year, compared to what would have happened had law adoption not occurred. Lax laws regulating civilian carrying of concealed firearms were associated with higher incidence of OIS. The increase in concealed gun carrying frequency associated with these laws may influence the perceived threat of danger faced by law enforcement. This could contribute to higher rates of OIS.

Impact of ShotSpotter Technology on Firearm Homicides and Arrests Among Large Metropolitan Counties: a Longitudinal Analysis, 1999-2016

Over the past decade, large urban counties have implemented ShotSpotter, a gun fire detection technology, across the USA. It uses acoustic listening devices to identify discharged firearms' locations. We examined the effect of ShotSpotter with a pooled, cross-sectional time-series analysis within the 68 large metropolitan counties in the USA from 1999 to 2016. We identified ShotSpotter implementation years through publicly available media. We used a Poisson distribution to model the impact of ShotSpotter on firearm homicides, murder arrests, and weapons arrests. ShotSpotter did not display protective effects for all outcomes. Counties in states with permit-to-purchase firearm laws saw a 15% reduction in firearm homicide incidence rates; counties in states with right-to-carry laws saw a 21% increase in firearm homicide incidence rates. Results suggest that implementing ShotSpotter technology has no significant impact on firearm-related homicides or arrest outcomes. Policy solutions may represent a more cost-effective measure to reduce urban firearm violence.

Alcohol policies, firearm policies, and suicide in the United States: a lagged cross-sectional study

BACKGROUND

Alcohol and firearms are commonly involved in suicide in the United States. State alcohol and firearm policies may impact alcohol and firearm related suicide, yet little is known about these relationships. This study examines relationships between state alcohol and firearm policies and suicides involving alcohol, guns, or both, and explores interactive policy associations.

METHODS

Alcohol policies were assessed with the Alcohol Policy Scale. Firearm policies were assessed using the Gun Law Scorecard from Giffords Law Center. Suicide data from the National Violent Death Reporting System in 2015 covered 22 states. State- and individual-level GEE Poisson and logistic regression models assessed relationships between policies and firearm- and/or alcohol-involved suicides with a 1-year lag.

RESULTS

In 2015, there were 8996 suicide deaths with blood alcohol concentration test results in the 22 included states. Of those deaths, alcohol and/or firearms were involved in 5749 or 63.9%. Higher alcohol and gun law scores were associated with reduced incidence rates and odds of suicides involving either alcohol or firearms (adjusted incidence rate ratios [IRR] 0.72 (95% CI 0.63, 0.83) for alcohol policies, 0.86 (95% CI 0.82, 0.90) for firearm policies). Relationships were similar for suicides involving both alcohol and firearms, and there was an interactive effect, such that states with restrictive policies for both had the lowest rates of suicides involving alcohol or guns.

CONCLUSIONS

More restrictive alcohol and firearm policies are associated with lower rates and odds of suicides involving alcohol or firearms, and alcohol and firearms, and may be a promising means by which to reduce suicide.

Gunshot suicides caused by cane-gun and alarm garden gun cannon: Two cases report."

Obtaining a firearm is not always easy, which is why some firearms that are antique or whose use is not intended to kiss are modified for suicide purposes. The two cases report a suicide with an original historical firearm as the canegun, a walking stick which conceals a firearm and a suicide with a modified alarm cannon, which is a small cannon, which fires blanks to scare away garden animals. The aims of the study were to describe the scene, the corpse external examination and the autopsy to understand the death mechanism. We wish to highlight the importance of the forensic pathologist's fieldwork, especially in complex or atypical suicides.

Impact on Nonfirearm Deaths of Firearm Laws Affecting Firearm Deaths: A Systematic Review and Meta-Analysis

Background. There is debate whether policies that reduce firearm suicides or homicides are offset by increases in non-firearm-related deaths.Objectives. To assess the extent to which changes in firearm homicides and suicides following implementation of various gun laws affect nonfirearm homicides and suicides.Search Methods. We performed a literature search on 13 databases for studies published between 1995 and October 31, 2018 (PROSPERO CRD42019120105).Selection Criteria. We included studies if they (1) estimated an effect of 1 of 18 included classes of gun policy on firearm homicides or suicides, (2) included a control group or comparison group and evaluated time series data to establish that policies preceded their purported effects, and (3) provided estimated effects of the policy and inferential statistics for either total or nonfirearm homicides or suicides.Data Collection and Analysis. We extracted data from each study, including study timeframe, population, and statistical methods, as well as point estimates and inferential statistics for the effects of firearm policies on firearm deaths as well as either nonfirearm or overall deaths. We assessed quality at the estimate (study-policy-outcome) level by using prespecified criteria to evaluate the validity of inference and causal identification. For each estimate, we derived the mortality multiplier (i.e., the ratio of the policy's effect on total homicides or suicides; expressed as a change in the number of deaths) as a proportion of its effect on firearm homicides or suicides. Finally, we performed a meta-analysis to estimate overall mortality multipliers for suicide and homicide that account for both within- and between-study heterogeneity.Main Results. We identified 16 eligible studies (study timeframes spanning 1977-2015). All examined state-level policies in the United States, with most estimating effects of multiple policies, yielding 60 separate estimates of the mortality multiplier. From these, we estimated that a firearm law's effect on homicide, expressed as a change in the number of total homicide deaths, is 0.99 (95% confidence interval = 0.76, 1.22) times its effect on the number of firearm homicides. Thus, on average, changes in the number of firearm homicides caused by gun policies are neither offset nor compounded by second-order effects on nonfirearm homicides. There is insufficient evidence in the existing literature on suicide to indicate the extent to which the effects of gun policy changes on firearm suicides are offset or compounded by their effects on nonfirearm suicides.Authors' Conclusions. State gun policies that reduce firearm homicides are likely to reduce overall homicides in the state by approximately the same number. It is currently unknown whether the same holds for state gun policies that significantly reduce firearm suicides. The small number of studies meeting our inclusion criteria, issues of methodological quality within those studies, and the possibility of reporting bias are potential limitations of this review.Public Health Implications. Policies that reduce firearm homicides likely have large benefits for public health as there is little evidence to support a strong substitution effect between firearm and nonfirearm homicides at the population level. Further research is needed to determine whether policies that produce population-level reductions in firearm suicides will translate to overall declines in suicide rates.

Temporal trend of research related to gun violence from 1981 to 2018 in the United States: a bibliometric analysis

BACKGROUND

We aimed to evaluate the variation in gun violence-related research in the US over time to determine if there are meaningful changes in frequency of research at certain time points. Related publications were searched from the Web of Science.

METHODS

We searched articles from Web of Science to collect publication data of gun violence research in three disciplines (clinical sciences, life sciences, and social behavior sciences) from 1981 to 2018. The joinpoint regression approach was applied to evaluate the trend of publication ratio. We also adopted the generalized additive mixed model to compare the publication ratio among the three research disciplines.

RESULTS

During the study period, each research discipline had a significant decrease in publication ratios, especially social behavioral sciences from 2001 to 2011, with an annual percentage change = - 9.77% (95% CI = - 13.45, - 5.93; p-value < .0001). After combining the three research disciplines, the average change of the publication ratio was significantly increased 9.18% (95% CI = 6.42, 12.01; p-value < .0001) per year from 1981 to 2018. Compared to social behavioral sciences, both clinical sciences and life sciences had a significantly smaller publication ratio.

CONCLUSIONS

Gun violence research exhibited a significant downward trend in publications in the early 2000s, which may be attributed at least in part to limited federal funding, but the publication ratio increased since the 2010s. To enhance the amount of peer-reviewed gun violence research so that research-informed gun violence interventions are more likely to succeed, decision-makers should keep supporting quality research.

Incidence of Gunshot Wounds: Before and After Implementation of a Shall Issue Conceal Carry Law

INTRODUCTION

This study examined the incidence of gunshot wounds before and after enacting a conceal carry (CC) law in a predominately rural state.

METHODS

A retrospective review was conducted of all patients who were admitted with a gunshot injury to a Level I trauma center. Patient data collected included demographics, injury details, hospital course, and discharge destination.

RESULTS

Among the 238 patients included, 44.6% (n = 107) were admitted during the pre-CC period and 55.4% (n = 131) in the post-CC period. No demographic differences were noted between the two periods except for an increase in uninsured patients from 43.0% vs 61.1% (p = 0.020). Compared to pre-CC patients, post-CC patients experienced a trend toward increased abdominal injury (11.2% vs 20.6%, p = 0.051) and increased vascular injuries (11.2% vs 22.1%, p = 0.026) while lower extremity injuries decreased significantly (38.3% vs 26.0%, p = 0.041). Positive focused assessment with sonography in trauma (FAST) exams (2.2% vs 16.8, p < 0.001), intensive care unit admission (26.2% vs 42.0%, p = 0.011) and need for ventilator support (11.2% vs 22.1%, p = 0.026) all increased during the post-CC period. In-hospital mortality more than doubled (8.4% vs 18.3%, p = 0.028) across the pre- and post-CC time periods.

CONCLUSION

Implementation of a CC law was not associated with a decrease in the overall number of penetrating injuries or a decrease in mortality.

International comparison of civilian violent deaths: a public health approach to reduce gun-related deaths in US youth

OBJECTIVES

The political controversy surrounding firearm fatalities in US youths (aged 15-24 years) continues. This study examines whether a public health approach could reduce gun-related deaths in the US.

METHODS

Based on the latest World Health Organization (WHO) data, current (2015) numbers and rates per million of US civilian violent deaths (CVDs) (including transport deaths, suicides and homicides) for both the general population and youths (aged 15-24 years) are examined. US CVD results are considered in a wider context by comparing the results with those of seven other major Western countries (MWCs). To demonstrate the effectiveness of a public health policy, transport deaths between 1979 and 2015 are analysed, which corresponds to a time period when government interventions based on technical improvements and behaviour change were implemented to improve road safety. The statistical significance of the comparison between road fatalities and suicide rates between 1979 and 2015 is determined by the chi-squared test.

RESULTS

In 2015, the total number of US CVDs was 101,456, consisting of 44,193 suicides and 17,588 homicides (of which 30,891 were likely to be gun-related deaths). Youth deaths totalled 17,432; 5491 suicides and 4732 homicides, including approximately 5112 gun-related deaths. US CVDs are substantially higher than the other MWCs for both the general population and youths. In 1979, US transport deaths were 57,577, which decreased to 39,675 in 2015. Every country's public health approach to reduce road deaths, when compared with suicides, was highly statistically significant.

CONCLUSIONS

Government interventions have reduced transport deaths; thus, new policies may also reduce gun-related violence. The evidence points towards a public health approach, such as that used to reduce road deaths, which could help reduce US firearm-related deaths to levels comparable with other MWCs.

Social determinants of health in relation to firearm-related homicides in the United States: A nationwide multilevel cross-sectional study

BACKGROUND

Gun violence has shortened the average life expectancy of Americans, and better knowledge about the root causes of gun violence is crucial to its prevention. While some empirical evidence exists regarding the impacts of social and economic factors on violence and firearm homicide rates, to the author's knowledge, there has yet to be a comprehensive and comparative lagged, multilevel investigation of major social determinants of health in relation to firearm homicides and mass shootings.

METHODS AND FINDINGS

This study used negative binomial regression models and geolocated gun homicide incident data from January 1, 2015, to December 31, 2015, to explore and compare the independent associations of key state-, county-, and neighborhood-level social determinants of health-social mobility, social capital, income inequality, racial and economic segregation, and social spending-with neighborhood firearm-related homicides and mass shootings in the United States, accounting for relevant state firearm laws and a variety of state, county, and neighborhood (census tract [CT]) characteristics. Latitude and longitude coordinates on firearm-related deaths were previously collected by the Gun Violence Archive, and then linked by the British newspaper The Guardian to CTs according to 2010 Census geographies. The study population consisted of all 74,134 CTs as defined for the 2010 Census in the 48 states of the contiguous US. The final sample spanned 70,579 CTs, containing an estimated 314,247,908 individuals, or 98% of the total US population in 2015. The analyses were based on 13,060 firearm-related deaths in 2015, with 11,244 non-mass shootings taking place in 8,673 CTs and 141 mass shootings occurring in 138 CTs. For area-level social determinants, lag periods of 3 to 17 years were examined based on existing theory, empirical evidence, and data availability. County-level institutional social capital (levels of trust in institutions), social mobility, income inequality, and public welfare spending exhibited robust relationships with CT-level gun homicide rates and the total numbers of combined non-mass and mass shooting homicide incidents and non-mass shooting homicide incidents alone. A 1-standard deviation (SD) increase in institutional social capital was linked to a 19% reduction in the homicide rate (incidence rate ratio [IRR] = 0.81, 95% CI 0.73-0.91, p < 0.001) and a 17% decrease in the number of firearm homicide incidents (IRR = 0.83, 95% CI 0.73-0.95, p = 0.01). Upward social mobility was related to a 25% reduction in the gun homicide rate (IRR = 0.75, 95% CI 0.66-0.86, p < 0.001) and a 24% decrease in the number of homicide incidents (IRR = 0.76, 95% CI 0.67-0.87, p < 0.001). Meanwhile, 1-SD increases in the neighborhood percentages of residents in poverty and males living alone were associated with 26%-27% and 12% higher homicide rates, respectively. Study limitations include possible residual confounding by factors at the individual/household level, and lack of disaggregation of gun homicide data by gender and race/ethnicity.

CONCLUSIONS

This study finds that the rich-poor gap, level of citizens' trust in institutions, economic opportunity, and public welfare spending are all related to firearm homicide rates in the US. Further establishing the causal nature of these associations and modifying these social determinants may help to address the growing gun violence epidemic and reverse recent life expectancy declines among Americans.

Right-to-Carry Laws and Firearm Workplace Homicides: A Longitudinal Analysis (1992-2017)

Objectives. To examine the impact of right-to-carry (RTC) firearm laws on firearm workplace homicides (WPHs) in the United States from 1992 to 2017.Methods. We employed 2 longitudinal methods to examine the average effect (pooled, cross-sectional, time-series analysis) and the state-specific effect (random effects meta-analysis) of RTC laws on WPHs committed by firearms from 1992 to 2017 in a 50-state panel. Both methods utilized a generalized linear mixed model with a negative binomial distribution.Results. From 1992 to 2017, the average effect of having an RTC law was significantly associated with 29% higher rates of firearm WPHs (95% confidence interval [CI] = 1.14, 1.45). No other state-level policies were associated with firearm WPHs. Sensitivity analyses suggest robust findings. State-specific estimates suggest that passing an RTC law during our study period was significantly associated with 24% increase in firearm WPH rates (95% CI = 1.09, 1.40).Conclusions. This is the first study to our knowledge to examine the link between RTC firearm laws and firearm WPHs. Findings indicate that RTC laws likely pose a threat to worker safety and contribute to the recent body of literature that finds RTC laws are associated with increased incidence of violence.

The Impact of State Firearm Laws on Homicide Rates among Black and White Populations in the United States, 1991-2016

This study aimed to investigate the potential differential effects of state-level firearm laws on black and white populations. Using a panel design, authors examined the relationship between state firearm laws and homicide victimization rates among white people and black people in 39 states during the period between 1991 and 2016. Authors modeled homicide rates using linear regression with year and state fixed effects and controlled for a range of time-varying, state-level factors. Results showed that universal background check laws and permit requirement laws were associated with lower homicide rates among both white and black populations, and "shall issue" laws were associated with higher homicide rates among both white and black populations. Laws that prohibit firearm possession among people convicted of a violent misdemeanor or require relinquishment of firearms by people with a domestic violence restraining order were associated with lower black homicide rates, but not with white homicide rates. Author identification of heterogeneity in the associations between state firearm laws and homicide rates among different racial groups has implications for reducing racial health disparities.

The Impact of State Firearm Laws on Homicide and Suicide Deaths in the USA, 1991-2016: a Panel Study

BACKGROUND

Firearm injuries are a major cause of mortality in the USA. Few recent studies have simultaneously examined the impact of multiple state gun laws to determine their independent association with homicide and suicide rates.

OBJECTIVE

To examine the relationship between state firearm laws and overall homicide and suicide rates at the state level across all 50 states over a 26-year period.

DESIGN

Using a panel design, we analyzed the relationship between 10 state firearm laws and total, age-adjusted homicide and suicide rates from 1991 to 2016 in a difference-in-differences, fixed effects, multivariable regression model. There were 1222 observations for homicide analyses and 1300 observations for suicide analyses.

PARTICIPANTS

Populations of all US states.

MAIN MEASURES

The outcome measures were the annual age-adjusted rates of homicide and suicide in each state during the period 1991-2016. We controlled for a wide range of state-level factors.

KEY RESULTS

Universal background checks were associated with a 14.9% (95% CI, 5.2-23.6%) reduction in overall homicide rates, violent misdemeanor laws were associated with a 18.1% (95% CI, 8.1-27.1%) reduction in homicide, and "shall issue" laws were associated with a 9.0% (95% CI, 1.1-17.4%) increase in homicide. These laws were significantly associated only with firearm-related homicide rates, not non-firearm-related homicide rates. None of the other laws examined were consistently related to overall homicide or suicide rates.

CONCLUSIONS

We found a relationship between the enactment of two types of state firearm laws and reductions in homicide over time. However, further research is necessary to determine whether these associations are causal ones.

The Impact of State Firearm Laws on Homicide Rates in Suburban and Rural Areas Compared to Large Cities in the United States, 1991-2016

PURPOSE

This article aims to examine whether state firearm laws impact homicide rates differently in suburban and rural areas compared to large cities in the United States.

METHODS

We analyzed serial, cross-sectional data for the 26-year period 1991-2016 using a panel design. We examined the relationship between 6 specific state firearm laws and homicide rates in large cities (those with greater than 100,000 people in 1990) and in all geographic areas outside of these cities. Using a city-level fixed effects negative binomial regression, we modeled the number of homicides as a function of state firearm laws, while controlling for time fixed effects and time-varying state- and city-level sociodemographic factors.

FINDINGS

Two policies-universal background checks and "may issue" laws that required a heightened showing of suitability for concealed carry-were associated with lower firearm homicide rates in large cities but were not associated with firearm homicide rates in suburban and rural areas. In contrast, laws that prohibited gun possession by people convicted of a violent misdemeanor were associated with lower firearm homicide rates in suburban and rural areas, but were not associated with firearm homicide rates in large cities. Permit requirements were associated with lower firearm homicide rates in both large cities and suburban and rural areas.

CONCLUSIONS

This article provides the first evidence that state firearm laws may have a differential impact on firearm homicide rates in suburban and rural areas compared to urban areas in the United States.

Workplace homicides committed by firearm: recent trends and narrative text analysis

Background

Firearm workplace homicides are a significant problem in the United States. We sought to provide a current, national-level examination of these crimes and examine how perpetrators accessed firearms used in workplace homicides.

Methods

We abstracted information on all firearm workplace homicides from the Bureau of Labor Statistics’ Census of Fatal Occupational Injuries from 2011 to 2015. We classified deaths by perpetrator’s relationship to the workplace/victim, motive (robbery v. non-robbery), circumstance (argument v. other circumstances), and firearm access points using narrative text fields.

Results

There were 1553 firearm workplace homicides during the study period. Robbery crime trended downward from 2011 to 2015. In contrast, non-robbery crimes constituted almost 50% of the homicides and trended upward in recent years. Customers and co-workers were the most frequent perpetrators of non-robbery crimes, most after an argument. While customers and co-workers who commit these crimes were often armed at the time of the argument, some were not and retrieved a firearm from an unspecified location before committing a homicide. Thus, immediate and ready firearm access was commonly observed in argumentative workplace deaths.

Conclusions

Limiting firearm access in the workplace is a possible measure for preventing deadly workplace violence and should be considered as part of a comprehensive strategy for addressing this reemerging public health concern.

A Public Health Approach to Gun Violence, Legally Speaking

The call for a public health approach to gun violence has largely ignored what role the nascent Second Amendment jurisprudence will play in hindering change. Given the state interest for infringing on Second Amendment rights is nearly always public safety, public health law doctrine provides an apt framework for analysis.

An Integrated Public Health Approach to Interpersonal Violence and Suicide Prevention and Response

Violence is a leading source of morbidity and mortality in the United States. In this article, we suggest a public health framework for preventing community violence, intimate partner violence and sexual violence, and suicide as key forms of interpersonal and self-directed violence. These types of violence often co-occur and share common risk and protective factors. The gender, racial/ethnic, and age-related disparities in violence risk can be understood through an intersectionality framework that considers the multiple simultaneous identities of people at risk. Important opportunities for cross-cutting interventions exist, and intervention strategies should be examined for potential effectiveness on multiple forms of violence through rigorous evaluation. Existing evidence-based approaches should be taken to scale for maximum impact. By seeking to influence the policy and normative context of violence as much as individual behavior, public health can work with the education system, criminal justice system, and other sectors to address the public health burden of interpersonal violence and suicide.

State Level Firearm Concealed-Carry Legislation and Rates of Homicide and Other Violent Crime

BACKGROUND

Over the last 30 years, public opinion and state level legislation regarding the concealed-carry of firearms have shifted dramatically. Previous studies of potential effects have yielded mixed results, making policy recommendations difficult. We investigated whether liberalization of state level concealed-carry legislation was associated with a change in the rates of homicide or other violent crime.

STUDY DESIGN

Data on violent crime and homicide rates were collected from the US Department of Justice Uniform Crime Reporting Program (UCR) and the Centers for Disease Control and Prevention (CDC) over 30 years, from 1986 to 2015. State level concealed-carry legislation was evaluated each study year on a scale including "no carry," "may issue," "shall issue," and "unrestricted carry." Data were analyzed using general multiple linear regression models with the log event rate as the dependent variable, and an autoregressive correlation structure was assumed with generalized estimating equation (GEE) estimates for standard errors.

RESULTS

During the study period, all states moved to adopt some form of concealed-carry legislation, with a trend toward less restrictive legislation. After adjusting for state and year, there was no significant association between shifts from restrictive to nonrestrictive carry legislation on violent crime and public health indicators. Adjusting further for poverty and unemployment did not significantly influence the results.

CONCLUSIONS

This study demonstrated no statistically significant association between the liberalization of state level firearm carry legislation over the last 30 years and the rates of homicides or other violent crime. Policy efforts aimed at injury prevention and the reduction of firearm-related violence should likely investigate other targets for potential intervention.

What have we learned from the time trend of mass shootings in the U.S.?

Little is known regarding the time trend of mass shootings and associated risk factors. In the current study, we intended to explore the time trend and relevant risk factors for mass shootings in the U.S. We attempted to identify factors associated with incidence rates of mass shootings at the population level. We evaluated if state-level gun ownership rate, serious mental illness rate, poverty percentage, and gun law permissiveness could predict the state-level mass shooting rate, using the Bayesian zero-inflated Poisson regression model. We also tested if the nationwide incidence rate of mass shootings increased over the past three decades using the non-homogenous Poisson regression model. We further examined if the frequency of online media coverage and online search interest levels correlated with the interval between two consecutive incidents. The results suggest an increasing trend of mass shooting incidences over time (p < 0.001). However, none of the state-level variables could predict the mass shooting rate. Interestingly, we have found inverse correlations between the interval between consecutive shootings and the frequency of on-line related reports as well as on-line search interests, respectively (p < 0.001). Therefore, our findings suggest that online media might correlate with the increasing incidence rate of mass shootings. Future research is warranted to continue monitoring if the incidence rates of mass shootings change with any population-level factors in order to inform us of possible prevention strategies.

The Effect of Concealed Handgun Carry Deregulation in Arizona on Crime in Tucson

In 2010, the Arizona legislature effectively deregulated concealed handgun carry in the state by passing Senate Bill (SB) 1108, which eliminated licensing and training requirements for concealed carry. Although researchers have extensively examined the impact of state adoption of concealed carry laws, almost nothing is known about the effects of deregulating concealed carry altogether. This study contributes to the more guns, less crime debate by examining the impact of Arizona’s decision to deregulate concealed carry. Using a multiple time-series research design with an experimental (Tucson) and control city (El Paso), the present study examines the impact of deregulation on handgun-related violent crime and gun larcenies in Arizona’s second largest city—Tucson. We find that the passage of SB 1108 had no impact on handgun-related offenses that could be expected to change following deregulation. The implications of these findings for policy making and future research are discussed.