Acute alcohol consumption, alcohol outlets, and gun suicide

Relationship Between Alcohol Use and Firearm-Involved Suicide: Findings From the National Violent Death Reporting System, 2003-2020

INTRODUCTION

Acute alcohol intoxication is a contributing factor in firearm-involved suicides. However, knowledge of the relationship between alcohol intoxication and firearm-involved suicide by age and sex (defined herein as the biological sex of the decedent) is limited. The purpose of the current study was to evaluate the sex- and age group-specific relationship between alcohol intoxication and firearm-involved suicide.

METHODS

Data from the National Violent Death Reporting System, 2003-2020, on suicide decedents (18+ years of age) were utilized. Age-group- and sex-specific multivariate binary logistic regression analyses were conducted. Statistical analyses were performed in 2023.

RESULTS

Alcohol intoxication (i.e., having a blood alcohol concentration of 0.08 g/dL or more) was significantly associated with using a firearm as the method of suicide for young (18-34 years; relative risk (RR)=1.31, 95% CI: 1.22-1.40) and middle-aged (35-64 years; RR=1.34, 95% CI: 1.27-1.39) females but not among older females (65+ years; RR=1.01, 95% CI: 0.87-1.17). Among males, the association was significant for all age-groups (young: RR=1.28, 95% CI: 1.25-1.30; middle-aged: RR=1.17, 95% CI: 1.15-1.19; and older: RR=1.04, 95% CI: 1.01-1.07).

CONCLUSIONS

Among males of all ages and young and middle-aged females, alcohol intoxication was associated with increased risk of suicide by firearm-an extremely lethal method that accounts for a majority of suicides in the U.S.-compared to their non-intoxicated counterparts. Interventions targeting excessive alcohol consumption may be effective in reducing suicide mortality rates.

Association Between Acute Alcohol Use and Firearm-Involved Suicide in the United States

Importance

Firearms are the method of suicide used most often in the US. Acute alcohol use is associated with an increased risk of suicide by firearm. However, the dose-response association between acute alcohol use and the probability of using a firearm as the method of suicide is unknown.

Objective

To evaluate the association between the amount of alcohol consumed and the probability of using a firearm as the method of suicide.

Design, Setting, and Participants

This cross-sectional study used mortality data from the US National Violent Death Reporting System on suicide decedents aged 18 years or older with a positive blood alcohol concentration (BAC; ie, ≥0.01 g/dL). Statistical analysis was performed from January 2003 to December 2020.

Exposure

Acute alcohol use, ascertained via postmortem toxicologic examination.

Main Outcomes and Measures

Probability of using a firearm as the method of suicide compared with all other methods of suicide.

Results

The study included 45 959 male suicide decedents (mean [SD] age, 42.6 [14.8] years) and 12 136 female suicide decedents (mean [SD] age, 44.2 [13.8] years) with a positive BAC; of those, 24 720 male decedents (53.8%) and 3599 female decedents (29.7%) used a firearm as the method of suicide. The probability of using a firearm as the method of suicide when alcohol is consumed was higher for male decedents, with the probability starting at just below 0.50 and increasing to approximately 0.75. In contrast, for female decedents, the probability began at just above 0.30 and increased to approximately 0.55. For both male and female decedents, the dose-response curves were an inverted U shape; as BAC increased, the probability of firearm-involved suicide initially increased and then decreased at very high BACs (approximately 0.40 g/dL for male decedents and approximately 0.30 g/dL for female decedents; these BACs were present among only a small percentage of alcohol-involved suicides: male decedents, 589 [1.3%]; female decedents, 754 [6.2%]).

Conclusions and Relevance

This cross-sectional study of suicide decedents who had consumed alcohol prior to their death suggests that, as alcohol consumption increased, the probability of a firearm-involved suicide increased until a certain BAC, at which point the probability started to decrease.

The role of firearm and alcohol availability in firearm suicide: A population-based weighted case-control study

Firearm availability has been linked to firearm self-harm, but the joint relationship with alcohol availability, while supported by theory, has not been examined. This study sought to quantify the separate and joint relations of community firearm and alcohol availability with individual-level risk of (fatal and nonfatal) firearm self-harm. We conducted a case-control study of California residents, 2005-2015, using statewide mortality, hospital, firearm transfer, and alcohol license data. We estimated monthly marginal risk differences per 100,000 in the overall population and in white men aged 50+ under various hypothetical changes to firearm and alcohol availability and assessed additive interactions using case-control-weighted g-computation. In the overall population, non-pawn shop firearm dealer density was associated with firearm self-harm (RD: 0.02, 95% CI: 0.003, 0.04) but pawn shop firearm dealer and alcohol outlet densities were not. Secondary analyses revealed a relationship between firearm sales density and firearm self-harm (RD: 0.07, 95% CI: 0.04, 0.10). There were no additive interactions between measures of firearm and alcohol availability. Among older white men, generally the same exposures were related to self-harm as in the overall population, but point estimates were substantially larger. Findings suggest community-level approaches to reducing firearm sales may help mitigate suicide risk.

Registry Data in Injury Research: Study Designs and Interpretation

Purpose of Review

Injury data is frequently captured in registries that form a census of 100% of known cases that meet specified inclusion criteria. These data are routinely used in injury research with a variety of study designs. We reviewed study designs commonly used with data extracted from injury registries and evaluated the advantages and disadvantages of each design type.

Recent Findings

Registry data are suited to 5 major design types: (1) Description, (2) Ecologic (with Ecologic Cohort as a particularly informative sub-type), (3) Case-control (with location-based and culpability studies as salient subtypes), (4) Case-only (including case-case and case-crossover subtypes), and (5) Outcomes.

Summary

Registries are an important resource for injury research. Investigators considering use of a registry should be aware of the advantages and disadvantages of available study designs.

Causal Inference with Case-Only Studies in Injury Epidemiology Research

Purpose of Review

We review the application and limitations of two implementations of the "case-only design" in injury epidemiology with example analyses of Fatality Analysis Reporting System data.

Recent Findings

The term "case-only design" covers a variety of epidemiologic designs; here, two implementations of the design are reviewed: (1) studies to uncover etiological heterogeneity and (2) studies to measure exposure effect modification. These two designs produce results that require different interpretations and rely upon different assumptions. The key assumption of case-only designs for exposure effect modification, the more commonly used of the two designs, does not commonly hold for injuries and so results from studies using this design cannot be interpreted. Case-only designs to identify etiological heterogeneity in injury risk are interpretable but only when the case-series is conceptualized as arising from an underlying cohort.

Summary

The results of studies using case-only designs are commonly misinterpreted in the injury literature.

Alcohol Consumption and 15 Causes of Fatal Injuries: A Systematic Review and Meta-Analysis

INTRODUCTION

The proportion of fatal nontraffic injuries that involve high levels of alcohol use or alcohol intoxication was assessed by cause of injury to generate alcohol-attributable fractions. Updated alcohol-attributable fractions can contribute to improved estimates of the public health impact of excessive alcohol use.

METHODS

Peer-reviewed and gray literature for 1995-2019 on 15 causes of fatal nontraffic injuries in the U.S., Canada, or Mexico were systematically reviewed, and state data systems were queried for available estimates of fatalities with recorded blood alcohol concentration levels and proportions of decedents with blood alcohol concentrations ≥0.10 g/dL by cause of injury. For each injury cause, alcohol-attributable fractions across studies were synthesized by meta-analysis of single proportions using generalized linear mixed models.

RESULTS

In total, 60 published studies and 40 additional population-level data points from 6 state data systems were included. The meta-analyzed alcohol-attributable fractions by cause of injury are as follows: air-space transport (0.03), aspiration (0.24), child maltreatment (0.09), drowning (0.31), fall injuries (0.37), fire injuries (0.34), firearm injuries (0.24), homicide (0.29), hypothermia (0.29), motor vehicle nontraffic crashes (0.42), occupational and machine injuries (0.08), other road vehicle crashes (railroad trespasser injuries) (0.63), poisoning (not alcohol) (0.20), suicide (0.21), and water transport (0.27), yielding an overall median alcohol-attributable fraction of 0.27.

DISCUSSION

Excessive alcohol use is associated with substantial proportions of violent and nonviolent injury deaths. These findings can improve the data used for estimating alcohol-attributable injury deaths and inform the planning and implementation of evidence-based strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) to prevent them.

Psychoactive substances use before suicide: detailed analysis of all cases that occurred in the Brazilian Federal District in a 10-years period

BACKGROUND

Psychoactive substances (PASs) are an important risk factor for suicide. This study investigated the sociodemographic characteristics, data related to the suicidal behavior, the methods employed, the circumstances of the events, and the use of PASs before dying in all suicides that occurred between 2005-2014 in the Brazilian Federal District, comparing cases with positive and negative detection for PASs in the post-mortem analysis to identify groups at greatest risk.

METHODS

A population-based, observational, cross-sectional study with an analytical aspect was conducted with suicides cases collected from local police, which toxicological examination was performed (headspace gas chromatographic-mass spectrometry-HS-GC/MS) for detection of ethanol and methanol in blood samples; immunoassay for other substances (cocaine, marijuana, benzodiazepine).

RESULTS

The results showed that the increase in the suicide rate was 10 × greater than the population growth, and 44% of the individuals used PASs before suicide. Individuals are more likely to die by suicide at home, be male, have tried before, and change their behavior days before death; they choose to hang as the method and are influenced by alcohol.

CONCLUSION

Identifying what sociodemographic characteristics are associated with a fatal suicide attempt among individuals who use PASs and those who do not use and those who have/do not have mental disorders and what methods are employed could be employed as a path to better interventions. Thus, prevention actions could be planned and directed to individuals with greater risk.

Alcohol and drug offenses and suicide risk among men who purchased a handgun in California: A cohort study

Firearm access is a risk factor for firearm suicide; substance use may confer additional risk. In this retrospective cohort study, we estimated the associations between prior alcohol and drug charges at the time of handgun purchase and subsequent suicide among men in California. The sample comprised all men who legally purchased a handgun in California in 2001 and who were age ≥ 21 at the time of acquisition (N = 101,377), identified in the California Department of Justice (CA DOJ) Dealer's Record of Sale database. Exposures included alcohol and drug criminal charges and convictions accrued January 1, 1990 until the first ('index') handgun acquisition in 2001, recorded in the CA DOJ Criminal History Information System. Outcomes included suicide and firearm suicide occurring after the index purchase and before January 1, 2016. A total of 1907 purchasers had alcohol charges, 1248 had drug charges, and 304 had both; 594 purchasers died by suicide (516 by firearm suicide). Compared with those with neither alcohol nor drug charges, those with alcohol charges had 2.20 times the hazard of suicide (95% confidence interval [CI], 1.39-3.46) and 2.22 times the hazard of firearm suicide (95% CI, 1.36-3.62). Risk was most elevated among those with more recent charges and those with 2 or more charges, and in the time period closest to the purchase. The associations for drug charges and the combination of alcohol and drug charges were not distinguishable from the null. Firearm owners with alcohol offenses may benefit from intervention to reduce firearm access and alcohol use.

"What Will Happen If I Say Yes?" Perspectives on a Standardized Firearm Access Question Among Adults With Depressive Symptoms

OBJECTIVE

Addressing firearm access is recommended when patients are identified as being at risk of suicide. However, the practice of assessing firearm access is controversial, and no national guidelines exist to inform practice. This study qualitatively explored patient perspectives on a routine question about firearm access to optimize the patient centeredness of this practice in the context of suicide risk.

METHODS

Electronic health record data were used to identify primary care patients reporting depressive symptoms, including suicidal thoughts, within 2 weeks of sampling. Participants completed a semistructured telephone interview (recorded and transcribed), which focused broadly on the experience of being screened for suicidality and included specific questions to elicit beliefs and opinions about being asked a standard firearm access question. Directive (deductive) and conventional (inductive) content analysis was used to analyze responses to the portion of the interview focused on firearm assessment and disclosure.

RESULTS

Thirty-seven patients in Washington State ages 20-95 completed the qualitative interview by phone. Organizing themes included apprehensions about disclosing access to firearms related to privacy, autonomy, and firearm ownership rights; perceptions regarding relevance of the firearm question, informed by experiences with suicidality and common beliefs and misconceptions about the inevitability of suicide; and suggestions for connecting questions about firearms and other lethal means to suicide risk.

CONCLUSIONS

Clarifying the purpose and use of routine firearm access assessment, contextualizing firearm questions within injury prevention broadly, and addressing misconceptions about suicide prevention may help encourage disclosure of firearm access and increase the patient centeredness of this practice.

Alcohol outlets, drug paraphernalia sales, and neighborhood drug overdose

BACKGROUND

Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association.

METHODS

A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly.

RESULTS

Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose.

CONCLUSION

This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

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.

Mediational Role of Drinking to Cope in the Associations of Depression and Suicidal Ideation with Solitary Drinking in Adults Seeking Alcohol Treatment

BACKGROUND

Little research on solitary drinking has focused on clinical samples. Previous research in college students has found that depression, suicidal ideation, and drinking to cope with negative affect are associated with drinking in solitary, but not social, contexts. These associations have not been examined among individuals with alcohol use disorder, despite their high rates of depression and suicidal behavior.

METHOD

To fill this gap in knowledge, the associations of depression and suicidal ideation with solitary and social drinking were examined among 96 individuals seeking alcohol treatment, the majority of whom had alcohol use disorder (97.9%). Multiple mediation models were conducted to examine the mediating effects of two drinking to cope variables (drinking excessively to cope and coping motives) on the associations of depression and suicidal ideation with drinks per month and heavy episodic drinking in social and solitary contexts.

RESULTS

Significant indirect effects were found for depression and suicidal ideation with solitary drinking variables through greater drinking excessively to cope. No significant indirect effects were found for social drinking variables. However, a positive direct association was found between suicidal ideation and greater social drinks per month that was not mediated by drinking to cope.

CONCLUSIONS

These findings suggest that greater depression or suicidal ideation, through their effect on greater drinking to cope, are associated with greater solitary drinking in a treatment seeking sample. Drinking context should perhaps be considered in alcohol interventions, particularly when treating individuals suffering from depression or suicidal ideation.

A Multilevel Model of Alcohol Outlet Density, Individual Characteristics and Alcohol-Related Injury in Argentinean Young Adults

OBJECTIVES

Previous research from high-income countries has consistently shown an association between alcohol-related harms and neighborhood characteristics such as alcohol outlet density, but this research has not been extended to middle- and low-income countries. We assessed the role of neighborhood characteristics such as alcohol outlet density, overcrowding and crime rates, and individual characteristics including gender, age, alcohol and marijuana use, and geographic mobility associated with alcohol-related injuries in university students in Argentina.

METHODS

Data were collected from a randomized sample of students attending a national public university (n = 1346). Descriptive, bivariable, and multilevel logistic regression analyses were performed.

RESULTS

In the final model, on-premises alcohol outlet density-but not off-premises outlet density, overcrowding or crime-was associated with past-year and lifetime alcohol-related injury (median odds ratio=1.16). At the individual level, quantity (odds ratio (OR)=1.05, 95% CI=(1.01, 1.10)) and frequency (OR=1.66, 95% CI=(1.41,1.97)) of alcohol consumption and age (OR=0.81, 95% CI=(0.74, 0.88)) were associated with past-year and lifetime alcohol-related injury.

CONCLUSIONS

This study contributes to an area with a paucity of information from non-high-income countries, finding differences with previous literature.

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.

Impact of Alcohol Policies on Suicidal Behavior: A Systematic Literature Review

Alcohol consumption has been found to be related to suicidal behavior at the individual and population level, but there is lack of literature reviews on the effect of alcohol policies on suicidal behavior. Therefore, the aim of the current study is to conduct a systematic literature review of the impact of alcohol policies at the population level on suicidal behavior and ideation. We searched the Cochrane CENTRAL, Cochrane DARE, EMBASE, Medline, ProQuest, PsycINFO, PubMed, SCOPUS, and Web of Science electronic databases in March 2019. Papers analyzing alcohol policies limiting alcohol use and studying suicidal behaviors as an outcome measure were included; we identified 19 papers. Although the methods and effect sizes varied substantially in the studies, reducing alcohol often led to reduction in suicidal behavior. Ecological-level studies predominantly investigated the effect of restrictions on alcohol availability and increased cost of alcohol, and the majority presented a reduction in suicides across Western and Eastern Europe, as well as the US. The majority of studies were rated as unclear risk of bias for a number of domains due to a lack of clear reporting. Policies targeting harmful alcohol consumption may contribute towards a reduction in suicidal behavior at the population level.

Acute alcohol use in Australian coronial suicide cases, 2010-2015

BACKGROUND

Acute use of alcohol is a robust risk factor for suicide, reported in approximately one- to two-fifths of suicide cases. Comparisons of risk factors between suicides with and without prior acute alcohol consumption have not been investigated in Australia. This study addresses the gap by examining individual factors (age, sex, employment status, method of suicide) and environmental factors (month of death, jurisdiction) between alcohol and non-alcohol suicide.

METHODS

Data for all suicide deaths (aged 15 and over) in Australia were obtained from the National Coronial Information System (NCIS). Blood alcohol concentrations (BAC) were extracted from coronial reports, along with demographic information. Alcohol consumption prior to suicide was assumed if BAC ≥ 0.05 g/100 mL. We compared case characteristics between alcohol related and non-alcohol related suicides using logistic regression.

RESULTS

26.7% of suicide deaths in Australia had a BAC ≥ 0.05 g/100 mL. Alcohol use prior to suicide was associated with male gender (adjusted odds ratio [AOR]: 1.14, 95% confidence interval [95%CI]: 1.03, 1.26), being aged between 35-44 years (AOR: 1.26, 95%CI: 1.08, 1.46) and hangings (AOR: 1.53, 95%CI: 1.08, 1.46). Mean suicides per month over the timeframe demonstrated significant seasonality. Mean counts per month for alcohol related suicides peaked in December, compared to a peak in September for non-alcohol related suicides.

CONCLUSIONS

This study highlights differences between alcohol related and non-alcohol related suicides including sex, age, method of death, time of year and location within Australia. Targeting alcohol related suicide should be a key priority in comprehensive suicide prevention strategies.

Looking Back and Moving Forward: The Evolution and Potential Opportunities for the Future of Alcohol Outlet Density Measurement

The literature consistently finds that areas with greater density of alcohol outlets (places that sell alcohol) tend to have higher levels of public health harms. However, conflicting findings arise when researchers drill down to identify the type(s) of alcohol outlets with the strongest associations with harms and the mechanisms that explain these associations. These disagreements could be a result of the outdated methods commonly used to quantify the alcohol environment: counts of the number of outlets in an area. This manuscript reviews the events and ideas that shaped the literature on the physical alcohol environment. It then defines the three main methods used to measure alcohol outlet density, conducts an exploratory factor analysis to explore the constructs underlying each method, and presents a novel conceptual framework that summarizes the three methods, their respective underlying constructs, and the setting(s) in which each may be most appropriate. The framework proposes that counts of alcohol outlets measure availability, proximity to the nearest outlet measures accessibility, and spatial access measures measure access, which comprises both availability and accessibility. We argue that researchers should consider using proximity and spatial access measures when possible and outline how doing so may present opportunities to advance theory and the design and implementation of alcohol outlet zoning regulations. Finally, this manuscript draws on research from other areas of the built environment to suggest opportunities to use novel methods to overcome common hurdles (e.g., separating subtypes of outlets, ecologic designs) and a new challenge on the horizon: home delivery.

Exploring the psychiatric and social risk factors contributing to suicidal behaviors in religious young adults

The religion-suicide relationship is complex, and evidence of the role of religion in suicidal behaviors is inconsistent. This cross-sectional study aims to explore suicidal ideation and attempts among Modern Orthodox Jews and to examine the risk factors for suicidality in the presence of religious practice and affiliation, help-seeking behaviors, and social support. 321 young adults aged 18 to 36 completed self-report questionnaires assessing religious commitment and perception of religion as important, suicidal risk, depression, somatic symptoms, alcohol misuse, social support, and help-seeking patterns. The past 12-month suicide ideation prevalence was 8.7%. 14% of the sample were at risk for suicide. Those at a higher risk for suicide were less involved in religious practices and perceived religion as less important. In addition, depressive symptoms and alcohol misuse at a younger age presented the highest correlation with suicidal risk. The high rate of suicidal ideation among Modern Orthodox young adults highlights their vulnerability in the face of a lack of social support and mental health resources. Due to the limitations inherent in a convenience sampling, i.e., limited generalizability, this study may represent an underestimation of a risk for suicide amongst Modern Orthodox adults.

A hospital-based treatment of suicide attempt patients with problematic alcohol use: Rationale and treatment development

OBJECTIVE

Problematic alcohol use (PAU) is a potent risk factor for suicidal behavior yet individuals with PAU presenting to hospital with suicidal risk may receive less intensive hospital-based treatment than suicidal patients without PAU. Developing efficacious interventions for at-risk patients with PAU that may be delivered in hospital is critical, particularly for those hospitalized following a suicide attempt, a group at marked risk.

METHOD

The authors identified the Attempted Suicide Short Intervention Program (ASSIP) for adaption for hospitalized suicide attempt patients with PAU because of its flexibility, brevity, and evidence of efficacy to reduce risk for suicide reattempt. After consulting with the developers of ASSIP, clinical research experts in the treatment of suicidal risk and PAU, and treatment providers of hospitalized suicide attempt patients, the authors made modifications to ASSIP to tailor it to hospitalized suicide attempt patients with PAU. Results and conclusion Our modifications to ASSIP include highlighting links between PAU and the timing of the attempt; integrating such links into the narrative story of the attempt, the written case formulation, and the homework task; and identifying concrete strategies to address PAU-related risk in the prevention plan. These modifications are the focus of an ongoing treatment development study.

Variation in Alcohol Policy Enforcement Across Urban and Nonurban Communities

PURPOSE

The goal of this study was to assess whether different types of communities (ie, urban, suburban, small town, and rural) vary in the alcohol enforcement activities they conduct.

METHODS

We conducted a cross-sectional study using data from a national survey of local law enforcement agencies.

DATA

The survey assessed enforcement of a range of alcohol policies at 1,082 law enforcement agencies. U.S. Census data were used to categorize agencies based on community type.

RESULTS

Agencies in urban areas conducted more enforcement activities than agencies in other community types. Urban agencies were more likely than rural agencies to conduct underage compliance checks (prevalence ratio [PR]: 0.42; CI: 0.34-0.53), saturation patrols (PR: 0.80; CI: 0.67-0.95), sobriety checkpoints (PR: 0.68; CI: 0.53-0.86), and enforcement aimed at illegal sales to intoxicated patrons (PR: 0.59; CI: 0.42-0.81). Urban agencies were also more likely than small town agencies to do compliance checks (PR: 0.66; CI: 0.56-0.79) and sobriety checkpoints (PR: 0.75; CI: 0.61-0.91), and they were more likely than suburban agencies to do compliance checks (PR: 0.67; CI: 0.57-0.78) and enforcement actions around the sale of alcohol to intoxicated patrons (PR: 0.64; CI: 0.45-0.90), provision of alcohol to minors (PR: 0.77; CI: 0.65-0.92), and consumption by minors (PR: 0.90; CI: 0.82-0.99).

CONCLUSIONS

Enforcement of alcohol laws differs by community type. Future research is needed to identify mechanisms to increase enforcement by agencies in different types of communities.

Geographic gender differences in traumatic unintentional injury hospitalization and youth drinking

INTRODUCTION

Few studies have used both spatial and non-spatial techniques to the study of alcohol outcomes. The objectives of this study were to identify clusters of traumatic unintentional injury hospitalizations by gender and blood alcohol concentration (BAC), and to determine trends and correlates by BAC levels.

METHODS

State Trauma Registry data capturing unintentional injuries for those aged 10 to 24 hospitalized with negative and positive BAC levels (n = 6233) were analyzed from 2006 to 2015 for all Chicago block groups. Spatial clustering techniques were applied to detect spatial clusters and Generalized Estimating Equations to determine correlates and trends while controlling for correlation within block groups.

RESULTS

Regardless of BAC level, hospitalization rates decreased for all age groups between 2006 to 2010 and 2011 to 2015 from 94.41 to 67.69 per 100,000 population. The decline for males hospitalized with positive BAC was 1.4 times greater than the decline for their female counterparts. Risk factors included being male, black or of a minority race, having no private insurance and living in a disadvantaged neighborhood. Male hospitalization rates clustered among 33 census block groups located in three Chicago Community Areas. No clustering was detected for female patients. Motor vehicle accidents were the leading cause of hospitalization.

CONCLUSIONS

Hospitalizations are decreasing in Chicago, yet the risk is concentrated, with greater decreasing rates among males than females. Spatial approaches can be valuable tools in analyzing substance abuse outcomes, to identify high-risk areas and shifts in risk within a large geographic area.

Metaanalysis of Mood and Substance Use Disorders in Proximal Risk for Suicide Deaths

Evidence for proximal risk factors for suicide is based on case-control psychological autopsy studies, with these reports showing that mood and substance use disorders are the most prevalent mental disorders among suicide decedents worldwide and are associated with marked risk. However, moderators of risk and the degree of risk associated with (nonalcohol) drug use disorder are unknown. A comprehensive search was used to identify 35 case-control psychological autopsy studies published worldwide over a 30-year period that were metaanalyzed using random effects models. Major depression, odds ratio (95% confidence interval) = 9.14 (5.53, 15.09), and drug use disorder, OR (95% CI) = 7.18 (3.22, 16.01), had large effect sizes, among other results. Risk estimates associated with major depression were greater in studies with a larger proportion of women and those conducted in Asia compared with other regions. There was no evidence of publication bias or that any one study had a disproportionate impact on findings. Risk for suicide associated with major depression appears to be moderated by sex and/or world region. Drug use disorder is a potent risk factor, illustrating the importance of assessing drug use in clinical risk assessment.

Understanding the relationship between alcohol outlet density and life expectancy in Baltimore City: The role of community violence and community disadvantage

This research investigated the relationship between alcohol outlet density (AOD) and life expectancy, as mediated by community violence and community disadvantage. We used linear regression models to assess bivariate and multivariate relationships. There was a negative bivariate association between liquor store density and average life expectancy (β = -7.3370, p < 0.001). This relationship was partially attenuated when controlling for community disadvantage and fully attenuated when controlling for community violence. Bars/taverns (i.e., on-premise) were not associated with average life expectancy (β = -0.589, p = 0.220). Liquor store density is associated with higher levels of community disadvantage and higher rates of violence, both of which are associated with lower life expectancies. Future research, potential intervention, and current related policies are discussed.

Suicidal Behavior: Links Between Alcohol Use Disorder and Acute Use of Alcohol

Research on associations of suicidal behavior, including suicide and suicide attempt, with alcohol use disorder (AUD) and acute use of alcohol (AUA) are discussed, with an emphasis on data from meta-analyses. Based on psychological autopsy investigations, results indicate that AUD is prevalent among individuals who die by suicide. Results also indicate that AUD is a potent risk factor for suicidal behavior. Risk estimates are higher for individuals with AUD in treatment settings, when compared to individuals in the community who have AUD. Also, although rates of suicide and prevalence of AUD remain higher in men, they have increased more among women in recent decades. Based on postmortem blood alcohol concentrations, AUA was commonly present among those who died by suicide. AUA is a potent proximal risk factor for suicidal behavior, and the risk increases with the amount of alcohol consumed, consistent with a dose-response relationship. Research indicates that AUA increases risk for suicidal behavior by lowering inhibition and promoting suicidal thoughts. There is support for policies that serve to reduce alcohol availability in populations with high rates of AUD and suicide, that promote AUD treatment, and that defer suicide risk assessments in intoxicated patients to allow the blood alcohol concentration to decrease.

Firearm Violence: A Global Priority for Nursing Science

PURPOSE

This purpose of this article is to frame firearm violence as a health and public health problem, to illustrate the magnitude of the problem, to examine factors that increase the risk to be injured by a firearm, or conversely, that confer protection, and to identify relevant priority areas for nursing science.

ORGANIZING CONSTRUCT

Firearm violence results in physical and psychological injuries and is a global health priority. Firearm violence is categorized as intentional (interpersonal and self-inflicted) and unintentional (interpersonal and self-inflicted) and accounts for an estimated 196,000 to 220,000 nonconflict deaths annually.

METHODS

We reviewed the theoretical and scientific literature to analyze the magnitude and geographic distribution of firearm violence, the factors associated with firearm injury, the consequences of firearm violence, and areas where nursing science can make an impact on prevention, outcomes, and recovery.

FINDINGS

Firearm violence is a significant public health problem that affects the health of individuals, families, and communities. The burdens and contributors to firearm violence vary worldwide, making it important to understand the local context of this global phenomenon. Relevant areas of inquiry span primary prevention focusing on individual and environmental risk factors; and focus on managing the physical and psychological consequences postinjury; and mitigating long-term consequences of firearm violence.

CONCLUSIONS

Reducing the global burden of firearm violence and improving the health and safety of individuals, families, and communities provide compelling reasons to integrate this area into nursing science.

CLINICAL RELEVANCE

The goals of nursing are to keep people healthy and safe and to help return those injured to their optimal levels of health and well-being. Understanding the factors that come together to injure people with a firearm in various physical, social, economic, and cultural environments positions nurses to both extend the dialogue beyond pro-gun versus anti-gun and to design and carry out rigorous studies to reduce firearm violence.

Prior Arrest, Substance Use, Mental Disorder, and Intent-Specific Firearm Injury

INTRODUCTION

Substance use, mental disorders, and arrest are markers of increased firearm injury risk. It is unclear how these markers vary by intent. Examining these interrelated factors together can clarify their associations with assault-related, self-inflicted, unintentional, and legal intervention firearm injuries, informing intent-specific interventions.

METHODS

In 2017-2018, 2-year diagnosis and arrest histories of intent-specific firearm injury cases were compared with those of unintentionally injured motor vehicle collision passenger controls. Fatal and nonfatal firearm and motor vehicle collision injury records in Seattle (2010-2014) were linked to statewide hospitalization and arrest records. Multinomial logistic regression models compared odds of prior arrest, substance use, and mental disorder diagnoses among intent-specific firearm injury cases relative to controls, adjusting for age, race, and gender.

RESULTS

A total of 763 cases and 335 controls were identified. Unintentional and self-inflicted cases did not differ significantly from controls in arrest history. Legal intervention cases resembled assault-related cases in their arrest history, and self-inflicted cases in their hospitalization history. The legal intervention cases were more likely than controls to have a prior felony arrest (OR=7.72, 95% CI=2.63, 20.97), and diagnoses involving alcohol (OR=4.06, 95% CI=1.04, 15.84); cannabis (OR=11.00, 95% CI=1.01, 119.36); depression/anxiety (OR=7.22, 95% CI=1.89, 27.67); psychosis (OR=6.99, 95% CI=1.35, 36.24); or conduct disorder (OR=22.01, 95% CI=1.44, 335.93).

CONCLUSIONS

Individuals with intent-specific firearm injuries have distinct patterns of prior substance use, mental disorder, and arrest. Many injuries occur after a series of encounters with institutions meant to help individuals during crises that can fail to provide longer-term solutions.

Alcohol Outlets, Neighborhood Retail Environments, and Pedestrian Injury Risk

BACKGROUND

Alcohol outlet density has been associated with increased pedestrian injury risk. It is unclear whether this is because alcohol outlets are located in dense retail areas with heavy pedestrian traffic or whether alcohol outlets contribute a unique neighborhood risk. We aimed to compare the pedestrian injury rate around alcohol outlets to the rate around other, similar retail outlets that do not sell alcohol.

METHODS

A spatial analysis was conducted on census block groups in Baltimore City. Data included pedestrian injury emergency medical services (EMS) records from January 1, 2014 to April 15, 2015 (n = 848); locations of alcohol outlets licensed for off-premise (n = 726) and on-premise consumption (n = 531); and corner (n = 398) and convenience stores (n = 192) that do not sell alcohol. Negative binomial regression was used to determine the relationship between retail outlet count and pedestrian injuries, controlling for key confounding variables. Spatial autocorrelation was also assessed and variable selection adjusted accordingly.

RESULTS

Each additional off-premise alcohol outlet was associated with a 12.3% increase in the rate of neighborhood pedestrian injury when controlling for convenience and corner stores and other confounders (incidence rate ratio [IRR] = 1.123, 95% confidence interval [CI] = 1.065, 1.184, p < 0.001). The attributable risk was 4.9% (95% CI = 0.3, 8.9) or 41 additional injuries. On-premise alcohol outlets were not significant predictors of neighborhood pedestrian injury rate in multivariable models (IRR = 0.972, 95% CI = 0.940, 1.004, p = 0.194).

CONCLUSIONS

Off-premise alcohol outlets are associated with pedestrian injury rate, even when controlling for other types of retail outlets. Findings reinforce the importance of alcohol outlets in understanding neighborhood pedestrian injury risk and may provide evidence for informing policy on liquor store licensing, zoning, and enforcement.

Is externalizing psychopathology a robust risk factor for suicidal thoughts and behaviors? A meta-analysis of longitudinal studies

OBJECTIVE

Our primary objective was to determine the potency of externalizing psychopathology as a risk factor for suicidal thoughts and behaviors (STBs).

METHOD

We conducted a random effects meta-analysis of 174 prospective studies (839 unique statistical tests) examining externalizing psychopathology and suicidal thoughts and behaviors (STBs) published prior to December 8, 2017. The weighted mean odds ratios for the overall relationship between externalizing psychopathology and STBs were below 2.00 in magnitude, and all risk factor subcategories were also fairly modest predictors of STBs. Taking publication bias into account reduced the magnitude of these associations, particularly for death. Although externalizing psychopathology modestly predicts STBs, this may be due to design limitations of existing studies. Future research should employ shorter follow-up periods, consider risk factors in combination, and focus on forms of externalizing psychopathology that have not been studied extensively.

RESULTS

The weighted mean odds ratios for the overall relationship between externalizing psychopathology and STBs were below 2.00 in magnitude, and all risk factor subcategories were also fairly modest predictors of STBs. Taking publication bias into account reduced the magnitude of these associations, particularly for death. Additionally, our results were mostly consistent regardless of sample age, sample severity, follow-up length, and predictor scale.

CONCLUSIONS

Although externalizing psychopathology modestly predicts STBs, this may be due to design limitations of existing studies. Future research should employ shorter follow-up periods, consider risk factors in combination, and focus on forms of externalizing psychopathology that have not been studied extensively.

Novel Methods for Environmental Assessment of Pedestrian Injury: Creation and Validation of the Inventory for Pedestrian Safety Infrastructure

Nationally, 80% of pedestrian fatalities occur in urban environments, yet the distribution of injuries across urban areas is not uniform. Identifying street-level risk factors for pedestrian injury is essential for urban planning and improvement projects, as well as targeted injury prevention efforts. However, creating and maintaining a comprehensive database of a city's traffic safety infrastructure can be cumbersome and costly. The purpose of this study was to create and validate a neighborhood environmental observational assessment tool to capture evidence-based pedestrian safety infrastructure using Google Street View (GSV)-The Inventory for Pedestrian Safety Infrastructure (IPSI). We collected measures in-person at 172 liquor stores in Baltimore City from June to August 2015 to assess the tool's reliability; we then collected IPSI measures at the same 172 locations using GSV from February to March 2016 to assess IPSI reliability using GSV. The majority of items had good or excellent levels of inter-rater reliability (ICC ≥ 0.8), with intersection features showing the highest agreement across raters. Two scales were also developed using exploratory factor analysis, and both showed strong internal consistency (Cronbach's alpha ≥ 0.6). The IPSI provides a valid, economically efficient tool for assessing pedestrian safety infrastructure that can be employed for a variety of research and urban planning needs. It can also be used for in-person or GSV observation. Reliable and valid measurement of pedestrian safety infrastructure is essential to effectively prevent future pedestrian injuries.

Neighbourhood alcohol environment and injury risk: a spatial analysis of pedestrian injury in Baltimore City

OBJECTIVES

The purpose of this study was to investigate the contribution of neighbourhood disorder around alcohol outlets to pedestrian injury risk.

METHODS

A spatial analysis was conducted on census block groups in Baltimore City. Data included pedestrian injury EMS records from 1 January 2014 to 15 April 2015 (n=858), off-premise alcohol outlet locations for 2014 (n=693) and neighbourhood disorder indicators and demographics. Negative binomial regression models were used to determine the relationship between alcohol outlet count and pedestrian injuries at the block group level, controlling for other neighbourhood factors. Attributable risk was calculated by comparing the total population count per census block group to the injured pedestrian count.

RESULTS

Each one-unit increase in the number of alcohol outlets was associated with a 14.2% (95% CI 1.099 to 1.192, P<0.001) increase in the RR of neighbourhood pedestrian injury, adjusting for traffic volume, pedestrian volume, population density, per cent of vacant lots and median household income. The attributable risk was 10.4% (95% CI 7.7 to 12.7) or 88 extra injuries. Vacant lots was the only significant neighbourhood disorder indicator in the final adjusted model (RR=1.016, 95% CI 1.007 to 1.026, P=0.003). Vacant lots have not been previously investigated as possible risk factors for pedestrian injury.

CONCLUSIONS

This study identifies modifiable risk factors for pedestrian injury previously unexplored in the literature and may provide evidence for alcohol control strategies (eg, liquor store licencing, zoning and enforcement).

Unintentional Firearm Injuries Remain Prevalent Over a 12 Year Experience at a Rural Midwestern Level 1 Trauma Center

Recently, firearm injuries in the United States have taken center stage in political debates and in the media. Much of the past epidemiological research on firearm injuries has focused primarily on the urban landscape. This study was undertaken to highlight the unique spectrum of firearm injuries seen at a rural level 1 trauma center to provide insight into prevalence, mechanism of injury, and seasonal variation. An IRB-approved retrospective study was performed of the trauma registry at a rural Level 1 hospital to identify all patients with firearm injuries from January 2002 to May 2014. Data obtained for each patient included demographics, injury date, a brief injury summary, and results of drug/ alcohol screening. Chart review was performed to confirm accuracy of the database and descriptive statistics were calculated to compare subgroups. During the 12 year study period, 408 patients with firearm injuries were treated at our hospital. There were 360 males and 48 females. Ages ranged from an infant to 90 years. Handguns were the most common type of firearm (49%). Mortality in this series was 19%. The median age for fatal and non-fatal wounds was 44 and 27 years, respectively. The three main causes of injury were accidental (36%), self-inflicted (33%), and assault (26%). Alcohol and drugs were commonly present. Hunting incidents accounted for 26% of accidents and most of these occurred while deer hunting in November and December. The demographics and mechanism of firearm injuries vary across the urban-rural continuum and it is important to identify these subgroups so targeted interventions can be pursued.

A dose-response estimate for acute alcohol use and risk of suicide attempt

This study reports dose-response estimates for the relative risk and population attributable risk (PAR) between acute alcohol use and serious suicide attempt. Data were analyzed on 272 suicide attempters arriving at 38 emergency departments within 6 hours of the event in 17 countries. Case-crossover analysis, pair-matching the number of standard drinks consumed within the 6 hours prior to the suicide attempt with that consumed during the same 6-hour period of the previous week, was performed using fractional polynomial analysis for dose-response. Every drink increased the risk of a suicide attempt by 30 percent; even one-two drinks was associated with a sizable increase in the risk of a serious suicide attempt, and a dose-response was found for the relationship between drinking 6 hours prior and the risk of a suicide attempt up to 20 drinks. Acute use of alcohol was responsible for 35 percent PAR of all suicide attempts. While very high levels of drinking were associated with larger relative risk s of suicide attempt, the control and reduction of smaller quantities of acute alcohol use also had an impact on population levels of suicide attempt, as showed here for the first time with our PAR estimates. Interventions to stop drinking or at least decrease levels of consumption could reduce the risk of suicide attempt. Screening people more at risk to suffer these acute effects of ethanol and offering interventions that work to these high-risk groups are a matter of urgent new research in the area.

Acute and chronic alcohol use correlated with methods of suicide in a Swiss national sample

OBJECTIVES

Chronic and acute alcohol use are highly associated risk factors for suicides worldwide. Therefore, we examined suicide cases with and without alcohol use disorder (AUD) using data from the SNSF project "Suicide in Switzerland: A detailed national survey". Our investigations focus on correlations between acute and chronic alcohol use with reference to suicide and potential interactions with the methods of suicide.

METHODS

We used data from the SNSF project in which all cases of registered completed suicide in Switzerland reported to any of the seven Swiss institutes of legal and forensic medicine between 2000 and 2010 were collected. We extracted cases that were tested for blood alcohol to use in our analysis. We compared clinical characteristics, blood alcohol concentrations, and methods of suicide in cases with and without AUD.

RESULTS

Out of 6497 cases, 2946 subjects were tested for acute alcohol use and included in our analysis. Of the latter, 366 (12.4%) persons had a medical history of AUD. Subjects with AUD significantly had higher blood alcohol concentrations and were more often in medical treatment before suicide. Drug intoxication as method of suicide was more frequent in cases with AUD compared to NAUD.

CONCLUSION

Overall, we found a high incidence of acute alcohol use at the time of death in chronic alcohol misusers (AUD). The five methods of suicide most commonly used in Switzerland differed considerably between individuals with and without AUD. Blood alcohol concentrations varied across different methods of suicide independently from the medical history in both groups.

Predictors of using trains as a suicide method: Findings from Victoria, Australia

This study aimed to investigate the factors associated with the choice of trains over other means of suicide. We performed a case-control study using data on all suicides in Victoria, Australia between 2009 and 2012. Cases were those who died by rail suicide and controls were those who died by suicide by any other means. A logistic regression model was used to estimate the association between the choice of trains and a range of individual-level and neighbourhood-level factors. Individuals who were never married had double odds of using trains compared to individuals who were married. Those from areas with a higher proportion of people who travel to work by train also had greater odds of dying by railway suicide compared to those from areas with a relatively lower proportion of people who travel to work by train. Prevention efforts should consider limiting access to the railways and other evidence-based suicide prevention activities.

A meta-analysis of acute use of alcohol and the risk of suicide attempt

BACKGROUND

No review has used a meta-analytic approach to estimate common odds ratios (ORs) for the effect of acute use of alcohol (AUA) on suicide attempts. We aim to report the results of the first meta-analysis of controlled epidemiological studies on AUA and suicide attempt.

METHOD

The English-language literature on Medline, PsycINFO and Google Scholar was searched for original articles and critical review on AUA and suicide attempt (period 1996-2015). Studies had to report an OR estimate for this association. Common ORs and 95% confidence intervals (CIs) from random effects in meta-analyses for any AUA and two levels of alcohol use on suicide attempt were calculated.

RESULTS

In all, seven studies provided OR estimates for the likelihood of suicide attempt by AUA, compared with those who did not drink alcohol. Studies used case-control (n 3) and case-crossover designs (n 4). Meta-analysis revealed a common OR of 6.97 (95% CI 4.77-10.17) for any AUA. Using four studies, 'low levels of acute drinking' resulted in an OR of 2.71 (95% CI 1.56-4.71) and 'high levels' had an OR of 37.18 (95% CI 17.38-79.53).

CONCLUSIONS

AUA is associated with increased likelihood of a suicide attempt, particularly at high doses. Such data should be incorporated into estimates of the burden of disease associated with alcohol use, which are currently limited by a consideration of only alcohol's chronic effects. Future research should focus on the mechanisms through which AUA confers risk for attempt.

Alcohol Use and Firearm Violence

Although the misuse of firearms is necessary to the occurrence of firearm violence, there are other contributing factors beyond simply firearms themselves that might also be modified to prevent firearm violence. Alcohol is one such key modifiable factor. To explore this, we undertook a 40-year (1975-2014) systematic literature review with meta-analysis. One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths. Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims. A small group of studies investigated the intersection of alcohol and firearms laws and alcohol outlets and firearm violence. One of these controlled studies found that off-premise outlets selling takeout alcohol were significantly associated with firearm assault. Additional controlled, population-level risk factor and intervention studies, including randomized trials of which only 1 was identified, are needed. Policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider prior drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study.

Association Between Substance Use and Gun-Related Behaviors

Gun-related violence is a public health concern. This study synthesizes findings on associations between substance use and gun-related behaviors. Searches through PubMed, Embase, and PsycINFO located 66 studies published in English between 1992 and 2014. Most studies found a significant bivariate association between substance use and increased odds of gun-related behaviors. However, their association after adjustment was mixed, which could be attributed to a number of factors such as variations in definitions of substance use and gun activity, study design, sample demographics, and the specific covariates considered. Fewer studies identified a significant association between substance use and gun access/possession than other gun activities. The significant association between nonsubstance covariates (e.g., demographic covariates and other behavioral risk factors) and gun-related behaviors might have moderated the association between substance use and gun activities. Particularly, the strength of association between substance use and gun activities tended to reduce appreciably or to become nonsignificant after adjustment for mental disorders. Some studies indicated a positive association between the frequency of substance use and the odds of engaging in gun-related behaviors. Overall, the results suggest a need to consider substance use in research and prevention programs for gun-related violence.

Alcohol, drug and other prior crimes and risk of arrest in handgun purchasers: protocol for a controlled observational study

BACKGROUND AND OBJECTIVE

Alcohol abuse is common in the USA and is a well-established risk factor for violence. Other drug use and criminal activity are risk factors as well and frequently occur together with alcohol abuse. Firearm ownership is also common; there are >50 million firearm owners in the USA. This study assesses the relationships between alcohol and drug abuse and future violence among firearm owners, which no prior research has done.

DESIGN AND STUDY POPULATION

This records-based retrospective cohort study will involve all persons who legally purchased handguns in California in 2001-approximately 116 000 individuals-with follow-up through the end of 2013.

METHODS

The principal exposures include prior convictions for alcohol-related and drug-related offenses. The primary outcome measure is an arrest following handgun purchase for a violent Crime Index offense: homicide, rape, robbery or aggravated assault. Subjects will be considered at risk for outcome events for only as long as their residence in California can be established independently of outcome events. Covariates include individual characteristics (eg, age, sex, criminal history, firearm purchase history) and community characteristics (eg, demographics, socioeconomic measures, firearm ownership and alcohol outlet density). We will employ survival analytic methods, expressing effects as HRs.

DISCUSSION

The results of this large-scale study are likely to be generalisable and to have important implications for violence prevention policies and programmes.

Alcohol misuse, firearm violence perpetration, and public policy in the United States

OBJECTIVE

Firearm violence is a significant public health problem in the United States, and alcohol is frequently involved. This article reviews existing research on the relationships between alcohol misuse; ownership, access to, and use of firearms; and the commission of firearm violence, and discusses the policy implications of these findings.

METHOD

Narrative review augmented by new tabulations of publicly-available data.

RESULTS

Acute and chronic alcohol misuse is positively associated with firearm ownership, risk behaviors involving firearms, and risk for perpetrating both interpersonal and self-directed firearm violence. In an average month, an estimated 8.9 to 11.7 million firearm owners binge drink. For men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. Enforceable policies restricting access to firearms for persons who misuse alcohol are uncommon. Policies that restrict access on the basis of other risk factors have been shown to reduce risk for subsequent violence.

CONCLUSION

The evidence suggests that restricting access to firearms for persons with a documented history of alcohol misuse would be an effective violence prevention measure. Restrictions should rely on unambiguous definitions of alcohol misuse to facilitate enforcement and should be rigorously evaluated.

An investigation of neighborhood-level social, economic and physical factors for railway suicide in Victoria, Australia

BACKGROUND

This study investigates the associations between railway suicide and neighborhood social, economic, and physical determinants using postcode-level data. It also examines whether the associations are influenced by having high concentration of high-risk individuals in a neighborhood area.

METHODS

Railway suicide cases from Victoria, Australia for the period of 2001-2012, their age, sex, year of death, usual residential address and suicide location were obtained from the National Coronial Information System. Univariate negative binomial regression models were used to estimate the association between railway suicide and neighborhood-level social, economic and physical factors. Variables which were significant in these univariate models were then assessed in a multivariate model, controlling for age and sex of the deceased and other known confounders.

RESULTS

Findings from the multivariate analysis indicate that an elevated rate of railway suicide was strongly associated with neighborhood exposure of higher number of railway stations (IRR=1.30 95% CI=1.16-1.46). Other significant neighborhood risk factors included patronage volume (IRR=1.06, 95% CI=1.02-1.11) and train frequency (IRR=1.02, 95% CI=1.01-1.04). An increased number of video surveillance systems at railway stations and carparks was significantly associated with a modest reduction in railway suicide risk (IRR=0.93, 95% CI=0.88-0.98). These associations were independent of concentration of high-risk individuals.

LIMITATIONS

Railway suicide may be under-reported in Australia.

CONCLUSIONS

Interventions to prevent railway suicide should target vulnerable individuals residing in areas characterized by high station density, patronage volume and train frequency.

Gender differences in socio-demographic, clinical characteristics and psychiatric diagnosis in/of suicide attempters in a Mexican population

OBJECTIVE

The aim of the present study was to analyse demographic and clinical characteristics, as well as psychiatric diagnoses to identify gender differences in patients with attempted suicide in a Mexican population.

METHODS

Between September 2010 and September 2012, 140 suicide attempts were documented in the Department of Psychiatry at the General Hospital of Comalcalco (Hospital General de Comalcalco in Spanish) in Tabasco, Mexico. Diagnoses were established using the DSM-IV questionnaire in which Axis I and II were considered. The Suicide Intent Scale was also applied.

RESULTS

In our sample, 63.6% were females and 36.4% males. With regard to socio-demographic characteristics, the predominant marital status in males was single, and in females married (χ2=5.93, df=2, p=0.05). In occupation the male group was mainly unemployed and housewife in females (χ2=55.51, df=4, p<0.001). Male subjects were more likely to consume alcohol (χ2=20.40, df=1, p≤0.001), cannabis (χ2=16.62, df=1, p≤0.001) or tobacco. The prevalence of psychiatric diagnosis was significantly different because, the male group was mainly diagnosed with substance-related disorders, whereas female participants showed a prevalence of stress-related disorders (χ2=34.17, gl=4, p=0.0001).

CONCLUSION

Our results provide evidence that the characteristics of suicide attempt are different by gender in the Mexican population. Interventions are necessary for the development of prevention strategies that may lead to a reduction in suicidal behaviour. These preventive activities should consider the occupation for the female group and consumption of alcohol, cannabis or tobacco in the male group.