Toward a clearer understanding of what works to reduce gun violence: the role of falsification strategies.

Strong epidemiologic evidence from ecological and individual-level studies in the United States supports the claim that access to firearms substantially increases the risk of dying by suicide, homicide, and firearm accidents. Less certain is how well particular interventions work to prevent these deaths and other firearm-related harms. Given the limits of existing data to study firearm violence and the infeasibility of conducting randomized trials of firearm access, it is important to do the best we can with the data we already have. We argue that falsification strategies are a critical-yet underutilized-component of any such analytical approach. The falsification strategies we focus on are versions of "negative controls" analyses in which we expect that an analysis should yield a null causal effect, and thus where not obtaining a null effect estimate raises questions about the assumptions underlying causal interpretation of a study's findings. We illustrate the saliency of this issue today with examples drawn from studies published in leading peer-reviewed journals within the last 5 years. Collecting rich, high-quality data always takes time, urgent as the need may be. On the other hand, doing better with the data we already have can start right now.

Nearly 20 Years Since the Federal Ban: Can State-Level Assault Weapon Prohibitions Fill the Void? Comparative Analysis of Case Fatality and Assault Weapon Recovery in States With and Without an Assault Weapon Ban.

INTRODUCTION: Few states established assault weapon bans (AWBs) after the federal AWB expired. The effectiveness of state AWBs as well as neighboring state legislation, in reducing the local prevalence of assault weapons (AWs) or in reducing overall shooting lethality is unknown. METHODS: We queried the Gun Violence Archive (2014-2021) to identify US firearm injuries and fatalities. Shooting case fatality rates were compared among states with and without AWBs, as reported in the State Firearm Laws Database. Data on recovered firearms was obtained from the ATF Firearms Trace Database and used to estimate weapon prevalence. Recovered firearms were classified as AWs based on caliber (7.62 mm, 5.56 mm, 0.223 cal). We performed spatially weighted linear regression models, with fixed effects for state and year to assess the association between geographically clustered state legislation and firearm outcomes. RESULTS: From 2014 to 2021, the US shooting victim case fatality rate was 8.06% and did not differ among states with and without AWBs. The proportion of AWs to total firearms was 5.0% in states without an AWB and 6.0% in states with an AWB (mean difference [95% CI] = -0.8% [-1.6% to -0.2%], P = 0.03). Most recovered firearms in AWB states originated from non-AWB states. On adjusted models, there was no association between state-level AWB and firearm case fatality; however, adjacency to states with an AWB was associated with lower case fatality (P < 0.001). Clustered AWB states with shared borders had lower AW prevalence and fatality rates than the rest of the US. CONCLUSIONS: Isolated state AWBs are not inversely associated with shooting case fatality rates nor the prevalence of AWs, but AWBs among multiple neighboring states may be associated with both outcomes.

Firearm-Related Injuries and the US Opioid and Other Substance Use Epidemic: A Nationwide Evaluation of Emergency Department Encounters.

INTRODUCTION: There has been a sharp climb in the Unites States' death rate among opioid and other substance abuse patients, as well as an increased prevalence in gun violence. We aimed to investigate the association between substance abuse and gun violence in a national sample of patients presenting to US emergency departments (EDs). METHODS: We queried the 2018-2019 Nationwide Emergency Department Sample for patients ≥18 years with substance abuse disorders (opioid and other) using International Classification of Diseases, 10th Revision, Clinical Modification codes. Within this sample, we analyzed characteristics and outcomes of patients with firearm-related injuries. The primary outcome was mortality; secondary outcomes were ED charges and length of stay. RESULTS: Among the 25.2 million substance use disorder (SUD) patients in our analysis, 35,306 (0.14%) had a firearm-related diagnosis. Compared to other SUD patients, firearm-SUD patients were younger (33.3 versus 44.7 years, P < 0.001), primarily male (88.6% versus 54.2%, P < 0.001), of lower-income status (0-25th percentile income: 56.4% versus 40.5%, P < 0.001), and more likely to be insured by Medicaid or self-pay (71.6% versus 53.2%, P < 0.001). Firearm-SUD patients had higher mortality (1.4% versus 0.4%, P < 0.001), longer lengths of stay (6.5 versus 4.9 days, P < 0.001), and higher ED charges ($9269 versus $5,164, P < 0.001). Firearm-SUD patients had a 60.3% rate of psychiatric diagnoses. Firearm-SUD patients had 5.5 times greater odds of mortality in adjusted analyses (adjusted odds ratio: 5.5, P < 0.001). CONCLUSIONS: Opioid-substance abuse patients with firearm injuries have higher mortality rates and costs among these groups, with limited discharge to postacute care resources. All these factors together point to the urgent need for improved screening and treatment for this vulnerable group of patients.

Situational and Victim Correlates of Increased Case Fatality Rates in Los Angeles Shootings, 2005-2021.

The gun assault case fatality rate measures the fraction of shooting victims who die from their wounds. Considerable debate has surrounded whether gun assault case fatality rates have changed over time and what factors may be involved. We use crime event data from Los Angeles to examine the victim and situational correlates of gun assault case fatality rates over time. We estimated log binomial regression models for the probability of death in each year from 2005 to 2021, conditioned on situational and victim characteristics of the crime. Case fatality rates increased by around 1.3% per year between 2005 and 2021 from around 15.9 to 19.7%. Baseline case fatality rates differed systematically by most situational and victim but followed similar temporal trends. Only victim age significantly covaried with the temporal trend in case fatality rates. An individual shot in Los Angeles in 2021 was 23.7% more likely to die than the equivalent victim in 2005. The steady increase in case fatality rates suggests that there were around 394 excess fatalities over what would have occurred if case fatality rates remained at the 2005 level. Increases in the average age of victims over time may contribute to the general temporal trend. We hypothesize that older victims are more likely to be shot indoors where lethal close-range wounds are more likely.

Public health framing of firearm violence on local television news in Philadelphia, PA, USA: a quantitative content analysis.

BACKGROUND: Firearm violence is an intensifying public health problem in the United States. News reports shape the way the public and policy makers understand and respond to health threats, including firearm violence. To better understand how firearm violence is communicated to the public, we aimed to determine the extent to which firearm violence is framed as a public health problem on television news and to measure harmful news content as identified by firearm-injured people. METHODS: This is a quantitative content analysis of Philadelphia local television news stories about firearm violence using a database of 7,497 clips. We compiled a stratified sample of clips aired on two randomly selected days/month from January-June 2021 from the database (n = 192 clips). We created a codebook to measure public health frame elements and to assign a harmful content score for each story and then coded the clips. Characteristics of stories containing episodic frames that focus on single shooting events were compared to clips with thematic frames that include broader social context for violence. RESULTS: Most clips employed episodic frames (79.2%), presented law enforcement officials as primary narrators (50.5%), and included police imagery (79.2%). A total of 433 firearm-injured people were mentioned, with a mean of 2.8 individuals shot included in each story. Most of the firearm-injured people featured in the clips (67.4%) had no personal information presented apart from age and/or gender. The majority of clips (84.4%) contained at least one harmful content element. The mean harmful content score/clip was 2.6. Public health frame elements, including epidemiologic context, root causes, public health narrators and visuals, and solutions were missing from most clips. Thematic stories contained significantly more public health frame elements and less harmful content compared to episodic stories. CONCLUSIONS: Local television news produces limited public health coverage of firearm violence, and harmful content is common. This reporting likely compounds trauma experienced by firearm-injured people and could impede support for effective public health responses to firearm violence. Journalists should work to minimize harmful news content and adopt a public health approach to reporting on firearm violence.

Community exposure to gun homicide and adolescents' educational aspirations.

INTRODUCTION: Witnessing violence and violent victimization have detrimental effects on adolescents' emotional functioning and ability to envision and plan for their futures. However, research is limited on the impact of violence that occurs in adolescents' communities-whether or not it was witnessed or experienced firsthand. This paper investigated the associations between community exposure to gun homicide and adolescents' high school and college graduation aspirations. METHODS: We analyzed data from the Future of Families and Child Wellbeing Study (N = 3031), a cohort study of children born 1998-2000 in 20 large US cities, merged with incident-level data on deadly gun violence from the Gun Violence Archive (2014-2017). Outcomes were reported by adolescents (girls and boys) during wave 6 (2014-2017) of the study, conducted when the children were 15 years of age. We employed ordinary least squares regression, ordered logistic regression, and multilevel stratification to examine the average and heterogeneous impacts of community exposure to gun homicide on adolescents' educational aspirations. RESULTS: Community exposure to gun homicide was associated with reduced high school graduation aspirations, particularly among adolescents with the lowest risk of exposure to gun homicide. Gun homicide exposure was also associated with increased college graduation aspirations; this association was concentrated among adolescents with moderate-high risk of exposure. CONCLUSIONS: Given the importance of education for job opportunities and the better health that accompanies education and occupational attainment, preventing early exposure to gun violence and providing institutional supports to help adolescents facing adversity realize their goals is essential to their long-term health and success.

Youth Experiencing Parental Death Due to Drug Poisoning and Firearm Violence in the US, 1999-2020.

Importance: Youth (those aged <18 years) parental death has been associated with negative health outcomes. Understanding the burden of parental death due to drug poisoning (herein, drugs) and firearms is essential for informing interventions. Objective: To estimate the incidence of youth parental death due to drugs, firearms, and all other causes. Design, Setting, and Participants: This cross-sectional observational study was conducted using vital registration, including all US decedents, and census data from January 1990 through December 2020. Data were analyzed from May 30, 2023, to March 28, 2024. Exposures: Parental death due to drug poisoning or firearms. Main Outcomes and Measures: A demographic matrix projection model was used to estimate the number and incidence of youth experiencing parental death, defined as the death of 1 or more parents, per 1000 population aged less than 18 years. Analyses evaluated parental deaths by drugs, firearms, and all other causes from 1999 through 2020 by race and ethnicity. Results: Between 1999 and 2020, there were 931 785 drug poisoning deaths and 736 779 firearm-related deaths with a mean (SD) age of 42.6 (16.3) years. Most deaths occurred among males (73.8%) and White decedents (70.8%) followed by Black (17.5%) and Hispanic (9.5%) decedents. An estimated 759 000 (95% CI, 722 000-800 000) youth experienced parental death due to drugs and an estimated 434 000 (95% CI, 409 000-460 000) youth experienced parental death due to firearms, accounting for 17% of all parental deaths. From 1999 to 2020, the estimated number of youth who experienced parental death increased 345% (95% CI, 334%-361%) due to drugs and 39% (95% CI, 37%-41%) due to firearms compared with 24% (95% CI, 23%-25%) due to all other causes. Black youth experienced a disproportionate burden of parental deaths, based primarily on firearm deaths among fathers. In 2020, drugs and firearms accounted for 23% of all parental deaths, double the proportion in 1999 (12%). Conclusions and Relevance: Results of this modeling study suggest that US youth are at high and increasing risk of experiencing parental death by drugs or firearms. Efforts to stem this problem should prioritize averting drug overdoses and firearm violence, especially among structurally marginalized groups.

Handgun Ownership and Suicide in California.

BACKGROUND: Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership. METHODS: We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns). RESULTS: A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition. CONCLUSIONS: Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.).

Neighborhood Racial and Economic Segregation and Disparities in Violence During the COVID-19 Pandemic.

Objectives. To describe associations between neighborhood racial and economic segregation and violence during the COVID-19 pandemic. Methods. For 13 US cities, we obtained zip code-level data on 5 violence outcomes from March through July 2018 through 2020. Using negative binomial regressions and marginal contrasts, we estimated differences between quintiles of racial, economic, and racialized economic segregation using the Index of Concentration at the Extremes as a measure of neighborhood privilege (1) in 2020 and (2) relative to 2018 through 2019 (difference-in-differences). Results. In 2020, violence was higher in less-privileged neighborhoods than in the most privileged. For example, if all zip codes were in the least privileged versus most privileged quintile of racialized economic segregation, we estimated 146.2 additional aggravated assaults (95% confidence interval = 112.4, 205.8) per zip code on average across cities. Differences over time in less-privileged zip codes were greater than differences over time in the most privileged for firearm violence, aggravated assault, and homicide. Conclusions. Marginalized communities endure endemically high levels of violence. The events of 2020 exacerbated disparities in several forms of violence. Public Health Implications. To reduce violence and related disparities, immediate and long-term investments in low-income neighborhoods of color are warranted. (Am J Public Health. 2022;112(1):144-153. https://doi.org/10.2105/AJPH.2021.306540).

The Co-Occurrence of Illegal Gun Carrying and Gun Violence Exposure: Evidence for Practitioners From Young People Adjudicated for Serious Involvement in Crime.

We depicted the episodic nature of illegal gun carrying and tested its co-occurrence with gun violence victimization and exposure. We tested differences in differences using data from the Pathways to Desistance Study, originally collected between 2000 and 2010 (Phoenix, Arizona, and Philadelphia, Pennsylvania), on young people adjudicated for serious involvement in crime. We then tested the changes in gun victimization experiences attending gun-carrying changes for this sample. We found gun victimization to be highest during periods of gun carrying, and this correspondence held regardless of future or past gun-carrying behavior. This manifests both in direct victimization and witnessing gun violence. Even among gun carriers, episodes of noncarrying are common, with 76.4% of gun carriers in a 1-year period also reporting a pause in their carrying behavior of at least 6 months. Gun carrying and gun violence exposure co-occur at a high rate. During any period of gun carrying, the carrier has at least a 2% chance of getting shot versus near 0% for periods of noncarrying. Our results suggest that illegal gun carrying is malleable, and public health efforts to reduce the incidence of gun carrying could yield meaningful reductions in violence.

Patterns and Trends of Gun Violence Against Women in the United States.

OBJECTIVE: To examine patterns and trends of firearm injuries in a nationally representative sample of US women. SUMMARY OF BACKGROUND DATA: Gun violence in the United States exceeds rates seen in most other industrialized countries. Due to the paucity of data little is known regarding demographics and temporal variations in firearm injuries among women. METHODS: Data were extracted from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (2001-2017) for women 18 years and older. Number of nonfatal firearm assaults and homicide per year were extracted and crude population-based injury rates were calculated. Sub-stratification by age-group and time period were performed. RESULTS: Between 2001 and 2017, there were 88,823 nonfatal firearm assaults involving women and 29,106 firearm homicides. There were 4116 victims of nonfatal firearm assault in 2001 (3.8 per 105) and 12,959 by 2017 (10.0 per 105). Homicide rates were 1.5 per 105 in 2001 and 1.7 per 105 in 2017. Sub-stratification by age-group and time period showed that there were no significant changes in nonfatal firearm assault rates between 2001 and 2010 (P-trend = 0.132 in 18-44 yo; 0.298 in 45-64 yo). However between 2011 and 2017, nonfatal assault rates increased from 7.10 per 105 to 19.24 per 105 in 18-44 yo (P-trend = 0.013) and from 1.48 per 105 to 3.93 per 105 in 45-64 yo (P-trend = 0.003). Similar trends were seen with firearm homicide among 18-44 yo (1.91 per 105 to 2.47 per 105 in 2011-2017, P-trend = 0.022). However, the trends among 45-64 yo were not significant in both time periods. CONCLUSIONS: Female victims of gun violence are increasing and more recent years have been marked with higher rates of firearm injuries, particularly among younger women. These data suggest that improved public health strategies and policies may be beneficial in reducing gun violence against US women.

Association of Gun Violence With Emergency Department Visits for Stress-Responsive Complaints.

STUDY OBJECTIVE: We evaluate the association between living near a neighborhood shooting and emergency department (ED) utilization for stress-responsive complaints. METHODS: In this location-based before-and-after neighborhood study, we examined variability in ED encounter volume for stress-responsive complaints after neighborhood shooting incidents around 2 academic hospitals. We included patients residing within 1/8- and 1/2-mile-diameter buffers around a shooting (place) if their ED encounter occurred 7, 30, or 60 days before or after the shooting (time). Prespecified outcomes were stress-responsive complaints (chest pain, lightheadedness, syncope, hypertension, shortness of breath, asthma, anxiety, depression, and substance use) based on prior literature for stress-responsive diseases. Conditional logistic regression was used to calculate the odds of presentation to the ED with a stress-responsive complaint after, compared with before, a neighborhood shooting incident. RESULTS: Between January 2013 and December 2014, 513 shooting incidents and 19,906 encounters for stress-responsive complaints were included in the analysis. Mean age was 50.3 years (SD 22.3 years), 61.5% were women, and 91% were black. We found increased odds of presenting with syncope in 2 place-time buffers: 30 days in the 1/8-mile buffer (odds ratio 2.61; 99% confidence interval 1.2 to 5.67) and 60 days in 1/8-mile buffer (odds ratio 1.56; 99% confidence interval 0.99 to 2.46). No other chief complaints met our statistical threshold for significance. CONCLUSION: This study evaluated the relationship between objectively measured gun violence exposure and short-term health effect at a microspatial scale. Overall, this was a study with largely negative results, and we did not find any consistent dose-response pattern in time or space regarding neighborhood shootings and stress-responsive presentations to the ED. Theoretic links make this relationship plausible, however, and further investigation is needed to understand the short-term health consequences of violence exposure, and whether those vary based on the circumstances that are experienced inherently by residents of a given neighborhood.

Gun violence in Australia, 2002-2016: a cohort study.

OBJECTIVES: To describe the burden, geographic distribution, and outcomes of firearm-related violence in New South Wales during 2002-2016. DESIGN, SETTING, PARTICIPANTS: Population-based record linkag study of people injured by firearms in NSW, 1 January 2002 - 31 December 2016. MAIN OUTCOME MEASURES: Frequency, proportion, and rate of firearm-related injuries and deaths by intent category (assault, intentional self-harm, accidental, undetermined/other) and socio-demographic characteristics; medical service use (hospitalisations, ambulatory mental health care) before and after firearm-related injuries; associations between rates of firearm-related injury and those of licensed gun owners, by statistical area level 4. RESULTS: Firearm-related injuries were recorded for 2390 people; for 849 people, the injuries were caused by assault (36%), for 797 by intentional self-harm (33%), and for 506 by accidents (21%). Overall rates of firearm injuries were 4.1 per 100 000 males and 0.3 per 100 000 females; the overall rate was higher in outer regional/rural/remote areas (3.8 per 100 000) than in major cities (1.6 per 100 000) or inner regional areas (1.8 per 100 000). During 2002-2016, the overall firearm-related injury rate declined from 3.4 to 1.8 per 100 000 population, primarily because of declines in injuries caused by assault or accidental events. The rate of self-harm injuries with firearms were highest for people aged 60 years or more (41.5 per 100 000 population). Local rates of intentional self-harm injuries caused by firearms were strongly correlated with those of licensed gun owners (r = 0.94). CONCLUSIONS: Rates of self-harm with firearms are higher for older people, men, and residents in outer regional and rural/remote areas, while those for assault-related injuries are higher for younger people, men, and residents of major cities. Strategies for reducing injuries caused by self-harm and assault with firearms should focus on people at particular risk.

Risk and Protective Factors for Gun Violence in Male Juvenile Offenders.

OBJECTIVE: To examine several risk and protective factors as predictors of future gun violence among male juvenile offenders. METHOD: Data came from a longitudinal cohort of 1,170 male juvenile offenders (42.1% Black; 34.0% Latino; 19.2% White) ages 14-19 who were adjudicated for a serious offense. Interviews were conducted with participants every 6 months for 3 years and then annually for 4 years. The outcome was self-reported gun violence assessed at each follow-up. The time-lagged predictors included several self-reported risk factors (i.e., gun carrying, non-gun violence, drug dealing, heavy drinking, poor impulse control, rewards for crime, peer gun carrying, peer non-gun delinquency, gang membership) and protective factors (i.e., concern for others, expectations, and aspirations for work/family, religious beliefs, adult social supports). The data were analyzed using generalized estimating equation models. RESULTS: There were 266 participants who reported engaging in gun violence at one or more assessments. Gun carrying was a significant predictor of future gun violence; however, nearly half (49%) of the juveniles who reported gun carrying across the repeated assessments did not report engaging in gun violence. Besides gun carrying, several risk (i.e., drug dealing, heavy drinking, rewards for crime, gang membership, peer gun carrying) and protective (i.e., concern for others, aspirations for work/family, religious beliefs, adult social supports) factors significantly predicted gun violence, after controlling for their co-occurrence (Risk factor odds ratios = 1.18-1.50; Protective factor odds ratios =.44-.87; ps<.05). CONCLUSIONS: Interventions designed to prevent gun violence among juvenile offenders should reduce targeted risk factors, while strengthening protective factors that may offset these risks.

The Direct and Indirect Associations between Childhood Socioeconomic Disadvantage and Adolescent Gun Violence.

We examined whether childhood socioeconomic disadvantage was associated with adolescent gun violence and whether early symptoms of conduct disorder and/or exposure to delinquent peers accounted for the linkage. Participants were 503 predominately Black and White boys who were recruited in 1st grade from Pittsburgh public schools. Multi-informant assessments were conducted regularly from approximately ages 7 to 20. A latent socioeconomic disadvantage factor was estimated with census-tract and parent-reported data when boys were about age 7½. Latent growth curve models assessed parent/teacher-reported conduct problems and youth-reported peer delinquency from about ages 7½ to 10. The outcome was youth-reported engagement in gun violence by about age 20. We also controlled for race. Analyses examined whether the association between childhood socioeconomic disadvantage and adolescent gun violence was mediated through early conduct problems and/or increased exposure to delinquent peers. Childhood socioeconomic disadvantage was associated with adolescent gun violence, and some of this effect was mediated through peer delinquency and conduct problems. Specifically, childhood socioeconomic disadvantage was associated with greater affiliation with delinquent peers in early childhood, and early peer delinquency promoted a greater increase in conduct problems across childhood, and these conduct problems, in turn, led to an increased risk for adolescent gun violence. In summary, this study found that early socioeconomic disadvantage was directly and indirectly related to adolescent gun violence. Results suggest that interventions that aim to reduce conduct problems and deviant peer group affiliation in childhood might be important windows of opportunity for reducing gun violence in impoverished neighborhoods.