Firearm-Related Juvenile Death Rates Correlate With Gun Ownership Rates, Measures of Guns in Circulation, and Leniency of Existing Firearm Laws Among U.S. States.

INTRODUCTION: Firearms now represent the leading cause of death in U.S. children. Therefore, this study aimed to determine if state-level rates of gun ownership, guns in circulation, and strictness of firearm-related laws are related to firearm-related mortality among both juveniles and overall populations. MATERIALS AND METHODS: State firearm mortality rates among the juvenile and overall populations were obtained from 2010 to 2020. The number of weapons registered with the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) and federal firearms licensees for each state were also recorded. Giffords Law Center Scorecard Rankings, a relative measure of the restrictiveness of each state's gun laws, were also collected. Unadjusted linear regressions modeled the relationships between firearm-associated mortality and ATF-registered weapons, federal firearm licensees, Giffords Center rankings, and gun ownership rates. Multivariable (adjusted) analyses were performed to control for poverty, unemployment, and poor mental health. RESULTS: Unadjusted analyses demonstrated that higher gun ownership rates and more lenient gun laws were associated with increased firearm-associated mortality among juveniles. Similarly, these measures as well as increased ATF-registered weapons and ATF federal firearm licensees were associated with increased firearm mortality in the overall population. In the adjusted analyses, more ATF-registered weapons, more ATF federal firearm licensees, higher gun ownership rates, and more lenient firearm laws were associated with increased firearm-related mortality in the overall population, while increased gun ownership and higher Giffords Center rankings were associated with increased firearm-associated mortality in the pediatric population. CONCLUSIONS: To reduce the toll of gun violence in the United States, policymakers should focus on implementing more restrictive firearm laws and reducing the prevalence of guns in their communities.

Bullet holes: A novel model to identify the most impactful gaps in the firearm homicide prevention laws of each state.

BACKGROUND: Firearm homicides (FH) are a major cause of mortality in the United States. Firearm law implementation is variable across states, and legislative gaps may represent opportunities for FH prevention. For each state, we sought to identify which firearm law category would have been most effective if implemented and how effective it would have been. METHODS: We conducted a retrospective cohort study examining the effects of firearm laws on FH rates in the 48 contiguous US states 2010 to 2019. Data were obtained from the CDC WONDER and FBI UCR databases, State Firearm Law Database, and US Census. Firearm laws were grouped into 14 categories. We assessed the association between the presence of each law category and FH rate as an incidence rate ratio (IRR) using a Poisson regression accounting for state population characteristics and laws of surrounding states. We estimated the IRR for each state that did not have a given law category present and determined which of these missing law categories would have been associated with the greatest reduction in FH rate. RESULTS: FH rates varied widely across states and increased from a mean of 3.2 (SD = 1.7) to 4.2 (SD = 2.9) FH per 100,000. All law categories were significantly associated with decreased FH rate ( p < 0.05), with IRR ranging from 0.25 to 0.85. The most effective missing law category differed between states but was most commonly child access prevention (34.09% of states), assault weapons and large-capacity magazines (15.91%), preemption (15.91%), and concealed carry permitting (13.64%). In total across 2010 to 2019, we estimated that 129,599 fewer FH would have occurred with enactment of the most effective missing law category in each state. CONCLUSION: Modeling firearm law prevention of FH with regard to state legislative and population characteristics can identify the highest impact missing law categories in each state. These results can be used to inform efforts to reduce FH. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Promoting Firearm Injury Prevention and Advocacy as Pediatric Surgeons: A Call to Action From the APSA/AAP Advocacy Committee.

Firearm injuries have become the leading cause of death among American children. Here we review the scope of the problem, and the pivotal role pediatric surgeons have in preventing pediatric firearm injury. Specific methods for screening and counseling are reviewed, as well as how to overcome barriers. Community and hospital resources as well as organizational efforts are discussed. Finally, a path for surgeon advocacy is outlined as is a call to action for the pediatric surgeon, as we are uniquely poised to identify pediatric patients and deliver timely interventions to reduce the impact of firearm violence. LEVEL OF EVIDENCE: Level IV.

State firearm laws and nonfatal firearm injury-related inpatient hospitalizations: A nationwide panel study.

BACKGROUND: Firearm injury remains a major cause of morbidity and mortality in the United States. Because of prior lack of comprehensive data sources, there is a paucity of literature on nonfatal firearm injury. Associations have previously been shown between state-level firearm laws and firearm fatalities, but few studies have examined the effects of these laws on nonfatal firearm hospitalization rates. Our objective was to examine the relationship between state firearm laws and firearm injury-related hospitalization rates across all 50 states over a 17-year period. METHODS: In this panel study design, we used fixed effects multivariate regression models to analyze the relationship between 12 laws and firearm state-level injury-related hospitalization rates from 2000 to 2016 using the RAND Corporation Inpatient Hospitalizations for Firearm Injury Database. We used difference-in-differences to determine the impact of law passage in a given state compared with those states without the law, controlling for state-level covariates. The main outcome measure was the change in annual firearm injury-related inpatient hospitalization rates after passage or repeal of a state-level firearm law. RESULTS: Examining each law individually, passage of violent misdemeanor, permitting, firearm removal from domestic violence offenders, and 10-round limit laws were associated with significant firearm injury-related hospitalization rate reductions. Examining multiple laws in the same model, passage of violent misdemeanor laws was associated with a 19.9% (confidence interval, 11.6%-27.4%) reduction, and removal of firearms from domestic violence offenders was associated with a 17.0% (confidence interval, 9.9%-23.6%) reduction in hospitalization rates. CONCLUSION: State laws related to preventing violent offenders from possessing firearms are associated with firearm injury-related hospitalization rate reductions. Given significant physical, mental, and social burdens of nonfatal firearm injury, determining the efficacy of firearm-related policy is critical to violence and injury prevention efforts. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

The limitations of hospital and law enforcement databases in characterizing the epidemiology of firearm injury.

BACKGROUND: Current data on the epidemiology of firearm injury in the United States are incomplete. Common sources include hospital, law enforcement, consumer, and public health databases, but each database has limitations that exclude injury subgroups. By integrating hospital (inpatient and outpatient) and law enforcement databases, we hypothesized that a more accurate depiction of the totality of firearm injury in our region could be achieved. METHODS: We constructed a collaborative firearm injury database consisting of all patients admitted as inpatients to the regional level 1 trauma hospital (inpatient registry), patients treated and released from the emergency department (ED), and subjects encountering local law enforcement as a result of firearm injury in Jefferson County, Kentucky. Injuries recorded from January 1, 2016, to December 31, 2020, were analyzed. Outcomes, demographics, and injury detection rates from individual databases were compared with those of the combined collaborative database and compared using χ2 testing across databases. RESULTS: The inpatient registry (n = 1,441) and ED database (n = 1,109) were combined, resulting in 2,550 incidents in the hospital database. The law enforcement database consisted of 2,665 patient incidents, with 2,008 incidents in common with the hospital database and 657 unique incidents. The merged collaborative database consisted of 3,207 incidents. In comparison with the collaborative database, the inpatient, total hospital (inpatient and ED), and law enforcement databases failed to include 55%, 20%, and 17% of all injuries, respectively. The hospital captured nearly 94% of survivors but less than 40% of nonsurvivors. Law enforcement captured 93% of nonsurvivors but missed 20% of survivors. Mortality (11-26%) and injury incidence were markedly different across the databases. DISCUSSION: The utilization of trauma registry or law enforcement databases alone do not accurately reflect the epidemiology of firearm injury and may misrepresent areas in need of greater injury prevention efforts. LEVEL OF EVIDENCE: Epidemiological, level IV.

Firearm violence against children in the United States: Trends in the wake of the COVID-19 pandemic.

BACKGROUND: This study aimed to evaluate the patterns of firearm violence against children before and after the COVID-19 pandemic, as well as the patterns of specific types of firearm violence against children over time (2016-2020). METHODS: Retrospective firearm violence data were obtained from the Gun Violence Archive. The rate of firearm violence was weighted per 100,000 children. A scatterplot was created to depict the rate of total annual child-involved shooting incidents over time; with a linear trendline fit to 2016 to 2019 data to show projected versus actual 2020 firearm violence. All 50 states were categorized into either "strong gun law" (n = 25) or "weak gun law" (n = 25) cohorts. Multivariate linear regressions were performed for number of child-involved shootings over time. RESULTS: There were a total of 1,076 child-involved shootings in 2020, 811 in 2019, and 803 in 2018. The median total child-involved shooting incidents per month per 100,000 children increased from 2018 to 2020 (0.095 vs. 0.124, p = 0.003) and from 2019 to 2020 (0.097 vs. 0.124, p = 0.010). Child killed by adult incidents also increased in 2020 compared with 2018 (p = 0.024) and 2019 (p = 0.049). The scatterplot demonstrates that total child-involved shootings in addition to both fatal and nonfatal firearm violence incidents exceeded the projected number of incidents extrapolated from 2016 to 2019 data. Multivariate linear regression demonstrated that, compared with weak gun law states, strong gun law states were associated with decreased monthly total child-involved shooting incidents between 2018 and 2020 (p < 0.001), as well as between 2019 and 2020 (p < 0.001). CONCLUSION: Child-involved shooting incidents increased significantly in 2020 surrounding the COVID-19 pandemic. Given that gun law strength was associated with a decreased rate of monthly child-involved firearm violence, public health and legislative efforts should be made to protect this vulnerable population from exposure to firearms. LEVEL OF EVIDENCE: Epidemiological, level III.

The attitude of Brazilian federal police officers towards firearms / La actitud de los agentes de la Policía Federal brasileña en relación con las armas de fuego / A atitude de policiais Federais brasileiros em relação às armas de fogo

Abstract This research deals with one of the most problematic themes in the Brazilian public security agenda, firearm control. Since the publication of the Statute of the Disarmament in 2003, the Federal Police (FP) has been responsible for controlling firearm possession of the civilian population. Thus, FP officers become central players in firearm control policies in Brazil. In this research, we investigate the attitude of Brazilian FP officers towards firearms and what explains this attitude. We collected data from 800 police officers from different positions working in all regions of the country. The results show that police officers believe that firearm possession is an individual right, but firearms do not protect against crime. The results also show that the officers' attitude towards firearms is influenced by their position and their experience with firearms. The article presents the study's implications for management theory and practice.

Resumen Esta investigación aborda uno de los temas más problemáticos de la agenda de seguridad pública brasileña, el control de armas de fuego. Desde la publicación del Estatuto de Desarme, en 2003, la Policía Federal (PF) se ha encargado de controlar la tenencia y porte de armas de fuego por parte de la población civil. Así, los oficiales de la PF se convierten en actores centrales de las políticas de control de armas de fuego en Brasil. Investigamos la actitud de los oficiales de la PF brasileña hacia las armas de fuego y qué explica esta actitud. Recopilamos datos de 800 policías de diferentes cargos y que operan en todas las regiones del país. Los resultados muestran que los agentes de policía creen que la tenencia de armas de fuego es un derecho individual, pero que las armas no protegen contra el crimen. Los resultados también muestran que la actitud de los policías hacia las armas de fuego está influenciada por el cargo que ocupa y por la experiencia del policía con las armas de fuego. Al final, se presentan las implicaciones del estudio para la teoría y la práctica de la gestión.

Resumo Esta pesquisa trata de um dos temas mais problemáticos da agenda da segurança pública brasileira, o controle de armas de fogo. Desde a publicação do Estatuto do Desarmamento, em 2003, a Polícia Federal (PF) é responsável pelo controle da posse e porte de armas de fogo pela população civil. Assim, os oficiais da PF passaram a ser atores centrais nas políticas de controle de armas de fogo no Brasil. Nesta pesquisa, investigamos a atitude dos oficiais brasileiros de PF em relação às armas de fogo e o que explica essa atitude. Coletamos dados de 800 policiais, de diferentes cargos e atuantes em todas as regiões do país. Os resultados mostram que os policiais acreditam que possuir armas de fogo é um direito individual, mas que a arma não protege contra o crime. Os resultados também mostram que a atitude dos policiais em relação às armas de fogo é influenciada pelo cargo ocupado na PF e pela experiência do policial com armas de fogo. Ao final, são apresentadas as implicações do estudo para a teoria e prática gerencial.

Bang for the buck: The impact of political financial contributions on firearm law.

BACKGROUND: One hundred thousand Americans are shot annually, and 39,000 die. State laws restricting firearm sales and use have been shown to decrease firearm deaths, yet little is known about what impacts their passage or repeal. We hypothesized that spending by groups that favor firearm restrictive legislation would increase new state firearm restrictive laws (FRLs) and that states increasing these laws would endure fewer firearm deaths. METHODS: We acquired 2013 to 2018 state data on spending by groups against firearm restrictive legislation and for firearm restrictive legislation regarding lobbying, campaign, and independent and total expenditures from the National Institute on Money in State Politics. State-level political party representation data were acquired from the National Conference of State Legislatures. Mass shooting data were obtained from the Mass Shooter Database of the Violence Project, and firearm death rates were obtained from Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research and Federal Bureau of Investigation Uniform Crime Reporting databases. Firearm restrictive laws were obtained from the State Firearms Law Database. A univariate panel linear regression with fixed effect for state was performed with change in FRLs from baseline as the outcome. A final multivariable panel regression with fixed effect for state was then used. Firearm death rates were compared by whether states increased, decreased, or had no change in FRLs. RESULTS: Twenty-two states gained and 13 lost FRLs, while 15 states had no net change (44%, 26%, and 30%; p = 0.484). In multivariable regression accounting for partisan control of state government, for-firearm restrictive legislation groups outspending against-firearm restrictive legislation groups had the largest association with increased FRLs (ß = 1.420; 95% confidence interval, 0.63-2.21; p < 0.001). States that gained FRLs had significantly lower firearm death rates (p < 0.001). Relative to states with no change in FRLs, states that lost FRLs had an increase in overall firearm death of 1 per 100,000 individuals. States that gained FRLs had a net decrease in median overall firearm death of 0.5 per 100,000 individuals. CONCLUSION: Higher political spending by groups in favor of restrictive firearm legislation has a powerful association with increasing and maintaining FRLs. States that increased their FRLs, in turn, showed lower firearm death rates. LEVEL OF EVIDENCE: Epidemiological, level I.

The Association of State Firearm Legislation With the Burden of Firearm-Related Surgery.

BACKGROUND: United States state-level firearm legislation is linked to rates of firearm-related suicides, pediatric injuries, nonfatal injuries, hospital discharges, and mortality. Our objective was to evaluate the burden of firearm-related injuries requiring surgery for states with strict as opposed to nonstrict firearm legislation. MATERIALS AND METHODS: The 2014 Healthcare Cost and Utilization Project State Inpatient Database was utilized to extract data for all available 28 states and the District of Columbia. States were dichotomized into strict and nonstrict legislative categories using the 2014 Brady and Gifford's scores (15 strict, 14 nonstrict). Patients with a firearm injury requiring surgery were identified and the incidence of surgery aggregated to the county level. Negative binomial regression with an offset for county-level residential population was used to estimate the incident rate ratio for surgical volume comparing counties in strict and nonstrict states. Models were stratified by injury intent and adjusted for county population characteristics. RESULTS: A total of 11,939 patients were hospitalized with firearm-related injuries, with 65% (n = 7759) undergoing an operative procedure. The adjusted incidence rate of firearm-related surgery per 100,000 people was 1.29 (95% confidence interval; 1.13-1.46, P < 0.001) times higher and the adjusted cost of hospitalization per 100,000 people was $6028.69 ($3744.61-$8312.78, P = 0.001) greater for counties in nonstrict states than those for counties in strict states. The burden of health care for these injuries is invariably shifted to state- and county-level finances. CONCLUSIONS: The rate of firearm-related surgical intervention was higher for states with nonstrict firearm legislation than that for states with strict legislation. States should reevaluate their firearm legislation to potentially reduce the burden of firearm-related surgery and health care costs.

Universal background checks for handgun purchases can reduce homicide rates of African Americans.

BACKGROUND: Federal law requires background checks for firearms purchased from licensed dealers, but states can extend requirements to private sales of handguns and purchases at gun shows (universal background checks for handguns [UBC-HG]). Although firearm homicide disproportionately affects African Americans, little is known about how UBG-HG impacts African Americans. We hypothesized that implementation of UBC-HG would reduce rates of firearm homicide of African Americans. METHODS: We collected Centers for Disease Control firearm homicide counts for African American and white populations in the 50 states, 1999 to 2017. Laws were drawn from the State Firearm Laws Database. The exposure and outcome of interest were UBC-HG adoption and firearm homicide. We included non-Hispanic African American and non-Hispanic white populations. We used Poisson regression to perform a differences-in-differences analysis. A categorical variable for state accounted for time-stable state characteristics. We controlled for year to account for trends over time unrelated to policy. We controlled for state-specific, time-variable factors, including median household income, population younger than 25 years or 65 years or older, alcohol consumption, and count of firearm laws (UBC-HG excluded). Standard errors were adjusted for clustering at the state level. RESULTS: The firearm homicide rate among whites was 1.8 per 100,000 (interquartile range, 1.2-2.7) ranging from 1.4 in 2011 to 1.8 in 2016. The firearm homicide rate was 15.6 per 100,000 (interquartile range, 11.6-21.0) among African Americans, ranging from 14.0 in 2009 to 19.6 in 2017. While no significant difference in firearm homicides among whites (incidence rate ratio, 0.93; 95% confidence interval, 0.73-1.20) was appreciated, the passage of UBC-HG was associated with an 19% decrease in African Americans firearm homicides (incidence rate ratio, 0.81; 95% confidence interval, 0.70-0.94; p = 0.006). CONCLUSION: Implementing UBC-HG was associated with decreased firearm homicides among African Americans-the population most at risk. Expanding UBC-HG may be an effective approach to reducing racial disparities in firearm homicides. LEVEL OF EVIDENCE: Epidemiological, level III.

Firearm laws and illegal firearm flow between US states.

BACKGROUND: Considerable variation in firearm legislation exists. Prior studies show an association between stronger state laws and fewer firearm deaths. We hypothesized that firearms would flow from states with weaker laws to states with stronger laws based on proximity and population. METHODS: Crime gun trace data from 2015 to 2017 was accessed from the Bureau of Alcohol, Tobacco, Firearms and Explosives and compared with the count and composition of firearm legislation in 2015 among the contiguous 48 states. Additional independent variables included population, median household income, distance, and presence or absence of a shared border. We used Exponential Random Graph Models to identify predictors of traced firearm transfers between origin and destination states. RESULTS: After controlling for network structure, firearm laws in origin states were associated with fewer traced firearm transfers (incidence rate ratio [IRR], 0.88; 95% confidence interval [CI], 0.83-0.93; p < 0.001). Conversely, more firearm laws in destination states were associated with more traced firearm transfers (IRR, 1.10; 95% CI, 1.06-1.15; p < 0.001). Larger population at the origin was associated with increased transfers (IRR, 1.38; 95%CI, 1.27-1.50; p < 0.001), as was larger population at the destination state (IRR, 1.45; 95% CI, 1.35-1.56; p < 0.001). Greater distance was associated with fewer transfers (for each 1,000 km; IRR, 0.35; 95% CI, 0.27-0.46; p < 0.001), and transfers were greater between adjacent states (IRR, 2.49; 95% CI, 1.90-3.27; p < 0.001). CONCLUSION: State firearm legislation has a significant impact on gun trafficking even after controlling for network structure. States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state. LEVEL OF EVIDENCE: Epidemiologic, level III.

Gun Regulation Exceptionalism and Adolescent Violence: A Comparison to Tobacco.

This article compares the landscape of tobacco regulations to the landscape of gun regulations, with a focus on regulations that target youth. This article argues that guns are significantly less regulated compared to tobacco, despite the frequency with which each product causes significant harm to both self and other.Many of the specific ways tobacco is regulated can be applied analogously to firearms while plausibly surviving potential Second Amendment challenges. This article compares the regulatory landscape of tobacco and firearms across six categories: (a) minimum age for purchase, (b) sale by unlicensed individuals, (c) taxation, (d) advertising, (e) graphic warning labels, and (f) zoning.At one time, tobacco was as central - or more so - to American culture as guns are today. However, many decades of public health advocacy led to historic tobacco regulations. Tobacco's regulatory history provides a valuable blueprint for gun regulation, despite Constitutional differences.

Gun Violence in Court.

Litigation cannot solve a public health crisis. But litigation can be an effective complementary tool to regulation by increasing the salience of a public health issue, eliciting closely guarded information to move public opinion, and prompting legislative action. From tobacco to opioids, litigants have successfully turned to courts for monetary relief, to initiate systemic change, and to hold industry accountableFor years, litigators have been trying to push firearm suits into their own litigation moment. But litigation against the gun industry poses special challenges. Not only has the regulatory regime failed to prevent a public safety hazard, Congress has consistently underfunded and understaffed the relevant regulatory actors. And in 2005 it legislatively immunized the gun industry from suit with the Protection of Lawful Commerce in Arms Act (PLCAA).This paper surveys the field of litigation in response to gun violence, tracking the limited successes of victims and stakeholders suing the gun industry. We find that victories remain confined to individual actors and unlike high-impact public litigations in other areas, aggregate class actions and major public litigation led by state attorneys general are noticeably absent in the firearm context.

Patients and Guns: Florida Physicians Are Not Asking.

OBJECTIVES: The number of deaths from gun violence continues to increase in the United States. Despite multiple studies demonstrating that counseling patients leads to safer gun storage, it is not routinely practiced by physicians. There are multiple barriers to discussing firearms with patients. A barrier in Florida, until recently, was a law preventing physicians from asking patients about firearms. The law was overturned in 2017; however, it is unclear whether physicians are aware of this decision. We undertook a survey to study University of Florida faculty physicians' knowledge, attitudes, and practices related to discussing firearms safety. METHODS: The survey consisted of 15 questions related to firearms and counseling. Invitations to participate were e-mailed in 2018 to faculty in general internal medicine, emergency medicine, and surgery within our institution. RESULTS: The response rate was 50% (n = 71/142). The majority of faculty surveyed did not own a gun (56%). Ninety-one percent of faculty surveyed agreed that "gun violence is a public health issue" and 93% agreed that gun safety discussion with patients at risk for suicidal or violent behavior is important. More than half of the respondents (62%) believed they could effectively discuss firearms safety with patients; 73% strongly agreed or agreed that they would discuss gun safety with at-risk patients, whereas 27% were either neutral or disagreed. Fewer still (55%) feel comfortable initiating conversations, and only 5% of participants always talk to at-risk patients about gun safety. Twenty-four percent discussed gun safety most of the time, 30% discussed it sometimes, 32% rarely discussed it, and 9% never discussed it; 76% were aware of the 2017 court decision overturning the physician gag law in Florida. The most-often cited barriers to discussions included lack of time (36%), worry about negative reaction from patient (30%), worry about lack of support from administration (13%), and lack of knowledge (20%). Gun owners and nonowners differed significantly on only two survey items: having taken a firearms safety course (gun owners more likely, relative risk 1.63, 95% confidence interval 1.16-2.29, P = 0.001) and agreeing with gun violence being a public health issue (gun owners being less likely, relative risk 1.24, 95% confidence interval 1.03-1.49, P = 0.006). CONCLUSIONS: Faculty miss opportunities to prevent gun violence despite acknowledging that it is important to do so. More than 40% of the physicians who were surveyed do not counsel at-risk patients about gun safety, citing a lack of knowledge, a persisting belief that asking patients about guns in Florida is illegal, worry about negative patient reactions, and time limitations. Inaction persists despite increased awareness and activism by physicians regarding gun violence. A wider availability of continuing medical education opportunities to learn about firearms counseling should be considered.