State gun laws, gun ownership, and mass shootings in the US: cross sectional time series

Gunshot injuries in Central Europe - Epidemiology and outcome in Germany, Switzerland and Austria - an analysis based on the TraumaRegister DGU®

BACKGROUND

Firearms are of special interest in trauma research due to high lethality and criminal value. Strong correlation between guns per capita and fire-arm related deaths has been shown. Most of existing literature regarding gun-shot fatalities are from the U.S. and data for Central Europe is lacking. Thus, the aim of this study was to assess the legal frameworks regarding gun-ownership in Germany (DE), Austria (A) and Switzerland (CH), and to retrospectively analyze data from the TraumaRegister DGU® regarding the epidemiology, injury severity, intention and outcome of gunshot-related deaths in these countries.

METHODS

All patients from TR-DGU who sustained a gunshot injury in the time period from 1st January 2009 to 31st December 2019 were considered for analysis. Only cases admitted to level 1 or 2 trauma center in Germany, Switzerland, or Austria were included. Predicted mortality was calculated using the RISC-II. Further, the legal framework for firearm posession were explored.

RESULTS

The legal frameworks do not differ significantly between the countries. However, only ex-military men from Switzerland are allowed to keep their automatic (military) weapon at home. We assessed 1312 gunshot fatalities (DE 1,099, A 111, CH 102) of which most were due to suspected suicide (A 72.1 %, CH 64.7 %, and DE 56.6 %, p = 0.003). Act of suspected violent crime or accidental gunshots were rare in all three countries. Amongst all gunshot fatalities, Austria showed the highest mean age (57.6 years), followed by DE (53.4 years) and CH (49.4 years; p < 0.01). Gunshot fatalities amongst all assessed countries due to suspected suicide showed a peak at the age of 60 years and above, whereas suspected violent crime delicts with gunshots were mainly seen in younger age groups. The highest mortality was found in suspected suicide cases, showing a mortality of 82.1 % (predicted 65.2 %) in Switzerland, 75.3 % (predicted 65.8 %) in Austria and 63.7 % (predicted 56.2 %) in Germany.

CONCLUSION

Gunshot wounds are still rare in central Europe, but gunshot-related suicide rates are high. Gun ownership laws may have an impact on gunshot wounds due to suspected suicide. Injury patterns differ compared to countries where a high incidence of gun ownership is seen.

Washington State Assault Weapon Firearm Violence Before and After Firearm Legislation Reform

BACKGROUND

In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639.

METHODS

Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis.

RESULTS

From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law.

DISCUSSION

Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings.

Gun-free zones and active shootings in the United States: a matched case-control study

Background

Most Americans believe that gun-free zones make locations more vulnerable to violent crimes, particularly active shootings. However, there is no empirical evidence regarding the impact of gun-free zones on protecting locations from violence. The objective of this study was to estimate the association between gun-free zones and active shootings.

Methods

We used a pair-matched case-control study where cases were all US establishments where active shootings occurred between 2014 and 2020, and controls were randomly selected US establishments where active shootings could have but did not occur, pair-matched by establishment type, year, and county. Gun-free status of included establishments was determined via local laws, company policy, news reporting, Google Maps and posted signage, and calling establishments.

Findings

Of 150 active shooting cases, 72 (48.0%) were determined to have occurred in a gun-free zone. Of 150 controls where no active shooting occurred, 92 (61.3%) were determined to be gun-free. After accounting for matched pairs, the conditional odds of an active shooting in gun-free establishments were 0.38 times those in non-gun-free establishments, with a 95% confidence interval of 0.19-0.73 (p-value = 0.0038). Several robustness analyses affirmed these findings.

Interpretation

It is unlikely that gun-free zones attract active shooters; gun-free zones may be protective against active shootings. This study challenges the proposition of repealing gun-free zones based on safety concerns.

Funding

This work was funded in part by the National Collaborative on Gun Violence Research and the Arnold Foundation.

Firearm ownership and storage among US college students: results from the healthy minds study, 2021-2022

The purpose of this study is to address a significant gap in knowledge on firearm ownership rates and storage characteristics in a national sample of college students. We used 2021-2022 survey data from the Healthy Minds Study, which included approximately 88,500 students at over 100 US colleges and universities. We conducted analyses using descriptive statistics and two-sample proportion tests. About 4% of respondents reported having a firearm on or around campus. Among firearm owners, 68.8% reported storing firearms at their permanent address within an hour's drive from campus, and 43.1% reported storing their firearms unloaded and locked. Firearm ownership rates were significantly higher for respondents who were positive for specific risk factors (i.e., in a relationship, suicide ideation, recent binge drinking, and having been physically assaulted) versus those who were negative. These findings support the need for targeted messaging and firearm safety training for college students to reduce firearm-related risks.

State Policies Regulating Firearms and Changes in Firearm Mortality

Importance

Despite high social and public health costs of firearm violence in the United States, the effects of many policies designed to reduce firearm mortality remain uncertain.

Objective

To estimate the individual and joint effect sizes of state firearm policies on firearm-related mortality.

Design, Setting, and Participants

In this comparative effectiveness study, bayesian methods were used to model panel data of annual, state-level mortality rates (1979-2019) for all US firearm decedents, with analyses conducted in October 2023.

Exposures

Six classes of firearms policies: background checks, minimum age, waiting periods, child access, concealed carry, and stand-your-ground laws.

Main Outcome and Measures

Primary outcomes (total firearm deaths, firearm homicide deaths, and firearm suicide deaths) were assessed using the National Vital Statistics System. Bayesian estimation was used to estimate the partial association of changes in firearms policies with subsequent changes in firearm mortality.

Results

The estimated effect sizes of individual policies 5 or more years after implementation were generally small in magnitude and had considerable uncertainty. The policy class with the highest probability of reducing firearm deaths was child-access prevention laws, estimated to reduce overall firearm mortality by 6% (80% credible interval [CrI], -2% to -9%). The policy class with the highest probability of increasing firearm deaths was stand-your-ground laws, estimated to increase firearm homicides by 6% (80% CrI, 0% to 13% increase). Estimates of association of implementing multiple firearm restrictions with subsequent changes in firearm mortality yielded larger effect sizes. Moving from the most permissive to most restrictive set of firearm policies was associated with an estimated 20% reduction in firearm deaths (80% CrI, 10% to 28% reduction), with a 0.99 probability of any reductions in firearm death rates.

Conclusions and Relevance

In this comparative effectiveness study of state firearm policies, the joint effect estimates of combinations of firearm laws were calculated, showing that restrictive firearm policies were associated with substantial reductions in firearm mortality. Although policymakers would benefit from knowing the effects of individual policies, the estimated changes in firearm mortality following implementation of individual policies were often small and uncertain.

A Statistical Analysis of the Impact of Gun Ownership on Mass Shootings in the USA Between 2013 and 2022

Mass shootings (incidents with four or more people shot in a single event, not including the shooter) are becoming more frequent in the United States, posing a significant threat to public health and safety in the country. In the current study, we intended to analyze the impact of state-level prevalence of gun ownership on mass shootings-both the frequency and severity of these events. We applied the negative binomial generalized linear mixed model to investigate the association between gun ownership rate, as measured by a proxy (i.e., the proportion of suicides committed with firearms to total suicides), and population-adjusted rates of mass shooting incidents and fatalities at the state level from 2013 to 2022. Gun ownership was found to be significantly associated with the rate of mass shooting fatalities. Specifically, our model indicated that for every 1-SD increase-that is, for every 12.5% increase-in gun ownership, the rate of mass shooting fatalities increased by 34% (p value < 0.001). However, no significant association was found between gun ownership and rate of mass shooting incidents. These findings suggest that restricting gun ownership (and therefore reducing availability to guns) may not decrease the number of mass shooting events, but it may save lives when these events occur.

Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018

INTRODUCTION

The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers.

METHODS

Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018.

RESULTS

A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico.

CONCLUSION

States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Trends in Legal Firearm Transactions: A Possible Protective Role of Gun Law Strength

INTRODUCTION

The United States (US) holds the highest personal firearm ownership among industrialized nations, with implications for firearm-related deaths tied to increased per capita gun ownership and varying gun laws. This study examines the influence of gun law strength on legal firearm transactions, positing a correlation between stronger laws and reduced transactions. The analysis, focused on the stress-laden COVID-19 pandemic, evaluates handgun, long gun, and multiple gun transactions in 2020 and 2021 compared to 2018-2019.

METHODS

The Giffords Gun Law scorecard categorized states into the top 25 "strong" and bottom 25 "weak" gun law groups. Multivariate linear regressions assessed the association between strong gun law states and monthly National Instant Criminal Background Check System (NICS) data from 2018 to 2021. The study queried NICS for handgun, long gun, and multiple gun transactions, comparing median monthly transactions in 2018 and 2019 to 2020 and 2018-2020 to 2021.

RESULTS

When evaluating gun law strength through multivariate linear regression models, stronger gun law states had fewer monthly NICS transactions for handguns, long guns, and multiple guns in 2020 and 2021 versus all comparison years (all P < .05). However, from 2018-2019 to 2020 and 2018-2020 to 2021, median monthly NICS transactions per 100,000 people for all gun types increased (all P < .05).

CONCLUSION

Stricter gun laws correlated with decreased firearm transactions in stronger law states, yet handgun, long gun, and multiple gun transactions increased during the pandemic years of 2020 and 2021. Therefore, strengthening firearm legislation may be protective against the proliferation of firearms, which warrants further research.

Association Between Markers of Structural Racism and Mass Shooting Events in Major US Cities

Importance

The root cause of mass shooting events (MSEs) and the populations most affected by them are poorly understood.

Objective

To examine the association between structural racism and mass shootings in major metropolitan cities in the United States.

Design, Setting, and Participants

This cross-sectional study of MSEs in the 51 largest metropolitan statistical areas (MSAs) in the United States analyzes population-based data from 2015 to 2019 and the Gun Violence Archive. The data analysis was performed from February 2021 to January 2022.

Exposure

Shooting event where 4 or more people not including the shooter were injured or killed.

Main Outcome and Measures

MSE incidence and markers of structural racism from demographic data, Gini income coefficient, Black-White segregation index, and violent crime rate.

Results

There were 865 MSEs across all 51 MSAs from 2015 to 2019 with a total of 3968 injuries and 828 fatalities. Higher segregation index (ρ = 0.46, P = .003) was associated with MSE incidence (adjusted per 100 000 population) using Spearman ρ analysis. Percentage of the MSA population comprising Black individuals (ρ = 0.76, P < .001), children in a single-parent household (ρ = 0.44, P < .001), and violent crime rate (ρ = 0.34, P = .03) were other variables associated with MSEs. On linear regression, structural racism, as measured by percentage of the MSA population comprising Black individuals, was associated with MSEs (β = 0.10; 95% CI, 0.05 to 0.14; P < .001). Segregation index (β = 0.02, 95% CI, -0.03 to 0.06; P = .53), children in a single-parent household (β = -0.04, 95% CI, -0.11 to 0.04; P = .28), and Gini income coefficient (β = -1.02; 95% CI, -11.97 to 9.93; P = .93) were not associated with MSEs on linear regression.

Conclusions and Relevance

This study found that major US cities with higher populations of Black individuals are more likely to be affected by MSEs, suggesting that structural racism may have a role in their incidence. Public health initiatives aiming to prevent MSEs should target factors associated with structural racism to address gun violence.

Identification of Performance Improvement Objectives After Management of a Mass Shooting Incident: A Retrospective Study

Mass shootings are firearm incidents involving four or more victims at one or more locations close to one another. Although some American College of Surgeons designated trauma centers have the experience and resources to adequately treat mass shooting victims who arrive simultaneously or in close proximity to each other, many others do not. Therefore, the objective of this retrospective case series was to evaluate the effectiveness of the treatment of five consecutive gunshot wound victims who presented to a Level II trauma center within 36 minutes of each other. Lessons learned from that experience were used to identify the most effective pre-hospital and hospital management interventions. Opportunities for performance improvement were analyzed with respect to the current literature and the American College of Surgeons 2022 consensus recommendations for mass shootings.

State Firearm Laws and Rate of Assault-Related Firearm Death

BACKGROUND

Studying firearm-related mortality is important to reduce preventable firearm death in the US. This study aims to determine the relationship between firearm laws and assault death with firearms.

STUDY DESIGN

This ecologic study used public data from the CDC Wide-Ranging Online Data for Epidemiologic Research on decedents age 18 years or older who died from assault with firearms between 2009 and 2018 in all 50 states and Washington, DC. The outcomes were the rate of mortality per 100,000 persons from assault death by firearm used. Exposures of interest included the presence of 7 state firearm laws extracted from the RAND State Firearm Law Database. Welch's t tests were performed to compare mean mortality rate in states with each firearm law to states without each law.

RESULTS

There were 114,945 deaths from assault with firearms from 2009 to 2018. States with "stand your ground" laws had a higher assault mortality rate from all firearms and from other/unspecified firearms than states without stand your ground laws (p = 0.026; p = 0.023). States with background checks for private sales of handguns and long guns had a lower assault mortality rate from handguns and rifles, shotguns, and large firearms, respectively, than states without either law (p = 0.019; p = 0.030).

CONCLUSIONS

Stand your ground laws are correlated with a higher rate of gun-related assault death, but background checks on private sales are correlated with a lower rate. Future studies should elucidate the specific pathways by which state laws reduce, or fail to reduce, firearm-related assault death.

State Gun Regulations and Reduced Gun Ownership are Associated with Fewer Firearm-Related Suicides Among Both Juveniles and Adults in the USA

BACKGROUND

Few studies have investigated the relationship between specific gun regulations and gun ownership with the firearm-related suicide rate among juveniles and adults across U.S. states. Therefore, this study seeks to determine if gun ownership rates and gun restrictions are related to the firearm-related suicide rate in both the pediatric and adult populations.

METHODS

Fourteen measures of state gun law restrictions and gun ownership were collected. These included Giffords Center ranking, gun ownership percentages, and 12 specific firearm laws. Unadjusted linear regressions modeled the relationship between each individual variable and the rate of firearm-related suicides for adults and children across states. This was repeated using a multivariable linear regression adjusting for poverty, poor mental health, race, gun ownership, and divorce rates by state. P values of <0.004 were considered significant.

RESULTS

In the unadjusted linear regression, 9 of 14 firearm-related measures were statistically associated with fewer firearm-related suicides in adults. Similarly, 9 of 14 measures were found to be associated with fewer firearm-related suicides in the pediatric population. In the multivariable regression, 6 of 14 vs. 5 of 14 measures were statistically associated with fewer firearm-related suicides in the adult and pediatric populations, respectively.

CONCLUSIONS

Ultimately, this study found that increased state gun restrictions and lower gun ownership rates were associated with fewer firearm related suicides among juveniles and adults in the US. This paper provides objective data to help lawmakers as they create gun control legislation that can potentially decrease the rate of fire-arm related suicide.

LEVELS OF EVIDENCE

II.

Trends in mass shootings in the United States (2013-2021): A worsening American epidemic of death

BACKGROUND

Mass shootings represent a significant problem in the United States (US). This study aimed to examine trends in mass shootings in the US over time.

METHODS

Retrospective mass shooting data (1/2013-12/2021) were collected from the Gun Violence Archive. A scatterplot was constructed showing predicted (extrapolated from 2013 to 2019) versus actual total mass shootings in 2020 and 2021. Multivariate linear regressions were performed to evaluate trends in mass shootings over time, associated with gun law strength.

RESULTS

Mass shooting incidents, injuries, and deaths in 2020 and 2021 exceeded extrapolations from previous years. When comparing 2019 to 2020, stronger gun laws were associated with decreased monthly mass shooting deaths. For these same strong gun law states, monthly mass shooting deaths decreased when comparing 2019 to 2021 and comparing 2020 to 2021.

CONCLUSIONS

US mass shootings have increased over the past decade. Stronger gun laws appear associated with fewer monthly mass shooting-related deaths. Firearm-related legislation may at least partially, curtail the worsening of this substantial "American problem" of mass shootings.

Violence Toward and by Youth: Part I: Looking for the "Whys"

Violence is a public health crisis. It is especially concerning when it involves youth, whether they be victims, perpetrators, or observers. Part 1 of this two-part series categorizes the types of violence toward and by youth. There is a great deal of information on the prevalence of violence, mostly related to school shootings. However, the literature provides limited information on the antecedents of violent behaviors, and there is a dearth of information on "why" youth engage in violence. This is the unanswered question that drives Part 1 of this series. The beginning steps to understand "why" are viewed through the lens of a modified ABC Model (antecedent, behavior, consequence). Interventions for youth violence will be explored in Part 2.

Missing Americans: Early death in the United States-1933-2021

We assessed how many US deaths would have been averted each year, 1933-2021, if US age-specific mortality rates had equaled the average of 21 other wealthy nations. We refer to these excess US deaths as "missing Americans." The United States had lower mortality rates than peer countries in the 1930s-1950s and similar mortality in the 1960s and 1970s. Beginning in the 1980s, however, the United States began experiencing a steady increase in the number of missing Americans, reaching 622,534 in 2019 alone. Excess US deaths surged during the COVID-19 pandemic, reaching 1,009,467 in 2020 and 1,090,103 in 2021. Excess US mortality was particularly pronounced for persons under 65 years. In 2020 and 2021, half of all US deaths under 65 years and 90% of the increase in under-65 mortality from 2019 to 2021 would have been avoided if the United States had the mortality rates of its peers. In 2021, there were 26.4 million years of life lost due to excess US mortality relative to peer nations, and 49% of all missing Americans died before age 65. Black and Native Americans made up a disproportionate share of excess US deaths, although the majority of missing Americans were White.

The COVID-19 pandemic and its impacts on mass shootings in six major US cities

BACKGROUND

The COVID-19 pandemic has significant impacts on the US socioeconomic structure. Gun violence is a major public health issue and the effects on this area have not been well-elucidated. The objective of this study was to determine the impacts of the pandemic on mass shootings in six major United States cities with historically high rates of gun violence.

METHODS

Mass shooting data were extracted from an open-source database, Gun Violence Archive. Mass shooting was defined as four or more people shot at a single event. Data from six cities with the highest incidence of mass shootings were analyzed in 2019 versus 2020 (Baltimore, Chicago, Detroit, New Orleans, Philadelphia, and St. Louis). Geographic data were examined to assess changes in each city's mass shooting geographic distribution over time. Quantitative changes were assessed using the Area Deprivation Index (ADI), and qualitative data were assessed using ArcGIS.

RESULTS

In 2020, the overall percentage of mass shootings increased by 46.7% though there was no change in the distribution of these events when assessed quantitatively (no change in average ADI) nor qualitatively (using ArcGIS). In the six cities analyzed, the total proportion of mass shooting events was unchanged during the pandemic (21.8% vs 20.6%, p = 0.64). Chicago, the US city with the highest incidence of mass shootings, did not experience a significant change in 2020 (n = 34/91, 37.3% vs. n = 53/126, 42.1%, p = 0.57). Baltimore had a significant decrease in mass shooting events (n = 18/91, 19.8% vs. 10/126, 7.9%, p = 0.01). The other four cities had no significant change in the number of mass shootings (p>0.05).

CONCLUSION

This study is the first to use ArcGIS technology to describe the patterns of mass shooting in six major US cities during the COVID-19 pandemic. The number of mass shootings in six US cities remained largely unchanged which suggests that changes in mass shootings is likely occurring in smaller cities. Future studies should focus on the changing patterns of homicides in at-risk communities and other possible social influences.

Black Household gun ownership and black suicide rates across U.S. States

INTRODUCTION

Ecologic studies have examined the relationship across states between levels of household gun ownership and suicide rates using household gun ownership data from the Behavioral Risk Factor Surveillance System (BFRSS) or proxies. However, no study has examined how race-specific survey-based or proxy measures of gun ownership are related to race-specific suicide rates.

METHODS

We use cross-sectional state-level race-specific data to examine how well various proxies correlate with race-specific BRFSS gun ownership rates. We examine whether BRFSS measures of household gun ownership are correlated with firearm suicide, non-firearm suicide, and total suicide rates, for Black and for White adults, and repeat these assessments with select proxies. The core BRFSS only included gun questions in 2001, 2002, and 2004, but not since; mortality data are collapsed 2001-2010.

RESULTS

Among a set of proxies, the race-specific fraction of suicides that are firearm suicides (FS/S) is the measure most highly correlated with BRFSS household gun ownership. Across states, White adult BFRSS household gun ownership levels are highly correlated with White adult firearm suicide rates (correlation coefficient .82) and moderately correlated with White overall suicide rates (.63). However, for Black adults, we find that while the state-level Black gun ownership levels are moderately correlated with Black firearm suicide rates (.67)-more strongly for older (.70) than for younger (.47) Black adults-Black BRFSS gun ownership levels are only weakly correlated with Black overall suicide rates (.17) owing to a moderate inverse correlation with Black non-firearm suicide rates (-.45). For Black adults, the relationship between FS/S and suicide is similar to the relation between BRFSS and suicide.

CONCLUSION

For White adults, states with higher levels of measured household gun ownership have higher overall suicide rates. This relationship does not hold for Black adults, largely due to a more attenuated correlation between these measures of firearm availability and firearm suicide rates coupled with a more substantial countervailing (inverse) relationship between these measures and non-firearm suicide rates. Future efforts using individual level data might help determine why this puzzling difference exists, especially for young Black adults.

Judicial Power and Influence on Population Health

Policy Points Since its founding, the Supreme Court has played a major role in defining the parameters of governments' public health powers and the scope of individual health-related rights. Although conservative courts have been less favorable to public health objectives, federal courts have, for the most part, advanced public health interests through consensus and adherence to the rule of law. In establishing the current six-three conservative supermajority, the Trump administration and the Senate shifted the Supreme Court dramatically. A majority of Justices, led by Chief Justice Roberts, did shift the Court in a decidedly conservative direction. It did so incrementally, guided by the Chief's intuition that the Institution itself should be preserved, mindful of maintaining public trust and appearing outside the political fray. That has all changed because Roberts' voice no longer holds sway. Five members of the Court have displayed a willingness to overturn even long-held precedent and dismantle public health policy in favor of the Justices' core ideological tenants-notably the extensive reach of the First and Second Amendments and a parsimonious view of executive and administrative action. Public health is vulnerable to judicial rulings in this new conservative era. This includes classic public health powers in infectious disease control as well as reproductive rights; lesbian, gay, bisexual, trans, queer or questioning, and others (LGBTQ+) rights; firearm safety; immigration; and climate change. Congress has the power to curb the most extreme actions of the Court while still adhering to the vital ideal of a nonpolitical branch. That does not require Congress itself to overreach (such as by "packing" the Supreme Court, as Franklin Delaeno Roosevelt once proposed). Congress could, however, 1) disempower lower federal judges from issuing injunctions that apply nationwide, 2) limit the Supreme Court's so-called shadow docket, 3) alter the way that presidents appoint federal judges, and 4) set reasonable term limits for federal judges and Supreme Court Justices.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Analyzing the impact of state gun laws on mass shootings in the United States from 2013 to 2021

OBJECTIVES

Mass shooting incidents have drastically increased in the United States in the last 10 years, with a disproportionate number of incidents occurring in some states. Gun laws vary greatly by state, but little research has been conducted to examine the association between the strength of state gun laws and mass shootings. This study aims to explore the aggregate effect of state gun laws on the rate of mass shooting incidents and fatalities.

STUDY DESIGN

This was a cross-sectional time series.

METHODS

This study applied the negative binomial generalized linear mixed model to assess the impact of state gun laws restrictiveness-as measured by the total number of active gun laws-on the rate of mass shooting incidents and fatalities.

RESULTS

The restrictiveness of state gun laws was significantly associated with the rate of mass shooting fatalities; specifically, for every 1 standard deviation (SD) increase in the state gun law restrictiveness score (i.e. for every additional 27 gun laws in place), the rate of mass shooting fatalities was decreased by 24% (P-value <0.0001), controlling for other predictor variables in the model. However, no significant association was found between the restrictiveness of state gun laws and rate of mass shooting incidents.

CONCLUSIONS

State gun laws may not decrease the number of mass shooting events, but they appear to help reduce the number of deaths when these mass shootings occur. Better data collection on mass shootings and further research on the impacts of specific gun laws are needed to help understand the effectiveness of gun laws and inform law-based interventions.

Should Teachers Carry Guns? An Emergency Room Survey of Parents of Two New York Communities

INTRODUCTION

The purpose of this study was to compare parents' perceptions of threats and solutions to school gun violence in two different communities.

METHODS

Parents of school-aged children visiting emergency rooms of two large trauma centers in Upstate New York (UNY) and New York City (NYC), between October 2019 and December 2020, were surveyed (UNY: n=202, NYC: n=100). Responses were compared by site, firearm experience, and concern for school safety.

RESULTS

Respondents from the two sites differed by sociodemographic characteristics. Of the 302 respondents, 64% feared a school shooting incident, but UNY respondents were less likely to report concern (46.5% vs 99%, p<0.001). UNY respondents were more likely to feel safe for their children (75.3% vs 7%, p<0.001) and to report feeling safer if guns were available to teachers (22.3% vs 6%, p <0.001). Both sites' respondents agreed on the need for armed police presence (76.7% vs 74%, p=0.11). Of the 193 parents concerned about a school shooting, 11.9% indicated feeling safer if guns were available to teachers versus 25.7% of those who were not (p=0.002). Agreement on solutions for making schools safer differed by the site. NYC respondents were unanimously supportive, but UNY support ranged from 52% for metal detectors to 84.5% for controlled entry points.

CONCLUSION

Although perceptions of child safety and experience with guns varied by location, most parents agreed on potential solutions, that it should be the security officers, not teachers, who should be carrying firearms and that armed police should be present in schools to provide safety.

Racial Differences in Firearms Used and Autopsies Following Gun Deaths Exist

INTRODUCTION

Disparities in gun violence across race are well documented. Studying these disparities is essential to reduce preventable gun deaths. This study evaluates the relationship between sociodemographic factors and firearms used in gun deaths.

MATERIALS AND METHODS

This retrospective cohort study of firearm mortalities from 2009 to 2018 used the Mortality Multiple Cause-of-Death Public Use Record from the National Center for Health Statistics. The primary outcome was the type of firearm used and the secondary outcome was autopsy status. Factors of interest include race, ethnicity, gender, marital status, age, education, and place of death. Factors significantly associated with outcomes in univariate analyses were included in separate multivariate logistic regression models for assaults, intentional self-harm, and accidents.

RESULTS

A total of 276,127 firearm deaths from 2009 to 2018 were analyzed. Compared to White victims, Black victims were less likely to die from handguns (accident: odds ratio [OR] = 0.70, P < 0.05; self-harm: OR = 0.84, P < 0.001; assault: OR = 0.58, P < 0.001) and rifles, shotguns, or large firearms (accident: OR = 0.30, P < 0.001; self-harm: OR = 0.37, P < 0.001; assault: OR = 0.28, P < 0.001). Black decedents were more likely to undergo autopsy than White decedents (accident: OR = 2.14, P < 0.001; intentional self-harm: OR = 2.02, P < 0.001; assault: OR = 2.02, P < 0.001). Ethnicity, gender, marital status, age, education, and other racial identities were also associated with firearms used and autopsy rates (P < 0.05).

CONCLUSIONS

Differences in firearms used and autopsy rates following gun deaths exist by race, ethnicity, gender, marital status, age, and education. Future studies should investigate the relationship between sociodemographic factors and firearms used and autopsy status following gun deaths.

A spatiotemporal model of firearm ownership in the United States

Firearm injury is a major public health crisis in the United States, where more than 200 people sustain a nonfatal firearm injury and more than 100 people die from it every day. To formulate policy that minimizes firearm-related harms, legislators must have access to spatially resolved firearm possession rates. Here, we create a spatiotemporal econometric model that estimates monthly state-level firearm ownership from two cogent proxies (background checks per capita and fraction of suicides committed with a firearm). From calibration on yearly survey data that assess ownership, we find that both proxies have predictive value in estimation of firearm ownership and that interactions between states cannot be neglected. We demonstrate use of the model in the study of relationships between media coverage, mass shootings, and firearm ownership, uncovering causal associations that are masked by the use of the proxies individually.

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A spatiotemporal model of firearm prevalence in the United States is created

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The econometric model predicts firearm ownership in every state for every month

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Information theory is used to detail causal links related to firearm prevalence

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The media can influence firearm prevalence, which in turn moderates mass shootings

Firearm violence is a major public health crisis in the United States, where more than 200 people sustain a nonfatal firearm injury and more than 100 people die from it every day. Despite these unsettling figures, scientific research on firearm-related harm significantly lags behind because spatially and temporally resolved data on firearm ownership are unavailable. This paper presents a spatiotemporal model that predicts firearm prevalence at the resolutions of one state and one month from the numbers of background checks and suicides committed with a firearm. Drawing on principles from econometrics, the model also accounts for interactions between states. The model’s output is challenged in causal analysis, which uncovers unprecedented associations between firearm prevalence, media output on firearm regulations, and mass shootings.

Simulating the bounds of plausibility: Estimating the impact of high-risk versus population-based approaches to prevent firearm injury

BACKGROUND

Firearm violence remains a persistent public health threat. Comparing the impact of targeted high-risk versus population-based approaches to prevention may point to efficient and efficacious interventions. We used agent-based modeling to conduct a hypothetical experiment contrasting the impact of high-risk (disqualification) and population-based (price increase) approaches on firearm homicide in New York City (NYC).

METHODS

We simulated 800,000 agents reflecting a 15% sample of the adult population of NYC. Three groups were considered and disqualified from all firearm ownership for five years, grouped based on prevalence: low prevalence (psychiatric hospitalization, alcohol-related misdemeanor and felony convictions, 0.23%); moderate prevalence (drug misdemeanor convictions, domestic violence restraining orders, 1.03%); and high prevalence (all other felony/misdemeanor convictions, 2.30%). Population-level firearm ownership was impacted by increasing the price of firearms, assuming 1% price elasticity.

RESULTS

In this hypothetical scenario, to reduce firearm homicide by 5% in NYC, 25% of the moderate prevalence group, or 12% of the high prevalence group needed to be effectively disqualified; even when all of the low prevalence group was disqualified, homicide did not decrease by 5%. An 18% increase in price similarly reduced firearm homicide by 5.37% (95% CI 4.43-6.31%). Firearm homicide declined monotonically as the proportion of disqualified individuals increased and/or price increased. A combined intervention that both increased price and effectively disqualified "high-risk" groups achieved approximately double the reduction in homicide as any one intervention alone. Increasing illegal firearm ownership by 20%, a hypothetical response to price increases, did not meaningfully change results.

CONCLUSION

A key takeaway of our study is that adopting high-risk versus population-based approaches should not be an "either-or" question. When individual risk is variable and diffuse in the population, "high-risk approaches" to firearm violence need to focus on relatively prevalent groups and be highly efficacious in disarming people at elevated risk to achieve meaningful reductions in firearm homicide, though countering issues of social justice and stigma should be carefully considered. Similar reductions can be achieved with population-based approaches, such as price increases, albeit with fewer such countering issues.

State Gun Law Grades and Impact on Mass Shooting Event Incidence: An 8-Year Analysis

BACKGROUND

Gun violence, particularly in the form of mass shooting events (MSE), is a growing, significant public health crisis in the US. Whether stricter gun laws decrease MSE is not known. We hypothesized that stronger state gun laws would be associated with lower MSE incidence.

STUDY DESIGN

Mass shooting events, defined as at least 4 people injured in a single event, and state gun law grade data for years 2014 through 2021 were obtained from the Gun Violence Archive and Giffords Law Center, respectively. An A grade indicated strictest gun control laws, and F indicated the weakest. US 2020 Census data were used to estimate MSE per million per state. The number of MSE per million was examined for association with gun law grades.

RESULTS

From 2014 through 2020, there were a total of 2,736 recorded MSE, with at least a 2-fold increase in incidence from 272 in 2014 to 626 in 2020. Concomitantly, the number of F grade states decreased from 27 to 21 (22%). The MSE mean (SD) per F state increased from 4.0 (5.1) in 2014 to 9.7 (10.3) in 2020 (p = 0.03). No differences were found in unadjusted number of MSE per year by gun law grade for any study year examined (p = 0.67). After adjusting for population, this finding of no difference persisted.

CONCLUSIONS

Strength of state gun law grades does not affect MSE incidence, even after correction for population size. This suggests that legislation by itself is not an effective prevention measure and other broader and meaningful primary gun violence interventions are needed.

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

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

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

Objectives

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

Study design

Panel longitudinal study.

Methods

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

Results

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

Conclusions

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

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

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

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

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

Firearm laws and the network of firearm movement among US states

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Pediatric upper extremity firearm injuries: an analysis of demographic factors and recurring mechanisms of injury

BACKGROUND

Little is known regarding risk factors specific to pediatric upper extremity firearm injuries. The purpose of this study is to evaluate pediatric patients treated for these injuries to identify at-risk populations and recurring mechanisms of injury.

METHODS

A 20-year retrospective review was conducted. Patients 17 years of age and younger, with upper extremity injuries related to a firearm, were included. Analysis involved Fisher's exact and Chi-square tests.

RESULTS

One hundred and eighty patients were included. The mean age was 12.04 ± 4.3 years. Most included patients were male (85%). Interestingly, females were more frequently victims of assault (P = 0.03), and males were more frequently injured due to accidental discharge (P < 0.001). The most affected race/ethnicity was White-not Hispanic or Latino (48%). The hand was the most frequent location injured (31%) and was more likely to be accidental than proximal injuries (P = 0.003). Air rifles were the most common firearm type used (56%). Pistols were implicated in 47 (26%) cases, rifles in 17 (9%), and shotguns in 10 (6%). Ninety-nine (55%) patients had procedures in the operating room. The most frequent procedure was foreign body removal (55%).

CONCLUSIONS

Risk factors such as male sex, White-not Hispanic or Latino race/ethnicity, and adolescent age were attributed to increased risk for injury. Male sex was associated with increased risk of injury by accidental discharge and female sex with intentional assault. Air rifles were the most common firearm type overall, although female sex was associated with increased risk for injury by powder weapon.

Machine learning takes a village: Assessing neighbourhood-level vulnerability for an overdose and infectious disease outbreak

BACKGROUND

Multiple areas in the United States of America (USA) are experiencing high rates of overdose and outbreaks of bloodborne infections, including HIV and hepatitis C virus (HCV), due to non-sterile injection drug use. We aimed to identify neighbourhoods at increased vulnerability for overdose and infectious disease outbreaks in Rhode Island, USA. The primary aim was to pilot machine learning methods to identify which neighbourhood-level factors were important for creating "vulnerability assessment scores" across the state. The secondary aim was to engage stakeholders to pilot an interactive mapping tool and visualize the results.

METHODS

From September 2018 to November 2019, we conducted a neighbourhood-level vulnerability assessment and stakeholder engagement process named The VILLAGE Project (Vulnerability Investigation of underlying Local risk And Geographic Events). We developed a predictive analytics model using machine learning methods (LASSO, Elastic Net, and RIDGE) to identify areas with increased vulnerability to an outbreak of overdose, HIV and HCV, using census tract-level counts of overdose deaths as a proxy for injection drug use patterns and related health outcomes. Stakeholders reviewed mapping tools for face validity and community distribution.

RESULTS

Machine learning prediction models were suitable for estimating relative neighbourhood-level vulnerability to an outbreak. Variables of importance in the model included housing cost burden, prior overdose deaths, housing density, and education level. Eighty-nine census tracts (37%) with no prior overdose fatalities were identified as being vulnerable to such an outbreak, and nine of those were identified as having a vulnerability assessment score in the top 25%. Results were disseminated as a vulnerability stratification map and an online interactive mapping tool.

CONCLUSION

Machine learning methods are well suited to predict neighborhoods at higher vulnerability to an outbreak. These methods show promise as a tool to assess structural vulnerabilities and work to prevent outbreaks at the local level.

Annual Incidence of Hospitalization for Nonfatal Firearm-Related Injuries in New York From 2005 to 2016

IMPORTANCE

In the US, approximately 40 000 people die due to firearm-related injuries annually. However, nonfatal firearm-related injuries are less precisely tracked.

OBJECTIVES

To assess the annual incidence of hospitalization for nonfatal firearm-related injuries in New York and to compare the annual incidence by sex, race/ethnicity, county of residence, and calendar years.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study used data from the New York Statewide Planning and Research Cooperative System for patients aged 15 years or older who presented to an emergency department in New York with nonfatal firearm-related injuries from January 1, 2005, to December 31, 2016. Data were analyzed from January 15, 2019, to April 21, 2021.

EXPOSURE

A nonfatal firearm-related injury, defined by International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

The annual incidence of nonfatal firearm-related injuries was calculated by determining the number of patients with a nonfatal firearm-related injury each year divided by the total population of New York.

RESULTS

The study included 31 060 unique patients with 35 059 hospital encounters for nonfatal firearm-related injuries. The mean (SD) age at admission was 28.5 (11.9) years; most patients were male (90.6%) and non-Hispanic Black individuals (62.0%). The overall annual incidence was 18.4 per 100 000 population. Although decreasing trends of annual incidence were observed across the state during the study period, this trend was not present in all 62 counties, with 32 counties (51.6%) having an increase in the incidence of injuries between 2005 and 2010 and 29 (46.8%) having an increase in the incidence of injuries between 2010 and 2015. In 19 of the 30 counties (63.3%) that had a decrease in incidence in earlier years, the incidence increased in later years.

CONCLUSIONS AND RELEVANCE

The annual incidence of hospitalization for nonfatal firearm-related injuries in New York during the study period was 18.4 per 100 000 population. Reliable tracking of nonfatal firearm-related injury data may be useful for policy makers, hospital systems, community organizers, and public health officials as they consider resource allocation for trauma systems and injury prevention programs.

The role of domestic violence in fatal mass shootings in the United States, 2014-2019

Background

Fatal mass shootings, defined as four or more people killed by gunfire, excluding the perpetrator, account for a small percentage of firearm homicide fatalities. Research has not extensively focused on the role of domestic violence (DV) in mass shootings in the United States. This study explores the role of DV in mass shootings in the United States.

Methods

Using 2014–2019 mass shooting data from the Gun Violence Archive, we indexed our data by year and mass shooting and collected the number of deaths and injuries. We reviewed news articles for each mass shooting to determine if it was 1) DV-related (i.e., at least one victim of a mass shooting was a dating partner or family member of the perpetrator); 2) history of DV (i.e., the perpetrator had a history of DV but the mass shooting was not directed toward partners or family members); or 3) non-DV-related (i.e., the victims were not partners or family members, nor was there mention of the perpetrator having a history of DV). We conducted descriptive analyses to summarize the percent of mass shootings that were DV-related, history of DV, or non-DV-related, and analyzed how many perpetrators died during the incidents. We conducted one-way ANOVA to examine whether there were differences in the average number of injuries or fatalities or the case fatality rates (CFR) between the three categories. One outlier and 17 cases with unknown perpetrators were excluded from our main analysis.

Results

We found that 59.1% of mass shootings between 2014 and 2019 were DV-related and in 68.2% of mass shootings, the perpetrator either killed at least one partner or family member or had a history of DV. We found significant differences in the average number of injuries and fatalities between DV and history of DV shootings and a higher average case fatality rate associated with DV-related mass shootings (83.7%) than non-DV-related (63.1%) or history of DV mass shootings (53.8%). Fifty-five perpetrators died during the shootings; 39 (70.9%) died by firearm suicide, 15 (27.3%) were killed by police, and 1 (1.8%) died from an intentional overdose.

Conclusions

Most mass shootings are related to DV. DV-related shootings had higher CFR than those unrelated to DV. Given these findings, restricting access to guns by perpetrators of DV may affect the occurrence of mass shootings and associated casualties.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00330-0.

K-12 School Shootings: Implications for Policy, Prevention, and Child Well-Being

Schools should be considered safe spaces for children; children need to feel secure in order to grow and learn. This article argues that when a school shooting occurs, the harm goes beyond those who are injured or killed, because the presumption of security is shattered, and the mental and emotional health of the students is threatened. There are many interventions for preventing these attacks at the school, state, and federal levels. This article explores evidence behind some of these interventions and describes the delicate balance in implementing interventions without introducing undue stress and anxiety into a child's everyday life.

Psychotic symptoms in mass shootings v. mass murders not involving firearms: findings from the Columbia mass murder database

BACKGROUND

Mass shootings account for a small fraction of annual worldwide murders, yet disproportionately affect society and influence policy. Evidence suggesting a link between mass shootings and severe mental illness (i.e. involving psychosis) is often misrepresented, generating stigma. Thus, the actual prevalence constitutes a key public health concern.

METHODS

We examined global personal-cause mass murders from 1900 to 2019, amassed by review of 14 785 murders publicly described in English in print or online, and collected information regarding perpetrator, demographics, legal history, drug use and alcohol misuse, and history of symptoms of psychiatric or neurologic illness using standardized methods. We distinguished whether firearms were or were not used, and, if so, the type (non-automatic v. semi- or fully-automatic).

RESULTS

We identified 1315 mass murders, 65% of which involved firearms. Lifetime psychotic symptoms were noted among 11% of perpetrators, consistent with previous reports, including 18% of mass murderers who did not use firearms and 8% of those who did (χ2 = 28.0, p < 0.01). US-based mass shooters were more likely to have legal histories, use recreational drugs or misuse alcohol, or have histories of non-psychotic psychiatric or neurologic symptoms. US-based mass shooters with symptoms of any psychiatric or neurologic illness more frequently used semi-or fully-automatic firearms.

CONCLUSIONS

These results suggest that policies aimed at preventing mass shootings by focusing on serious mental illness, characterized by psychotic symptoms, may have limited impact. Policies such as those targeting firearm access, recreational drug use and alcohol misuse, legal history, and non-psychotic psychopathology might yield more substantial results.

A comparison and analysis of seven gun law permissiveness scales

BACKGROUND

Due to the differences in the way gun law permissiveness scales were created and speculation about the politically motivated underpinnings of the various scales, there have been questions about their reliability.

METHODS

We compared seven gun law permissiveness scales, varying by type and sources, for an enhanced understanding of the extent to which choice of a gun law permissiveness scale could affect studies related to gun violence outcomes in the United States. Specifically, we evaluated seven different scales: two rankings, two counts, and three scores, arising from a range of sources. We calculated Spearman correlation coefficients for each pair of scales compared. Cronbach's standardized alpha and Guttman's lambda were calculated to evaluate the relative reliability of the scales, and we re-calculated Cronbach's alpha after systematically omitting each scale to assess whether the omitted scale contributed to lower internal consistency between scales. Factor analysis was used to determine single factor loadings and estimates. We also assessed associations between permissiveness of gun laws and total firearm deaths and suicides in multivariable regression analyses.

RESULTS

All pairs of scales were highly correlated (average Spearman's correlation coefficient r = 0.77) and had high relative reliability (Cronbach's alpha = 0.968, Guttman's lambda = 0.975). All scales load onto a single factor. The choice of scale did not meaningfully change the parameter estimates for the associations between permissiveness of gun laws and gun deaths and suicides.

CONCLUSION

Gun law permissiveness scales are highly correlated despite any perceived political agenda, and the choice of gun law permissiveness scale has little effect on study conclusions related to gun violence outcomes.

Mental Illness, Mass Shootings, and the Future of Psychiatric Research into American Gun Violence

ABSTRACT

This article outlines a four-part strategy for future research in mental health and complementary disciplines that will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated "lone wolf" individuals. The destructive motivations must be situated, instead, within larger social structures and cultural scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagnoses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time-and to prevent serious acts of violence more generally-will require an expanded body of well-funded interdisciplinary research that is informed and implemented through the sustained engagement of researchers with affected communities and other stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp increase both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special urgency to this agenda.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

From Regression Analysis to Deep Learning: Development of Improved Proxy Measures of State-Level Household Gun Ownership

In the absence of direct measurements of state-level household gun ownership (GO), the quality and accuracy of proxy measures for this variable are essential for firearm-related research and policy development. In this work, we develop two highly accurate proxy measures of GO using traditional regression analysis and deep learning, the former accounting for non-linearities in the covariates (portion of suicides committed with a firearm [FS/S] and hunting license rates) and their statistical interactions. We subject the proxies to extensive model diagnostics and validation. Both our regression-based and deep-learning proxy measures provide highly accurate models of GO with training R² of 96% and 98%, respectively, along with other desirable qualities-stark improvements over the prevalent FS/S proxy (R² = 0.68). Model diagnostics reveal this widely used FS/S proxy is highly biased and inadequate; we recommend that it no longer be used to represent state-level household gun ownership in firearm-related studies.

Association between Torso Gunshot Wound Volumes of Trauma Centers and Outcomes of Torso Gunshot Wound Patients. A Propensity-Matched Nationwide Cohort Study

Objective: The number and type of patients treated by trauma centers can vary widely because of a number of factors. There might be trauma centers with a high volume of torso GSWs that are not designated as high-level trauma centers. We proposed that, for torso gunshot wounds (GSWs), the treating hospital's trauma volume and not its trauma center level designation drives patient prognosis.Methods: The National Trauma Data Bank was queried for torso GSWs. The characteristics of torso GSWs in trauma centers with different volumes of torso GSWs were compared. The association between torso GSW volumes of trauma centers and the outcomes of torso GSWs were evaluated with propensity score matching (PSM) and multivariate logistic regression (MLR) analysis.Results: There were 618 trauma centers that treated 14,804 torso GSW patients in two years (2014-2015). In 191 level I trauma centers, 82 of them (42.9%, 82/191) treated <1 torso GSW per month. After well-balanced PSM, patients who were treated in higher volume trauma centers (≥9 torso GSWs/month) had a significantly lower mortality rate (7.9% vs. 9.7%). Patients treated in trauma centers with ≥9 torso GSWs/month had a 30.9% (odds ratio = 0.764) lower probability of death than if sent to trauma centers with <9 torso GSWs/month. Treatment in level I or II trauma centers did not significantly affect mortality.Conclusion: There is an uneven distribution of torso GSWs among trauma centers. Torso GSWs treated in trauma centers with ≥9 torso GSWs/month have significantly superior outcomes with regard to survival.

Self-Protection versus Fear of Stricter Firearm Regulations: Examining the Drivers of Firearm Acquisitions in the Aftermath of a Mass Shooting

Discovering causal mechanisms underlying firearm acquisition can provide critical insight into firearm-related violence in the United States. Here, we established an information-theoretic framework to address the long-disputed dichotomy between self-protection and fear of firearm regulations as potential drivers of firearm acquisition in the aftermath of a mass shooting. We collected data on mass shootings, federal background checks, media output on firearm control and shootings, and firearm safety laws from 1999 to 2017. First, we conducted a cluster analysis to partition States according to the restrictiveness of their firearm-related legal environment. Then, we performed a transfer entropy analysis to unveil causal relationships at the State-level in the Wiener-Granger sense. The analysis suggests that fear of stricter firearm regulations is a stronger driver than the desire of self-protection for firearm acquisitions. This fear is likely to cross State borders, thereby shaping a collective pattern of firearm acquisition throughout the Nation.

A systematic review of the causes and prevention strategies in reducing gun violence in the United States

BACKGROUND

Approximately 100 lives are lost each day as a result of gun violence in the United States (US) with civilian mass shootings increasing annually. The gun violence rate in the US is almost 20 times higher than other comparable developed countries and has the most gun ownership per capita of any nation in the world. Understanding the causes and risk factors are paramount in understanding gun violence and reducing its incidence.

METHODS

A literature search of all published articles relating to gun violence and mass shootings in the US was conducted using the Medline and PMC databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used in conducting this study. Rayyan statistical software was utilized for analysis. Statistical significant was defined as p < .05.

RESULTS

Of the initial 2304 eligible manuscripts identified, 22 fulfilled our selection criteria. A variety of common causal and contributory factors were identified including but not limited to mental illness, suicidal ideation, intimate partner violence, socioeconomic status, community distress, family life, childhood trauma, current or previous substance abuse, and firearm access.

CONCLUSION

Gun violence is pervasive and multi-factorial. Interventions aimed at reducing gun violence should be targeted towards the most common risk factors cited in the literature such as access, violent behavioral tendencies due to past exposure or substance abuse, and mental illness including suicidal ideation.

Characteristics of Gun Advertisements on Social Media: Systematic Search and Content Analysis of Twitter and YouTube Posts

Background

Although gun violence has been identified as a major public health concern, the scope and significance of internet gun advertising is not known.

Objective

This study aimed to quantify the characteristics of gun advertising on social media and to compare the reach of posts by manufacturers with those of influencers.

Methods

Using a systematic search, we created a database of recent and popular Twitter and YouTube posts made public by major firearm manufacturers and influencers. From our sample of social media posts, we reviewed the content of the posts on the basis of 19 different characteristics, such as type of gun, presence of women, and military or police references. Our content analysis summarized statistical differences in the information conveyed in posts to compare advertising approaches across social media platforms.

Results

Sample posts revealed that firearm manufacturers use social media to attract audiences to websites that sell firearms: 14.1% (131/928; ±2.9) of Twitter posts, 53.6% (228/425; ±6.2) of YouTube videos, and 89.5% (214/239; ±5.1) of YouTube influencer videos link to websites that facilitate sales. Advertisements included women in efforts to market handguns and pistols for the purpose of protection: videos with women included protection themes 2.5 times more often than videos without women. Top manufacturers of domestic firearms received 98 million channel views, compared with 6.1 billion channel views received by the top 12 YouTube influencers.

Conclusions

Firearm companies use social media as an advertising platform to connect viewers to websites that sell guns. Gun manufacturers appropriate YouTube servers, video streaming services, and the work of YouTube influencers to reach large audiences to promote the widespread sale of consumer firearms. YouTube and Twitter subsidize gun advertising by offering server and streaming services at no cost to gun manufacturers, to the commercial benefit of Google and Twitter’s corporate ownership.

Emergency Providers' Familiarity with Firearms: A National Survey

BACKGROUND

Emergency providers (EPs) are uniquely placed to advocate for firearm safety and have been shown to be at risk of exposure to firearms in the emergency department (ED). We sought to characterize EPs' knowledge of firearms, frequency of encountering firearms in the ED and level of confidence with safely removing firearms from patient care settings.

METHODS

This was a survey study of EPs representing medical centers in 22 states. A 15-item questionnaire was e-mailed to all EPs at all included institutions. Questions pertained to EPs' knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions with p-values and conducted association analyses among survey items.

RESULTS

Of 2,192 survey recipients, 1,074 (49.0%) completed the survey. A total of 635 (59.1%) reported encountering firearms in the ED or its immediate environment at least once per year, and 582 (54.2%) were not confident in their ability to safely handle a firearm found in a patient's possession. Frequency of handling firearms was significantly higher in states in the top quartile for firearm ownership, with 21.5% of respondents reporting handling firearms daily or weekly, compared to 10.9% in bottom-quartile states. Level of firearms training also differed significantly: 42.1% of respondents in top-quartile states reported formal training compared to 33.0% in bottom-quartile states. Increased regional firearm ownership rates were associated with decreased rates of feeling unsafe at work.

CONCLUSIONS

The majority of surveyed EPs reported little experience with handling firearms. Firearm experience was associated with comfort with managing firearms found in patients' possession. Regional differences were found regarding personal firearm experience and perceptions of workplace safety, both of which were associated with regional variations in firearm ownership. Despite this, no regional differences were found in encountering firearms in or around the ED. EPs may benefit from training on safely handling firearms.

Traumatic brain injury mortality among U.S. children and adolescents ages 0-19 years, 1999-2017

INTRODUCTION

To examine recent traumatic brain injury (TBI) mortality changes among Americans aged 0-19 years by sex, age, urbanicity, state, and intent/causes of injury.

METHOD

TBI mortality per 100,000 population and average annual percent changes (AAPCs), plus 95% confidence intervals (CIs) based on Joinpoint regression models.

RESULTS

Age-adjusted TBI mortality among Americans aged 0-19 years declined consistently, though at varying rates between 1999 and 2013 (AAPC = -4.8%, 95%CI: -6.3%, -3.2%), and then significantly increased from 4.42 per 100,000 population in 2013 to 5.17 per 100,000 population in 2017 (AAPC = 3.4%, 95% CI: 1.7%, 5.1%). During the study time period, boys, rural children, and youth aged 15-19 years had higher TBI mortality rates than girls, urban children, and younger children, respectively. TBI mortality from unintentional transport crashes decreased substantially in all age groups between 1999 and 2017, and especially from 1999 to 2010. TBI mortality from suicide increased significantly from 2008 to 2017 in the 10-14-year age group (AAPC = 14.6%, 95% CI: 12.6%, 16.6%) and from 2007 to 2017 in the 15-19-year age group (AAPC = 6.3%, 95% CI: 3.8%, 8.7%). Unintentional transport crashes were the leading cause of TBI-related mortality in 46 states in 1999, but by 2017, suicide became the first leading cause in 14 states.

CONCLUSIONS

Pediatric TBI mortality declined consistently between 1999 and 2013 and increased significantly from 2013 to 2017, driven primarily by the mortality decrease from unintentional transport crashes and increase in suicide mortality. The spectrum of leading causes of pediatric TBI mortality changed across age groups and over time from 1999 to 2017. Practical Applications: TBI mortality increases in the United States since 2013 are driven primarily by increasing suicide rates, a trend that merits the attention of policy-makers and injury researchers. Action should be taken to curb growing TBI mortality rates among adolescents aged 10-19 years.

Describing a "mass shooting": the role of databases in understanding burden

Background

The mass shooting phenomenon has gained much attention lately as this form of gun violence appears to increase in frequency. Although many organizations collect information on mass shootings (fatal and nonfatal injuries), no federal definition of this phrase exists. The purpose of this study was to highlight the different statistics that result among databases that define and track “mass shootings.” Establishing definitive guidelines for a mass shooting definition could improve research credibility when presenting evidence to policy makers.

Methods

We obtained data for mass shootings that occurred in 2017 from four sources: Gun Violence Archive, Mother Jones Investigation, Everytown for Gun Safety, and FBI’s Supplemental Homicide Report. We also examined FBI’s Active Shooter Report to compare the mass shootings datasets with active shooter situations, which have been federally defined. First, we examined the overlap among databases. Then, we applied the strictest fatal mass shooting definition to the mass shooting datasets to determine whether the differences in databases could be contributing to differences in fatalities and injuries recorded.

Results

Gun Violence Archive recorded the most mass shooting incidents at 346 incidents in 2017, while Mother Jones only recorded 11 cases. Only 2 events were found in all four mass shooting datasets. When the strictest definition – four or more individuals fatally shot – was applied to all datasets, the number of mass shootings in 2017 ranged from 24 (Gun Violence Archive) to 5 (Mother Jones), but incidents collected still varied.

Conclusions

There is much variety in statistics obtained from the different sources that have collected mass shooting information, with little overlap among databases. Researchers should advocate for a standard definition that considers both fatalities and nonfatalities to most appropriately convey the burden of mass shootings on gun violence.

The Effect of Large-Capacity Magazine Bans on High-Fatality Mass Shootings, 1990-2017

Objectives. To evaluate the effect of large-capacity magazine (LCM) bans on the frequency and lethality of high-fatality mass shootings in the United States.Methods. We analyzed state panel data of high-fatality mass shootings from 1990 to 2017. We first assessed the relationship between LCM bans overall, and then federal and state bans separately, on (1) the occurrence of high-fatality mass shootings (logit regression) and (2) the deaths resulting from such incidents (negative binomial analysis). We controlled for 10 independent variables, used state fixed effects with a continuous variable for year, and accounted for clustering.Results. Between 1990 and 2017, there were 69 high-fatality mass shootings. Attacks involving LCMs resulted in a 62% higher mean average death toll. The incidence of high-fatality mass shootings in non-LCM ban states was more than double the rate in LCM ban states; the annual number of deaths was more than 3 times higher. In multivariate analyses, states without an LCM ban experienced significantly more high-fatality mass shootings and a higher death rate from such incidents.Conclusions. LCM bans appear to reduce both the incidence of, and number of people killed in, high-fatality mass shootings.