No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Homicide, Suicide, and Unintentional Firearm Fatality: Comparing the United States With Other High-Income Countries, 2003
Abstract
Violent death is a major public health problem in the United States and throughout the world.
A cross-sectional analysis of the World Health Organization Mortality Database analyzes homicides and suicides (both disaggregated as firearm related and non-firearm related) and unintentional and undetermined firearm deaths from 23 populous high-income Organization for Economic Co-Operation and Development countries that provided data to the World Health Organization for 2003.
The US homicide rates were 6.9 times higher than rates in the other high-income countries, driven by firearm homicide rates that were 19.5 times higher. For 15-year olds to 24-year olds, firearm homicide rates in the United States were 42.7 times higher than in the other countries. For US males, firearm homicide rates were 22.0 times higher, and for US females, firearm homicide rates were 11.4 times higher. The US firearm suicide rates were 5.8 times higher than in the other countries, though overall suicide rates were 30% lower. The US unintentional firearm deaths were 5.2 times higher than in the other countries. Among these 23 countries, 80% of all firearm deaths occurred in the United States, 86% of women killed by firearms were US women, and 87% of all children aged 0 to 14 killed by firearms were US children.
The United States has far higher rates of firearm deaths-firearm homicides, firearm suicides, and unintentional firearm deaths compared with other high-income countries. The US overall suicide rate is not out of line with these countries, but the United States is an outlier in terms of our overall homicide rate.
... The United States of America (USA) has firearm-associated injuries that far outnumber those of other affluent nations. In a cross-sectional analysis of high-income countries, the USA was found to contribute 80% of all firearm-associated deaths (1) with a crude rate of 11.1 per 100,000 individuals in 2015 (2) . A retrospective survey of firearm-associated injuries (2006-2014) estimated that the combined financial burden of emergency room visits, hospitalization, and lost wages was $45.6 billion per year (3) . ...
... In an analysis of a World Health Organization mortality database, Richardson et al. found that 80% of all firearm-related deaths occurred in the USA. Despite having a 30% lower suicide rate than other high-income countries, the USA had a 5.8-fold higher rate of firearm-associated suicide (1) . Through the Center for Disease Control questionnaire data (2000)(2001)(2002), Miller et al. found that with every 1% increase in firearm ownership, the rate of firearm-related suicide increased by 3.5% (24) . ...
... They concluded that since firearms are implicated in >50% of suicides in the USA, reductions in firearm ownership would drastically reduce the rate of firearm-related suicide. With the progressive aging of the USA population, there exists a growing need to develop strategies for identifying these high-risk elderly patients (1,25,26) . Although effective worthy treatment algorithms have been developed to restore appearance and functionality in patients maxillofacial and ocular injuries after failed suicide attempts (27) , associated residual visual compromise and the high rate of TBI and mortality in elderly individuals warrants the creation of targeted prevention strategies. ...
Purpose:
The United States of America has the highest gun ownership rate of all high-income nations, and firearms have been identified as a leading cause of ocular trauma and visual impairment. The purpose of this study was to characterize firearm-associated ocular injury and identify at-risk groups.
Methods:
Patients admitted with firearm-associated ocular injury were identified from the National Trauma Data Bank (2008-2014) using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes for external causes. Statistical analysis was performed using the SPSS 24 software. Significance was set at p<0.05.
Results:
Of the 235,254 patients, 8,715 (3.7%) admitted with firearm-associated trauma had ocular injuries. Mean (standard deviation) age was 33.8 (16.9) years. Most were males (85.7%), White (46.6%), and from the South (42.9%). Black patients comprised 35% of cases. Common injuries were orbital fractures (38.6%) and open globe injuries (34.7%). Frequent locations of injury were at home (43.8%) and on the street (21.4%). Black patients had the highest risk of experiencing assault (odds ratio [OR]: 9.0; 95% confidence interval [CI]: 8.02-10.11; p<0.001) and street location of injury (OR: 3.05; 95% CI: 2.74-3.39; p<0.001), while White patients had the highest risk of self--inflicted injury (OR: 10.53; 95% CI: 9.39-11.81; p<0.001) and home location of injury (OR: 3.64; 95% CI: 3.33-3.98; p<0.001). There was a steadily increasing risk of self-inflicted injuries with age peaking in those >80 years (OR: 12.01; 95% CI: 7.49-19.23; p<0.001). Mean (standard deviation) Glasgow Coma Scale and injury severity scores were 10 (5.5) and 18.6 (13.0), respectively. Most injuries (53.1%) were classified as severe or very severe injury, 64.6% had traumatic brain injury, and mortality occurred in 16% of cases.
Conclusion:
Most firearm-associated ocular injuries occurred in young, male, White, and Southern patients. Blacks were disproportionally affected. Most firearm-associated ocular injuries were sight--threatening and associated with traumatic brain injury. The majority survived, with potential long-term disabilities. The demographic differences identified in this study may represent potential targets for prevention.
... The current rate is merely the highest since the mid-1990s, but still well below the peak of 16.3 gun deaths per 100,000 people in 1974. 1 Mass shooting deaths, while increasing over the last 2 decades from a low of 7 deaths in 2000, to a high of 59 as of October 18, 2022, represent less than 0.1% of all firearm-related deaths. 2 Still, the reality is that the United States remains the frontrunner, among developed countries with high income, for both homicide and firearm-related homicide which is 19.5 times higher than comparable nations. 3 The higher burden of firearm associated morbidity and mortality translates to an exorbitant financial burden. 2,3 A report from between 2006 and 2010 showed that the shared cost to the American Health Care system in treating gunshot wounds (GSWs) equated to $88.6 billion. ...
... 3 The higher burden of firearm associated morbidity and mortality translates to an exorbitant financial burden. 2,3 A report from between 2006 and 2010 showed that the shared cost to the American Health Care system in treating gunshot wounds (GSWs) equated to $88.6 billion. 4,5 Previous reports studied socio-economic correlates and the everincreasing health care burden of GSWs utilizing the 2004 to 2013 National (Nationwide) Inpatient Sample database developed for the Healthcare Cost and Utilization Project (HCUP). ...
Background:
Gun violence in the United States rose continuously from 2010 to 2022, spiking during the pandemic, and peaking in 2021 at 48,830 deaths (14.8 per 100,000). Previous reports investigated health and financial burden associated with gunshot wounds (GSWs) during 2004 to 2013; however estimates related specifically to head and neck (H&N) injuries have been lacking. This population-based study aims to examine incidence, morbidity, mortality, and health resource utilization of H&N injuries utilizing the Nationwide Inpatient Sample database.
Methods:
A population-based study was undertaken using the National (Nationwide) Inpatient Sample (NIS) database (2015Q4-2017Q4). The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to create a composite variable (inclusive of brain, eye, facial nerve, and facial fractures) resulting from GSW to the H&N. Incidence per 100,000 hospitalizations and case fatality rates were calculated to determine the health burden of H&N injuries. Length of hospital stay, and inflation- adjusted hospital charges were compared among H&N and non-H&N injuries. Χ2 (classical and bootstrapped) and Mann-Whitney tests were used to compare groups.
Results:
Of 101,300 injuries caused by firearms, 16,140 injuries (15.9%) involved H&N region. The average incidence of H&N injuries was 20.1 cases per 100,000 hospitalizations, with intentional injuries having the highest case fatality rates of 32.4%. Patients with H&N injuries had extreme loss of function (33.4% versus 18.3%, P<0.001) and extreme likelihood of mortality (27.0% versus 11.3%, P<0.001) than non-H&N injuries. Statistically significant differences in the median length of stay (4.8 d versus 3.7 d; P<0.001) and median inflation-adjusted hospital charges ($80,743 versus $58,946, P<0.001) were found among H&N and non-H&N injuries.
Conclusions:
Injuries due to GSW remain an inordinate health care and financial burden, with trauma to the H&N carrying an especially high cost in dollars, morbidity, and mortality.
... In particular world regions like India, USA and Japan, the incidence of homicide and suicide is stagnant or rising 2,23,24 . On the other side, in some countries these forms of lethal violence are considered as the most common causes of death in the population under 40 years of age 25 . The effect of these forms of violent death on overall mortality rates will likely become more notable in the future following numerous societal and technological changes worldwide. ...
... These results could to some extent explain the differences in homicide and suicide rates between younger and older persons. Our results are in concordance with numerous studies that showed that most of the population of suicide victims are persons older than 65 years, whereas victims of murder were most often persons under 40 years of age 5,18,[25][26][27] . The older population is prone to develop different organic diseases connected with certain psychiatric disorders 27 . ...
Background/Aim. Suicide and homicide are very important social problem, especially frequent among the population younger than 40 years old. The aim of this study was to assess the influence of different sociodemographic factors and relevant psychoactive substances on the difference between homicide and suicide victims. Methods. A cross - sectional study analysed autopsy reports of 714 suicide cases and 166 homicide cases, autopsied in a five-year period (2011-2016). Out of these, 666 suicide cases and 127 homicide cases met the inclusion criteria for this study. Blood-ethanol concentration was determined by headspace gas chromatography with flame ionisation detection (HS-GCFID). Analysis of substances other than ethanol was accomplished by gas chromatography-mass spectrometry (GC-MS) and liquid chromatography tandem-mass spectrometry (LC-MS/MS).Results. There was a significant difference in age, level of education and employment rate between suicide and homicide cases (p < 0.05). The distribution of suicide and homicide cases differed significantly on weekdays in comparison to weekends (OR=1.5; 95 % CI=1 - 2.3; p < 0.05). Presence of a psychoactive substance remained a non - significant predictor of whether a person would become a homicide or suicide victim (p > 0.05). Homicide victims were more likely to have significantly higher blood alcohol concentration (0.2 - 0.3 g/dL) than suicide victims (OR=2.2; 95 % CI=1 - 5; p < 0.05).Conclusion. Victim's age, level of education, employment status and high blood alcohol concentration (0.2 - 0.3 g/dL) are significantly different between sucide and homicide cases.
... Among all children aged #14 years killed by guns in high-income countries, children in the United States account for 87%. 1 Although the majority of pediatric firearm-related deaths are due to homicide, at least onethird are due to suicide, most often with a gun found at home. 2 Approximately 5% are due to unintentional shootings, in which a child accesses a loaded, unlocked gun in a home or car and pulls the trigger, mistakenly killing themselves or another child. [2][3][4] Fewer than 1 in 3 gun-owning households with children keep guns unloaded and locked separately from ammunition; 15 million children have access to guns in their homes. ...
... Study personnel approached a convenience sample on the basis of recruiter availability (March 2017 to July 2019) of parents and/or guardians of hospitalized children aged <20 years and assessed eligibility. After informed consent, participants were randomly assigned to 1 of 3 study groups: (1) BeSMART alone, (2) BeSMART 1 physician review, or (3) control. Participants were randomly assigned by using a computer-generated block randomization scheme (www.randomization.com) ...
Objectives:
To assess an educational intervention (BeSMART) for parents of hospitalized children on behaviors, beliefs, and knowledge about firearm safety.
Methods:
A randomized controlled, 3-arm preintervention and postintervention study compared BeSMART video and handout interventions (with and without physician review) to tobacco smoke videos and handouts (control) on parental behaviors, beliefs, and knowledge. Eligibility criteria included parents and/or guardians residing with hospitalized children aged <20 years. The primary outcome was a change in parent-reported frequency of asking about guns in homes visited by their children preintervention to 1 month after intervention. Secondary outcomes were parent-reported likelihood of asking about guns in others' homes immediately postintervention and change in firearm safety beliefs and/or knowledge in the intervention versus control group, analyzed with analysis of variance. McNemar's and paired t tests compared changes within groups, and generalized estimating equations compared change between groups for the primary outcome.
Results:
A total of 225 participants enrolled. Both intervention and control groups revealed significant increase mean in parent-reported Likert score of frequency of asking about guns within groups preintervention to 1 month after intervention (BeSMART: 1.5 to 2.3, P = .04; BeSMART + physician review: 1.4 to 1.9, P = .03; control: 1.4 to 2.3, P = .01). Change between groups was not significant (P = .81). Immediately postintervention, intervention groups reported higher likelihood of asking about guns (P < .001). Study groups revealed no significant differences in beliefs. Firearm safety knowledge increased significantly in the intervention groups.
Conclusions:
BeSMART firearm injury prevention intervention in a hospital setting increased parental knowledge regarding firearm safety. Immediately postintervention, BeSMART groups reported higher likelihood of asking about guns in others' homes compared with controls. At 1 month after intervention, all groups reported increased frequency asking about guns. Future investigations are needed to understand the duration of intervention impact.
... Information is limited regarding risk factors for firearm deaths in children, especially information related to individual, familial, and psychosocial factors [16][17][18][19][20]. Further research on how these factors relate to homicide, suicide, and unintentional firearm deaths may help identify injury patterns that guide preventive efforts. ...
We sought to compare risk factors contributing to unintentional, homicide, and suicide firearm deaths in children. We conducted a retrospective review of the National Fatality Review Case Reporting System. We included all firearm deaths among children aged 0–18 years occurring from 2007 to 2016. Descriptive analyses were performed on demographic, psychosocial, and firearm characteristics and their relationship to unintentional, homicide, and suicide deaths. Regression analyses were used to compare factors contributing to unintentional vs. intentional deaths. There were 6148 firearm deaths during the study period. The mean age was 14 years (SD ± 4 years), of which 81% were male and 41% were non-Hispanic White. The most common manners of death were homicide (57%), suicide (36%), and unintentional (7%). Over one-third of firearms were stored unlocked. Homicide deaths had a higher likelihood of occurring outside of the home setting (aOR 3.2, 95% CI 2.4–4.4) compared with unintentional deaths. Suicide deaths had a higher likelihood of occurring in homes with firearms that were stored locked (aOR 4.2, 95% CI 2.1–8.9) compared with unintentional deaths. Each manner of firearm death presents a unique set of psychosocial circumstances and challenges for preventive strategies. Unsafe firearm storage practices remain a central theme in contributing to the increased risk of youth firearm deaths.
... The United States stands out among the G7 nations both for its higher levels of violence and its high lifetime uncertainty. This is in line with the higher rate of gun violence in the United States compared with other high-income nations (21). ...
Uncertainty around age at death, or lifetime uncertainty, is a key public health indicator and a marker of inequality in survival. How does the extent of violence affect lifetime uncertainty? We address this question by quantifying the impact of violence on dispersion in the ages at death, the metric most used to measure lifetime uncertainty. Using mortality data from the Global Burden of Disease Study and the Internal Peace Index between 2008 and 2017, we find that the most violent countries are also those with the highest lifetime uncertainty. In the Middle East, conflict-related deaths are the largest contributor to lifetime uncertainty. In Latin America, a similar pattern is attributable to homicides. The effects are larger in magnitude for men, but the consequences remain considerable for women. Our study points to a double burden of violence on longevity: Not only does violence shorten individual lives, but it also makes the length of life less predictable.
... There is a positive relationship between the increase in the use of firearms and the increase in homicides committed with firearms. According to a study conducted in the United States of America, the country with the highest individual armament in the world, compared with other high-income countries, the USA has a youth firearm-related homicide rate that is 49 times higher than the aggregate rate of 22 countries (Grinshteyn and Hemenway 2016;Richardson and Hemenway 2011). Although there is no reliable data on individual armament in Turkey, according to the 2019 data of the Turkish Forensic Medicine Institute; in 2012, injuries due to firearms were determined as 5485, and in 2019 it was 10488. ...
Background: As in all over the world, healthcare professionals in Turkey are increasingly afected by violence.
The purpose of this study was to evaluate homicide, which is the most severe form of violence against health care
professionals.
Methods: Information regarding characteristics of the incidents, victims, and perpetrators were gathered from the
media reports subjecting murders of healthcare professionals between 2000 and 2019 were compiled and discussed
with descriptive statistics.
Results: There were 60 homicides involving health professionals (35 male, 25 female) between 2000 and 2019. Homicides of health professionals were found to have increased signifcantly between 2015 and 2019. The most common
crime scene was the victim’s workplace, whereas the most common method of homicide was the use of frearms. In
female healthcare professional homicides, the murderer was a former or existing partner in most cases.
Conclusions: The assessment of cultural factors, and the performance of various studies to prevent homicide of
health professionals is crucial. Policies against individual weaponry and the prevention of armed persons entering
healthcare facilities could be useful. In addition, regulations prohibiting targeting health professionals as a scapegoat
for system failures will help address this problem.
... 34 Although unintentional injuries have decreased since 2002, 32 US children 0 to 14 years of age have disproportionately higher rates of unintentional firearm death compared with other high-income countries. 35 Approximately 80% of unintentional firearm-related deaths of young children occur in the home 36 when they are playing with a firearm. 32 The vast majority of these incidents are self-inflicted, and when not self-inflicted, the shooters themselves are often young children. ...
Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them—referred to as lethal means restriction of firearms—is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.
... Until now, much of the research on this topic has been conducted in the U.S., which represents a relatively high-disorganization and highhomicide context (Richardson and Hemenway, 2011;National Center for Health Statistics, 2015). Here, we examine if and how clustering between homicide and other adverse health outcomes occurs in the Netherlands. ...
In this project we examine whether homicide ‘clusters together’ with other adverse health outcomes in the Netherlands, focusing on child mortality, suicide, sexual risk behavior, and substance abuse. We expected moderate-to-strong correlations between homicide and the other adverse health phenomena (hypothesis 1). Further, we expected that these correlations would be reduced when social disorganization is controlled for (hypothesis 2).
The study used population-level data between the years 1996 and 2019, for each of the 40 local regions of the Netherlands. We applied a multilevel correlation procedure to evaluate correlations between homicide and the other adverse health outcomes. Correlations between homicide and the other adverse health outcomes were modest. That is, we found only limited evidence for clustering between homicide and the other adverse health outcomes. The patterns of clustering that did occur, suggested that social disorganization in the region promotes risk-taking behaviors in the population, which ultimately increases rates of homicide, abuse of illegal drugs and births to adolescent parents.
Project materials, syntax and supplementary information can be found on the Open Science Framework at https://osf.io/jd5yu/.
... The United States experience 19.5, 5.8, and 5.2 times more homicides, suicides, and unintentional deaths, respectively, with firearms than other high-income countries. 65 In Switzerland, where firearm prevalence is among the highest in Europe (partly because of mandatory military conscription), firearm ownership translates to significantly lower rates of harm, and most of it is self-inflicted rather than aimed toward others. 66 Such stark contrasts suggest that gun culture and other socioeconomic factors play a role in the realization of firearm violence in the United States. ...
Firearm injury is a major public health crisis in the United States, where more than 200 people sustain a nonfatal firearm injury and more than 100 people die from it every day. To formulate policy that minimizes firearm-related harms, legislators must have access to spatially resolved firearm possession rates. Here, we create a spatiotemporal econometric model that estimates monthly state-level firearm ownership from two cogent proxies (background checks per capita and fraction of suicides committed with a firearm). From calibration on yearly survey data that assess ownership, we find that both proxies have predictive value in estimation of firearm ownership and that interactions between states cannot be neglected. We demonstrate use of the model in the study of relationships between media coverage, mass shootings, and firearm ownership, uncovering causal associations that are masked by the use of the proxies individually.
... The United States (US), as compared to other high-income countries, has the highest rates of gunshot-related deaths in all age groups (Richardson and Hemenway, 2011;Grinshteyn and Hemenway, 2019). Firearm violence amongst the pediatric population in the US is a significant cause of morbidity and mortality. ...
Pediatric firearm violence carries significant morbidity and mortality. Studies targeting children ≤14 years are limited. Our goal was to study the distribution and determinants of GSWs in the pediatric population. We performed a retrospective review of children ≤14 years presenting with GSWs at this level 1 trauma center. This cohort was split into younger children, 0–12 years, and older children, 13–14 years. Summary and bivariate statistics were calculated using Stata v10. 142 patients (68.3% black, 76.7% male) were identified. Injuries more often occurred at home (39.6%) by family or friends (60.7%). Older children often suffered handgun injuries (85.5%) and more often were sent immediately to the OR on presentation (29.2%). Younger children more often suffered from air-gun (50%) and pistols (40%). Younger children more commonly had blood transfusions (9.4%) compared to exploratory laparotomy in older children (13.5%). The most common disposition from the ED was home (36.2%). Descriptive data entailing incident specifics such as time of injury and CPS involvement were frequently missing in the healthcare record. Older children were more likely to be injured by strangers, have longer lengths of stay especially associated with surgical operations, and have a disposition of immediate arrest compared to their younger cohort. Consequently, this group may benefit from interventions typically aimed at older patients such as violence intervention programs. When available, differences in demographics and outcomes were identified which could shape novel prevention strategies for firearm injury.
... However, in the USA, compared with other countries, violent death was still the most important public health problem. Richardson and Hemenway [23] compared the crime and suicide rates for the USA and 23 high-income OECD countries. ey conducted cross-sectional analysis according to death rate data provided by WHO in 2003. ...
In this study, the panel smooth transition regression model was used for an empirical survey to investigate the dynamic effect of unemployment rate and crime rate on suicide rate under economic growth rate. The research period was from 2000 to 2019. Statistical results indicated that unemployment rate and crime rate had dynamic effects on suicide rate and that nonlinear relationships existed among them. In addition, depending on the fluctuation of dynamic value, the rise or fall of suicide rate had an asymmetrical influence on the value of unemployment rate and crime rate. Finally, when the rate of change of economic growth rate was larger than the dynamic value, the unemployment rate and crime rate had an aggressive influence on suicide rate.
... Firearm injuries are common in the USA and rates are 19.5 times higher than other high-income countries. 1 Blood vessel injury may also be a common complication; however, the occurrence of an intravascular missile embolism is rare. There have only been 216 cases documented in the English literature over the last 30 years and only 38 cases with embolisation to the heart. ...
Vascular injury is a common complication in firearm injuries; however, intravascular missile embolism is relatively rare. There are only 38 documented cases of intravascular missile embolisation to the heart. Bullet embolisms are difficult to diagnose even with multiple diagnostic modalities and even once identified, the most optimal choice of surgical management is debated. Our patient presented with a gunshot wound to the right posterior shoulder. Cardiac focused assessment with sonography for trauma, chest X-ray, CT and echocardiogram were performed, showing missile location adjacent to the right ventricle with inconclusive evidence of pericardial injury. Exploratory median sternotomy was performed, revealing intact pericardium and injury to the superior vena cava (SVC) with bullet embolisation to the right ventricle. The patient became temporarily asystolic secondary to haemorrhage from the SVC injury. Cardiac massage was performed, dislodging the missile into the inferior vena cava. A venotomy was performed to retrieve the bullet and vascular injuries were primarily repaired.
... Firearm death rates secondary to homicide, suicide, and unintentional injury are more than seven times higher in the United States (US) compared to other developed countries. (1,2) Over the past decade, gun violence numbers have steadily increased. Annual firearm deaths in the US rose by 56% from 2014 to 2020, while firearm injuries grew by 73%. ...
Background:
Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence.
Methods:
Firearm injury data was collected from 2016-2020 (n = 3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data was linked with Map the Meal Gap data, a publicly available dataset which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. FI by county of patient residence was categorized by rates less than the national average of 11.5% (Low), between the national and state average (16.5%) (Moderate), and greater than the state average (High). Out of state residents were excluded from the analyses.
Results:
Of the 3115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a level 1 trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. FI was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval (CI): 54 - 59) and increased odds of the injury classified as assault (odds ratio: 1.13, 95% CI 1.07-1.19).
Conclusion:
Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism.
Level of evidence:
IV.
... Both types of factors matter, and they are not easily separable. For example, high rates of homicide are related to inequality and residential segregation, high rates of firearm-related deaths are influenced by both behavioral factors and the greater availability of guns in the United States, and motor vehicle fatalities are driven by risky behaviors like drunk driving as well as structural factors like long commutes and lower population density (Evans, 2014;Hemenway & Miller, 2000;Massey, 1995;Peterson & Krivo, 1993, 1999Richardson & Hemenway, 2011;Siegel et al., 2013;Transportation Research Board, 2011). In other words, Americans are highly exposed to risky conditions and a high prevalence of negative behavioral factors, the consequences of which may be exacerbated by poor structural and organizational conditions including a lack of universal access to health care. ...
Objectives:
This study assesses how American life expectancy compares to other high-income countries and identifies key age groups and causes of death responsible for the U.S. life expectancy shortfall.
Methods:
Data from the Human Mortality Database, World Health Organization Mortality Database, and vital statistics agencies for 18 high-income countries are used to examine trends in U.S. life expectancy gaps and how American age-specific death rates compare to other countries. Decomposition is used to estimate the contribution of 19 age groups and 16 causes to the U.S. life expectancy shortfall.
Results:
In 2018, life expectancy for American men and women was 5.18 and 5.82 years lower than the world leaders and 3.60 and 3.48 years lower than the average of the comparison countries. Americans aged 25-29 experience death rates nearly three times higher than their counterparts. Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer's disease) account for 86% and 67% of American men's and women's life expectancy shortfall.
Discussion:
American life expectancy has fallen far behind its peer countries. The U.S.'s worsening mortality at the prime adult ages and eroding old-age mortality advantage drive its deteriorating performance in international comparisons.
... Rates of homicide and firearm homicide are markedly higher in the US than any other high-income county. [1][2][3] In 2020, the US saw a further upsurge, with homicide rates increasing by approximately 30%. 4 These deaths are ...
Importance:
Most US states have amended self-defense laws to enhance legal immunities for individuals using deadly force in public. Despite concerns that "stand your ground" (SYG) laws unnecessarily encourage the use of deadly violence, their impact on violent deaths and how this varies across states and demographic groups remains unclear.
Objective:
To evaluate the association of SYG laws with homicide and firearm homicide, nationally and by state, while considering variation by the race, age, and sex of individuals who died by homicide.
Design, setting, and participants:
This cohort study used a controlled, multiple-baseline and -location interrupted time series design, using natural variation in the timings and locations of SYG laws to assess associations. Changes in homicide and firearm homicide were modeled using Poisson regression analyses within a generalized additive model framework. Analyses included all US states that enacted SYG laws between 2000 and 2016 and states that did not have SYG laws enacted during the full study period, 1999 to 2017. Data were analyzed from November 2019 to December 2020.
Exposures:
SYG self-defense laws enacted by statute between January 1, 2000, to December 31, 2016.
Main outcomes and measures:
The main outcomes were statewide monthly rates of homicide and firearm-related homicide (per 100 000 persons) from January 1, 1999, to December 31, 2017, grouped by characteristics (ie, race, age, sex) of individuals who died by homicide.
Results:
Forty-one states were analyzed, including 23 states that enacted SYG laws during the study period and 18 states that did not have SYG laws, with 248 358 homicides (43.7% individuals aged 20-34 years; 77.9% men and 22.1% women), including 170 659 firearm homicides. SYG laws were associated with a mean national increase of 7.8% in monthly homicide rates (incidence rate ratio [IRR],1.08; 95% CI, 1.04-1.12; P < .001) and 8.0% in monthly firearm homicide rates (IRR, 1.08; 95% CI, 1.03-1.13; P = .002). SYG laws were not associated with changes in the negative controls of suicide (IRR, 0.99; 95% CI, 0.98-1.01) or firearm suicide (IRR, 1.00; 95% CI, 0.98-1.02). Increases in violent deaths varied across states, with the largest increases (16.2% to 33.5%) clustering in the South (eg, Alabama, Florida, Georgia, Louisiana). There were no differential associations of SYG laws by demographic group.
Conclusions and relevance:
These findings suggest that adoption of SYG laws across the US was associated with increases in violent deaths, deaths that could potentially have been avoided.
... Even so, the current study results, in combination with prior research, suggest that interventions with SUD clients who have experienced firearm victimization need to address the link between firearm victimization, gun acquisition, and other gun-related risks to themselves and to others in the household. Having a firearm in the household can increase risks for other family members and children as well (20,71,72). ...
Background:
Exposure to firearm victimization has often been overlooked as a sequela of substance use disorders (SUD).
Objectives:
The overall objective of this study was to explore firearm-related victimization and associated factors among men and women entering a supportive housing SUD recovery program.
Methods:
This study used program intake information from men (n = 1,758) and women (n = 1,066) clients entering a SUD recovery program.
Results:
Results found that almost half (49.3%) of the clients entering the program had ever been threatened with a firearm or held at gunpoint, and one-quarter of those clients had experienced firearm-related threats in the 6 months before entering the program. Economic vulnerability, mental health problems, polysubstance use, interpersonal victimization, and early use of drugs and alcohol were associated with firearm-related threat exposure. Many of the factors associated with firearm-related threat exposure were similar for men and women. Multivariate results found that polysubstance use (OR 1.16 men and 1.13 women), number of adverse childhood events (OR 1.13 men and 1.09 women), and interpersonal victimization (OR 3.41 men and 2.05 women) in the 6 months before program entry were significantly associated with ever being threatened with a firearm. Suicidality (OR 1.53 men and 1.80 women) and interpersonal victimization (OR 6.38 men and 6.08 women) were associated with being threatened with a firearm in the 6 months before program entry for both men and women.
Conclusion:
Results suggest there is a need for firearm-related risk reduction interventions for individuals in SUD recovery programs.
... More than two-thirds of homicides in the United States are committed by gun, and more gun homicides are committed each year in the United States than in all other high-income Organisation for Economic Co-operation and Development (OECD) nations combined. 16 In 2017, there were more than 14,000 victims of gun homicide and more than 107,000 people nonfatally wounded in gun assaults in the United States. 17 That this exposure to serious violence is sharply stratified by race is a social fact of contemporary American society. ...
Guns are central to the comprehension of the racial inequalities in neighborhood violence. This may sound simple when presented so plainly. However, its significance derives from the limited consideration that the neighborhood research paradigm has given guns: they are typically conceived of as a background condition of disadvantaged neighborhoods where violence is concentrated. Instead, I argue that guns belong at the forefront of neighborhood analyses of violence. Employing the logic and language of the ecological approach, I maintain that guns must be considered as mechanisms of neighborhood violence, with the unequal distribution of guns serving as a critical link between neighborhood structural conditions and rates of violence. Furthermore, I make the case that American gun policy should be understood as a set of macrostructural forces that represent a historic and persistent source of disadvantage in poor Black neighborhoods.
... Our meta-analysis reinforces findings from four included studies reporting higher firearm-related elder homicide rates in the United States compared to other high-income OECD countries (Grinshteyn & Hemenway, 2016Langlois et al., 1995;Richardson & Hemenway, 2011). This might be partially explained by the presence of more stringent gun policy in the other countries included in this review (L. ...
Background
Empirical research investigating older adult homicide is sparse and rarely accumulated for greater insights. This systematic review and meta-analysis quantifies the prevalence and characteristics of homicide victimization among older adults (65 years and older) compared with younger adults (18–64 years).
Method
We searched Cumulative Index to Nursing and Allied Health Literature, Cochrane, Criminal Justice Abstracts, EMBASE, MEDLINE, ProQuest, PsycINFO, Scopus, and Web of Science for studies published before December 31, 2018 (International Prospective Register of Systematic Reviews registration: CRD42017054536). Included were English-language, original, peer-reviewed studies describing the homicide of older adults. Excluded were studies not meeting age criteria, residence as an institution, or with insufficient outcome variables. The review included 39 studies; 17 were included in the meta-analysis. Data were extracted via open access or from study authors. Heterogeneity was assessed through study-level random effects estimates.
Results
Pooled homicide rates per 100,000 population were 2.02 (95% CI [1.23, 3.33]) for older adults ( n = 35,325) and 3.98 (95% CI [2.42, 6.53]) for younger adults ( n = 607,224; rate ratio = .51, 95% CI [0.37, 0.70], p < .001). Proportion estimates for older adults: victim female 46.3%, location home 71.4%, offender familiar 25.2%, compared to stranger, 24.2%, motive argument 36.1%, compared to felony 30.8%, and weapon firearm 24.5%. Older adults were significantly different to younger adult victims ( p = <.001) for female ( OR = 2.5, 95% CI [2.02, 3.10]), home (3.87, 95% CI [3.45, 4.35]), stranger (1.81, 95% CI [1.66, 1.98]), argument (0.33, 95% CI [0.28, 0.39]), felony (2.78, 95% CI [2.58, 2.99]), and firearm (0.38, 95% CI [0.36, 0.40]).
Conclusions
Homicide against older adults differs from younger adults and warrants specific research and tailored prevention strategies.
... Violence in the United States is unique from other nations in some respects. While the US is not an outlier with respect to most nonlethal crime, rates of lethal and non-lethal firearm-related violence are significantly higher than in other developed nations (Richardson & Hemenway, 2011;Zimring & Hawkins, 1997). For example, in 2010, an international comparison of murder rates in 2010 suggested the rate of homicide in the US (4.8 per 100,000) was 7 times that of other highincome countries, while the rate of firearm-related homicides was over 25 times greater than in these comparable nations (Grinshteyn & Hemenway, 2016). ...
Geographic information systems enable the study of the spatial distribution of gun violence in American cities. While sociodemographic characteristics and disinvestment patterns have been correlated to their presence, little work has examined spatio-temporal patterns among them. Understanding where shootings are more likely to be fatal may be of great value to criminologists, urban planners, and emergency department researchers. In this paper, we leveraged a crime database for Milwaukee spanning 2006 to 2015, geocoding every crime to its reported location. We ran kernel density analysis on each dataset to derive the relative density of gun homicides and non-fatal shootings. We then created space–time cubes for each crime type. These cubes were used with ESRI’s emerging hot spot analysis tool, highlighting different types of hot and cold spots. We appended these results to individual parcels to study the relationship between shooting hot or cold spots and sociodemographic characteristics. Lastly, we identified ‘islands’ with relatively fewer lethal shootings inside gun homicide hot spots, exploring reasons for their differentiation. While hot spots occurred primarily in African American neighborhoods, the worst areas were in more transitional neighborhoods, perhaps where disinvestment had not yet fully taken hold. Neighborhoods with the highest rate of homicides to total shootings included the most heavily Hispanic neighborhoods in Milwaukee, while lower rates were found in predominately African American neighborhoods. This work introduces a nuance into the discussion on policing gun violence, giving researchers and practitioners a finer lens in which to examine where and why gun violence occurs.
... Yet, the literature has failed to fully account for officer exposure to civilian gun possession and gun violence, despite the fact that American law enforcement officers operate in jurisdictions with some of the highest rates of gun ownership and firearm violence in the world (Richardson & Hemenway, 2011). The wide availability of firearms and their capacity for serious harm represent salient factors in officers' assessments of dangerousness during police-community encounters, whether during a routine traffic stop, call for service, or casual encounter (Smith, 2018;Stoughton, 2014). ...
Police use of deadly force represents a pressing public policy issue with implications for police-community relationships and equitable access to justice. A growing body of literature considering the structural factors influencing officers’ exposure to potential violence suggests that context plays a pivotal role in officer use of deadly force. This study explores how local gun ownership rates impact fatal police shootings for a national sample of large law enforcement agencies. Two-level negative binomial regression models examine the organizational and contextual correlates of fatal police shootings from 2014 to 2018, nesting 758 law enforcement agencies within 408 counties. Results indicate that agencies operating within areas characterized by high rates of violent crime and gun ownership were involved in more fatal police shootings. The findings underscore the importance of contextual cues of danger that police officers respond to during fatal police shootings.
... Gun violence in the United States is a national public heath crisis [1] with firearm homicide rates 19.5 times that of other high-income countries [2]. Mass shootings in particular represent a phenomenon of interest in that these high-profile events with multiple, and occasionally numerous, victims generate large amounts of media coverage. ...
Gun violence and mass shootings are high-profile epidemiological issues facing the United States with questions regarding their contagiousness gaining prevalence in news media. Through the use of nonparametric Hawkes processes, we examine the evidence for the existence of contagiousness within a catalog of mass shootings and highlight the broader benefits of using such nonparametric point process models in modeling the occurrence of such events.
... The epidemiology of firearm injuries (FI) varies among countries. [1][2][3][4][5][6] Excluding war areas, the USA reports the highest rate of gunshot-related fatalities, including homicides, suicides and unintentional deaths. 1 2 Injuries remain rare in industrialised European countries, as shown by data collected in studies carried out in Finland, Sweden, Spain, Germany, Austria and Belgium. 1 3-6 But no European country is spared from ballistic trauma. Even Switzerland, which is supposed to be the country with the lowest crime rate in the world. ...
Background
Firearm injuries (FI) are an increasing problem in Europe but there have been few European epidemiological studies on civilian FI, particularly in France. This study investigated the epidemiology of FI at a French level I trauma centre.
Methods
A retrospective cohort study was conducted of all patients admitted to our centre with an FI between January 2009 and December 2019. We investigated the epidemiological trends of FI during the study period, and characterised the FI.
Results
A total of 162 patients were victims of FI. Prevalence was 0.11% and the mean annual incidence was 10.4 per 100 000 habs. A significant increase has been observed over the last 10 years, from 5 cases in 2009 (3.1%) to 30 in 2019 (18.5%). Of the 162 victims, 85 (52.5%) died as a direct result of the FI: 72 suicides (88.9%) and 9 victims of urban violence (11.1%) (armed public environment disorder). 95.3% of the patients died before reaching at the hospital. There were 95 cases (58.7%) of suicide and 33 cases (20.4%) of urban violence. The head was shot in 87 cases (48.9%), the thorax in 32 cases (18.5%) and the lower limbs in 24 cases (13.5%). A total of 106 surgeries were performed on 54 patients (33.3%).
Conclusions
We identified 162 cases of FI with a mean annual incidence of 10.4 per 100 000 habs. A significant increase in FI was observed over the last 10 years. 52.2% of patients died, and the main context was suicide or attempted suicide.
... For example, victims may feel that a firearm is the only way to protect themselves and/or their loved ones if an abuser refuses to abide by a protective order or continues to threaten them even after an arrest is made . Victims who decide to utilize firearms for protection should be properly trained on how to safely use and store firearms to avoid accidental injury or death, particularly in light of the high rate of unintentional firearm death in the United States compared with other developed countries (Richardson and Hemenway 2011). Even so, pushing firearms into the hands of those who are experiencing fear and trauma is not empowering but rather exploitive-particularly in the absence of policies that aim to disarm perpetrators of crime. ...
An abusive partner’s access to a firearm is one of the strongest predictors of intimate partner homicide, and there is evidence that laws limiting abusers’ access to firearms are associated with fewer fatalities. Yet, there is a movement to increase access to firearms as a strategy for self‐protection among intimate partner violence (IPV) victims. The present study describes both firearm‐related and non‐firearm‐related protective actions among victims of IPV, and further examines which factors (e.g., pro‐gun attitudes) are associated with engaging in firearm‐related protective actions. Questionnaires were administered to women recruited from six domestic violence shelters in Texas from December 2017 to September 2018. Nearly 13 percent of victims in the analytic sample (N = 197) engaged in one or more forms of firearm‐related protective actions in the past year. Multivariate analyses revealed that participants were more likely to have engaged in firearm‐related protective actions if they experienced higher firearm‐related IPV and if they held stronger pro‐gun attitudes. The results highlight the importance of basing firearm policy on empirical evidence as firearms can have deadly consequences.
... When examining firearm-related worries, only about 1 in 5 men and women handgun owners agreed that they worried about children accessing their firearm. The rate of unintentional firearm death in the United States is 10 times higher than in other developed countries (Richardson and Hemenway 2011) and children and adolescents are at highest risk of firearm injuries (Everytown for Gun Safety 2020; Marshall et al. 2020). It may be that fewer handgun owners worried about children accessing their gun because the majority of the sample did not have children. ...
... By comparison, in 2017, Canada had 266 firearm-related homicides (rate of 0.72/100,000) which was the highest recorded since 1992 [7,3], whereas the USA had a homicide rate of 4.5/100,000. In the same year, Mexico had 15,400 total firearm-related deaths (rate 7.6/ 100,000) compared to the USA who had 39,773 (rate 12.2/ 100,000) [3,8]. ...
Background
To analyze and report on the changes in epidemiology traumatic causes of death in the USA.Methods
Data were extracted from the annual National Vital Statistics Reports (2008–2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software.ResultsFirearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55–64.
Conclusions
Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946–1964).
Background
Firearm violence is the leading cause of pediatric mortality in the USA. The presence of a firearm in the home poses an immense risk to children with increased rates of suicide and unintentional injury by firearm. Recent literature has not explored child ACEs and child behavioral health needs with the presence of a firearm in the home. The objective of this study was to explore an association between these factors, parent health, family experience with firearm violence, and demographics, and the presence of a firearm in the home.
Results
Overall, 382 of 1,436 (weighted to 22.0%) responding parents reported the presence of a firearm in the home. In an adjusted model, the odds ratio of firearm presence increased incrementally with a child’s increasing exposure to ACEs. Compared to a child in the household exposed to no ACEs, a child in the household exposed to two or more ACEs was associated with a 5.16 times higher odds of firearm presence in the home (95% confidence interval (CI) 2.92–9.10). Similarly, a child in the household who had used behavioral health services was associated with a 2.10 times higher odds of firearm presence in the home (95% CI 1.35–3.26), compared to a child in the household who had not. Presence of firearm in the home was also associated with higher household income, younger parent age (under 35 years), and male parent gender.
Conclusions
Chicago parents have higher odds of reporting the presence of a firearm in the home when living in a household with a child exposed to ACEs and with behavioral health needs. These findings could inform future public health interventions and targeted safe storage messaging to prevent pediatric firearm injury in the home.
This book deals with criminological theory, criminology, and criminal justice. It addresses a wide range of topics relevant to criminology, including socioeconomic factors that contribute to crime such as biology, community and inequality, emotions, immigration, social institutions, social learning, social support, parenting, peer networks, street culture, and market economy. It also examines the developmental criminology perspective and the developmental risk factors for crime and delinquency across five key risk domains (individuals, family, peers, schools, and community). Moreover, it reviews criminological research that ascribes criminal behavior to the interaction between individuals and street culture; Cesare Lombroso's views about the causes and correlates of crime as delineated in his book, Criminal Man ; the state of contemporary gang ethnography; Travis Hirschi's major contributions to the methods of analysis in criminology; the role of gender in delinquency; the link between coercion and crime; the psychology of criminal conduct; violence in drug markets in suburbs and the code of the suburb; the impact of imprisonment on reoffending; green criminology; and why crime levels are extraordinarily high in some places but low or totally absent in most places, and how place management accounts for this disparity. The book also looks at a variety of theories on criminology, including the rational choice theory, the theory of target search, Robert Agnew's general strain theory, the “Integrated Cognitive Antisocial Potential” theory developed by David Farrington, routine activity theory, and crime-as-choice theory.
Introduction
Pediatric firearm injury became the leading cause of death among U.S. children in 2020. Studies evaluating wounding patterns in military and mass casualty shootings have provided insights into treatment and potential salvageability in adults, however, similar studies in the pediatric population do not exist. Hence, our study aimed to analyze wounding patterns of pediatric firearm fatalities and associated demographics and characteristics, such as place of death, to better understand pediatric firearm injuries, potential salvageability, and opportunities to reduce firearm deaths among vulnerable pediatric populations.
Methods
A retrospective review of the National Violent Death Reporting System from 2005-2017 was performed on patients 18 and younger. Mortalities were stratified by patient age: <12 years and 13-18 years and by intent— homicide, suicide, and unintentional. Comparative and exploratory analyses of demographics, location of death and anatomic location of wounds were performed.
Results
Of 8,527 pediatric firearm mortalities identified, 4,728 were homicides, 3,180 were suicides and 619 were unintentional injuries. Suicide victims were most likely to be dead on scene and >90% of suicide victims suffered head/neck injuries. For victims of homicide, younger children were more likely to die on scene (60.9% vs 44.2 p < 0.001). The pattern of injury in homicides differed for younger children compared to adolescents, with younger children with more head/neck injuries and older children more thoracic, thoracoabdominal, abdominal, and junctional injuries. In both age groups, children with extremity, abdominal and thoracoabdominal injuries were more likely to die later in the emergency department or inpatient setting.
Conclusions
Wounding patterns across pediatric firearm mortalities in the U.S. vary by age and intent. The majority of pediatric firearm deaths were due to head/neck injuries. Children with homicide and unintentional deaths had more wounding pattern variation, including more injuries to the thorax and abdomen, and a much lower rate of dead-on scene than suicide victims. Our study of wounding patterns among U.S. children killed by firearms highlights the complexity of these injuries and offers opportunities for tailored public health strategies across varying vulnerable pediatric populations.
There is a growing understanding that the producers and sellers of harmful products directly and indirectly affect population health and policy, including through seeking to influence public understanding about the nature of harms and their solutions. However, the firearm industry and related organisations have not to date been the subject of this type of enquiry. This study sought to address this evidential gap through examining the ways in which the firearm industry and industry-associated organisations frame firearms, firearm-related harms and possible solutions to gun violence. This was a thematic qualitative documentary analysis of materials from 7 of the largest firearm manufacturers and associated organisations. Two authors independently extracted textual material from web articles, press releases, annual reports and shareholder communications between 1st April 2019 to 1st April 2020 (302 documents). A hybrid approach combining both deductive and inductive coding was adopted, guided by the literature on the commercial determinants of health and using NVivo version 12. The firearm industry and firearm-industry-funded organisations use framings about the safety and role of guns, evidence on associated harms and solutions that align with the industry's business interests, consistent with evidence on other harmful product manufacturers. This study identified framing strategies employed by the firearm industry and related organisations. These included attempts to undermine evidence, linking regulation to a dystopian future, minimising some of the most common harms, placing the responsibility for harms on individuals, and attempting to foster a heightened sense of risk to personal safety.
Firearm violence is a significant cause of morbidity and mortality among children and adolescents in the United States and a complex public health problem. Researchers have explored social risk and protective factors at the level of the individual, relationship, community, and societal level which tend to vary by intent. However, further research is needed in this area to aid the development of targeted public health interventions.
Background
Firearm injuries’ association with individual-level socioeconomic risk is well described. Trauma research has suggested that neighborhood level risk factors may be associated with differences in firearm injury outcome. We analyzed the relationship between hospital length of stay (LOS), mortality and neighborhood level social markers from the Center for Disease Control (CDC) Social Vulnerability Index (SVI) after firearm injury.
Materials and Methods
We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) in 2016 to identify firearm injuries using ICD-10 E-codes. Patient locations were identified at the census tract level. The 2016 CDC SVI was used to evaluate neighborhood level social vulnerability. Logistic and linear multivariable regression were used to evaluate the association between SVI percentile rank, mortality, and LOS.
Results
We identified 9,764 cases of firearm injury in our database; 88.2% of individuals were male, and the average age was 33.8 years. Assault was the most common intent, accounting for 4682 (48.0%) of all admissions. Overall, SVI was correlated with the risk of firearm injury, but not associated with either outcome of length of stay or risk of death.
Conclusions
While there is significant disparity between SVI and risk of firearm injury, once admitted to the hospital outcomes are similar between low and high-vulnerable populations. To reduce disparities in risk, funding and effort should focus on primary prevention.
Background
Successful public health policies and injury prevention efforts have reduced pediatric automobile fatalities across the United States. In 2019, firearm injuries exceeded motor vehicle crashes (MVC) as the leading cause of childhood death in Colorado. We sought to determine if similar trends exist nationally and if state gun laws impact firearm injury fatality rates.
Methods
Annual pediatric (≤19 years-old) fatality rates for firearm injuries and MVCs were obtained from the CDC WONDER database (1999-2020). State gun law scores were based on the 2014-2020 Gifford's Annual Gun Law Scorecard and strength was categorized by letter grades A-F. Poisson generalized linear mixed models were used to model fatality rates. Rates were estimated for multiple timepoints and compared between grade levels.
Results
In 1999, the national pediatric fatality rate for MVCs was 248% higher than firearm injuries (Incidence Rate Ratio (IRR) 95% Confidence Interval (CI): 2.25-2.73, p<0.0001). By 2020, the fatality rate for MVCs was 16% lower than that of firearm injuries (IRR 95% CI: 0.75- 0.93, p=0.0014). For each increase in letter grade for gun law strength there was an 18% reduction in the firearm fatality rate (IRR 95%CI: 0.78-0.86, p<0.0001). States with the strongest gun laws (A) had a 55% lower firearm fatality rate compared to those with the weakest laws (F).
Conclusion
Firearm injuries are the leading cause of death in pediatric patients across the United States. State gun law strength has a significant impact on pediatric firearm injury fatality rates. New public health policies, political action, media attention and safer guns are urgently needed to curb this national crisis.
Level of Evidence/Study Type
Level III, Retrospective
Introduction
Firearm injuries (GSW) in the pediatric population is a public health crisis. Little is known about the outcomes of damage control laparotomy (DCL) following abdominal GSW. This study aims to evaluate outcomes from abdominal GSWs in the pediatric population.
Methods
The trauma registry from an urban Level 1 trauma was queried for pediatric (0-18 y) GSW was queried from September 2013 to June 2020. Demographics, clinical variables, outcomes, readmissions, and recidivism were analyzed.
Results
Abdominal GSW were identified in 83 patients (17% of all GSW). The median age was 16 [15-17], 84% were male and 86% Black. Violent intent accounted for 90% of GSW. The injury severity score was 16 [9-26] and 80% went directly from the resuscitation bay to the operating room. Laparotomy was required in 87% of patients, and surgery was not required in any patient initially managed nonoperatively. The most common complications were intraabdominal infection (20%), other infections (13%), and small bowel obstruction (8%). DCL with temporary abdominal closure was performed in 16% of laparotomies and was associated with a longer length of stay, more infections, but similar rates of readmission and mortality. Overall mortality was 13%, with all but one patient expiring in the resuscitation bay or the operating room. All patients who underwent DCL survived to discharge.
Conclusions
Abdominal firearm injuries have high morbidity and mortality in the pediatric population. Damage control operations for abdominal GSWs are a valuable surgical option with similar outcomes to primary abdominal closure after initial injury survival.
States with more gun laws have fewer gun assaults, and associations are strongest for background check laws. However, sales between private buyers and sellers (i.e., gun shows) are exempt from some background check requirements according to federal and most state laws. The aim of this study was to determine whether gun shows are more likely to take place in counties that are near states with universal background check laws. This cross-sectional study used gun show data from a 2018 public online listing aggregated within 3107 counties in the contiguous 48 states. The main independent variable was the presence of a universal background check law in neighboring states. We controlled for potential drivers of demand for gun shows, including the total number of gun laws within-state and in neighboring states, local and in-flowing population size, and proportion of the local and in-flowing population who were gun owners. Bayesian conditional autoregressive Poisson models estimated associations between neighboring-state universal background check law and the presence of a gun show in each county while accounting for spatial dependencies and nesting of counties within states. Of the 1869 identified gun shows, nine of the states in which they occurred had a universal background check law. The presence of excess gun shows in counties near states with universal background check laws is consistent with the hypothesis that gun shows service demand from people seeking to circumvent prohibitions against gun purchases.
Background
In the United States, firearms now rank as the second-leading cause of death among children and adolescents, trailing only motor-vehicle accidents. Prior reports have calculated that 87% of all children aged 0-14 killed by firearms in high-income countries are US children. This study sets out to determine how rates of gun ownership, surrogate markers for the number of guns in circulation and strictness of firearm-related correlated with firearm-related mortality among both juvenile and overall populations at the state level.
Methods
Firearm-associated mortality rates among juveniles, as well as among all ages, were obtained for each US state from the Centers for Disease Control and Prevention (CDC). The number of National Firearms Act weapons and federal firearms licensees for each state was taken from the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). State-level gun ownership rates, poverty rates and unemployment rates were procured from the RAND corporation, US. Census Bureau and US Department of Labor, respectively. Mental health data was taken from the CDC’s behavioral risk factor surveillance system. Gifford Center Scorecard Rankings were used a relative measure of firearm law strictness. Bivariate linear regression was used to model the relationships between firearm-associated mortality as well as ATF registered weapons, ATF federal firearm licensees, Giffords Center scorecard rankings and gun-ownership rates. Multivariate analysis was then performed to control for state-level differences in poverty rates, unemployment rates and poor mental health.
Results
Unadjusted analysis showed that more ATF federal firearm licensees, higher gun ownership rates and more lenient gun laws were associated with increased rates of firearm-associated mortality among juveniles. Similarly, all 3 such measures as well as more ATF registered weapons were associated with increased rates of firearm-related death among overall populations. In the adjusted analysis, more ATF registered weapons, more ATF federal firearm licensees, higher gun ownership rates and more lenient firearm laws were all associated with higher rates of firearm-related mortality among both juvenile and overall populations.
Conclusions
In order to reduce the risk of firearm-associated death among children, US policy makers and stakeholders should focus on implementing more restrictive firearm laws and decreasing gun ownership rates.
Importance
Youth firearm-related deaths are a public health crisis in the US. The association between county-level poverty and the risk of firearm-related deaths among youth is unknown, however.
Objective
To examine the association between county-level poverty concentration and firearm-related mortality rates in US youth.
Design, Setting, and Participants
This cross-sectional study analyzed US firearm fatalities in children and young adults aged 5 to 24 years that occurred between January 1, 2007, and December 31, 2016. Data were obtained from the Centers for Disease Control and Prevention’s Compressed Mortality File, and annual intercensal county population data were obtained from the US Census Bureau. Data analyses were conducted between November 1, 2019, and June 30, 2020.
Exposures
County-level poverty was categorized into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20% of the population living below the federal poverty level.
Main Outcomes and Measures
The main outcomes were firearm-related deaths in total and by specific intent (homicide, suicide, and unintentional) per 100 000 youths over the entire study period. Multivariable negative binomial regression models were used to analyze the association between firearm-related mortality rates and county poverty concentration, controlling for demographic variables, urbanicity, and statewide firearm prevalence. Adjusted incidence rate ratios (IRRs) were calculated, and statewide firearm prevalence was estimated. The population-attributable fraction (PAF) and years of potential life lost for each intent were calculated.
Results
A total of 67 905 firearm-related deaths among youth (predominantly composed of 60 164 male individuals [88.6%]) from 2007 to 2016 were analyzed. Of these deaths, 42 512 were homicides (62.6%), 23 034 were suicides (33.9%), and 1627 were unintentional (2.4%). Firearm-related mortality risk increased in a stepwise manner with increasing county poverty concentration. Compared with counties with the lowest poverty concentration, counties with the highest poverty concentration had an increased rate of total firearm-related deaths (adjusted IRR, 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The PAF was 0.51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This calculation translated to 34 292 firearm-related deaths that would not have occurred if all counties had the same risk as counties with the lowest poverty concentration. A total of 3 833 105 years of potential life lost was observed.
Conclusions and Relevance
This study found an association between firearm-related mortality rates among youth and county-level poverty concentration. With more than half of firearm-related deaths and two-thirds of firearm-related homicides potentially associated with living in an area with a high concentration of poverty, a multidimensional strategy to reduce poverty and firearm-related deaths is urgently needed.
Background
The COVID-19 pandemic caused an abrupt change to societal norms. We anecdotally noticed an increase in penetrating and violent trauma during the period of stay-at-home orders. Studying these changes will allow trauma centers to better prepare for future waves of COVID-19 or other global catastrophes.
Methods
We queried our institutional database for all level 1 and 2 trauma activations presenting from the scene within our local county from March 18 to May 21, 2020 and matched time periods from 2016 to 2019. Primary outcomes were overall trauma volume, rates of penetrating trauma, rates of violent trauma, and transfusion requirements.
Results
The number of penetrating and violent traumas at our trauma center during the period of societal quarantine for the COVID-19 pandemic was more than any historical total. During the COVID-19 time period, we saw 39 penetrating traumas, while the mean value for the same time period from 2016 to 2019 was 26 ( P = .03). We saw 45 violent traumas during COVID; the mean value from 2016 to 2019 was 32 ( P = .05). There was also a higher rate of trauma patients requiring transfusion in the COVID cohort (6.7% vs 12.2%).
Discussion
Societal quarantine increased the number of penetrating and violent traumas, with a concurrent increased percentage of patients transfused. Despite this, there was no change in outcomes. Given the continuation of the COVID-19 pandemic, quarantine measures could be re-implemented. Data from this study can help guide expectations and utilization of hospital resources in the future.
Gun violence is a public health crisis plaguing the United States, deeply affecting individuals, communities, and the nation as a whole—a crisis that is garnering increasing attention in public and political discourse. In order to better understand and thus mitigate the effects of gun violence, it is vital to understand where it is happening and why. The United States suffers from uniquely high rates of gun violence compared to other developed nations, and adolescents shoulder a disproportionately large share of morbidity and mortality. The adolescent gun violence epidemic is characterized by two parallel tragedies: gun homicide deaths among boys in urban areas and gun suicide deaths among teen boys in rural areas. By understanding the epidemiology of gun violence and the most vulnerable populations it affects, the United States can move toward thoughtful policies and solutions to decrease the devastation it brings to the children and families of the United States.
Much of the research on firearm owners implies that the U.S. population can be divided into two groups-those that own guns and those that do not; however, there is a third group-those thinking of getting a gun and almost nothing is known about this group. A survey on gun ownership, experiences, and behaviors was deployed online via Prolific in June and July 2020 to recruit women from the general U.S. population who were planning on getting a gun (n = 187), who owned a gun (n = 288) and who did not own or plan to own guns (n = 968). Results show that women planning on getting a gun worried more about their personal safety and more had experienced recent interpersonal violence victimization compared to the other two groups. Almost all of the women planning on getting a gun believed that carrying a gun would make them safer. Even though women planning on getting a gun had limited experience with guns, they expressed fewer gun related worries than nongun owners. Additionally, women planning on getting a gun had more depression symptoms and more of them indicated they had thoughts of self-harm in the past two weeks than current gun owners. Depression symptoms were significantly associated with plans to get a gun in the multivariate model. Given the risks associated with having firearms in the household, interventions could target those considering getting a gun as well as educating friends and family about what to say when someone close is considering obtaining a firearm for safety.
Introduction:
Firearm-related injuries (FRI) are an important public health crisis in the US. There is relatively less city level data examining the injury-related trends in Tucson, Arizona. Our study aims to examine FRI, in Southern Arizona's only Level I trauma center.
Methods:
We conducted a (2014-2019) review of our Level-I trauma center registry. We selected all patients who were evaluated for a FRI. We collected patient and center related variables. Our outcomes were the trends of FRI, injury-related characteristics, and mortality. Cochran-Armitage trend analysis was performed.
Results:
A total of 1012 FRI patients were identified. The majority of patients were teenagers (32%) and young adults (30%), and 88% were male. Greater than 80% of patients belonged to the low/low-middle socioeconomic class, and 18.5% completed college. The most common firearm utilized was the handgun (45%). The prevalence of FRI increased significantly (2014:15%; 2019:21%; P< 0.01). The most common injury intention was assault (75%). The median ISS was 17(9-25) with most injuries sustained to the extremities (23%). Also, 25% required emergent operative intervention. There is a significant rise in the number of severely injured patients (ISS≥25) (2014:12.1%, 2019:20%; P< 0.01), self-inflicted injuries (2014:10%, 2019:17%; P < 0.01), unintentional injuries (2014:6%, 2019:12%; P< 0.01), and mortality (2014:11%; 2019:19%; P< 0.01). A high prevalence of substance abuse was noted (73% alcohol, 64% drugs).
Conclusions:
The prevalence of FRI at our center has been rising over the past decade with a shift towards more severe injuries and higher mortality rates. Addressing these alarming changes requires targeted interventions on multiple frontiers.
Firearm injuries are a serious public health problem for children and adolescents in the United States and even more of a problem in some low- and middle-income countries. A number of countries in Central and South America report extremely high rates of firearm death, though data in these countries are less reliable than data from high-income countries. Globally, there were more firearm homicides than firearm suicides among those 0–24 years old in 2016. Among high-income countries, the United States has the highest pediatric firearm death rates. It appears that a main reason for our relatively high firearm death rate is widespread firearm availability. Unfortunately, pediatric firearm injury prevention is still a topic about which little is known, not only for low- and middle-income countries but also for high-income nations. More research is needed on risk and protective factors specific to children and adolescents, and better data are needed especially for nonfatal gun injuries.
School shootings are broadly defined as acts of violence carried out with firearms in which schools are deliberately chosen as the site of violence. Not only do school shootings claim the lives of students and school staff at the time, but they also lead to residual psychological trauma among survivors and global fear in the broader school community. School shootings are a new phenomenon in the past 50–60 years, with increasing frequency in the past two decades. Between 2013 and 2015, there was on average one school shooting per week in the United States. Though school shootings, especially mass school shootings, capture the world’s attention, the majority of firearm deaths in children in the United States are not due to mass school shootings. Despite a paucity of high-quality evidence due to underreporting of school shootings and general underfunding of firearm research, there are documented factors associated with school shootings. These include weaker state-level firearm legislation, increased state-level firearm ownership, recent school shootings contributing to a contagion effect in school shootings, and declines in federal and state funding for education. In contrast, stronger state-level firearm laws, safe firearm storage, and restriction of firearm access for unsupervised minors may reduce firearm-related deaths in schools. Only through comprehensive, multifaceted approaches employing rigorous research and meaningful legislation identifying risk factors and preventive strategies can the rise of school shootings in the US be curbed. Further research on survivors of school shootings is also warranted to identify those at risk for long-term adverse outcomes.
Research on the role of firearms in violence and fatal events has focused heavily on American data and research. This implies certain limitations, since the United States is one of the Western countries with exceptionally high homicide and gun ownership rates. Thus, the American context offers only limited variance in the most prominent independent as well as dependent variables. International comparisons offer challenging new perspectives. This research is based on data on gun availability in private households, collected through the international victimization surveys of 1989, 1992, and 1996, and World Health Organization data on homicide and suicide from 21 countries. It updates and extends former research conducted on this issue, based on the surveys of 1989 and 1992. In addition, data from the International Crime Victimization Surveys were used on total and gun-related robbery and assault (including threats).
The International Crime Victimisation Survey (ICVS) is the most far-reaching programme of fully standardised sample surveys looking at householders' experience of crime in different countries. The first ICVS took place in 1989, the second in 1992, and the third in 1996. Surveys have been carried out in over 50 countries since 1989, including a large number of city surveys in developing countries and countries in transition. This report deals with eleven industrialised countries which took part in the third sweep. The reason for setting up the ICVS was the inadequacy of other measures of crime across country. Figures of offences recorded by the police are problematic due to differences in the way the police define, record and count crime. And since most crimes the police know about are reported by victims, police figures can differ simply because of differences in reporting behaviour. It is also difficult to make comparisons of independently organised crime surveys, as these differ in design and coverage. For the countries covered in this report, interviews were mainly conducted by telephone (with samples selected through variants of random digit dialling). There is no reason to think results are biased because of the telephone mode. Response rates varied but we show that there is no overriding evidence that this affects the count of victimisation. Samples were usually of 1,000 or 2,000 people which means there is a fairly wide sampling error on the ICVS estimates. The surveys cannot, then, give precise estimates of crime in different countries. But they are a unique source of information and give good comparative information The results in this report relate mainly to respondents' experience of crime in 1995, the year prior to the 1996 survey. Those interviewed were asked about crimes they had experienced, whether or not reported to the police. The main results follow.
Suicide and suicidal behaviour are multifaceted events requiring complex solutions. Controlling the environment is a neglected solution, despite strong support for this approach from the World Health Organization (WHO).
To discuss this approach from a global view, this review is written by authors from various cultures: American, Australian, Canadian, Chinese, Cuban, Dutch, Indian, Irish, Japanese, Lithuanian, Native North American, Russian, and South African.
We examine gun control to illustrate the environmental control approach; however, the worldwide diversity of suicide methods calls for diverse responses. Further, controlling the environment encompasses more than restricting the means of suicide, which we illustrate with examples of toned-down media reports and restricted medicine availability.
Controlling the environment may be a viable strategy for preventing suicide, although research shows that few clinicians implement such approaches.
to determine the association between firearm availability and female homicide victimization among high-income countries.
Data were assembled for the most recent available year (1994-1999) from the official reports of the ministries of health for those countries that had more than 2 million inhabitants and were dassified as high income by the World Bank. Twenty-five nations provided sufficient information for the analysis. Rates of female victimization from homicide, firearm homicide, and nonfirearm homicide were compared with a validated proxy for household firearm ownership (the percentage of total national suicides that are committed with firearms). Possible confounding variables included in the analysis were the percentage of the population living in urban areas and income inequality.
The United States is an outlier. It had the highest level of household firearm ownership and the highest female homicide rate. The United States accounted for 32% of the female population in these high-income countries, but for 70% of all female homicides and 84% of all female firearm homicides. Female homicide victimization rates were significantly associated with firearm availability largely because of the United States.
Among high-income countries, where firearms are more available, more women are homicide victims. Women in the United States are at higher risk of homicide victimization than are women in any other high-income country.
Elderly white men are at the highest risk for suicide. Firearms are the most common method of suicide used by both men and women in later life, and a greater proportion of older than younger suicide victims use a gun. This psychological autopsy study aimed to test hypotheses concerning the risk for suicide associated with access to and storage of firearms. Subjects included 86 suicide victims age 50 years of age and over and 86 community control subjects individually matched on age, sex, race, and county of residence. Presence of a firearm in the home was associated with increased risk for suicide, even after controlling for psychiatric illness. Elevated risk was accounted for by access to handguns rather than long guns and was more pronounced in men than women. Among subjects who kept a gun in the home, storing the weapon loaded and unlocked were independent predictors of suicide. Findings support the potential benefit for suicide prevention of restricting access to handguns. Education programs for older persons, their families, and healthcare providers concerning the risks of having a gun in the home and reinforcement of rules for safe storage may contribute to reducing the rate of suicide in older people.
(1) To quantify lethality of firearms relative to other suicide methods, (2) to quantify the extent to which suicide mortality may be reduced by limiting access to firearms.
Data on suicides and hospitalised para-suicides that occurred in the state of Illinois from 1990 to 1997 were combined. Total number of episodes for each suicide method was estimated as the sum of the number of suicides and the number of para-suicides for that method. Gender and suicide method were used as proxies for intention to die, and estimated lethality of suicide methods within method-gender groups (for example, male firearm users). Logistic regression was used to quantify the lethality of firearms relative to other suicide methods. Excess mortality associated with the use of firearms was estimated by conservatively assuming that in the absence of firearms the next most lethal suicide method would be used.
From January 1990 to December 1997, among individuals 10 years or older in the state of Illinois, there were 37,352 hospital admissions for para-suicide and 10,287 completed suicides. Firearms are the most lethal suicide method. Episodes involving firearms are 2.6 times (95% CI 2.1 to 3.1) more lethal than those involving suffocation-the second most lethal suicide method. Preventing access to firearms can reduce the proportion of fatal firearms related suicides by 32% among minors, and 6.5% among adults.
Limiting access to firearms is a potentially effective means of reducing suicide mortality.
Violent behavior among adolescents is a significant problem worldwide, and a cross-national comparison of adolescent violent behaviors can provide information about the development and pattern of physical violence in young adolescents.
To determine and compare frequencies of adolescent violence-related behaviors in 5 countries and to examine associations between violence-related behaviors and potential explanatory characteristics.Design, Setting, and
Cross-sectional, school-based nationally representative survey at ages 11.5, 13.5, and 15.5 years in 5 countries (Ireland, Israel, Portugal, Sweden, and the United States).
Frequency of physical fighting, bullying, weapon carrying, and fighting injuries in relation to other risk behaviors and characteristics in home and school settings.
Fighting frequency among US youth was similar to that of all 5 countries (nonfighters: US, 60.2%; mean frequency of 5 countries, 60.2%), as were the frequencies of weapon carrying (noncarriers: US, 89.6%; mean frequency of 5 countries, 89.6%) and fighting injury (noninjured: US, 84.5%; mean frequency of 5 countries, 84.6%). Bullying frequency varied widely cross-nationally (nonbullies: from 57.0% for Israel to 85.2% for Sweden). Fighting was most highly associated with smoking, drinking, feeling irritable or bad tempered, and having been bullied.
Adolescents in 5 countries behaved similarly in their expression of violence-related behaviors. Occasional fighting and bullying were common, whereas frequent fighting, frequent bullying, any weapon carrying, or any fighting injury were infrequent behaviors. These findings were consistent across countries, with little cross-national variation except for bullying rates. Traditional risk-taking behaviors (smoking and drinking) and being bullied were highly associated with the expression of violence-related behavior.
Household firearms are associated with an elevated risk of firearm death to occupants in the home. Many organizations and health authorities advocate locking firearms and ammunition to prevent access to guns by children and adolescents. The association of these firearm storage practices with the reduction of firearm injury risk is unclear.
To measure the association of specific household firearm storage practices (locking guns, locking ammunition, keeping guns unloaded) and the risk of unintentional and self-inflicted firearm injuries.
Case-control study of firearms in events identified by medical examiner and coroner offices from 37 counties in Washington, Oregon, and Missouri, and 5 trauma centers in Seattle, Spokane, and Tacoma, Wash, and Kansas City, Mo. CASES AND CONTROLS: Case firearms were identified by involvement in an incident in which a child or adolescent younger than 20 years gained access to a firearm and shot himself/herself intentionally or unintentionally or shot another individual unintentionally. Firearm assaults and homicides were excluded. We used records from hospitals and medical examiners to ascertain these incidents. Using random-digit dial telephone sampling, control firearms were identified by identification of eligible households with at least 1 firearm and children living or visiting in the home. Controls were frequency matched by age group and county. MAIN EXPOSURE MEASURES: The key exposures of interest in this study were: (1) whether the subject firearm was stored in a locked location or with an extrinsic lock; (2) whether the firearm was stored unloaded; (3) whether the firearm was stored both unloaded in a locked location; (4) whether the ammunition for the firearm was stored separately; and (5) whether the ammunition was stored in a locked location. Data regarding the storage status of case and control guns were collected by interview with respondents from the households of case and control firearms.
We interviewed 106 respondents with case firearms and 480 with control firearms. Of the shootings associated with the case firearms, 81 were suicide attempts (95% fatal) and 25 were unintentional injuries (52% fatal). After adjustment for potentially confounding variables, guns from case households were less likely to be stored unloaded than control guns (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16-0.56). Similarly, case guns were less likely to be stored locked (OR, 0.27; 95% CI, 0.17-0.45), stored separately from ammunition (OR, 0.45; 95% CI, 0.34-0.93), or to have ammunition that was locked (OR, 0.39; 95% CI, 0.23-0.66) than were control guns. These findings were consistent for both handguns and long guns and were also similar for both suicide attempts and unintentional injuries.
The 4 practices of keeping a gun locked, unloaded, storing ammunition locked, and in a separate location are each associated with a protective effect and suggest a feasible strategy to reduce these types of injuries in homes with children and teenagers where guns are stored.
In 2002, an estimated 877,000 lives were lost worldwide through suicide. Some developed nations have implemented national suicide prevention plans. Although these plans generally propose multiple interventions, their effectiveness is rarely evaluated.
To examine evidence for the effectiveness of specific suicide-preventive interventions and to make recommendations for future prevention programs and research.
Relevant publications were identified via electronic searches of MEDLINE, the Cochrane Library, and PsychINFO databases using multiple search terms related to suicide prevention. Studies, published between 1966 and June 2005, included those that evaluated preventative interventions in major domains; education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide.
Data were extracted on primary outcomes of interest: suicidal behavior (completion, attempt, ideation), intermediary or secondary outcomes (treatment seeking, identification of at-risk individuals, antidepressant prescription/use rates, referrals), or both. Experts from 15 countries reviewed all studies. Included articles were those that reported on completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. We included 3 major types of studies for which the research question was clearly defined: systematic reviews and meta-analyses (n = 10); quantitative studies, either randomized controlled trials (n = 18) or cohort studies (n = 24); and ecological, or population- based studies (n = 41). Heterogeneity of study populations and methodology did not permit formal meta-analysis; thus, a narrative synthesis is presented.
Education of physicians and restricting access to lethal means were found to prevent suicide. Other methods including public education, screening programs, and media education need more testing.
Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.
Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality.
The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature.
Non-conflict related firearm deaths.
Global non-conflict related firearm deaths were estimated to fall between 196,000 and 229,000, adjusted to the year 2000. 162,800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33,200 to 66,200.
This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.
Background
The Forty-Ninth World Health Assembly recenttly declared violence a worldwide public health problem. Improved understand of cross-national differences is useful for identifying risk factors and may facilitate prevention efforts. Few cross-national studies, however, have explored firearm-related deaths. We compared the incidence of firearm-related deaths among 36 countries.
Methods
Health officials in high-income (HI) and upper-middle-income countries (UMI) with populations greater than one million were asked to provide data using ICD-9 codes on firearm-related homicides, suicides, unintentional deaths and deaths of undetermined intent, as well as homicides and suicides for all methods combined. Thirty-six (78%) of the 46 countries provided complete data. We compared age-adjusted rates per 100 000 for each country and pooled rates by income group and geographical location.
Results
During the one-year study period, 88 649 firearm deaths were reported. Overall firearm mortality rates are five to six times higher in HI and UMI countries in the Americas (12.72) than in Europe (2.17), or Oceania (2.57) and 95 times higher than in Asia (0.13). The rate of firearm deaths in the United States (14.24 per 100 000) exceeds that of its economic counterparts (1.76) eightfold and that of UMI countries (9.69) by a factor of 1.5. Suicide and homicide contribute equally to total firearm deaths in the US, but most firearm deaths are suicides (71%) in HI countries and homicides (72%) in UMI countries.
Conclusions
Firearm death rates vary markedly throughout th industrialized world. Further research to identify risk factors associated with these variations may help improve prevention efforts.
Organized suicide prevention efforts usually have been linked to clinical models that use either individual or small group approaches. This paper explores the use of a public health/public model to prevent suicide. Various methods of suicide are analyzed using the concepts of availability and lethality to illustrate means by which they might be modified through the public health/public policy approach of community action and legislative change.
Comparison of national crime surveys must be made very cautiously because of differences in sampling, methodology and content. In this report methodological differences between the United States' National Crime Survey and victimization surveys of other countries are examined and survey estimates of victimization are adjusted. It is found that U.S. rates of assault/threat, robbery, and burglary are not extraordinarily higher than those of other eleven other countries or regions. However, U.S. levels of gun use are much higher and U.S. levels of both gun and non-gun lethal violence (using Killias, 1990) far exceed those of other industrialized societies.
Suicide attempts often are impulsive, yet little is known about the characteristics of impulsive suicide. We examined impulsive suicide attempts within a population-based, case-control study of nearly lethal suicide attempts among people 13–34 years of age. Attempts were considered impulsive if the respondent reported spending less than 5 minutes between the decision to attempt suicide and the actual attempt. Among the 153 case-subjects, 24% attempted impulsively. Impulsive attempts were more likely among those who had been in a physical fight and less likely among those who were depressed. Relative to control subjects, male sex, fighting, and hopelessness distinguished impulsive cases but depression did not. Our findings suggest that inadequate control of aggressive impulses might be a greater indicator of risk for impulsive suicide attempts than depression.
The evidence linking firearms in the home to risk for suicide is reviewed. These data come from epidemiological, case-control, quasiexperimental, and prospective studies. The convergent finding from this wide range of studies is that there is a strong relationship between firearms in the home and risk for suicide, most firmly established in the United States.
Suicide rates are affected by many factors—psychiatric, biological, familial and situational. This paper focuses on one potential risk factor for completed suicide in the United States—the availability of firearms. Whether the availability of firearms might increase the rate of attempted suicide is not examined. This article is not an exhaustive review of every existing firearm-related suicide study. Rather, it provides a detailed review of the most commonly cited, representative, and thorough empirical studies in the published peer-reviewed literature relating firearms and suicide, focusing largely on the United States. The empirical studies reviewed are grouped according to whether the unit of analysis is the individual (e.g., case-control studies) or a population (e.g., ecological studies) and further divided depending on whether the analysis uses cross-sectional or time-series (longitudinal) data. We begin with a very brief overview of the suicide problem in the United States.
This article reviews the most commonly cited, representative, empirical studies in the peer-reviewed literature that directly investigate the association of gun availability and homicide victimization. Individual-level studies (n=4) are reviewed that investigate the risks and benefits of owning a personal or household firearm. The research suggests that households with firearms are at higher risk for homicide, and there is no net beneficial effect of firearm ownership. No longitudinal cohort study seems to have investigated the association between a gun in the home and homicide. Two groups of ecological studies are reviewed, those comparing multiple countries and those focused solely on the United States. Results from the cross-sectional international studies (n=7) typically show that in high-income countries with more firearms, both men and women are at higher risk for homicide, particularly firearm homicide. Time series (n=10) and cross-sectional studies (n=9) of U.S. cities, states, and regions and for the United States as a whole, generally find a statistically significant gun prevalence–homicide association. None of the studies prove causation, but the available evidence is consistent with the hypothesis that increased gun prevalence increases the homicide rate.
"In this small book David Hemenway has produced a masterwork. He has dissected the various aspects of the gun violence epidemic in the United States into its component parts and considered them separately. He has produced a scientifically based analysis of the data and indeed the microdata of the over 30,000 deaths and 75,000 injuries which occur each year. Consideration and adoption of the policy lessons he recommends would strengthen the Constitutional protections that all of our citizens have to life, liberty, and the pursuit of happiness." -Richard F. Corlin, Past President, American Medical Association "This lucid and penetrating study is essential reading for anyone who wishes to understand the tragedy of gun violence in America and-even more important-what we can do to stop it. David Hemenway cuts through the cant and rhetoric in a way that no fair-minded person can dismiss, and no sane society can afford to ignore." -Richard North Patterson, novelist "The rate of gun-related homicide, suicide, and accidental injury has reached epidemic proportions in American society. Diagnosing and treating the gun violence epidemic demands the development of public health solutions in conjunction with legislative and law enforcement strategies." -Kweisi Mfume, President and CEO of NAACP "In scholarly, sober analytic assessments, including rigorous critiques of NRA-popularized pseudoscience, David Hemenway constructs a convincing case that firearm availability is a critical and proximal cause of unparalleled carnage. By formulating such violence as a public health issue, he proposes workable policies analogous to ones that reduced injuries from tobacco, alcohol, and automobiles." -Jerome P. Kassirer, Editor-in-Chief Emeritus, New England Journal of Medicine, and Distinguished Professor, Tufts University School of Medicine "As a former District Attorney and Attorney General, I know the urgency of providing safe homes, schools and neighborhoods for all. This remarkable tour-de-force is a powerful study of one promising solution: a data-rich, eminently readable demonstration of why we should treat gun violence as an American epidemic." -Scott Harshbarger, Former Attorney General of Massachusetts, President and CEO of Common Cause On an average day in the United States, guns are used to kill almost eighty people, and to wound nearly three hundred more. If any other consumer product had this sort of disastrous effect, the public outcry would be deafening; yet when it comes to guns such facts are accepted as a natural consequence of supposedly high American rates of violence. Private Guns, Public Health explodes that myth and many more, revealing the advantages of treating gun violence as a consumer safety and public health problem. David Hemenway fair-mindedly and authoritatively demonstrates how a public-health approach-which emphasizes prevention over punishment, and which has been so successful in reducing the rates of injury and death from infectious disease, car accidents, and tobacco consumption-can be applied to gun violence. Hemenway uncovers the complex connections between guns and self-defense, gun violence and schools, gun prevalence and homicide, and more. Finally, he outlines a policy course that would significantly reduce gun-related injury and death. With its bold new public-health approach to guns, Private Guns, Public Health marks a shift in our understanding of guns that will-finally-point us toward a solution.
It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period.
For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods.
During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5).
Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.
The purpose of this study was to determine whether purchase of a handgun from a licensed dealer is associated with the risk of homicide or suicide and whether any association varies in relation to time since purchase.
A case-control study was done among the members of a large health maintenance organization. Case subjects were the 353 suicide victims and 117 homicide victims among the members from 1980 through 1992. Five control subjects were matched to each case subject on age, sex, and zip code of residence. Handgun purchase information was obtained from the Department of Licensing.
The adjusted relative risk of suicide was 1.9 (95% confidence interval [CI] = 1.4, 2.5) for persons with a history of family handgun purchase from a registered dealer. The adjusted relative risk for homicide, given a history of family handgun purchase, was 2.2 (95% CI = 1.3, 3.7). For both suicide and homicide, the elevated relative risks persisted for more than 5 years after the purchase.
Legal purchase of a handgun appears to be associated with a long-lasting increased risk of violent death.
The Forty-Ninth World Health Assembly recently declared violence a worldwide public health problem. Improved understanding of cross-national differences is useful for identifying risk factors and may facilitate prevention efforts. Few cross-national studies, however, have explored firearm-related deaths. We compared the incidence of firearm-related deaths among 36 countries.
Health officials in high-income (HI) and upper-middle-income countries (UMI) with populations greater than one million were asked to provide data using ICD-9 codes on firearm-related homicides, suicides, unintentional deaths and deaths of undetermined intent, as well as homicides and suicides for all methods combined. Thirty-six (78%) of the 46 countries provided complete data. We compared age-adjusted rates per 100,000 for each country and pooled rates by income group and geographical location.
During the one-year study period, 88,649 firearm deaths were reported. Overall firearm mortality rates are five to six times higher in HI and UMI countries in the Americas (12.72) than in Europe (2.17), or Oceania (2.57) and 95 times higher than in Asia (0.13). The rate of firearm deaths in the United States (14.24 per 100,000) exceeds that of its economic counterparts (1.76) eightfold and that of UMI countries (9.69) by a factor of 1.5. Suicide and homicide contribute equally to total firearm deaths in the US, but most firearm deaths are suicides (71%) in HI countries and homicides (72%) in UMI countries.
Firearm death rates vary markedly throughout the industrialized world. Further research to identify risk factors associated with these variations may help improve prevention efforts.
The evidence linking firearms in the home to risk for suicide is reviewed. These data come from epidemiological, case-control, quasiexperimental, and prospective studies. The convergent finding from this wide range of studies is that there is a strong relationship between firearms in the home and risk for suicide, most firmly established in the United States.
Causes and correlations of lethal violence in America: American homicide exceptionalism.
- Polsby
Polsby DD, Kates DB Jr. Causes and correlations of lethal violence in
America: American homicide exceptionalism. U Colo L Rev. 1998;69:
969 -1008.
A cross-national study of violence-related behaviors in adolescents Block R. A cross-national comparison of victims of crime: victim surveys of twelve countries
- E Smith-Khuri
- R Iachan
- Scheidt
- Pc
Smith-Khuri E, Iachan R, Scheidt PC, et al. A cross-national study of violence-related behaviors in adolescents. Arch Pediatr Adolesc Med. 2004;158:539 –544. 6. Block R. A cross-national comparison of victims of crime: victim surveys of twelve countries. Int Rev Victimol. 1993;2:183–207.
National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) Available at: www.cdc.gov/ncipc
Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: www.cdc.gov/ncipc/wisqars.
Accessed August 2009.
Rates of homicide, suicide, and firearm-related death among children: twenty-six industrialized countries
Centers for Disease Control and Prevention (CDC). Rates of homicide,
suicide, and firearm-related death among children: twenty-six industrialized countries. MMWR Morb Mort Wkly Rep. 1997;46:101-105.
World prison population list, eighth edition International Centre for Prison Studies, Kings College London Available at
- R Walmsley
Walmsley R. World prison population list, eighth edition. International
Centre for Prison Studies, Kings College London. 2009. Available at:
http://www.kcl.ac.uk/depsta/law/research/icps/downloads/wppl-8th_41.pdf.
International Centre for Prison Studies
- R Walmsley
Walmsley R. World prison population list, eighth edition. International
Centre for Prison Studies, Kings College London. 2009. Available at:
http://www.kcl.ac.uk/depsta/law/research/icps/downloads/wppl-8th_41.pdf.
Accessed October 3, 2009.