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Background: Firearm-related deaths are an issue of ongoing public interest, from a health and economic perspective. Worldwide, firearm prevalence in suicides varies widely, depending on multiple factors including the availability of weapons in each country. Although several studies have shown that national laws about gun ownership, reducing legal access to guns, decrease the risk of suicide by firearm, the current situation clashes with widely differing legislations., Study Design: Retrospective study on a forensic case series., Methods: Autopsy reports assessed at the Section of Legal Medicine of Milan (Italy) from January 2014 to December 2023 were retrospectively documented. Only firearm suicides were considered. For each case, a close analysis of the criminal offence reports has been performed to obtain information about the gender and age of the victim, as well as the legal possession of firearms, psychiatric disorders, alcohol, and illicit drug abuse., Results: Among all the 1,164 suicides assessed at the Section of Legal Medicine of Milan over a 10-year-period, 101 cases (8.7%) were firearm-related. The male to female ratio was therefore about 13:1. No seasonal trends were observed. Most of the individuals owned the firearm license. Of the entire dataset, 35.6% suffered from psychiatric disorders, 4% of alcohol abuse and 2% of drug addiction. Among the owners of a firearm license, 42.3% had psychiatric disorders., Conclusions: Knowledge about firearm suicide and its relation to firearm legal possession is limited and current preventive laws should be reconsidered. Present administrative and clinical examinations required to obtain a firearm license in Italy and in some European territories are dealt with. The evaluation of the firearm-related risk of abuse is an essential but complex procedure, which requires not only clinic-anamnestic data but also in-deep psychiatric information. There is a need to develop and reinvigorate a debate that currently presents very heterogeneous solutions, but which would probably benefit from a common vision of the prevention strategies that can be implemented and enacted for the benefit of the entire community.

Gun control is a pressing issue in Aotearoa New Zealand that has garnered the attention of policymakers and the general public. Given the physical and social harms that guns potentiate, healthcare workers in Aotearoa New Zealand have a critical role in analysing and advocating for evidence-based legislation to ensure low levels of gun-related harm.We reviewed the historical and contemporary circumstances that have created the societal and legislative landscape of gun culture in Aotearoa New Zealand. The current Coalition Government is undertaking a review of the Arms Act, which could lead to weakening of current gun legislation.We, as healthcare providers, advocate for an evidence-based approach in relation to gun laws in Aotearoa New Zealand. Ongoing monitoring, evaluation and adaptation of gun control regulation is essential to ensure effectiveness and responsiveness to evolving challenges., Competing Interests: Nil., (© PMA.)

Guns and gun violence have become a widely discussed and hotly debated concern across the United States. With gun violence on the rise and mass shootings provoking powerful emotional outrage, the question often rests with what can or should be done to rectify these societal issues. This paper examines the attitudes of guns expressed through two qualitative interviews of gun owners in the United States. The paper observes many of the same outrage amongst these gun owners of Americans with seemingly little to show in the way of public policy progress for protecting citizens. Still, differences persist in what should be or can be done. The paper recommends more expansive study on this critical group of citizens involved in future United States gun safety and policy debate., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The primary objective of the current study was to add to the literature and broaden our understanding of gun violence victims by examining attitudes towards gun legislation held by victims of gun violence. To our knowledge, there are only two quantitative studies that have examined the impact of gun victimization on attitudes towards gun control legislation. A secondary objective was to examine the link between impressions of the National Rifle Association (NRA) and gun policy preferences, which remains an understudied area in the gun legislation literature. The current study additionally examined other factors that may impact support for gun control measures. Utilizing data from a national sample of 880 adults and controlling for demographic predictors, logistic regression was employed to examine the impact of gun victimization on attitudes towards gun control legislation. Although prior gun victimization did not yield any significant findings, concordant with prior research, regression results indicated that gun ownership was a strong predictor of opposition to gun control among respondents. Interestingly, holding a favorable attitude towards the NRA was an even stronger predictor of opposition to firearms legislation than gun ownership. Findings point to the need for additional empirical research on the impact of gun victimization and the influence that organizations like the NRA have on public opinion and subsequent gun safety legislative efforts., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives. To examine whether, through interactions with preexisting socioeconomic status vulnerabilities, the COVID-19 pandemic exacerbated exposure to firearm violence among communities with a legacy of redlining (i.e., grading the creditworthiness of neighborhoods based on their sociodemographic composition). Methods. We used an exogenous population threshold whereby the Home Owners Loan Corporation graded neighborhoods only in US cities with populations of more than 40 000 and used a difference-in-difference strategy to examine the evolution of fatal firearm incidents between 2017 and October 2022. Results. After the COVID-19 pandemic began, fatal firearm violence increased significantly in low-graded neighborhoods that the Home Owners Loan Corporation had deemed risky for mortgage lending. The effect held consistently across various model specifications. Conclusions. Social and environmental constructs can interact in a complex manner to compound disadvantage and exacerbate the consequences of negative shocks for marginalized communities. Public Health Implications. Home Owners Loan Corporation policies contributed to widening racial disparities in firearm violence, highlighting the need for reinvestment in marginalized communities to keep future shocks from exacerbating vulnerability to adverse outcomes. ( Am J Public Health . 2025;115(2):161-169. https://doi.org/10.2105/AJPH.2024.307891).

This paper situates current social psychological research on the symbolic use of firearms (e.g., as a source of personal safety) in broader historical context to motivate a more thorough consideration of collective power motives. Historically, firearms have been used to dominate racial outgroup members (e.g., White Americans use of firearms and firearm laws to dispossess indigenous people of land or control free and enslaved Black people) or, at times, attempt to resist group-based oppression (e.g., Black Americans use of firearms to struggle against White Jim Crow terrorism). Given most gun owners report self-protection as their primary reason for firearm ownership and yet anti-Black attitudes are still a consistently important predictor of firearm ownership among dominant group members (e.g., White Americans), this paper examines how guns may function as a perceived source of personal safety and collective power. I center the persistent role of White supremacy and anti-Blackness in original U.S. firearm psychology and policy to illuminate the interrelatedness of personal safety and collective power perceptions, and how perceived threats to in-group power may motivate the use of guns and policies that selectively regulate gun access to mitigate associated safety concerns. Seeking to nudge social psychology to more thoroughly examine firearms' potential function as a symbolic source of collective power, I end by discussing how considering collective power can help us better understand how historically dominant and historically marginalized groups view firearms today while also illuminating some barriers to the pursuit of gun safety for all., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

In 2022 we conducted a literature review, surveyed 1078 gun owners, and conducted post-survey focus groups and interviews of gun owners and non-gun owners, to determine a common ground gun violence prevention (GVP) policy package. This allowed us to see policies that would save lives and be widely accepted: (1) violent misdemeanor laws, (2) state permit laws, combined with universal background checks; (3) red flag laws. Based on our review of relevant research, we conservatively estimate that in states without any of the policy package components, implementing this package would result in a 27.9% reduction in firearm deaths. We believe that polarization between firearm owners and non-firearm owners, which has thwarted a widely supported response to the problem of gun violence, is largely a harmful myth that can be overcome by including gun owners in the process of fashioning an effective policy approach., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Justifying a proposed government regulation intended to reduce firearm violence requires a conceptually sound estimate of the monetized value of that impact and how that value is distributed across the population. Some previous estimates do not serve as a valid basis for policy evaluation or are out of date. A nationally representative survey was conducted by the AP-NORC Center for Public Affairs Research in August 2022 (n = 660). The authors designed and added a series of contingent-valuation items to the questionnaire. Double-bounded estimates of willingness-to-pay (WTP) were derived from a regression analysis of responses regarding voting on a hypothetical referendum on a state-wide package of measures designed to reduce gun violence at specified cost to taxpayers. Average WTP for a reduction of 20% in the state rate of gun violence was $744 per household (IQR:$668-$928), implying a national total of $97.6 billion. Household WTP was positively associated with household income, the respondent's assessment of the seriousness of gun violence in their community and the subjective likelihood that they would become a victim of gun violence. A variety of tests support the claim that this application of the contingent-valuation method provided valid results. WTP is the recognized basis for assessing the value of proposed federal regulations. The estimated WTP for reducing gun violence is about twice as high as a recent cost-of-injury estimate and provides a much different picture of the incidence of costs by income and demographic characteristics., Competing Interests: Competing interests statement:The Harris School of Public Policy, University of Chicago, supported the inclusion of several items in a national survey. The Crime Lab of the University of Chicago supported a research assistant.

The study of firearm violence in Mexico has primarily focused on homicides and trafficking. Less attention has been given to understanding how firearms affect other crimes and facilitate criminal activity beyond drug markets. By analyzing two questions, this study explores the role of firearms in extortions perpetrated in Mexico from 2012 to 2021. Questions are: What is the likelihood of reporting extortions to the police if offenders exhibited firearms? What is the likelihood of compliance with demands when offenders are armed with firearms? We obtained data from Mexico's National Crime Victimization Surveys and analyzed 2,619 extortions reported from 2012 to 2021. To explore our research questions, we ran two binary logistic regressions. Our dependent variables were dichotomous (reported to police = 1, complied with demands = 1). The independent variables were weapon types (extortions involving firearms as the reference group). We controlled for victim demographics as well as crime characteristics. Our results indicate that 40% of these extortions ( n  = 1,058) were perpetrated with a firearm. Fifty-two percent of extortions were perpetrated by unarmed offenders ( n  = 1,348) and 8% ( n  = 213) were perpetrated with other weapons (no firearms). Models suggest that, when compared to extortions perpetrated by unarmed offenders or those exhibiting other weapons (no firearms), victims of extortions involving firearms are less likely to report these crimes to police, mainly because of fear of reprisal. Similarly, victims are more likely to comply with demands if offenders exhibit firearms. Findings highlight the role of firearms in criminal enterprises and support the need for a comprehensive policy agenda to address firearm violence in Mexico., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Introduction: Federal firearm licensee density is associated with interpersonal firearm violence. Yet the role of Federal firearm licensees in firearm suicide remains understudied, even though firearms are the method used in more than half of suicides. This study tested associations between the spatial distribution of federal firearm licensees and firearm suicides in Maryland., Methods: Kernel density estimation measured federal firearm licensee and suicide rates at the census tract level (n=1,397), and SaTScan detected clusters of licensees and suicides. Choropleth maps compared visual associations between federal firearm licensee, firearm, and non-firearm suicide rates and clusters. Generalized estimating equations tested associations between Federal firearm licensee rates and clusters and the odds of using a firearm as the lethal means overall and after stratifying by biological sex. Data were obtained in 2020 and analyzed in 2020-2024., Results: The federal firearm licensee rate was associated with greater odds of firearm suicide overall (aOR=1.29, 95% CI=1.21, 1.38, p<0.001), for men (aOR=1.29, 95% CI=1.20, 1.39, p<0.001), and for women (aOR=1.26, 95% CI=1.07, 1.49, p=0.007). Suicide decedents in a census tract located in a federal firearm licensee cluster (vs not) had higher odds of firearm use overall (aOR=1.70, 95% CI=1.28, 2.27, p<0.001) and for men (aOR=1.67, 95% CI=1.22, 2.27, p=0.001), but not for women (aOR=1.65, 95% CI=0.81, 3.34, p=0.168)., Conclusions: The federal firearm licensee rate and clusters were associated with firearm suicides and unrelated to the spatial distribution of non-firearm suicides. Prevention approaches that limit the number of these federal firearm licensees or alter their sales practices, such as federal firearm licensee zoning and land use provisions, advertising restrictions, or gun shop projects, may prevent firearm suicides., (Copyright © 2024. Published by Elsevier Inc.)

Background: Firearms are the leading cause of death among US children and adolescents. This study evaluates whether state gun laws are associated with firearm suicides and homicides in children., Study Design: This is a cross-sectional database study comparing childhood firearm mortality with 36 state firearm laws using data from CDC WONDER and the RAND State Firearm Law Database. Primary outcomes were firearm-related suicide and homicide mortalities per 100,000 persons. We examined suicide deaths by all firearms, including intentional self-harm by handguns only, intentional self-harm by rifles, shotguns, or large firearms only, and intentional self-harm by other or unspecified firearms, as well as homicide deaths for the same firearm types in each state. Welch's t -tests compared mean rates of suicide and homicide mortality between states with and without these laws. States that either enacted or rescinded firearm legislation during this period were excluded., Results: From 2009 to 2020, there were 6,735 suicides and 10,278 homicides by firearm totaling 17,013 child deaths (younger than 18 years of age) by firearm. States with "child access prevention-negligent storage" laws demonstrated lower suicide mortality rates across all firearm types (handguns: N 13, M [mean per 100,000] 0.68, SD 0.27, p < 0.001; long guns: N 12, M 0.65, SD 0.25, p < 0.001). There were no significant differences in mean suicide death rates across all firearm types when comparing states with or without firearm laws related to "minimum age youth possession," "minimum age youth purchase and sale," or "child access prevention intentional." Comparing homicide mortality rates for all firearm types revealed no notable distinctions between states with and without the identified laws., Conclusions: Firearm legislation is associated with decreased suicide rates for individuals younger than 18 years of age, but its influence on homicides is less certain. Comprehensive research and thoughtful policy formulation are essential for addressing this pressing public health concern., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: This review aims to provide an updated overview of trends in firearm- related deaths, the mental health impact on communities, and clinical and legislative interventions. We examine existing interventions and highlight lesser-known yet impactful strategies, such as incorporating appropriate training in medical education on firearm safety. Additionally, we explore the broader impacts of firearm violence on community mental health and address the disputed topic of whether mental illness is a driving factor behind mass shootings., Recent Findings: The rate of firearm suicides has continued to grow in the United States, even as firearm homicides have slightly declined. While the media often attributes mass shootings to the perpetrator having a mental illness, research indicates such symptoms only account for a small subset of shooters. Recent studies highlight the benefits of incorporating firearm safety into professional medical education, which can reduce barriers for healthcare providers when discussing safe storage practices with patients. While suicide risk is frequently assessed among individuals with mental illnesses due to their heightened risk, other factors should be considered by all clinicians, not just those in mental health. Similarly, certain mental health symptoms may play a role in a small fraction of gun violence, but other risk factors account for most violence risk. Despite the implementation of firearm restriction laws and increased access to mental health resources, gaps remain that must be addressed to reduce not only the rate of suicide by firearm, but also the mental burden the aftermath has on the community., Competing Interests: Declarations. Competing Interests: The authors declare no competing interests., (© 2024. The Author(s).)

From 2015 to 2020, shootings by police injured or killed 1769 people annually in the United States, disproportionately harming members of minoritized groups. Prior studies of the structural determinants of these inequities have largely examined state-level aggregations and fatal outcomes. This study aimed to: 1) describe state and county variation in fatal and nonfatal injurious shootings by police, and 2) analyze the relationship between state and county context and differences in county rates of injurious shootings by police. Injury data were developed from manual review of incidents listed in the Gun Violence Archive, then aggregated by county-year. Covariate selection was informed by theories of police use of force and the Social Basis of Disparities in Health conceptual framework. Fixed effects negative binomial regression models were estimated, nesting years within counties and states. Analyses controlled for county population, local reporting presence, and multiple measures of social conflict and community violence. From 2015 to 2020, 56% of counties experienced injurious shootings by police. Higher county rates of victimization were associated with greater state spending on police relative to health, county income inequality, prevalence of unmet substance use disorder needs, higher county firearm availability, and permitless concealed carry statutes. Firearm purchaser licensing polices were associated with lower incidence of injurious shootings by police. To prevent patterns of injurious shootings by police, policymakers should consider addressing undermanaged substance use disorder through crisis fund allocation and use, adopting stronger firearm licensing systems, and evaluating local strategies to combat inequities and strengthen non-policing responses to social needs., Competing Interests: Declaration of competing interest The authors declare no actual or potential conflicts of interest., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: National-level data suggest that gun owners in the U.S. carry concealed weapons in public at growing rates. This research investigates whether these trends are associated with state adoption of more permissive concealed carry-licensing laws between 2002 and 2019., Methods: Data were obtained from 31 U.S. states from 2002 to 2019. State-level rates of licenses issued, denied, and newly issued per 100,000 residents were calculated and compared across 3 state legal categories: (1) states that banned carrying-concealed weapons and adopted a shall-issue law, (2) states with a may-issue law that adopted a shall-issue law, and (3) states that made no changes to concealed carry-licensing laws. Difference-in-differences methods were used to compare the rate of licenses newly issued and denied in ban to shall-issue states relative to those in states with no concealed carry-licensing law change during the study timeframe. Data were analyzed in 2022-2023., Results: States that transitioned from a ban on concealed weapons carrying to shall-issue laws were positively associated (2%-6%, SE=0.11-0.13) with additional new licenses relative to states that did not enact concealed carry-licensing law changes. Ban to shall-issue law changes were also associated with denial of substantially more licenses (75%-85%, SE=0.24-0.23). Furthermore, states that transitioned from may-issue to shall-issue laws awarded fewer licenses than those transitioning from a concealed weapons ban to shall-issue laws., Conclusions: State-level concealed carry licensing may inform public health and safety policies as large restrictive U.S. states transition to more permissive concealed carry-licensing laws., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Understanding gun owners' perceptions of potential firearm policies' harms and benefits is critical to successful policy development and implementation. We used national survey data to develop and validate a novel instrument, the Harms and Benefits Inventory (HBI), for policy-makers and advocates to better consider the citizen perspective., Method: We conducted a nationally representative survey of American gun owners and non-owners (N=2007) using the Social Science Research Solutions probability panel. The survey included 31 candidate HBI items and questions about gun ownership and exposure, storage and carry behaviours, policy positions, and sociodemographic characteristics. Exploratory factor analyses (EFAs) were conducted on HBI items from a randomly selected subsample (N=1003) and then tested with a confirmatory factor analysis (CFA) on data from the second half of the sample (N=1004)., Results: The best-fitting EFA model was upheld in the CFA and included 21 items with 5 underlying factors. Underlying factors included: (1) firearm regulation, cost and accessibility, (2) special restrictions, (3) permit and education, (4) relaxed restrictions and (5) and hobby and sport. Internal consistency was good to excellent within each of the five scales. Validity was supported by correlations between HBI scales and survey questions., Discussion: Findings support the validity of the HBI in assessing perceptions of potential harms and benefits of firearm policies and practices. Understanding perceptions of potential harms and benefits of gun policies at the time of development or implementation can improve uptake and reduce unintended consequences of these policies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Illinois experienced a historic firearm violence surge in 2016 with a decline to baseline rates in 2018. This study aimed to understand this 2016 surge through the direct accounts of violence prevention community-based organisations (CBOs) in Illinois., Methods: We conducted semistructured interviews with 20 representatives from 13 CBOs from the south and west sides of greater Chicago metropolitan area. Interviews were audio recorded, coded and analysed thematically., Results: We identified lack of government-derived infrastructure and systemic poverty as the central themes of Illinois's 2016 firearm violence surge. Participants highlighted the Illinois Budget Impasse halted funding for violence prevention efforts, leading to 2016's violence. This occurred in the context of a strained relationship with the criminal justice system, where disengagement from police and mistrust in the justice system led victims and families to seek justice outside of the judicial system. Participants emphasised that systemic poverty and the obliteration of community support structures led to overwhelming desperation, which, in turn, increased risky behaviours perceived as necessary for survival. Participants disproportionately identified that this impacted the young people in their communities., Conclusions: Lack of government-derived infrastructure and systemic poverty were the central themes of the 2016 firearm violence surge. The insights gained from the 2016 surge are applicable to understanding both current and future surges. CBOs focused on violence prevention offer insights into the context and conditions fuelling surges in the epidemic of violence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Poverty is a consistent correlate of firearm-involved mortality, yet little work has considered the effects of social and economic policies on these deaths. This study examined associations of state elimination of the asset test and increases in the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility with rates of firearm-involved suicide and homicide deaths in the United States., Methods: This ecological repeated cross-sectional study used 2015-2019 data from the SNAP Policy Database and death certificate data from the National Vital Statistics System. The exposures were (1) state elimination of the asset test for SNAP eligibility and (2) state elimination of the asset test and increases in the income limit for SNAP eligibility, compared with (3) state adoption of neither policy. The outcomes were firearm-involved suicide deaths and firearm-involved homicide deaths. The research team conducted mixed-effects regressions to estimate associations., Results: State elimination of the asset test for SNAP eligibility (incidence rate ratio (IRR), 0.67; 95% CI, 0.48 to 0.91) and state adoption of both eliminating the asset test and increasing the income limit for SNAP eligibility (IRR, 0.68; 95% CI, 0.49 to 0.92) were associated with decreased rates of firearm-involved suicide deaths compared with state adoption of neither policy. There were no associations with state firearm-involved homicide rates., Conclusions: SNAP is an important social safety net programme that addresses food insecurity, and the present results suggest it may also contribute to reducing firearm-involved suicide., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Over 40,000 people die by suicide annually in the U.S., and firearms are the most lethal suicide method. There is limited evidence on the effectiveness of many state-level policies on reducing firearm suicide. The objective of this study was to identify public policies that best predict state-level firearm suicide rates., Methods: Data from the Centers for Disease Control and Prevention's WONDER system and the State Firearm Law Database, a longitudinal catalog of 134 firearm safety laws, were analyzed. The analysis included 1,450 observations from 50 states spanning 1991-2019. An ElasticNet regression technique was used to analyze the relationship between the policy variables and firearm suicide rates. Nested cross-validation was performed to tune the model hyperparameters. The study data were collected and analyzed in 2023 and 2024., Results: The optimized ElasticNet approach had a mean squared error of 2.07, which was superior to nonregularized and dummy regressor models. The most influential policies for predicting the firearm suicide rate on average included laws requiring firearm dealers that sell handguns to have a state license and laws requiring individuals to obtain a permit to purchase a firearm through an approval process that includes law enforcement, among others., Conclusions: On average, firearm suicide rates were lower in state-years that had each influential policy active. Notably, these analyses were ecological and noncausal. However, this study was able to use a supervised machine learning approach with inherent feature selection and many policy types to make predictions using unseen data (i.e., balancing Lasso and Ridge regularization penalties)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Pandemic-era social and political tensions may have accelerated pre-existing trends in gun owner diversification and shifts toward protection from people as a primary reason for gun ownership. Specific ownership motivations may shape storage behaviors, use patterns, policy support, and perceptions of safety. This study's objective was to assess the importance of specific reasons for owning guns, including protection from whom and in what circumstances, among demographic subgroups of new and prior gun owners., Methods: From January 4, 2023 to February 6, 2023, the National Survey of Gun Policy was fielded among a nationally representative sample of U.S. adults (N=3,096), including gun owners (n=1,002). Respondents rated the importance of 10 potential reasons for gun ownership, including at-home protection, out-of-home protection, protection in ideologic conflict, and hunting or recreation. In 2023-2024, respondents' self-report of important and highly important reasons for gun ownership were compared across political affiliation, race, ethnicity, age, sex, location, income, education, and recency of first purchase., Results: Majorities of gun owners from all demographic groups cited at-home protection, out-of-home protection, and hunting or recreation as very or extremely important. At least 10% of every demographic group endorsed at least 1 ideologic reason as extremely important. Newer gun owners more frequently endorsed multiple important reasons., Conclusions: Concurrent, strongly held motivations may produce ambivalence or resistance to public health messaging that narrowly focuses on preventing violent firearm-related injury. Permissive firearm policies may compound behavioral ambivalence, exacerbating conditions that threaten collective safety and civic expression. These conditions call for more nuanced, multidimensional, societal efforts to assure collective safety., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Abstract: Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H936 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: In January of 2019, Washington State (WA) passed Initiative 1639 making it illegal for persons <21 years-old to buy assault weapons (AWs). This study aimed to evaluate the effects of WA-1639 on firearm-related incidents involving AWs by those <21 years-old in WA, hypothesizing a decrease in incidents after WA-1639., Methods: Retrospective (2016-2021) data on firearm violence (FV) events were gathered from the Gun Violence Archive. The rate of FV was weighted per 100,000 people. Total monthly incidents, injuries, and deaths were compared pre-law (January 2016-December 2018) vs post-law (January 2019-December 2021) implementation. Mann-Whitney U tests and Poisson's regression were used for analysis., Results: From 4091 FV incidents (2210 (54.02%) pre-law vs 1881 (45.98%) post-law), 50 involved AWs pre- (2.3%) and 15 (.8%) post-law. Of these, 11 were committed by subjects <21 years-old pre-law and only one occurred post-law. Total incidents of FV (z = -3.80, P < .001), AW incidents (z = -4.28, P < .001), and AW incidents involving someone <21 years-old (z = -3.01, P < .01) decreased post-law. Additionally, regression analysis demonstrated the incident rate ratio (IRR) of all FV (1.23, 95% CI [1.10-1.38], P < .001), all AW FV incidents (3.42, 95% CI [1.70-6.89], P = .001), and AW incidents by subjects <21 years-old (11.53, 95% CI [1.52-87.26], P = .02) were greater pre-law vs post-law., Discussion: Following implementation of WA-1639, there was a significant decrease in FV incidents and those involving AWs by individuals <21 years-old. This suggests targeted firearm legislation may help curtail FV. Further studies evaluating FV after legislation implementation in other states is needed to confirm these findings., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: While the United States has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies., Methods: This was a multicenter prospective cohort study of patients treated for firearm-related injuries at 128 US trauma centers from March 2021 to February 2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were used to characterize patient communities., Results: A total of 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. Self-inflicted firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades, whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness., Conclusion: Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

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., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Lead's neurotoxic properties and potential harmful effects to humans, particularly young children, have been recognized for decades, influencing public health policies to reduce its admixture in house paint and passenger car gasoline. We signal 3 emergent trends: firearm proliferation, complex international food supply chains, and equally complex product marketing strategies, which have opened opportunities for lead exposure to children from guns and ammunition, and lead contamination in children's food and consumer goods. Readers will also be apprised of Childhood Lead Poisoning Prevention Program and education strategies cultivated and advanced by the Centers for Disease Control and Prevention and its lead prevention partners. A national governmental policy update is included, as are future considerations., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The findings and conclusions in this commentary are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry. The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Gunshot injuries are the leading cause of death among children in the United States. The goal of this study was to better understand if certain age groups, mechanisms of injury, and type of firearms were associated with the increasing rates of pediatric gun-related trauma. We hypothesized that the extremities were disproportionately targeted when compared with the random likelihood of striking specific body-surface areas., Methods: This study includes pediatric firearm-related injury (FRI) patients who presented to a single free-standing level 1 pediatric hospital or died at the scene from 2010 to 2021. The hospital data was collected prospectively as part of a level 1 trauma system electronic database. Death data was collected from the local coroner's office., Results: Between 2010 and 2021, 1,126 pediatric FRI occurred in the geographic region studied. Demographic information available for 1,118 patients showed that 897 (80.23%) were male, and that black individuals had a statistically significant increased rate of FRI compared with white or Hispanic individuals. Mean age was 13.69 years. Most injuries were caused by handguns., Conclusions: This data could help leaders design strategies to combat the violence, such as legislation that limits handgun access to all, especially children, and mandates safe storage of handguns. Gun-lock programs, universal background checks, and firearm-ownership education also might help stem this tide of violence., Level of Evidence: Level II Prognosis study., Competing Interests: Conflicts of interest Drs. Sheffer, Spence, Sawyer, Warner and Kelly receive royalties from Elsevier. Dr. Spence receives research support from Orthopediatrics. Dr. Sawyer receives financial support from Orthopediatrics and DePuy Synthes. Dr. Warner receives royalties from Wolters Kluwer Health - Lippincott Williams & Wilkins. The other authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Gun-related crime continues to be an urgent public health and safety problem in cities across the US. A key question is: how are firearms diverted from the legal retail market into the hands of gun offenders? With close to 8 million legal firearm transaction records in California (2010-2020) linked to over 380,000 records of recovered crime guns (2010-2021), we employ supervised machine learning to predict which firearms are used in crimes shortly after purchase. Specifically, using random forest (RF) with stratified under-sampling, we predict any crime gun recovery within a year (0.2% of transactions) and violent crime gun recovery within a year (0.03% of transactions). We also identify the purchaser, firearm, and dealer characteristics most predictive of this short time-to-crime gun recovery using SHapley Additive exPlanations and mean decrease in accuracy variable importance measures. Overall, our models show good discrimination, and we are able to identify firearms at extreme risk for diversion into criminal hands. The test set AUC is 0.85 for both models. For the model predicting any recovery, a default threshold of 0.50 results in a sensitivity of 0.63 and a specificity of 0.88. Among transactions identified as extremely risky, e.g., transactions with a score of 0.98 and above, 74% (35/47 in the test data) are recovered within a year. The most important predictive features include purchaser age and caliber size. This study suggests the potential utility of transaction records combined with machine learning to identify firearms at the highest risk for diversion and criminal use soon after purchase., (© 2024. The Author(s).)

Objective: Firearm injuries are the leading cause of death for children in the United States. Child access prevention (CAP) laws have been passed in some states. This study examines characteristics of children with firearm injuries in states with different types of CAP laws., Methods: The Pediatric Health Information System database was reviewed to identify all pediatric firearm injury patients between 2016 and 2021. Hospital data were categorized based on state laws as (1) no CAP laws (2) some CAP laws or (3) strict CAP laws. CAP laws that specifically outlined criminal liability for the negligent storage of firearms were considered a strict restriction, whereas any other form of CAP law was considered some restriction. χ-squared and independent-samples median testing were performed to compare restriction levels., Results: Between 2016 and 2021, 12 853 firearm injuries were recorded in the Pediatric Health Information System database. In states with strict CAP laws, patients were significantly older (P < .001) and had a significantly higher household income (P < .001) compared with patients in states with no CAP laws. Gender, race, and the number of firearm injuries differed between the 3 restriction levels. There were less firearm injuries observed than expected in cities with strict CAP laws., Conclusions: CAP laws are associated with a higher age and household income of pediatric firearm injury patients. Given the disparities seen between cities, a federal CAP law may best protect children nationwide., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Firearms are of special interest in trauma research due to high lethality and criminal value. Strong correlation between guns per capita and fire-arm related deaths has been shown. Most of existing literature regarding gun-shot fatalities are from the U.S. and data for Central Europe is lacking. Thus, the aim of this study was to assess the legal frameworks regarding gun-ownership in Germany (DE), Austria (A) and Switzerland (CH), and to retrospectively analyze data from the TraumaRegister DGU® regarding the epidemiology, injury severity, intention and outcome of gunshot-related deaths in these countries., Methods: All patients from TR-DGU who sustained a gunshot injury in the time period from 1st January 2009 to 31st December 2019 were considered for analysis. Only cases admitted to level 1 or 2 trauma center in Germany, Switzerland, or Austria were included. Predicted mortality was calculated using the RISC-II. Further, the legal framework for firearm posession were explored., Results: The legal frameworks do not differ significantly between the countries. However, only ex-military men from Switzerland are allowed to keep their automatic (military) weapon at home. We assessed 1312 gunshot fatalities (DE 1,099, A 111, CH 102) of which most were due to suspected suicide (A 72.1 %, CH 64.7 %, and DE 56.6 %, p = 0.003). Act of suspected violent crime or accidental gunshots were rare in all three countries. Amongst all gunshot fatalities, Austria showed the highest mean age (57.6 years), followed by DE (53.4 years) and CH (49.4 years; p < 0.01). Gunshot fatalities amongst all assessed countries due to suspected suicide showed a peak at the age of 60 years and above, whereas suspected violent crime delicts with gunshots were mainly seen in younger age groups. The highest mortality was found in suspected suicide cases, showing a mortality of 82.1 % (predicted 65.2 %) in Switzerland, 75.3 % (predicted 65.8 %) in Austria and 63.7 % (predicted 56.2 %) in Germany., Conclusion: Gunshot wounds are still rare in central Europe, but gunshot-related suicide rates are high. Gun ownership laws may have an impact on gunshot wounds due to suspected suicide. Injury patterns differ compared to countries where a high incidence of gun ownership is seen., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Introduction: Much research on shootings by police has focused on urban jurisdictions, but most U.S. law enforcement agencies are not located in cities. Prior research suggests that rates of fatal shootings by police are comparable between urban and nonurban areas. Yet, shooting characteristics across the urban-rural continuum are unknown. This study describes and compares fatal and nonfatal injurious shootings by officers in U.S. urban, suburban, and rural areas from 2015 to 2020., Methods: Characteristics of fatal and nonfatal injurious shootings by police were abstracted from Gun Violence Archive. In 2023-2024, using ZIP-code and county-based rurality designations, the national distribution, incidence, and characteristics of injurious shootings by police were compared across urban, suburban, and rural areas of the U.S., Results: Rates of injurious shootings in rural areas approached or exceeded those of urban rates. As rurality increased, proportionately more injurious shootings involved single responders, sheriffs, or multiple agency types. Across the urban-rural continuum, characteristics of precipitating incidents were similar. Injurious shootings were most frequently preceded by domestic violence incidents, traffic stops, or shots-fired reports; co-occurring behavioral health needs were common. After accounting for local demographic differences, Black, indigenous, and Hispanic residents were injured at higher rates than White residents in all examined areas., Conclusions: Shootings by police represent an overlooked and inequitable source of injury in rural areas. Broadly similar incident characteristics suggest potential for wide-reaching reforms. To prevent injuries, crisis prevention, dispatch, and response systems must assure proportionate rural-area coverage. In addition, legislative prevention and accountability measures should include sheriffs' offices for optimal rural-area impact., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Assault weapon and large-capacity magazine bans are potential tools for policy makers to prevent public mass shootings. However, the efficacy of these bans is a continual source of debate. In an earlier study, we estimated the impact of the Federal Assault Weapons Ban (FAWB) on the number of public mass shooting events in the United States. This study provides an updated assessment with 3 additional years of firearm surveillance data to characterize the longer-term effects., Objective: This study aims to estimate the impact of the FAWB on trends in public mass shootings from 1966 to 2022., Methods: We used linear regression to estimate the impact of the FAWB on the 4-year simple moving average of annual public mass shootings, defined by events with 4 or more deaths in 24 hours, not including the perpetrator. The study period spans 1966 to 2022. The model includes indicator variables for both the FAWB period (1995-2004) and the period after its removal (2005-2022). These indicators were interacted with a linear time trend. Estimates were controlled for the national homicide rate. After estimation, the model provided counterfactual estimates of public mass shootings if the FAWB was never imposed and if the FAWB remained in place., Results: The overall upward trajectory in the number of public mass shootings substantially fell while the FAWB was in place. These trends are specific to events in which the perpetrator used an assault weapon or large-capacity magazine. Point estimates suggest the FAWB prevented up to 5 public mass shootings while the ban was active. A continuation of the FAWB and large-capacity magazine ban would have prevented up to 38 public mass shootings, but the CIs become wider as time moves further away from the period of the FAWB., Conclusions: The FAWB, which included a ban on large-capacity magazines, was associated with fewer public mass shooting events, fatalities, and nonfatal gun injuries. Gun control legislation is an important public health tool in the prevention of public mass shootings., (© Alex Lars Lundberg, James Alan Fox, Hassan Mohammad, Maryann Mason, Doreen Salina, David Victorson, Ruben Parra-Cardona, Lori Ann Post. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org).)

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., (© 2024 American Academy of Psychiatry and the Law.)

Competing Interests: The authors declare no conflicts of interest.

Introduction: Firearm-related suicides among children present a significant public health concern and a tragic loss of young lives. This study explores the relationship between firearm-related suicides, gun ownership, and state-specific gun laws., Methods: This retrospective cohort study collected data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research on children under 18 who died by firearm-related suicides between 2009 and 2016 in all 50 states and D.C. It also utilized data from the RAND State-Level Estimates of Household Firearm Ownership. The study focused on the rate of child firearm suicide deaths per 100,000 individuals. The key variable of interest was the percentage of guns owned per household in each state. Univariable analysis was conducted to examine the association between individual gun laws and child firearm suicide mortalities, while multivariable regression, adjusting for household gun ownership and significant firearm legislation, was employed to assess connection to child firearm suicide mortality., Results: From 2009 to 2016, 3903 children died from firearm-related suicides in the United States. In our analysis, 15 out of 44 firearm laws were found to be associated with reducing the rates of firearm suicides among children (P < 0.05). However, multivariable regression showed that higher state gun ownership rates were the primary predictor of increased child fatalities from firearms, with children in such states being 325% more likely to die when analyzing handgun laws and 337% more likely when analyzing long gun laws, as indicated by coefficients of 4.25 and 4.37, respectively. No state laws alone notably improved death rates., Conclusions: Gun ownership has a stronger association with child suicide rates than state-specific gun laws. Given the weight of gun ownership, future research should prioritize comprehensive public health initiatives to prevent child firearm-related suicides., (Copyright © 2024. Published by Elsevier Inc.)

The leading cause of death in children in the United States is injury caused by firearm violence. States that enact stricter laws related to firearm injury prevention have lower rates of mortality in children. In Illinois, we formed a coalition with medical professionals, medical organizations, community partners, and legislators to craft legislation to reduce the burden of firearm violence on children. These laws can be politically charged. Therefore, we decided to focus on a safe storage education law. We met regularly as a group to draft the bill and an information sheet to support it. Pediatricians and pediatric providers worked with the government relations teams in children's hospitals throughout the state to garner supporting organizations. We also worked to garner cosponsors, provided written and oral testimony to the legislative body, and wrote op-eds to support the bill. Shortly after the bill was passed and signed into law in June of 2022, there was a mass shooting at Highland Park in Illinois. After the shooting, there was a mandate from the Illinois governor to work on passing an assault weapons ban. Pediatricians again provided input into the bill about how the weapons affect children, testified before the House Judiciary Committee, and wrote op-eds. Governor Pritzker signed the Protect Illinois Communities Act into law in January of 2023. Pediatricians actively worked in the passage of both bills, which highlights the importance of medical professionals as experts who can combine powerful stories and evidence based medicine to influence policy., (Copyright © 2024 by the American Academy of Pediatrics.)

Importance: Hospitals are hot zones of the US gun injury epidemic. To shelter these facilities from the dangers of gun violence, state legislatures have enacted laws to reduce the carrying of firearms on hospital premises. However, these efforts currently face serious Second Amendment challenges in federal courts. The ongoing legal battles, which have wide-ranging implications for patient and clinician safety as well as public health generally, are setting the stage for a Supreme Court case that may decide the fate of firearm regulations in US hospitals. A permissible pathway for advancing sensible gun regulation in hospitals is urgently needed., Observations: Since the Supreme Court established a new constitutional test for firearm laws in New York State Rifle & Pistol Association v Bruen (2022), states now face unprecedentedly high barriers to enacting health-protecting legislation regarding firearms. Post-Bruen, the Supreme Court requires that laws be consistent with "this Nation's historical tradition of firearms regulation." This means that states hoping to enact laws barring public carry of firearms in hospitals must demonstrate that hospitals are a "sensitive place" as a historical matter (ie, analogous to a location where firearms were traditionally restricted). By reasoning from analogy, it is clear several historical comparators exist for regulating firearms in hospitals. Although the hospital (as understood today) did not exist in the 1700s, it is sufficiently analogous to asylums and schools, to name a few examples. These settings all share a common denominator with the modern-day hospital: serving vulnerable populations or individuals who may be at heightened risk of misusing firearms., Conclusions and Relevance: The Supreme Court's interpretation of the Second Amendment right to bear arms is threatening democratically enacted laws seeking to shelter hospitals from firearm violence. However, it is clear that hospitals and other health care settings are a sensitive place with compelling historical analogies. Policymakers' strategic deployment of the sensitive places designation, along with its rightful judicial recognition in the hospital setting, are critical to upholding laws that protect health care facilities, patients, and professionals from firearm violence-a conclusion consistent with the US Constitution, history, medical ethics, and common sense.

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., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

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., (Copyright © 2024 Elsevier Inc. All rights reserved.)

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., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: A loophole in US gun policy is that people can purchase guns from private sellers without going through any background check. Some states have addressed this loophole by requiring universal background checks for all gun sales, either at the point of sale or through a permit system; however, most studies on the effectiveness of universal background checks have not analyzed these 2 policy mechanisms separately., Objective: To assess the association of point-of-sale background check law and gun permit law, separately, with firearm homicide rates from 1976 through 2022 using the same methods and model specification., Design, Setting, and Participants: This cross-sectional study used a difference-in-differences, fixed-effects regression model to evaluate firearm laws and firearm homicide rates in 48 states from 1976 through 2022. Data were obtained for 48 states except New Hampshire and Vermont and were analyzed in January 2024., Exposures: Implementation of either the law requiring a universal background check at point of sale for all firearms without a permit or the laws combining universal background checks and a state permit requirement for all gun purchasers., Main Outcomes and Measures: Annual, state-specific rates of firearm homicide per 100 000 people., Results: From 1976 through 2022, 12 states adopted the universal background check laws without permitting requirements and 7 states implemented gun permit laws covering all firearms. The mean (SD) firearm homicide rate was 4.3 (0.1) per 100 000 people. Universal background checks for all firearms alone (without a state permitting system) were not associated with overall homicide rates (percentage change, 1.3%; 95% CI, -6.9% to 10.4%) or firearm homicide rates (percentage change, 3.7%; 95% CI, -5.3% to 13.6%). A law requiring a permit for the purchase of all firearms was associated with significantly lower overall homicide rates (percentage change, -15.4%; 95% CI, -28.5% to -0.01%) and firearm homicide rates (percentage change, -18.3%; 95% CI, -32.0% to -1.9%)., Conclusions and Relevance: This cross-sectional study found that universal background checks alone were not associated with firearm homicide rates, but a permit requirement for the purchase and possession of firearms was associated with substantially reduced rates of firearm homicide. The findings suggest that combining universal background checks and permit-to-purchase requirements is an effective strategy for firearm-related fatality reduction.