Challenges, Successes, and the Future of Firearm Injury Prevention.

Policy Points Firearm injury is a leading cause of death in the United States, with fatality rates increasing 34.9% over the past decade (2010-2020). Firearm injury is preventable through multifaceted evidence-based approaches. Reviewing past challenges and successes in the field of firearm injury prevention can highlight the future directions needed in the field. Adequate funding, rigorous and comprehensive data availability and access, larger pools of diverse and scientifically trained researchers and practitioners, robust evidence-based programming and policy implementation, and a reduction in stigma, polarization, and politicization of the science are all needed to move the field forward.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80.

Firearms are a leading cause of injury mortality across the lifespan, with elevated risks for older adult populations. To inform prevention efforts, we conducted a probability-based web survey (12/1/2019-12/23/2019) of 2048 older adults (age 50-80) to characterize national estimates of firearm ownership, safety practices, and attitudes about health screening, counseling, and policy initiatives. Among older U.S. adults, 26.7% [95%CI = 24.8%-28.8%] report owning one or more firearms. The primary motivation for ownership was protection (69.5%), with 90.4% highlighting a fear of criminal assault. 39.4% of firearm owners reported regularly storing firearm(s) unloaded and locked, with 24.2% regularly storing at least one loaded and unlocked. While most firearm owners found healthcare screening (69.2% [95%CI: 64.9-73.1]) and safety counseling (63.2% [95%CI = 58.8-67.3]) acceptable, only 3.7% of older adults reported being asked about firearm safety by a healthcare provider in the past year. Among firearm owners, there was support for state-level policy interventions, including allowing family/police to petition courts to restrict access when someone is a danger to self/others (78.9% [95%CI = 75.1-82.3]), comprehensive background checks (85.0% [95%CI = 81.5-87.9]), restricting access/ownership under domestic violence restraining orders (88.1%; 95%CI = 84.9-90.7], and removing firearms from older adults with dementia/confusion (80.6%; 95%CI = 76.8-84.0]. Healthcare and policy-level interventions maintained higher support among non-owners than owners (p's < 0.001). Overall, data highlights opportunities exist for more robust firearm safety prevention efforts among older adults, particularly healthcare-based counseling and state/federal policies that focus on addressing lethal means access among at-risk individuals.

Extreme risk protection orders in response to threats of multiple victim/mass shooting in six U.S. states: A descriptive study.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy.

The association of firearm laws with firearm outcomes among children and adolescents: a scoping review.

We conducted a scoping review to determine the current state of knowledge and areas for advancements in research on the association of firearm laws with child and adolescent firearm-related outcomes. We queried Scopus, EMBASE, Pubmed, and CJ Abstracts for English language original empirical research articles on policies affecting child and adolescent firearm-related outcomes published between January 1, 1985 and July 1, 2018. Data were abstracted, and methodologic quality assessed. Twenty articles met inclusion criteria. Among the policies studied were child access prevention laws (12 studies) and minimum age restrictions for firearm purchase and possession (4 studies). Outside of child access prevention laws, which are associated with reductions in child and adolescent unintentional and firearm suicide deaths, there is, at best, equivocal evidence of policy effects. This area is understudied, particularly in regard to nonfatal firearm injuries, for which the lack of a national surveillance system hampers research efforts. Further rigorous firearm policy evaluations are needed.

Analysis of the Strength of Legal Firearms Restrictions for Perpetrators of Domestic Violence and Their Associations With Intimate Partner Homicide.

In this research, we estimate the association of firearm restrictions for domestic violence offenders with intimate partner homicides (IPHs) on the basis of the strength of the policies. We posit that the association of firearm laws with IPHs depends on the following characteristics of the laws: 1) breadth of coverage of high-risk individuals and situations restricted; 2) power to compel firearm surrender or removal from persons prohibited from having firearms; and 3) systems of accountability that prevent those prohibited from doing so from obtaining guns. We conducted a quantitative policy evaluation using annual state-level data from 1980 through 2013 for 45 US states. Based on the results of a series of robust, negative binomial regression models with state fixed effects, domestic violence restraining order firearm-prohibition laws are associated with 10% reductions in IPH. Statistically significant protective associations were evident only when restraining order prohibitions covered dating partners (-13%) and ex parte orders (-13%) and included relinquishment provisions (-12%). Laws prohibiting access to those convicted of nonspecific violent misdemeanors were associated with a 23% reduction in IPH rates; there was no association when prohibitions were limited to domestic violence. These findings should inform policymakers considering laws to maximize protections against IPH.

Analysis of the Strength of Legal Firearms Restrictions for Perpetrators of Domestic Violence and Their Associations With Intimate Partner Homicide.

In this research, we estimate the association of firearm restrictions for domestic violence offenders with intimate partner homicides (IPHs) on the basis of the strength of the policies. We posit that the association of firearm laws with IPHs depends on the following characteristics of the laws: 1) breadth of coverage of high-risk individuals and situations restricted; 2) power to compel firearm surrender or removal from persons prohibited from having firearms; and 3) systems of accountability that prevent those prohibited from doing so from obtaining guns. We conducted a quantitative policy evaluation using annual state-level data from 1980 through 2013 for 45 US states. Based on the results of a series of robust, negative binomial regression models with state fixed effects, domestic violence restraining order firearm-prohibition laws are associated with 10% reductions in IPH. Statistically significant protective associations were evident only when restraining order prohibitions covered dating partners (-11%) and ex parte orders (-12%). Laws prohibiting access to those convicted of nonspecific violent misdemeanors were associated with a 24% reduction in IPH rates; there was no association when prohibitions were limited to domestic violence. Permit-to-purchase laws were associated with 10% reductions in IPHs. These findings should inform policymakers considering laws to maximize protections against IPH.

Risks and Targeted Interventions: Firearms in Intimate Partner Violence.

The use of firearms in intimate partner violence (IPV) is widely recognized as an important public health threat. However, what we know about the risks of firearm access on IPV outcomes is limited. Therefore, we conducted a systematic review to determine the state of knowledge on 1) the risks of firearm access and use in IPV and 2) the effectiveness of interventions designed specifically to reduce firearm violence in intimate relationships. Only studies published in English in peer-reviewed journals from 1990 through 2014 were included. Results of the review suggest that, when violent intimates have access to firearms, IPV increases in severity and deadliness; however, increases in severity may not be due to firearm use. Additionally, statutes prohibiting persons under domestic violence restraining orders from accessing firearms are associated with reductions in intimate partner homicide, but certain provisions of these laws and their enforcement may impact their effectiveness. Future research should focus on elucidating the link between firearm access and increased IPV severity and on investigating whether and which specific provisions of domestic violence restraining order laws impact the laws' effectiveness. Additionally, more evaluations of initiatives designed to improve the enforcement of domestic violence restraining order firearm prohibitions are needed.

Modeling the Movement of Homicide by Type to Inform Public Health Prevention Efforts.

OBJECTIVES: We modeled the spatiotemporal movement of hotspot clusters of homicide by motive in Newark, New Jersey, to investigate whether different homicide types have different patterns of clustering and movement. METHODS: We obtained homicide data from the Newark Police Department Homicide Unit's investigative files from 1997 through 2007 (n = 560). We geocoded the address at which each homicide victim was found and recorded the date of and the motive for the homicide. We used cluster detection software to model the spatiotemporal movement of statistically significant homicide clusters by motive, using census tract and month of occurrence as the spatial and temporal units of analysis. RESULTS: Gang-motivated homicides showed evidence of clustering and diffusion through Newark. Additionally, gang-motivated homicide clusters overlapped to a degree with revenge and drug-motivated homicide clusters. Escalating dispute and nonintimate familial homicides clustered; however, there was no evidence of diffusion. Intimate partner and robbery homicides did not cluster. CONCLUSIONS: By tracking how homicide types diffuse through communities and determining which places have ongoing or emerging homicide problems by type, we can better inform the deployment of prevention and intervention efforts.

Examining the role of firearm involvement in repeat intimate partner violence assaults.

BACKGROUND: Intimate partner violence (IPV) remains a pervasive and complex issue with significant social and public health implications. The nexus of firearms and intimate partner violence (IPV) is an especially dangerous one. However, little is known about how firearm involvement can influence the risk of repeat IPV assaults. METHODS: We use data from 346 male perpetrated IPV incidents reported to the Detroit Police Department between December 2016 and April 2017 to examine the role of firearm involvement in IPV recidivism during a 5 and half year follow up period. Employing a conditional gap-time frailty model that accommodates heterogeneity among individuals through a frailty term, we analyze time to multiple IPV assaults that occur over the follow up period. We identify various pathways through which firearms impact the likelihood of subsequent IPV incidents, including intimidation, threats, and use of firearms, while controlling for observable perpetrator characteristics to understand the explicit roles of firearms. RESULTS: Firearm involvement at the index assault was not associated with IPV recidivism. However, involvement of firearms in past IPV assaults significantly increased the risk of subsequent physical IPV. The discrepancy is likely arising from a high degree of censoring among individuals who were armed with a firearm during the index assault. CONCLUSION: Our research reveals a nuanced relationship between firearm involvement and IPV recidivism, shedding light on the multifaceted dynamics at play. By elucidating the intricate dynamics at the intersection of firearms and intimate partner violence, our study underscores the need for targeted policy interventions and preventative measures aimed at reducing IPV recidivism.

Extreme Risk Protection Orders in Connecticut, 2013-2020.

Twenty-one states and the District of Columbia have enacted Extreme Risk Protection Order (ERPO) statutes, which allow temporary removal of firearms from individuals who pose an imminent risk of harm to themselves or others. Connecticut was the first state to enact such a law in 1999. The law's implementation and use between 1999 and 2013 were previously described, finding that ERPOs were pursued rarely for the first decade and that most orders were issued in response to concerns about suicide or self-harm rather than about interpersonal violence. The current study analyzes over 1,400 ERPOs in Connecticut between 2013 and 2020 in several domains: respondent demographics, circumstances leading to ERPO filing, type of threat (suicide, violence to others, or both), number and type of firearms removed, prevalence of mental illness and drug and alcohol use, and legal outcomes. Results are similar to the earlier study, indicating that ERPO respondents in Connecticut are primarily White, male, middle-aged residents of small towns and suburbs who pose a risk of harm to themselves (67.9%) more often than to others (42.8%). Significant gender differences between ERPO respondents are discussed, as are state-specific trends over time and differences between Connecticut and other states with published ERPO data.

The Association of Federal and State-level Firearm Restriction Policies With Intimate Partner Homicide: A Re-analysis by Race of the Victim.

Firearms present a significant risk of intimate partner homicide (IPH) among women in the United States, and Black women continue to be overrepresented among IPH fatalities. State-level firearm restrictions for individuals under domestic violence restraining orders (DVRO) and firearm restrictions for those convicted of violent misdemeanor crimes are associated with reductions in IPH. To receive these protections, individuals must engage with the civil or criminal justice system. While access to, and engagement with, these systems may differ between Black and White populations, research has yet to examine the impact of these firearm restriction laws on IPH by racial group.We conducted pooled, cross-sectional, time-series analyses to examine the association of selected firearm restriction laws on IPH by the race of the victims, from 1981 to 2013 for 45 states in the United States.State-level DVRO firearm restrictions were associated with reductions in IPH in the White population only. The inclusion of relinquishment provisions in state DVRO firearm laws is associated with an 11% reduction in IPH and a 16% reduction in firearm IPH for White, but not Black, victims. Similarly, laws prohibiting individuals convicted of violent misdemeanors from possessing firearms are associated with a 23% reduction in IPH and a 28% reduction in firearm IPH for White victims only. The federal DVRO firearm restriction law is associated with a 27% reduction in state-level IPH and a 28% reduction in firearm IPH for Black, but not White, victims.Firearm restriction laws may have a limited impact on IPH in Black populations. Future research should examine the factors behind the differential estimated impact of these laws by the race of the victims.

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.

Saving Lives: Working across Agencies and Individuals to Reduce Intimate Homicide among those at Greatest Risk.

This special issue of the Journal of Family Violence offers insights on intimate homicide prevention from leading researchers and practitioners. The insights offered are timely, given the pervasiveness of domestic violence (DV), including some data since the emergence of COVID-19 noting an increase in DV-related  cases with severe  injury and police calls. Contributors in this special issue argue for interagency advocacy, protection orders, and firearm removal, along with reimagining data capture, risk assessment, firearm protocols, and fatality reviews to improve equitable services and care for DV survivors at the highest risk of homicide.

Effects of domestic violence policies, alcohol taxes and police staffing levels on intimate partner homicide in large US cities.

OBJECTIVE: To assess the relationships between intimate partner homicide (IPH) and public policies including police staffing levels in large US cities. DESIGN: The research uses a multiple time-series design to examine the effects of statutes aimed at restricting access to firearms for perpetrators of domestic violence, allowing or mandating arrest for violators of domestic violence restraining orders (DVROs), beer excise taxes, and police staffing levels on IPH in 46 of the largest US cities from 1979 to 2003. Both total IPH and IPH committed with a firearm are analysed. Generalised estimating equations using a Poisson distribution are used to regress IPH on the policies and potential confounders. RESULTS: State statutes restricting those under DVROs from accessing firearms, and laws allowing the warrantless arrest of DVRO violators are associated with reductions in total and firearm IPH. Police staffing levels are also negatively associated with IPH and firearm IPH. There was no evidence that other policies to restrict firearm access to domestic violence offenders or alcohol taxes had a significant impact on IPH. CONCLUSIONS: Reducing access to firearms for DVRO defendants, increasing police staffing levels and allowing the warrantless arrest of DVRO violators may reduce the city-level risk of IPH. Future research should evaluate factors that may mediate the effect of these laws and increased police staffing levels on IPH to determine whether there are opportunities to increase their protective effect. Further research is needed on firearm law implementation to determine why the other tested laws were not found effective.

The Intersection of Firearms and Intimate Partner Homicide in 15 Nations.

Intimate partners commit approximately one in three homicides against women worldwide. Little is known about situational factors that contribute to intimate partner homicides (IPH) and how they may differ across nations. This article provides a cross-national exploration of one situational factor, the use of firearms in the commission of homicides, and considers whether nations have laws designed specifically to keep firearms out of the hands of batterers. We conducted a systematic search of peer-reviewed research and governmental and nongovernmental reports for data on weapon use in IPH. Data were located for 15 nations and subnational areas, which varied from firearms being involved in no IPHs in Fiji to 59% in Antalya, Turkey. Seven nations have legislation that addresses gun ownership as it relates to those who have been charged with, convicted of, or show a propensity toward the commission of intimate partner violence. These laws vary in whether domestic violence is a factor considered in whether to allow firearm ownership or whether it served to disqualify ownership. Due to the small number of nations for which data on weapon use in IPH were located, we did not conduct any hypothesis testing. There is a need for detailed homicide surveillance systems among nations so that researchers can explore the epidemiology of these homicides and ultimately identify opportunities for intervention.

Removing Firearms From Those Prohibited From Possession by Domestic Violence Restraining Orders: A Survey and Analysis of State Laws.

Under federal and many state laws, persons under domestic violence restraining orders (DVROs) are prohibited from possession of firearms. Using multiple sources and a Lexis Nexis search, we developed a list of state laws pertaining to the relinquishment or removal of firearms from persons prohibited from possession by DVROs. After downloading the text of each law, we conducted a legal analysis to enumerate provisions of the laws specifying implementation. We found 49 laws in 29 states and Washington, DC. The laws were conceptualized as instructions to the court, the respondent, and law enforcement. We detail the content of each state's law, including such elements as whether it applies to ex parte DVROs; whether certain criteria must be met, such as previous use of a firearm in domestic violence or lack of an employment exemption, before the law can be applied; and whether the application of the law is mandatory. We also detail instructions to the respondent regarding to whom firearms may be relinquished, whether the respondent must seek permission to transfer the firearm to a third party, and the time by which dispossession must occur. Finally, whether law enforcement bears the responsibility for removing the firearm or whether the law gives the court the authority to order a search and seizure for the firearms is discussed. The purpose of the research is to provide an overview of these state laws that can be used by key stakeholders in legislative, judicial, advocacy, or research roles. Implications are discussed.

Ecological Research for Studies of Violence: A Methodological Guide.

Ecological research is important to the study of violence in communities. The phrases "ecological research" and "ecologic study" describe those research studies that use grouped or geographic units of analysis, such as zip codes, cities, or states. This type of research allows for the investigation of group-level effects and can be inexpensive and relatively quick to conduct if the researcher uses existing data. And, importantly, ecological studies are an efficient means for hypothesis generation prior to, and can be used to justify, costlier individual-level studies. Ecological research designs may be employed to study violence outcomes when the research question is at the population level, either for theoretical reasons, or when an exposure or intervention is at the population level, or when individual-level studies are not feasible; however, ecological research results must not be used to make individual-level inferences. This article will discuss reasons to conduct ecological-level research, guidelines for choosing the ecological unit of analysis, frequently used research designs, common limitations of ecological research, including the ecological fallacy, and issues to consider when using existing data.

Prevention of Firearm Injuries Among Children and Adolescents: Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium.

IMPORTANCE: Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality. OBJECTIVE: The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development-funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic. EVIDENCE REVIEW: A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium. FINDINGS: Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement. CONCLUSIONS AND RELEVANCE: These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.