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Objective: To assess whether there are differences in support for handgun purchaser licensing., Methods: We used data from four waves of online, national polling on gun policy. To estimate differences in support for licensing across groups, we categorised respondents by whether they personally owned a gun, lived in a state with handgun purchaser licensing or lived in a state regulating private sales without a licensing system., Results: Eighty-four per cent of adults living in states with licensing supported the policy compared with 74% in states without the law (p<0.001). Seventy-seven per cent of gun owners living in states with licensing supported the policy vs 59% of gun owners in states without licensing (p<0.001)., Conclusions: Support for licensing among gun owners living in states with these laws, many of whom have presumably gone through the process, was much higher than gun owners in states without such laws., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

This paper outlines a novel application of the social ecological model (SEM) for firearm suicide prevention. It focuses on four levels of intervention (societal, relationship, community and individual) to reduce access to firearms, a practical contributor to the capacity to attempt suicide, from individuals when they are at an elevated risk for suicide. There is substantive research linking easy access to firearms with an increased risk of firearm suicide, and suicide prevention interventions that address access to lethal means are critical components of a comprehensive suicide prevention strategy. Potential interventions using the SEM framework include: at the policy level-extreme risk laws, voluntary self-prohibition policies and policies that reduce the availability of firearms; at the community level-gun shop projects; at the relationship level-lethal means safety counselling; and at the individual level-safer storage. Taken together with upstream interventions, such as increased access to mental health services and substance use treatment, a multilevel approach for suicide prevention that addresses access to firearms can save lives., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objective: This project links population data to the Wisconsin Violent Death Reporting System (WVDRS) to determine the extent to which firearm possession criteria are being followed as well as the potential impact of the adoption of proposed possession criteria., Design and Study Population: Criminal justice data for WVDRS homicide suspects and victims and suicide decedents 2008-2011 and a sample of matched control group of driver's license holders (to characterise the state population) will be abstracted., Methods: Individual legal possession statuses (prohibited/not prohibited) under each current and expanded criterion will be determined. Proportions of interest will be calculated from two-way contingency tables, and tests between groups with categorical variables (eg, criterion is met or not) will be performed with Fisher's exact or binomial proportion tests. Tests between groups with continuous variables (eg, number of misdemeanours) will be performed by zero inflated negative binomial regression. Area under the receiver operating characteristic curve will be used to quantify the prediction accuracy of specific univariate or multivariate logistic model for prediction. Inverse probability weighting will be used for analyses that extend from matched controls to the general state population of license holders., Discussion: Linked data sets and partnerships are challenging, but necessary for comprehensive public health research. Results of this study will contribute knowledge on the proportion of prohibited suspects and suicide decedents that used firearms in violent deaths and, if applying expanded criteria would have increased prohibited persons. This study will also investigate risk and protective factors for being a victim of homicide., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

The effectiveness of laws depends on circumstances affecting their enforcement. To assess such circumstances for comprehensive background check (CBC) and straw purchase laws for firearm sales, we examined prosecutions for CBC and straw purchase violations in Pennsylvania and CBC violations in Maryland. We generated pre-post variables and conducted t-tests to assess differences in the mean number of prosecutions filed following changes to the legal environments. The annual number of prosecutions for straw purchase violations increased significantly in Pennsylvania following the passage of a law that strengthened penalties for these violations (difference in means = +1310.86, P=0.003). The annual number of prosecutions for CBC violations decreased significantly in Maryland following a court decision that narrowed the definition of a firearm transfer making enforcement more difficult (difference in means = -20.52, P=0.026). Our findings suggest enforcement is likely influenced by the penalties associated with violating these laws and the interpretation of the language of the laws., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Firearm safety instructors and public health professionals are natural allies in the quest to prevent firearm injuries. We audited basic firearm classes to provide information that can help familiarise public health professionals and others with the content covered., Methods: With the advice of expert instructors, we created an audit form. Volunteers audited 20 basic firearm classes in seven north-eastern states., Results: All trainers covered a wide variety of safety issues. Some specific basics were covered in 90+% of the classes, including how to safely load/unload a gun, keeping your finger off the trigger until ready to shoot, and being aware of your target and what is behind it. In 50%-75% of the classes, the trainer covered topics such as operating a safety, clearing jams and cartridge malfunctions, and recommended storing guns unloaded and locked when not in use. Few instructors covered firearm suicide prevention (10%) or domestic violence (10%). Most encouraged gun ownership, gun carrying, gun use in self-defence and membership in a gun rights group., Discussion: From a public health standpoint, we would like to see more instructors covering topics such as firearm suicide and alternatives to gun use in self-defence, and to recommend safer storage of firearms., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Gun violence has increased in Mexico since the mid-2000s, but little is known about patterns of gun ownership. We examine the size and composition of the privately held urban firearm stock in Mexico, motivations for ownership, and attitudes about gun laws. To this end, a household telephone survey of 1361 adults living in nine Mexican cities was conducted in the summer of 2017. We find that few urban Mexican households contain guns. Most of those who report ownership possess one gun, having purchased it recently for self-defense. Few urban Mexican citizens plan to purchase a gun in the future. Respondents are more likely to believe that crime in Mexico would increase if guns were allowed in more places (ie, workplaces and motor vehicles). Evidence suggests urban Mexico has relative low rates of firearm ownership. Few city dwellers plan on obtaining a firearm in the near future., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Comprehensive background check (CBC) policies are hypothesised to reduce firearm-related violence because they extend background checks to private party firearm sales, but no study has determined whether these policies actually increase background checks, an expected intermediary outcome. We evaluate the association between CBC policies and the rates of firearm background checks in three states that recently implemented these policies: Delaware (July 2013), Colorado (July 2013) and Washington (December 2014)., Methods: We used the synthetic control group method to estimate the difference from estimated counterfactual postintervention trends in the monthly rate of background checks per 1 00 000 people for handguns, long guns and both types combined, using data for January 1999 through December 2016. Inference was based on results from permutation tests. We conducted multiple sensitivity analyses to assess the robustness of our results., Results: Background check rates increased in Delaware, by 22%-34% depending on the type of firearm, following enactment of its CBC law. No overall changes were observed in Washington and Colorado. Our results were robust to changes in the comparison group and statistical methods., Conclusions: The enactment of CBC policies was associated with an overall increase in firearm background checks only in Delaware. Data external to the study suggest that Washington experienced a modest, but consistent, increase in background checks for private party sales, and Colorado experienced a similar increase in checks for sales not at gun shows. Non-compliance may explain the lack of an overall increase in background checks in Washington and Colorado., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: One way that guns get into the wrong hands is via gun sales without a background check. While the large majority of Americans support laws requiring universal background checks, no prior study has assessed whether Americans think it is acceptable behaviour to sell a gun to a stranger without a background check, whether or not there is a law against it., Methods: We sponsored a nationally representative survey of over 3900 American adults, oversampling gun owners, using an online panel provided by the survey firm Growth for Knowledge., Results: Over 72% of American adults agree or strongly agree with the statement that 'whether it is legal or not, it is NOT acceptable to sell a gun to a stranger without a background check' and 11% disagree or strongly disagree. Subgroups less likely to agree are young adults, men, conservatives, those with less than a high school education and gun owners., Conclusion: Reducing the number of guns sold without a background check could help reduce the flow of guns to felons. Changes in normative attitudes and behaviours, as well as changes in law, could help accomplish this goal. Most Americans, including gun owners, believe selling a gun to a stranger without a background check is not acceptable behaviour., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Firearm violence frequently involves alcohol, but there are no studies of misuse of alcohol and risk for future violence among firearm owners. We examined the association between prior convictions for alcohol-related crimes, chiefly driving under the influence (DUI), and risk of subsequent arrest among 4066 individuals who purchased handguns in California in 1977. During follow-up through 1991, 32.8% of those with prior alcohol-related convictions and 5.7% of those with no prior criminal history were arrested for a violent or firearm-related crime; 15.9% and 2.7%, respectively, were arrested for murder, rape, robbery or aggravated assault. Prior alcohol-related convictions were associated with a fourfold to fivefold increase in risk of incident arrest for a violent or firearm-related crime, a relative increase greater than that seen for age, sex or prior violence. Prior convictions for alcohol-related crime may be an important predictor of risk for future criminal activity among purchasers of firearms., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Data on the factors associated with school shootings in the USA are limited. The public conversation has often suggested several factors that may be linked to these events, however with little empirical support. Aiming to fill this gap, we describe the characteristics of school shooting incidents in the USA between 2013 and 2015 and explore whether four factors that represent domains of firearm policy, educational policy and epidemiological risk factors for intentional firearm injuries-background check (BC) policies, per capita mental health expenditures (MHE), K-12 education expenditure (KEE) and urbanicity-were associated with school shootings during this period., Methods: We searched LexisNexis, a newspaper and broadcast media databases for school shooting incidents from 1 January 2013 to 31 December 2015. Presence of BC laws was extracted from legal information in LexisNexis. State-level covariates of per capita MHE (2013), KEE (2013) and urbanicity (2010) rates were obtained from publicly available data sources. We used negative binomial regression models accounting for clustering by state to explore unadjusted associations between the BC laws, state-level covariates and school shootings to report IRR and 95% CI., Results: We documented 154 school shootings (35, 55 and 64 each year). In unadjusted models, BC for firearm purchase (IRR=0.55, 95% CI 0.39 to 0.76), ammunition purchase (IRR=0.11, 95% CI 0.05 to 0.27), log per capita MHE (IRR=0.58, 95% CI 0.37 to 0.90), log per-capita KEE (IRR=0.09, 9% CI 0.02 to 0.29) and urbanicity (IRR=0.97, 95% CI 0.96 to 0.99) were associated with school shooting., Conclusions: School shootings are less likely in states with BC laws, higher MHE and KEE, and with greater per cent urban population., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Objective: Too little is known about the effectiveness of efforts to prevent firearm violence. Our objective is to evaluate California's Armed and Prohibited Persons System (APPS), a law enforcement intervention that seeks to recover firearms from individuals who purchased them legally but subsequently became prohibited from having access to firearms. Prohibitions usually arise from events suggesting an increased risk for future violence., Design and Study Population: This group-randomised trial involves approximately 20 000 APPS-eligible individuals in 1041 communities. Randomisation was performed at the community level, to early or later intervention (Group 1 and Group 2, respectively) with stratification by region, population and violent crime rate., Methods: APPS is being implemented by the California Department of Justice. The principal outcome measure is the incidence of arrest for a firearm-related or violent crime. Primary analysis will be on an intention-to-treat basis, comparing individuals in Group 1 and Group 2 communities. Analyses will focus on time to event, using proportional hazards regression with adjustment for the clustered nature of the data and incorporating individual- and community-level characteristics. Secondary analyses will examine the effect of the intervention on an as treated basis, effects on subgroups, and effects on community-wide measures such as crime rates., Discussion: APPS may have a significant impact on risk for future violence among members of its target population. The findings of this study will likely be generalisable and have clear implications for violence prevention policy and practice., Trial Registration Number: NCT02318732., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: California has strict firearm-related laws and is exceptional in its regulation of firearms retailers. Though evidence suggests that these laws can reduce illegal access to guns, high levels of gun violence persist in Los Angeles (LA), California. This research seeks to describe the sources of guns accessed by active offenders in LA, California and reports offenders' motivations for obtaining guns., Setting: Los Angeles County Jail (LACJ) system (four facilities)., Methods: Random sampling from a screened pool of eligible participants was used to conduct qualitative semistructured interviews with 140 incarcerated gun offenders in one of four (LACJ) facilities. Researchers collected data on firearm acquisition, experiences related to gun violence, and other topics, using a validated survey instrument. Grounded theory guided the collection and analysis of data., Results: Respondents reported possession of 77 specific guns (79.2% handguns) collectively. Social networks facilitate access to illegal guns; the majority of interviewees acquired their illegal guns through a social connection (85.7%) versus an outside broker/unregulated retailer (8.5%). Most guns were obtained through illegal purchase (n=51) or gift (n=15). A quarter of gun purchasers report engaging in a passive transaction, or one initiated by another party. Passive gun buyers were motivated by concerns for personal safety and/or economic opportunity., Conclusions: In LA's illegal gun market, where existing social relationships facilitate access to guns across a diffuse network, individuals, influenced by both fear and economic opportunity, have frequent opportunities to illegally possess firearms through passive transactions. Gun policies should better target and minimise these transactions., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Preventing dog bites is an intractable problem given the complex dog bite injury environment. Desexing of dogs has the opportunity of creating a safer injury environment, given the potential links between desexing and behaviour change in dogs., Methods: A systematic review of the literature was conducted to examine the evidence for desexing of dogs to reduce dog bite risk within a population health paradigm. Medline and CAB Abstracts were searched for studies that reported data on the association of dog neuter status with the risk of dog bite. All definitions of dog bite were included and all empirical studies were included in the review, limited to those published in English. Quality appraisal and data extraction were based on the 2013 evidence-based practice and critical appraisal tool from the University of Auckland., Results: Five out of six observational studies, from four study populations found evidence that intact dogs were associated with an increased risk of dog bite compared with desexed dogs. The effect sizes ranged across the studies and given the heterogeneity of the studies no single effect size on the association between desexing and dog bite risk could be estimated., Conclusions: There is consistent evidence that desexing dogs is associated with a reduced risk of dog bite, although the studies reflect association and may not be causal. Although recent publications have suggested desexing is associated with health and behavioural costs in some breeds, population level evidence supports desexed dogs having a longer lifespan, and being less likely to wander with the added benefit of reducing unwanted litters. Thus, mandatory desexing presents a possible opportunity for prevention of dog bites expanding dog bite prevention beyond an education-only approach., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Objective: Alcohol abuse is common in the USA and is a well-established risk factor for violence. Other drug use and criminal activity are risk factors as well and frequently occur together with alcohol abuse. Firearm ownership is also common; there are >50 million firearm owners in the USA. This study assesses the relationships between alcohol and drug abuse and future violence among firearm owners, which no prior research has done., Design and Study Population: This records-based retrospective cohort study will involve all persons who legally purchased handguns in California in 2001-approximately 116 000 individuals-with follow-up through the end of 2013., Methods: The principal exposures include prior convictions for alcohol-related and drug-related offenses. The primary outcome measure is an arrest following handgun purchase for a violent Crime Index offense: homicide, rape, robbery or aggravated assault. Subjects will be considered at risk for outcome events for only as long as their residence in California can be established independently of outcome events. Covariates include individual characteristics (eg, age, sex, criminal history, firearm purchase history) and community characteristics (eg, demographics, socioeconomic measures, firearm ownership and alcohol outlet density). We will employ survival analytic methods, expressing effects as HRs., Discussion: The results of this large-scale study are likely to be generalisable and to have important implications for violence prevention policies and programmes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To evaluate the impact of state-level policy changes on assaults on law enforcement officers (LEOs) in the USA., Methods: Pooled time series and cross-sections with negative binomial regression were used to estimate the impact of state-level changes of right-to-carry (RTC), three-strikes and permit-to-purchase (PTP) handgun laws on fatal and non-fatal assaults of LEOs. LEO assaults were stratified by weapon type (all methods, handgun and non-handgun) and whether or not the assault was fatal. Data were collected from the Federal Bureau of Investigation's Law Enforcement Officers Killed and Assaulted database and analysed for the period 1984-2013 for fatal assaults and 1998-2013 for non-fatal assaults., Results: RTC laws showed no association with fatal (p>0.4) or non-fatal (p>0.15) assaults on LEOs. Three-strikes laws were associated with a 33% increase in the risk of fatal assaults on LEOs. Connecticut's PTP law was not associated with fatal (p>0.16) or non-fatal (p>0.13) assaults. Missouri's repeal of its PTP legislation was marginally associated with a twofold increased risk of non-fatal handgun assaults (p=0.089)., Conclusions: This research indicates that three-strikes laws increase the risk of fatal assaults. RTC laws are not associated with increased risk of assault. Missouri's PTP repeal may increase the risk of non-fatal handgun assaults., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Despite state-owned tobacco companies (SOTCs) accounting for over 40% of global production, the significance of state-ownership for tobacco control strategies has received limited academic and policy attention. The complex interests associated with SOTCs present diverse challenges for tobacco control policy, particularly in implementing Article 5.3 of WHO's Framework Convention on Tobacco Control (FCTC). Based on a review of existing literature, this paper examines current challenges and potential opportunities presented by governmental participation in the tobacco industry, identifying three contrasting perspectives from academic and policy sources. The first two perspectives centre on recognising that economic interests inherent in an SOTC are in tension with a government's public health responsibilities. This conflict can be perceived as either fundamental and fixed ('intrinsic conflict') or as amenable to either exacerbation or amelioration via organisational mechanisms ('institutionally-mediated conflict')-as suggested by the contrasting examples of China and Thailand. A third, less prominent perspective (which we refer to as 'interest alignment') suggests that it may be possible to radically alter the objectives and behaviour of SOTCs in order to advance tobacco control. Finally, we draw on this analysis to consider policy options for advancing tobacco control in countries with SOTCs. Guidance on implementation of Article 5.3 demonstrates strategic ambiguity by including elements of all three perspectives described above. We argue that legislative separation of tobacco control from SOTC oversight provides a desirable alternative to industry privatisation, and that radically realigning the goals of SOTCs to reduce tobacco consumption could make an important contribution to endgame strategies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Determining the relationship between gun ownership levels and firearm homicide rates is critical to inform public health policy. Previous research has shown that state-level gun ownership, as measured by a widely used proxy, is positively associated with firearm homicide rates. A newly developed proxy measure that incorporates the hunting license rate in addition to the proportion of firearm suicides correlates more highly with state-level gun ownership. To corroborate previous research, we used this new proxy to estimate the association of state-level gun ownership with total, firearm, and non-firearm homicides. Using state-specific data for the years 1981-2010, we modelled these rates as a function of gun ownership level, controlling for potential confounding factors. We used a negative binomial regression model and accounted for clustering of observations among states. We found that state-level gun ownership as measured by the new proxy, is significantly associated with firearm and total homicides but not with non-firearm homicides., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Since many states are considering gun control laws, researchers need reliable data on rates of gun ownership at the state level. Survey measures of gun ownership in all 50 states, however, are only available for 3 years, and no state-level data have been collected since 2004. Consequently, the National Research Council has declared the development of a valid proxy that can be constructed from accessible, annual, state-level data to be a priority. While such a proxy does exist (the proportion of suicides in a state committed using a gun (FS/S), its correlation with state estimates of gun ownership in recent years is only 0.80. Using state-level data for the years 2001, 2002 and 2004, we developed an improved proxy for state-level gun ownership that uses FS/S (firearm suicides divided by all suicides) and also the per capita number of hunting licenses. We validated this measure using data from surveys of gun ownership conducted in 48 states during 1996 and 1999, and in 21 states during 1995-1998. Adding per capita hunting licenses to the proxy increased its correlation with survey-measured gun ownership from 0.80 to 0.95. The correlations of the new proxy with gun ownership in the two validation studies were 0.95 and 0.97. We conclude that the combination of FS/S and per capita hunting licenses improves substantially upon FS/S alone. This new proxy is easily computed from data that are available annually by state and may be useful for investigating the effect of gun prevalence on firearm-related morbidity and mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Gun possession by high-risk individuals presents a serious threat to public safety. U.S. federal law establishes minimum criteria for legal purchase and possession of firearms; many states have laws disqualifying additional categories for illegal possession., Methods: We used data from a national survey of state prison inmates to calculate: 1) the proportion of offenders, incarcerated for crimes committed with firearms in 13 states with the least restrictive firearm purchase and possession laws, who would have been prohibited if their states had stricter gun laws; and 2) the source of gun acquisition for offenders who were and were not legally permitted to purchase and possess firearms., Results: Nearly three of ten gun offenders (73 of 253 or 28.9%) were legal gun possessors but would have been prohibited from purchasing or possessing firearms when committing their most recent offense if their states had stricter prohibitions. Offenders who were already prohibited under current law acquired their gun from a licensed dealer, where a background check is required, five times less often than offenders who were not prohibited (3.9% vs. 19.9%; χ(2)=13.31; p≤0.001). Nearly all (96.1%) offenders who were legally prohibited, acquired their gun from a supplier not required to conduct a background check., Conclusions: Stricter gun ownership laws would have made firearm possession illegal for many state prison inmates who used a gun to commit a crime. Requiring all gun sales to be subject to a background check would make it more difficult for these offenders to obtain guns.