A multi-state evaluation of extreme risk protection orders: a research protocol.

BACKGROUND: Extreme Risk Protection Orders (ERPOs) are civil court orders that prohibit firearm purchase and possession when someone is behaving dangerously and is at risk of harming themselves and/or others. As of June 2024, ERPOs are available in 21 states and the District of Columbia to prevent firearm violence. This paper describes the design and protocol of a six-state study of ERPO use. METHODS: The six states included are California, Colorado, Connecticut, Florida, Maryland, and Washington. During the 3-year project period (2020-2023), ERPO case files were obtained through public records requests or through agreements with agencies with access to these data in each state. A team of over four dozen research assistants from seven institutions coded 6628 ERPO cases, abstracting 80 variables per case under domains related to respondent characteristics, events and behaviors leading to ERPO petitions, petitioner types, and court outcomes. Research assistants received didactic training through an online learning management system that included virtual training modules, quizzes, practice coding exercises, and two virtual synchronous sessions. A protocol for gaining strong interrater reliability was used. Research assistants also learned strategies for reducing the risk of experiencing secondary trauma through the coding process, identifying its occurrence, and obtaining help. DISCUSSION: Addressing firearm violence in the U.S. is a priority. Understanding ERPO use in these six states can inform implementation planning and ERPO uptake, including promising opportunities to enhance safety and prevent firearm-related injuries and deaths. By publishing this protocol, we offer detailed insight into the methods underlying the papers published from these data, and the process of managing data abstraction from ERPO case files across the multi-state and multi-institution teams involved. Such information may also inform future analyses of this data, and future replication efforts. REGISTRATION: This protocol is registered on Open Science Framework ( https://osf.io/kv4fc/ ).

Individual, firearm, and purchasing characteristics associated with risk of firearm-related violent crime arrest: a nested case-control study.

BACKGROUND: Firearm purchasing records offer a potentially important administrative data source to identify individuals at elevated risk of perpetrating firearm violence. In this study, we describe individual, firearm, and transaction characteristics of purchasers in California who were arrested for a firearm-related violent crime (FRV) as compared to the general population of registered purchasers in the state. METHODS: Relying on a dataset of all individuals with transaction records in California (1996-2021), linked to criminal records (1980-2021), we enrolled a cohort of individuals for whom we could capture the legal firearm purchase history. We identified those arrested for FRV post purchase, and using incidence density sampling, gender-matched cases to ten purchasers (controls) who remained "at risk" at the time the case was arrested. We focused on the purchase closest in time prior to the arrest ("index" purchase). We implemented conditional logistic regression and included models with controls for individual- and community-level demographics, as well as interactions between firearm and purchasing characteristics and criminal history. RESULTS: The cohort included 1,212,144 individuals, of whom 6153 were arrested for FRV (0.5%). Cases were matched to 61,530 controls to form the study sample. The largest risk factor was a prior criminal history: purchasers had 5.84 times the risk of FRV if they had a prior arrest within three years of the index purchase (CI 5.44-6.27). Several transaction and firearm characteristics were also associated with FRV. For example, risk increased if the firearm was redeemed at a pawn shop (aIRR: 1.37, CI 1.05-1.77) and decreased if the transaction was a registered private party transfer (vs. retail purchase) (aIRR: 0.83, CI 0.76-0.90) or the firearm was a bolt action firearm (vs. semi-automatic) (aIRR: 0.64, CI 0.51-0.79). In the interaction models, most of the purchase and firearm features only remained significant among those with no criminal history. CONCLUSIONS: Given limited data on firearm transactions, there has been little research on whether the type of firearm an individual purchases or the nature of the purchase might serve as indicators of risk for FRV. We found several transaction and firearm features were associated with risk of FRV. Notably, these features provided little evidence of additional risk for those with a prior criminal record.

Suicide Prevention Effects of Extreme Risk Protection Order Laws in Four States.

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool.

Confounder selection in firearm policy research: A scoping review.

Legislative firearm policies are often proposed as a way of preventing firearm-related harm. Confounding is a substantial threat to accurately estimating the causal effects of firearm policies. This scoping review characterizes selection of potential confounders in US firearm policy evaluations in the health sciences literature. We identified empirical research articles indexed in PubMed from 1/1/2000-9/1/2021 that examined any of 18 pre-specified firearm policies and extracted key study elements, including the exposure (firearm policy), outcomes, potential confounders adjusted for in analyses, and study approach (i.e., static, uncontrolled pre-post, and controlled pre-post). There was wide variation in potential confounders within study approach-policy-outcome combinations. The most common potential confounders included sociodemographic and economic variables, rurality/urbanicity, violent crime, law enforcement-related variables, alcohol use, and firearm access (mostly measured via proxies for firearm ownership). Firearm policies other than the policy being evaluated were included in the adjustment set in 23-44% of studies, depending on the study approach. Confounder selection was most often said to be based on prior research (n=49, 40%) or not explicitly stated (n=48, 39%). This scoping review provides a comprehensive resource for critically appraising the firearm policy literature and offers considerations to support more rigorous confounding control in future firearm policy research.

Firearm Ownership and Support for Political Violence in the United States.

Importance: Little is known about support for and willingness to engage in political violence in the United States. Such violence would likely involve firearms. Objective: To evaluate whether firearm owners' and nonowners' support for political violence differs and whether support among owners varies by type of firearms owned, recency of purchase, and frequency of carrying a loaded firearm in public. Design, Setting, and Participants: This cross-sectional nationally representative survey study was conducted from May 13 to June 2, 2022, among US adult members of the Ipsos KnowledgePanel, including an oversample of firearm owners. Exposure: Firearm ownership vs nonownership. Main Outcomes and Measures: Main outcomes concern (1) support for political violence, in general and to advance specific political objectives; (2) personal willingness to engage in political violence, by severity of violence and target population; and (3) perceived likelihood of firearm use in political violence. Outcomes are expressed as weighted proportions and adjusted prevalence differences, with P values adjusted for the false-discovery rate and reported as q values. Results: The analytic sample comprised 12 851 respondents: 5820 (45.3%) firearm owners, 6132 (47.7%) nonowners without firearms at home, and 899 (7.0%) nonowners with firearms at home. After weighting, 51.0% (95% CI, 49.9%-52.1%) were female, 8.5% (95% CI, 7.5%-9.5%) Hispanic, 9.1% (95% CI, 8.1%-10.2%) non-Hispanic Black, and 62.6% (95% CI, 61.5%-63.8%) non-Hispanic White; the mean (SD) age was 48.5 (18.0) years. Owners were more likely than nonowners without firearms at home to consider violence usually or always justified to advance at least 1 of 17 specific political objectives (owners: 38.8%; 95% CI, 37.3%-40.4%; nonowners: 29.8%; 95% CI, 28.5%-31.2%; adjusted difference, 6.5 percentage points; 95% CI, 4.5-9.3 percentage points; q < .001) but were not more willing to engage in political violence. Recent purchasers, owners who always or nearly always carry loaded firearms in public, and to a lesser extent, owners of assault-type rifles were more supportive of and willing to engage in political violence than other subgroups of firearm owners. Conclusions and Relevance: In this study of support for political violence in the United States, differences between firearm owners and nonowners without firearms at home were small to moderate when present. Differences were greater among subsets of owners than between owners and nonowners. These findings can guide risk-based prevention efforts.

Reporting and Description of Research Methodology in Studies Estimating Effects of Firearm Policies.

BACKGROUND: Evidence about which firearm policies work, to what extent, and for whom is hotly debated, perhaps partly because variation in research methodology has produced mixed and inconclusive effect estimates. We conducted a scoping review of firearm policy research in the health sciences in the United States, focusing on methodological considerations for causal inference. METHODS: We identified original, empirical articles indexed in PubMed from 1 January 2000 to 1 September 2021 that examined any of 18 prespecified firearm policies. We extracted key study components, including policy type(s) examined, policy operationalization, outcomes, study setting and population, study approach and design, causal language, and whether and how authors acknowledged potential sources of bias. RESULTS: We screened 7733 articles and included 124. A plurality of studies used a legislative score as their primary exposure (n = 39; 32%) and did not examine change in policies over time (n = 47; 38%). Most examined firearm homicide (n = 51; 41%) or firearm suicide (n = 40; 32%) as outcomes. One-third adjusted for other firearm policies (n = 41; 33%). Three studies (2%) explicitly mentioned that their goal was to estimate causal effects, but over half used language implying causality (n = 72; 58%). Most acknowledged causal identification assumptions of temporality (n = 91; 73%) and exchangeability (n = 111; 90%); other assumptions were less often acknowledged. One-third of studies included bias analyses (n = 42; 34%). CONCLUSIONS: We identified a range of methodologic approaches in firearm policy research in the health sciences. Acknowledging the imitations of data availability and quality, we identify opportunities to improve causal inferences about and reporting on the effects of firearm policies on population health.

Cohort Study of Downgraded Misdemeanor Convictions and Subsequent Violent Crime: Differences by Defendant Race and Ethnicity.

Introduction: Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity. Methods: The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine-Gray hazard models from June 2022 to November 2023. Results: There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants). Conclusions: Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions.

Measuring interpersonal firearm violence: natural language processing methods to address limitations in criminal charge data.

OBJECTIVE: Firearm violence constitutes a public health crisis in the United States, but comprehensive data infrastructure is lacking to study this problem. To address this challenge, we used natural language processing (NLP) to classify court record documents from alleged violent crimes as firearm-related or non-firearm-related. MATERIALS AND METHODS: We accessed and digitized court records from the state of Washington (n = 1472). Human review established a gold standard label for firearm involvement (yes/no). We developed a key term search and trained supervised machine learning classifiers for this labeling task. Results were evaluated in a held-out test set. RESULTS: The decision tree performed best (F1 score: 0.82). The key term list had perfect recall (1.0) and a modest F1 score (0.65). DISCUSSION AND CONCLUSION: This case report highlights the accuracy, feasibility, and potential time-saved by using NLP to identify firearm involvement in alleged violent crimes based on digitized narratives from court documents.

Codeveloping theories of change for improved community-based violence intervention evaluation.

BACKGROUND: Community-based violence intervention (CVI) programs are considered important strategies for preventing community violence and promoting health and safety. Mixed and inconclusive results from some prior CVI evaluations, as well as our general lack of understanding about the reasons for such varied findings, may be explained in part by misalignment of program theories of change and evaluation measures. Furthermore, most prior evaluations have focused solely on deficit-based outcomes; this narrow focus is inconsistent with the premise of CVI and may fail to capture improvements in health and well-being that are on the hypothesized pathway from intervention to violence reduction. METHODS: This article describes the process and results of codeveloping a theory of change for community-based youth firearm violence intervention and prevention programs in Washington state through a community-researcher partnership. We followed a multistep iterative process, involving (1) CVI program documentation review, (2) individual meetings, and (3) a day-long workshop. RESULTS: The theory of change included six key domains: (1) root causes, (2) promotive factors, (3) activities, (4) intermediate outcomes, (5) longer-term outcomes, and (6) multilevel context (youth/family, staff/organizational, community, and societal). Root causes were social and structural drivers of community violence. Promotive factors were assets and resources among the community, youth/their families, and community organizations that promote health and safety. Activities were supports and services the program provided to youth and their families, staff, and, potentially, the broader community. Intermediate and longer-term outcomes were the changes among youth, their families, staff, and the community that resulted from program activities. Intermediate outcomes may be felt within 6 months to 1 year, and longer-term outcomes may be felt after 1 to 2 years and beyond. CONCLUSION: The theory of change we codeveloped provides a common lens to conceptualize, compare, and evaluate CVI programs in Washington state and may support more rigorous and equity-centered evaluations. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level V.

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships.

PURPOSE: To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States. METHODS: We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317). RESULTS: We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state). CONCLUSIONS: This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

Organized abandonment under racial capitalism: Measuring accountable actors of structural racism for public health research and action.

Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism.

Strategies for recruiting adolescents in rural areas in firearm injury research.

BACKGROUND: Participant recruitment is a central aspect of human sciences research. Barriers to participant recruitment can be categorised into participant, recruiter and institutional factors. Firearm injury research poses unique barriers to recruitment. This is especially true for rural adolescents, who are at high risk for firearm-related injury and death, and whose voice is often absent in firearms research. In particular, recruitment strategies targeting adolescents should align with developmental changes occurring during this life stage. Identifying strategies to address recruitment barriers tailored to firearm-related research can help future researchers engage rural adolescents in injury prevention efforts. PURPOSE: The purpose of the current methodology paper is to outline barriers and provide strategies for recruiting rural adolescents in firearms research informed by the Youth Experiences in Rural Washington: Research on Firearm Safety project, a mixed-methods, community-based participatory research study of 13-18 year-olds residing in rural Washington. STRATEGIES: Recruitment barriers and related strategies were organised by participant-related and recruiter-related/institutional-related factors. While carrying out the study, key considerations or strategies which addressed multiple participant and recruiter/institutional factors, emerged with potential to enhance firearm-related research with rural adolescents more broadly. Key considerations included logistics (ie, scheduling flexibility, adequate and aligned incentives), use of a community-based participatory research approach and accounting for developmental stage. CONCLUSION: Reducing the burden of firearm injury and death for rural adolescents and developing effective interventions requires understanding and navigating recruitment barriers. Strategies used in the current project can guide future qualitative or mixed methods data collection informing firearm injury prevention.

The association of alcohol use and heavy drinking with subsequent handgun carrying among youth from rural areas.

PURPOSE: Alcohol use and handgun carrying are more prevalent among youth in rural than urban areas and their association may be stronger among rural adolescents. Alcohol use may be modifiable with implications for reducing handgun carrying and firearm-related harm. We examined the association between lagged alcohol use and subsequent handgun carrying in rural areas and examined variation in the association by developmental stages, hypothesizing that it would be stronger among adolescents than youth adults. METHODS: We used a longitudinal sample of 2,002 adolescents from ages 12 to 26 growing up in 12 rural communities in 7 states with surveys collected from 2004 to 2019. We estimated the association of lagged past-month alcohol use on handgun carrying in the subsequent 12 months using population-average generalized estimating equations with logistic regression on multiply imputed data. FINDINGS: During adolescence (ages 12-18), those who drank heavily had 1.43 times the odds (95% CI = [1.01, 2.03]) of subsequent handgun carrying compared to those who did not drink alcohol, and those who consumed alcohol but did not drink heavily had 1.30 times the odds of subsequent handgun carrying compared to those who did not drink (95% CI = [0.98, 1.71]). During young adulthood (ages 19-26), associations of alcohol use (OR = 1.28; 95% CI = [0.94, 1.63]) and heavy drinking (OR = 1.38; 95% CI = [1.08, 1.68]) were similar to adolescence. CONCLUSIONS: Alcohol use and subsequent handgun carrying were positively associated during adolescence and young adulthood among individuals who grew up in rural areas, similar to findings in urban areas. Reducing alcohol use may be an important strategy to prevent handgun carrying and firearm-related harm among young people in rural areas.

Misclassification of firearm-related violent crime in criminal legal system records: challenges and opportunities.

BACKGROUND: Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime. FINDINGS: In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2-21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5-93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession. CONCLUSIONS: Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime.

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.

Views of democracy and society and support for political violence in the USA: findings from a nationally representative survey.

BACKGROUND: Current conditions in the USA suggest an increasing risk for political violence. Little is known about the prevalence of beliefs that might lead to political violence, about support for and personal willingness to engage in political violence, and about how those measures vary with individual characteristics, lethality of violence, political objectives that violence might advance, or specific populations as targets. METHODS: This cross-sectional US nationally representative survey was conducted on May 13 to June 2, 2022, of adult members of the Ipsos KnowledgePanel. Outcomes are weighted, population-representative proportions of respondents endorsing selected beliefs about American democracy and society and violence to advance political objectives. RESULTS: The analytic sample included 8620 respondents; 50.5% (95% confidence interval (CI) 49.3%, 51.7%) were female; and weighted mean (± standard deviation) age was 48.4 (± 18.0) years. Nearly 1 in 5 (18.9%, 95% CI 18.0%, 19.9%) agreed strongly or very strongly that "having a strong leader for America is more important than having a democracy"; 16.2% (95% CI 15.3%, 17.1%) agreed strongly or very strongly that "in America, native-born white people are being replaced by immigrants," and 13.7% (95% CI 12.9%, 14.6%) agreed strongly or very strongly that "in the next few years, there will be civil war in the United States." One-third of respondents (32.8%, 95% CI 31.7%, 33.9%) considered violence to be usually or always justified to advance at least 1 of 17 specific political objectives. Among all respondents, 7.7% (95% CI 7.0%, 8.4%) thought it very or extremely likely that within the next few years, in a situation where they believe political violence is justified, "I will be armed with a gun"; 1.1% (95% CI 0.9%, 1.4%) thought it very or extremely likely that "I will shoot someone with a gun." Support for political violence and for the use of firearms in such violence frequently declined with increasing age, education, and income. CONCLUSIONS: Small but concerning proportions of the population consider violence, including lethal violence, to be usually or always justified to advance political objectives. Prevention efforts should proceed urgently based on the best evidence available.

The origins of California's gun violence restraining order law: a case study using Kingdon's multiple streams framework.

BACKGROUND: Firearm violence is a major public health problem in the United States, yet most states lack a mechanism to temporarily remove firearms from individuals who are at high and imminent risk of harming themselves or others and are not otherwise prohibited. Extreme risk protection order (ERPO) laws are intended to close this gap. The current study examines the passage of California's gun violence restraining order (GVRO) bill using Kingdon's multiple streams framework. METHODS: This study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation. RESULTS: Findings indicate policy entrepreneurs framed the problem and designed the policy to target individuals at behavioral risk of imminent firearm violence. Policy entrepreneurs comprised an integrated policy network that engaged in a lengthy period of collaboration and bargained with interest groups to yield a bill that satisfied diverse concerns. CONCLUSIONS: This case study may inform efforts in other states to pass ERPO policies and other firearm safety laws.

Association of medical conditions and firearm suicide among legal handgun purchasers in California: a case-control study.

BACKGROUND: Suicide is a pressing public health problem, and firearm owners are at especially elevated risk. Certain health conditions are markers of suicide risk, but more research is needed on clinical risk markers for suicide among firearm owners specifically. Our goal was to examine associations of emergency department and inpatient hospital visits for behavioral and physical health conditions with firearm suicide among handgun purchasers. METHODS: This was a case-control study of 5415 legal handgun purchasers in California who died between January 1, 2008, and December 31, 2013. Cases were firearm suicide decedents; controls were motor vehicle crash decedents. Exposures were emergency department and hospital visits for six categories of health diagnoses in the 3 years prior to death. To account for selection bias due to deceased controls, we used probabilistic quantitative bias analysis to generate bias-adjusted estimates. RESULTS: There were 3862 firearm suicide decedents and 1553 motor vehicle crash decedents. In multivariable models, suicidal ideation/attempt (OR 4.92; 95% CI 3.27-7.40), mental illness (OR 1.97; 95% CI 1.60-2.43), drug use disorder (OR 1.40; 95% CI 1.05-1.88), pain (OR 1.34; 95% CI 1.07-1.69), and alcohol use disorder (OR 1.29; 95% CI 1.01-1.65) were associated with higher odds of firearm suicide. When adjusting for all conditions simultaneously, only the associations for suicidal ideation/attempt and mental illness remained significant. Quantitative bias analysis indicated that observed associations were generally biased downward. For example, the bias-adjusted OR for suicidal ideation/attempt was 8.39 (95% simulation interval 5.46-13.04), almost twice that of the observed OR. CONCLUSIONS: Diagnoses for behavioral health conditions were markers for firearm suicide risk among handgun purchasers, even for conservative estimates that did not adjust for selection bias. Encounters with the healthcare system may provide opportunities to identify firearm owners at high risk of suicide.

Effect of the Communities That Care Prevention System on Adolescent Handgun Carrying: A Cluster-Randomized Clinical Trial.

Importance: There is little information on upstream community-based interventions that reduce the prevalence of handgun carrying among adolescents, especially those growing up in rural areas. Objective: To test whether Communities That Care (CTC), a community-based prevention system focusing on risk and protective factors for behavioral problems early in life, reduces handgun carrying prevalence among adolescents growing up in rural areas. Design, Setting, and Participants: Community-randomized trial of 24 small towns in 7 states assigned randomly to the CTC or control group with outcomes assessed from 2003 to 2011. Participants were youths attending public schools in grade 5 who received consent from their parents to participate (77% of the eligible population) and were repeatedly surveyed through grade 12 with 92% retention. Analyses were conducted from June to November 2022. Interventions: A coalition of community stakeholders received training and technical assistance to install CTC, used local epidemiologic data to identify elevated risk factors and low protective factors for adolescent behavioral problems, and implemented tested preventive interventions for youth, their families, and schools. Main Outcomes and Measures: Handgun carrying (never vs at least once) operationalized in 2 ways: (1) prevalence of past-year handgun carrying, and (2) cumulative prevalence of handgun carrying from grade 6 through grade 12. Results: Overall, the 4407 study participants' mean (SD) age was 12 (.4) years in both CTC (2405 participants) and control (2002 participants) communities in grade 6; about one-half of participants in each group were female (1220 [50.7 %] in the CTC group and 962 [48.1%] in the control group). From grade 6 through grade 12, 15.5% of participants in CTC communities and 20.7% of those in control communities reported carrying a handgun at least once. Youths in CTC communities were significantly less likely to report handgun carrying at a given grade than those in control communities (odds ratio [OR], 0.73; 95% CI, 0.65-0.82). The most pronounced effects were observed in grade 7 (OR, 0.70; 95% CI, 0.42-0.99), grade 8 (OR, 0.58; 95% CI, 0.41-0.74), and grade 9 (OR, 0.65; 95% CI, 0.39-0.91). Cumulatively from grade 6 through grade 12, youths in CTC communities were significantly less likely to report handgun carrying at least once than those in control communities (OR, 0.76; 95% CI, 0.70-0.84). Overall, CTC reduced the prevalence of past-year handgun carrying by 27% at a given grade and by 24% cumulatively through grade 12. Conclusions and Relevance: In this study, CTC reduced the prevalence of adolescent handgun carrying in participating communities. Trial Registration: ClinicalTrials.gov Identifier: NCT01088542.

Changes in suicide in California from 2017 to 2021: a population-based study.

BACKGROUND: Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years. METHODS: We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages. RESULTS: Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas. CONCLUSIONS: The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities.