Search

Background: In recent years, the United States (US) has witnessed a rise in political violence. Prior research has found that an individual's social network is associated with their likelihood of engaging in various forms of violence, but research on social networks and political violence in the US context is limited. This study examined associations between social network size and endorsement of political violence in a recent nationally representative survey and explored how the relationship varied by use of social media as a major news source, perceptions of the government as an enemy, and membership in a marginalized or privileged racial or ethnic group., Methods: This was a nationally representative cross-sectional survey study of adults aged 18 and older in the US, administered from May 13-June 2, 2022. The exposure was social network size, defined by the number of strong social connections. We examined three violence-related outcomes: support for non-political violence, support for political violence, and personal willingness to engage in political violence. We estimated prevalence ratios for associations using survey-weighted Poisson regression with robust standard errors, adjusting for hypothesized confounders and including interaction terms to examine effect measure modification., Results: The sample included 8,620 respondents. Median age was 48.4 years (95% CI = 47.9-48.8), 51.5% were female (95% CI = 50.4-52.7%), and 62.7% self-identified as non-Hispanic White (95% CI = 61.4-65.9%). In adjusted models, those with zero strong connections were more likely than those with 1-4 strong social connections to consider political violence usually/always justified in general (PR = 2.43, 95% CI = 1.47-4.01). Those with 50 + strong connections were more likely than those with 1-4 strong social connections to consider political violence usually/always justified in at least one situation (PR = 1.19, 95% CI = 1.03-1.37) and were more likely to report being willing to personally use political violence (PR = 1.52, 95% CI = 1.13-2.04). Associations varied somewhat by social media use, perceptions of the government as an enemy, and racialized identity., Conclusions: Individuals who reported very few and very many strong social connections were more likely than others to support political violence or be personally willing to engage in it in one form or another. Findings point toward potential intervention and prevention opportunities., (© 2024. The Author(s).)

Importance: Rural adolescents are at high risk for firearm-related injury, yet most existing prevention efforts are informed by research conducted in urban areas. Despite the need to account for rural perspectives, few studies have investigated the unique social ecological context of firearms for rural adolescents or have directly engaged with rural adolescents to understand their views on firearm use., Objective: To describe rural adolescents' firearm behaviors and perceptions of firearm-related social norms within their communities, peer groups, and families., Design, Setting, and Participants: This cross-sectional study used a convergent mixed-methods design and involved a community-based participatory research approach. Participants comprised 93 adolescents residing in rural Washington state and enrolled in a county or tribal reservation 4-H youth development program as an intermediate or senior age-level grouping (ie, aged 12-19 years). Adolescents completed a survey and participated in a semistructured focus group or interview between September 1, 2021, and September 30, 2022. Data were analyzed using descriptive and thematic analysis., Main Outcomes and Measures: Individual handgun behavior and peer, family, and community perceptions of firearm-related social norms., Results: The sample included 93 adolescents (mean [SD] age, 15.7 [1.7] years; 49 female participants [52.7%]). Approximately half of participants (52 [55.9%]) had carried a handgun at some point in their lives, with a mean (SD) age at first carry of 10.9 (3.1) years. Primary themes across quantitative and qualitative data focused on social norms (specifically, acceptable and unacceptable ways to engage with firearms, reasons for carrying firearms, and places to carry a firearm)., Conclusions and Relevance: In this cross-sectional study, rural adolescents in 4-H programs generally understood acceptable and unacceptable firearm carrying behaviors, which aligned with state laws. Findings provide context for rural adolescent behaviors such as carrying a firearm predominantly for prosocial reasons (hunting, recreation, and sport) and adult behavior such as carrying for protection of person and personal property. Understanding firearm-related social norms in rural communities holds implications for firearm injury prevention efforts, especially related to enhancing training, developing norms-based prevention approaches, and tailoring efforts to rural settings.

Objective: Firearm violence constitutes a public health crisis in the United States, but comprehensive data infrastructure is lacking to study this problem. To address this challenge, we used natural language processing (NLP) to classify court record documents from alleged violent crimes as firearm-related or non-firearm-related., Materials and Methods: We accessed and digitized court records from the state of Washington (n = 1472). Human review established a gold standard label for firearm involvement (yes/no). We developed a key term search and trained supervised machine learning classifiers for this labeling task. Results were evaluated in a held-out test set., Results: The decision tree performed best (F1 score: 0.82). The key term list had perfect recall (1.0) and a modest F1 score (0.65)., Discussion and Conclusion: This case report highlights the accuracy, feasibility, and potential time-saved by using NLP to identify firearm involvement in alleged violent crimes based on digitized narratives from court documents., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

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

Background: Firearm purchasing records offer a potentially important administrative data source to identify individuals at elevated risk of perpetrating firearm violence. In this study, we describe individual, firearm, and transaction characteristics of purchasers in California who were arrested for a firearm-related violent crime (FRV) as compared to the general population of registered purchasers in the state., Methods: Relying on a dataset of all individuals with transaction records in California (1996-2021), linked to criminal records (1980-2021), we enrolled a cohort of individuals for whom we could capture the legal firearm purchase history. We identified those arrested for FRV post purchase, and using incidence density sampling, gender-matched cases to ten purchasers (controls) who remained "at risk" at the time the case was arrested. We focused on the purchase closest in time prior to the arrest ("index" purchase). We implemented conditional logistic regression and included models with controls for individual- and community-level demographics, as well as interactions between firearm and purchasing characteristics and criminal history., Results: The cohort included 1,212,144 individuals, of whom 6153 were arrested for FRV (0.5%). Cases were matched to 61,530 controls to form the study sample. The largest risk factor was a prior criminal history: purchasers had 5.84 times the risk of FRV if they had a prior arrest within three years of the index purchase (CI 5.44-6.27). Several transaction and firearm characteristics were also associated with FRV. For example, risk increased if the firearm was redeemed at a pawn shop (aIRR: 1.37, CI 1.05-1.77) and decreased if the transaction was a registered private party transfer (vs. retail purchase) (aIRR: 0.83, CI 0.76-0.90) or the firearm was a bolt action firearm (vs. semi-automatic) (aIRR: 0.64, CI 0.51-0.79). In the interaction models, most of the purchase and firearm features only remained significant among those with no criminal history., Conclusions: Given limited data on firearm transactions, there has been little research on whether the type of firearm an individual purchases or the nature of the purchase might serve as indicators of risk for FRV. We found several transaction and firearm features were associated with risk of FRV. Notably, these features provided little evidence of additional risk for those with a prior criminal record., (© 2024. The Author(s).)

More than half of suicide deaths in the United States result from self-inflicted firearm injuries. Extreme risk protection order (ERPO) laws in 21 states and the District of Columbia temporarily limit access to firearms for individuals found in a civil court process to pose an imminent risk of harm to themselves or others. Research with large multistate study populations has been lacking to determine effectiveness of these laws. This study assembled records pertaining to 4,583 ERPO respondents in California, Connecticut, Maryland, and Washington. Matched records identified suicide decedents and self-injury method. Researchers applied case fatality rates for each suicide method to estimate nonfatal suicide attempts corresponding to observed deaths. Comparison of counterfactual to observed data patterns yielded estimates of the number of lives saved and number of ERPOs needed to avert one suicide. Estimates varied depending on the assumed probability that a gun owner who attempts suicide will use a gun. Two evidence-based approaches yielded estimates of 17 and 23 ERPOs needed to prevent one suicide. For the subset of 2,850 ERPO respondents with documented suicide concern, comparable estimates were 13 and 18, respectively. This study's findings add to growing evidence that ERPOs can be an effective and important suicide prevention tool., (© 2024 American Academy of Psychiatry and the Law.)

Background: Community-based violence intervention (CVI) programs are considered important strategies for preventing community violence and promoting health and safety. Mixed and inconclusive results from some prior CVI evaluations, as well as our general lack of understanding about the reasons for such varied findings, may be explained in part by misalignment of program theories of change and evaluation measures. Furthermore, most prior evaluations have focused solely on deficit-based outcomes; this narrow focus is inconsistent with the premise of CVI and may fail to capture improvements in health and well-being that are on the hypothesized pathway from intervention to violence reduction., Methods: This article describes the process and results of codeveloping a theory of change for community-based youth firearm violence intervention and prevention programs in Washington state through a community-researcher partnership. We followed a multistep iterative process, involving (1) CVI program documentation review, (2) individual meetings, and (3) a day-long workshop., Results: The theory of change included six key domains: (1) root causes, (2) promotive factors, (3) activities, (4) intermediate outcomes, (5) longer-term outcomes, and (6) multilevel context (youth/family, staff/organizational, community, and societal). Root causes were social and structural drivers of community violence. Promotive factors were assets and resources among the community, youth/their families, and community organizations that promote health and safety. Activities were supports and services the program provided to youth and their families, staff, and, potentially, the broader community. Intermediate and longer-term outcomes were the changes among youth, their families, staff, and the community that resulted from program activities. Intermediate outcomes may be felt within 6 months to 1 year, and longer-term outcomes may be felt after 1 to 2 years and beyond., Conclusion: The theory of change we codeveloped provides a common lens to conceptualize, compare, and evaluate CVI programs in Washington state and may support more rigorous and equity-centered evaluations., Level of Evidence: Diagnostic Test/Criteria; Level V., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Legislative firearm policies are often proposed as a way of preventing firearm-related harm. Confounding is a substantial threat to accurately estimating the causal effects of firearm policies. This scoping review characterizes selection of potential confounders in US firearm policy evaluations in the health sciences literature. We identified empirical research articles indexed in PubMed from 1/1/2000-9/1/2021 that examined any of 18 pre-specified firearm policies and extracted key study elements, including the exposure (firearm policy), outcomes, potential confounders adjusted for in analyses, and study approach (i.e., static, uncontrolled pre-post, and controlled pre-post). There was wide variation in potential confounders within study approach-policy-outcome combinations. The most common potential confounders included sociodemographic and economic variables, rurality/urbanicity, violent crime, law enforcement-related variables, alcohol use, and firearm access (mostly measured via proxies for firearm ownership). Firearm policies other than the policy being evaluated were included in the adjustment set in 23-44% of studies, depending on the study approach. Confounder selection was most often said to be based on prior research (n=49, 40%) or not explicitly stated (n=48, 39%). This scoping review provides a comprehensive resource for critically appraising the firearm policy literature and offers considerations to support more rigorous confounding control in future firearm policy research., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia., Methods: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment., Results: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% ( n  = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160)., Conclusions: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness., Clinical Implications: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Purpose: To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States., Methods: We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317)., Results: We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state)., Conclusions: This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: Evidence about which firearm policies work, to what extent, and for whom is hotly debated, perhaps partly because variation in research methodology has produced mixed and inconclusive effect estimates. We conducted a scoping review of firearm policy research in the health sciences in the United States, focusing on methodological considerations for causal inference., Methods: We identified original, empirical articles indexed in PubMed from 1 January 2000 to 1 September 2021 that examined any of 18 prespecified firearm policies. We extracted key study components, including policy type(s) examined, policy operationalization, outcomes, study setting and population, study approach and design, causal language, and whether and how authors acknowledged potential sources of bias., Results: We screened 7733 articles and included 124. A plurality of studies used a legislative score as their primary exposure (n = 39; 32%) and did not examine change in policies over time (n = 47; 38%). Most examined firearm homicide (n = 51; 41%) or firearm suicide (n = 40; 32%) as outcomes. One-third adjusted for other firearm policies (n = 41; 33%). Three studies (2%) explicitly mentioned that their goal was to estimate causal effects, but over half used language implying causality (n = 72; 58%). Most acknowledged causal identification assumptions of temporality (n = 91; 73%) and exchangeability (n = 111; 90%); other assumptions were less often acknowledged. One-third of studies included bias analyses (n = 42; 34%)., Conclusions: We identified a range of methodologic approaches in firearm policy research in the health sciences. Acknowledging the imitations of data availability and quality, we identify opportunities to improve causal inferences about and reporting on the effects of firearm policies on population health., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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

Introduction: Criminal convictions may be imperfect markers of criminalized behavior, in part because of criminal legal system processes (e.g., plea bargaining). In this retrospective cohort study of individuals convicted of misdemeanors, authors compared the risk of subsequent criminal charges for a violent crime among those initially charged with a felony with that among those initially charged with only misdemeanors, overall and by defendant race and ethnicity., Methods: The study population included individuals aged ≥18 years who were convicted of a misdemeanor in Washington Superior Courts from January 1, 2015 to December 31, 2019. Those with and without initial felony charges were age/gender matched in a 4:1 ratio. The primary outcome was the first subsequent violent crime charge in Washington Superior Courts through December 31, 2020. Data were analyzed with Fine-Gray hazard models from June 2022 to November 2023., Results: There were 3,841 individuals with initial felony charges and 956 with initial misdemeanor charges only. Median follow-up was 2.4 years for both groups. During follow-up, there were 166 new violent crime charges. In multivariable models, White defendants with initial felony charges had a greater risk of subsequent violent crime charges (subdistribution hazard ratio=2.58; 95% CI=1.24, 5.36) than White defendants with initial misdemeanor charges only. Among Black and Hispanic/Latinx defendants, initial felony versus misdemeanor charges were not associated with subsequent violent crime charges (subdistribution hazard ratio=0.93; 95% CI=0.44, 1.97 among Black defendants; subdistribution hazard ratio=0.49; 95% CI=0.15, 1.57 among Hispanic/Latinx defendants)., Conclusions: Findings suggest differential associations between downgrading of felony charges to misdemeanor convictions and future violent crime charges by defendant race and ethnicity, with implications for inequitable collateral consequences of criminal convictions., (© 2024 The Author(s).)

Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: Alcohol use and handgun carrying are more prevalent among youth in rural than urban areas and their association may be stronger among rural adolescents. Alcohol use may be modifiable with implications for reducing handgun carrying and firearm-related harm. We examined the association between lagged alcohol use and subsequent handgun carrying in rural areas and examined variation in the association by developmental stages, hypothesizing that it would be stronger among adolescents than youth adults., Methods: We used a longitudinal sample of 2,002 adolescents from ages 12 to 26 growing up in 12 rural communities in 7 states with surveys collected from 2004 to 2019. We estimated the association of lagged past-month alcohol use on handgun carrying in the subsequent 12 months using population-average generalized estimating equations with logistic regression on multiply imputed data., Findings: During adolescence (ages 12-18), those who drank heavily had 1.43 times the odds (95% CI = [1.01, 2.03]) of subsequent handgun carrying compared to those who did not drink alcohol, and those who consumed alcohol but did not drink heavily had 1.30 times the odds of subsequent handgun carrying compared to those who did not drink (95% CI = [0.98, 1.71]). During young adulthood (ages 19-26), associations of alcohol use (OR = 1.28; 95% CI = [0.94, 1.63]) and heavy drinking (OR = 1.38; 95% CI = [1.08, 1.68]) were similar to adolescence., Conclusions: Alcohol use and subsequent handgun carrying were positively associated during adolescence and young adulthood among individuals who grew up in rural areas, similar to findings in urban areas. Reducing alcohol use may be an important strategy to prevent handgun carrying and firearm-related harm among young people in rural areas., (© 2023 National Rural Health Association.)

Background: Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime., Findings: In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2-21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5-93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession., Conclusions: Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime., (© 2023. Columbia University Center for Injury Epidemiology and Prevention.)

Background: Current conditions in the USA suggest an increasing risk for political violence. Little is known about the prevalence of beliefs that might lead to political violence, about support for and personal willingness to engage in political violence, and about how those measures vary with individual characteristics, lethality of violence, political objectives that violence might advance, or specific populations as targets., Methods: This cross-sectional US nationally representative survey was conducted on May 13 to June 2, 2022, of adult members of the Ipsos KnowledgePanel. Outcomes are weighted, population-representative proportions of respondents endorsing selected beliefs about American democracy and society and violence to advance political objectives., Results: The analytic sample included 8620 respondents; 50.5% (95% confidence interval (CI) 49.3%, 51.7%) were female; and weighted mean (± standard deviation) age was 48.4 (± 18.0) years. Nearly 1 in 5 (18.9%, 95% CI 18.0%, 19.9%) agreed strongly or very strongly that "having a strong leader for America is more important than having a democracy"; 16.2% (95% CI 15.3%, 17.1%) agreed strongly or very strongly that "in America, native-born white people are being replaced by immigrants," and 13.7% (95% CI 12.9%, 14.6%) agreed strongly or very strongly that "in the next few years, there will be civil war in the United States." One-third of respondents (32.8%, 95% CI 31.7%, 33.9%) considered violence to be usually or always justified to advance at least 1 of 17 specific political objectives. Among all respondents, 7.7% (95% CI 7.0%, 8.4%) thought it very or extremely likely that within the next few years, in a situation where they believe political violence is justified, "I will be armed with a gun"; 1.1% (95% CI 0.9%, 1.4%) thought it very or extremely likely that "I will shoot someone with a gun." Support for political violence and for the use of firearms in such violence frequently declined with increasing age, education, and income., Conclusions: Small but concerning proportions of the population consider violence, including lethal violence, to be usually or always justified to advance political objectives. Prevention efforts should proceed urgently based on the best evidence available., (© 2023. Columbia University Center for Injury Epidemiology and Prevention.)

Background: Firearm violence is a major public health problem in the United States, yet most states lack a mechanism to temporarily remove firearms from individuals who are at high and imminent risk of harming themselves or others and are not otherwise prohibited. Extreme risk protection order (ERPO) laws are intended to close this gap. The current study examines the passage of California's gun violence restraining order (GVRO) bill using Kingdon's multiple streams framework., Methods: This study was based on an analysis of interview data from six key informants involved in the passage of the GVRO legislation., Results: Findings indicate policy entrepreneurs framed the problem and designed the policy to target individuals at behavioral risk of imminent firearm violence. Policy entrepreneurs comprised an integrated policy network that engaged in a lengthy period of collaboration and bargained with interest groups to yield a bill that satisfied diverse concerns., Conclusions: This case study may inform efforts in other states to pass ERPO policies and other firearm safety laws., (© 2023. The Author(s).)

Background: Suicide is a pressing public health problem, and firearm owners are at especially elevated risk. Certain health conditions are markers of suicide risk, but more research is needed on clinical risk markers for suicide among firearm owners specifically. Our goal was to examine associations of emergency department and inpatient hospital visits for behavioral and physical health conditions with firearm suicide among handgun purchasers., Methods: This was a case-control study of 5415 legal handgun purchasers in California who died between January 1, 2008, and December 31, 2013. Cases were firearm suicide decedents; controls were motor vehicle crash decedents. Exposures were emergency department and hospital visits for six categories of health diagnoses in the 3 years prior to death. To account for selection bias due to deceased controls, we used probabilistic quantitative bias analysis to generate bias-adjusted estimates., Results: There were 3862 firearm suicide decedents and 1553 motor vehicle crash decedents. In multivariable models, suicidal ideation/attempt (OR 4.92; 95% CI 3.27-7.40), mental illness (OR 1.97; 95% CI 1.60-2.43), drug use disorder (OR 1.40; 95% CI 1.05-1.88), pain (OR 1.34; 95% CI 1.07-1.69), and alcohol use disorder (OR 1.29; 95% CI 1.01-1.65) were associated with higher odds of firearm suicide. When adjusting for all conditions simultaneously, only the associations for suicidal ideation/attempt and mental illness remained significant. Quantitative bias analysis indicated that observed associations were generally biased downward. For example, the bias-adjusted OR for suicidal ideation/attempt was 8.39 (95% simulation interval 5.46-13.04), almost twice that of the observed OR., Conclusions: Diagnoses for behavioral health conditions were markers for firearm suicide risk among handgun purchasers, even for conservative estimates that did not adjust for selection bias. Encounters with the healthcare system may provide opportunities to identify firearm owners at high risk of suicide., (© 2023. The Author(s).)

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

Purpose: To characterize school handgun carrying and violence risk factors among rural youth., Methods: Using a sample of rural youth (n = 1995), we quantified the proportion who carried a handgun to school, carried but not to school, and did not carry across grades 7-12 and endorsed risk factors for violence in individual, peer, school, and community domains., Results: Overall, 3% (95% confidence interval [CI]: 2%-4%) of youth ever carried to school; 15% (95% CI: 14%-16%) carried but not to school; and 82% (95% CI: 80%-84%) never carried. Violence risk factors (e.g., attacking someone) were more commonly endorsed by youth who carried to school (84%; 95% CI: 73%-95%) than those who carried but not to school (51%; 95% CI: 44%-58%) and did not carry (23%; 95% CI: 20%-26%)., Discussion: Carrying a handgun to school in rural areas is not common; however, it is associated with risk factors for violence. Understanding violence risk factors among youth who carry handguns to school could inform violence prevention programs in rural areas., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Suicide is a major public health problem with immediate and long-term effects on individuals, families, and communities. In 2020 and 2021, stressors wrought by the COVID-19 pandemic, stay-at-home mandates, economic turmoil, social unrest, and growing inequality likely modified risk for self-harm. The coinciding surge in firearm purchasing may have increased risk for firearm suicide. In this study, we examined changes in counts and rates of suicide in California across sociodemographic groups during the first two years of the COVID-19 pandemic relative to prior years., Methods: We used California-wide death data to summarize suicide and firearm suicide across race/ethnicity, age, education, gender, and urbanicity. We compared case counts and rates in 2020 and 2021 with 2017-2019 averages., Results: Suicide decreased overall in 2020 (4123 deaths; 10.5 per 100,000) and 2021 (4104; 10.4 per 100,000), compared to pre-pandemic (4484; 11.4 per 100,000). The decrease in counts was driven largely by males, white, and middle-aged Californians. Conversely, Black Californians and young people (age 10 to 19) experienced increased burden and rates of suicide. Firearm suicide also decreased following the onset of the pandemic, but relatively less than overall suicide; as a result, the proportion of suicides that involved a firearm increased (from 36.1% pre-pandemic to 37.6% in 2020 and 38.1% in 2021). Females, people aged 20 to 29, and Black Californians had the largest increase in the likelihood of using a firearm in suicide following the onset of the pandemic. The proportion of suicides that involved a firearm in 2020 and 2021 decreased in rural areas compared to prior years, while there were modest increases in urban areas., Conclusions: The COVID-19 pandemic and co-occurring stressors coincided with heterogeneous changes in risk of suicide across the California population. Marginalized racial groups and younger people experienced increased risk for suicide, particularly involving a firearm. Public health intervention and policy action are necessary to prevent fatal self-harm injuries and reduce related inequities., (© 2023. The Author(s).)

Objectives: This study builds on prior research showing a strong relationship between handgun carrying and delinquent behaviors among urban youth by examining the association between handgun carrying trajectories and various types of violence in a rural sample., Methods: This study uses data from a longitudinal cohort study of 2002 public school students in the United States from 12 rural communities across 7 states from ages 12-26 (2005-2019). We used logistic regressions to assess associations of various bullying and physical violence behaviors with latent trajectories of handgun carrying from adolescence through young adulthood., Results: Compared to youth with very low probabilities of carrying a handgun in adolescence and young adulthood, trajectories with high probabilities of handgun carrying during adolescence or young adulthood were associated with greater odds of using bullying (odds ratios (ORs) ranging from 1.9 to 11.2) and higher odds of using physical violence during adolescence (ORs ranging from 1.5 to 15.9) and young adulthood (ORs ranging from 1.9 to 4.7). These trajectories with higher probabilities of handgun carrying were also associated with greater odds of experiencing physical violence like parental physical abuse and intimate partner violence, but not bullying., Conclusion and Implication: Experiencing and using bullying and physical violence were associated with specific patterns of handgun carrying among youth growing up in rural areas. Handgun carrying could be an important focus of violence prevention programs among those youth., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Adolescent handgun carrying is associated with increased risk of firearm-related violence. Most evidence on adolescent handgun carrying is from urban areas, but these findings may not generalize to rural areas., Objective: To examine differences in associations of adolescent interpersonal violence with handgun carrying across the rural-urban continuum., Design, Setting, and Participants: This cross-sectional study used nationally representative data from the US National Survey on Drug Use and Health among adolescents aged 12 to 17 years from 2002 to 2019 to estimate time-varying prevalence ratios (PRs) and prevalence differences (PDs) between interpersonal violence and handgun carrying across the rural-urban continuum. Analyses were conducted in April to July 2022., Exposures: Any past-year serious fighting, group fighting, and attacking with intent to harm., Main Outcomes and Measures: Any past-year handgun carrying. Associations were estimated within county rural-urban strata using the US Department of Agriculture's Rural-Urban Continuum Codes., Results: In each year, the sample included a weighted count of almost 25 million adolescents, with 50.9% (95% CI, 50.2%-51.6%) males and 24.7% (95% CI, 23.8%-25.6%) Hispanic adolescents, 13.5% (95% CI, 12.8%-14.2%) non-Hispanic Black adolescents, and 51.8% (95% CI, 50.8%-52.8%) non-Hispanic White adolescents in 2019. More rural counties had less racial and ethnic diversity. For example, 81.1% (95% CI, 75.9%-85.4%) of adolescents were non-Hispanic White in the most rural counties vs 43.1% (95% CI, 41.7%-44.6%) of adolescents were non-Hispanic White in the most urban counties in 2019. Adolescent handgun carrying increased over time, with the largest increases in the most rural counties, where the prevalence of adolescent handgun carrying increased from 5.2% (95% CI, 3.8%-7.0%) in 2003 to 12.4% (95% CI, 8.9%-16.9%) in 2019. PRs for the association of violence and handgun carrying were greater in more urban counties. For example, in the most urban counties in 2019, adolescents involved in a group fight had 3.7 (95% CI, 2.9-4.8) times the prevalence of handgun carrying vs those not involved in a group fight; this PR was 3.1 (95% CI, 1.6-5.6) in the most rural counties. PDs were similar and, in some cases, larger in rural areas. For example, in the most urban counties in 2019, handgun carrying prevalence was 7.5% (95% CI, 5.7%-9.5%) higher among adolescents who were involved in a group fight compared with those who were not; this PD was 21.8% (95% CI, 8.2%-37.8%) in the most rural counties, where handgun carrying was more common., Conclusions and Relevance: This cross-sectional study found that associations of interpersonal violence with handgun carrying were stronger in relative terms in urban areas than in rural areas; however, a higher percentage of rural than urban adolescents carried handguns, resulting in a greater absolute prevalence of handgun carrying associated with violence in rural areas than in urban areas. These findings suggest opportunities for preventing handgun carrying-related harms may differ between rural and urban communities.

Extreme risk protection orders (ERPOs), also known as red flag laws, are a potential tool to prevent firearm violence, including mass shootings, but little is currently known about the extent of their use in cases of mass shooting threats or about the threats themselves. We collected and abstracted information from ERPO cases from six states (California, Colorado, Connecticut, Florida, Maryland, and Washington). Ten percent (N = 662) of all ERPO cases (N = 6787) were in response to a threat of killing at least 3 people. Using these cases, we created a typology of multiple victim/mass shooting threats, the most common of which was the maximum casualty threat. The most common target for a multiple victim/mass shooting threat was a K-12 school, followed by businesses, then intimate partners and their children and families. Judges granted 93% of petitions that involved these threats at the temporary ERPO stage and, of those cases in which a final hearing was held, judges granted 84% of final ERPOs. While we cannot know how many of the 662 ERPO cases precipitated by a threat would have resulted in a multiple victim/mass shooting event had ERPO laws not been used to prohibit the purchase and possession of firearms, the study provides evidence at least that ERPOs are being used in six states in a substantial number of these kinds of cases that could have ended in tragedy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Extreme risk protection orders (ERPOs) provide a civil mechanism to temporarily remove firearm access from individuals at high risk of harming themselves or others. Evidence and theory suggest that ERPOs can prevent firearm-related harm, but the policy's impact on racial/ethnic equity is largely unknown. To examine potential inequities by race/ethnicity in public perceptions and use of California's ERPO law, we drew on two complementary data sources: 1) a 2020 state-representative survey of California adults, and 2) ERPO court documents for the first 3 years of policy implementation (2016-2018). Majorities (54-89%) of all racial/ethnic groups reported that ERPOs are at least sometimes appropriate, and 64-94% were willing to ask a judge for an ERPO for a family member. However, Black and Hispanic/Latinx survey participants less often perceived ERPOs as appropriate and were less willing to serve as petitioners, with Black participants citing lack of knowledge about ERPOs and not trusting the system to be fair as their top reasons for unwillingness. Similarly, review of ERPO court documents revealed that no family or household members served as petitioners for Black and Hispanic/Latinx ERPO respondents. Additionally, Black respondents were the least likely to have documented access to a firearm and legal representation in court. Racial/ethnic equity in ERPO use may be improved by reducing barriers to petitioning, incorporating non-law enforcement intervention professionals like behavioral health specialists into the ERPO process, providing legal assistance to respondents and petitioners, and investing in the social safety net., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Firearm violence is a major threat to global public health and safety. Several individual, family, peer, community, and societal risk and protective factors determine or modify the risk of firearm violence. Specifically, there is a strong relationship between poverty, income inequality, and firearm violence; as such, interventions that influence upstream determinants of health by providing income support may hold much promise in affecting multiple domains of risk that are on the causal pathway to firearm violence. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we conducted a scoping review to examine the current state of evidence on the relationship between income support policies and risk of firearm violence. We searched 8 databases related to health and social sciences from inception through March 30, 2022, and placed no time, language, setting, or other publication restrictions on our search, as long as the study was quantitative or mixed-methods and addressed firearm violence specifically, rather than violence more broadly, as an outcome in relation to income support policies. We found 4 studies; of those, 3 were conducted in the United States and 1 in Brazil. All 4 found associations of policy-relevant magnitude between income support policies and reductions in risk of inter-personal firearm violence. We propose future opportunities to enhance the substantive scope and methodologic rigor of this field of research and inform policy and practice for greater impact., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ali Rowhani-Rahbar reports funds outside of this work for research on firearms from the Centers for Disease Control and Prevention, National Institutes of Health, National Collaborative on Gun Violence Research, Fund for Safer Future, and State of Washington. Frederick Rivara reports funds outside of this work for research on firearms from the National Institutes of Health, National Collaborative on Gun Violence Research, and State of Washington. Julia Schleimer, Caitlin Moe, and Heather Hill do not report any potential competing interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Racial disparities in pain management have been reported among emergency department (ED) patients. In this study we evaluated the association between patients' self-identified race/ethnicity and the administration of opioid analgesia among ED patients with abdominal pain, the most common chief complaint for ED presentations in the United States., Methods: This was a retrospective cohort study of adult (age ≥18 years) patients who presented to the ED of a single center with abdominal pain from January 1, 2019-December 31, 2020. We collected demographic and clinical information, including patients' race and ethnicity, from the electronic health record. The primary outcome was the ED administration of any opioid analgesic (binary). Secondary outcomes included the administration of non-opioid analgesia (binary) and administration of any analgesia (binary). We used logistic regression models to estimate odds ratios (OR) of the association between a patient's race/ethnicity and analgesia administration. Covariates included age, sex, initial pain score, Emergency Severity Index, and ED visits in the prior 30 days. Subgroup analyses were performed in non-pregnant patients, those who underwent any imaging study, were admitted to the hospital, and who underwent surgery within 24 hours of ED arrival., Results: We studied 7,367 patients: 45% (3,314) were non-Hispanic (NH) White; 28% (2,092) were Hispanic/Latinx; 19% (1,384) were NH Black, and 8% (577) were Asian. Overall, 44% (3,207) of patients received opioid analgesia. In multivariable regression models, non-White patients were less likely to receive opioid analgesia compared with White patients (OR 0.73, 95% CI 0.65-0.83 for Hispanic/Latinx patients; OR 0.62, 95% CI 0.54-0.72 for Black patients; and OR 0.64, 95% CI 0.52-0.78 for Asian patients). Black patients were also less likely to receive non-opioid analgesia, and Black and Hispanic/Latinx patients were less likely than White patients to receive any analgesia. The associations were similar across subgroups; however, the association was attenuated among patients who underwent surgery within 24 hours of ED arrival., Conclusion: Hispanic/Latinx, Black, and Asian patients were significantly less likely to receive opioid analgesia than White patients when presenting to the ED with abdominal pain. Black patients were also less likely than White patients to receive non-opioid analgesia.

Background: Gun violence restraining orders (GVROs), implemented in California in 2016, temporarily prohibit individuals at high risk of violence from purchasing or possessing firearms and ammunition. We sought to describe the circumstances giving rise to GVROs issued 2016-2018, provide details about the GVRO process and quantify mortality outcomes for individuals subject to these orders ('respondents')., Methods: For this cross-sectional description of GVRO respondents, 2016-2018, we abstracted case details from court files and used LexisNexis to link respondents to mortality data through August 2020., Results: We abstracted information for 201 respondents with accessible court records. Respondents were mostly white (61.2%) and men (93.5%). Fifty-four per cent of cases involved potential harm to others alone, 15.3% involved potential harm to self alone and 25.2% involved both. Mass shooting threats occurred in 28.7% of cases. Ninety-six and one half per cent of petitioners were law enforcement officers and one-in-three cases resulted in arrest on order service. One-year orders after a hearing (following 21-day emergency/temporary orders) were issued in 53.5% of cases. Most (84.2%) respondents owned at least one firearm, and firearms were removed in 55.9% of cases. Of the 379 respondents matched by LexisNexis, 7 (1.8%) died after the GVRO was issued: one from a self-inflicted firearm injury that was itself the reason for the GVRO and the others from causes unrelated to violence., Conclusions: GVROs were used most often by law enforcement officers to prevent firearm assault/homicide and post-GVRO firearm fatalities among respondents were rare. Future studies should investigate additional respondent outcomes and potential sources of heterogeneity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Schools are important venues for addressing interpersonal violence among youth. However, it is unclear to what extent school violence prevention practices have been implemented across states and over time. This study examined trends in the percentage of US secondary schools that engaged in practices related to violence prevention (eg, bullying, fighting, dating violence) across 33 states., Methods: With representative data from 4 waves (2012-2018) of School Health Profiles, we used logistic regression to examine change over time of 5 practices related to violence prevention in school-based settings: professional development for health education teachers (received and would like to receive); increasing student knowledge; and teaching healthy and respectful relationships in grades 6-8 and grades 9-12., Results: Two practices had rates of adoption >90% across years (tried to increase student knowledge on violence prevention and taught healthy and respectful relationship in grades 9-12). Adoption of professional development on violence prevention for health education teachers was lowest (53%-61% across years). For all practices, most states experienced no change in the percentage of schools implementing violence prevention practices from 2012 to 2018., Conclusion: Education about healthy relationships in middle school and professional development on violence prevention for health education teachers are needed., (© 2022 American School Health Association.)

Importance: Characterizing patterns of handgun carrying among adolescents and young adults can inform programs to reduce firearm-related harm. Longitudinal patterns of handgun carrying among rural adolescents have not been identified., Objectives: To assess specific points of intervention by characterizing patterns of handgun carrying by youths in rural communities from early adolescence to young adulthood and to quantify how age at initiation, duration, and frequency of carrying differ across identified patterns., Design, Setting, and Participants: This cohort study uses the control group of the community-randomized trial of the Communities That Care prevention system, conducted among public school students in 12 rural communities across 7 states. Participants self-reported their handgun carrying at 10 data collection points from 12 to 26 years of age (2005-2019). Data were analyzed from January to July 2021., Main Outcomes and Measures: Handgun carrying in the past 12 months. Latent class growth analysis was used to estimate handgun carrying trajectories., Results: In this longitudinal rural sample of 2002 students, 1040 (51.9%) were male; 532 (26.6%) were Hispanic, Latino, Latina, or Latinx; 1310 (65.4%) were White; and the highest level of educational attainment of either parent was a high school degree or less for 649 students (32.4%). The prevalence of handgun carrying in the last 12 months ranged from 5.3% (95 of 1795) to 7.4% (146 of 1969) in adolescence and increased during the mid-20s (range, 8.9% [154 of 1722] to 10.9% [185 of 1704] from 23 to 26 years of age). Among the participants who reported handgun carrying at least once between 12 and 26 years of age (n = 601 [30.0%]), 320 (53.2%) reported carrying a handgun in only 1 wave. Latent class growth analysis indicated 6 longitudinal trajectories: never or low probability of carrying (1590 [79.4%]), emerging adulthood carrying (166 [8.3%]), steadily increasing carrying (163 [8.1%]), adolescent carrying (53 [2.6%]), declining carrying (24 [1.2%]), and high probability and persistent carrying (6 [0.3%]). The earliest mean (SD) age at initiation of handgun carrying occurred in both the adolescent and declining carrying groups at the ages of 12.6 (0.9) and 12.5 (0.7) years, respectively. More than 20% of some groups (emerging adulthood [age 26 years: 49 of 154 (31.8%)], steadily increasing [age 26 years: 37 of 131 (28.2%)], declining [age 13 years: 7 of 23 (30.4%)], and high probability and persistent carrying [age 15 years: 3 of 6 (50.0%)]) reported carrying 40 times or more in the past year by the age of 26 years., Conclusions and Relevance: This study found distinct patterns of handgun carrying from adolescence to young adulthood in rural settings. Findings suggest that promoting handgun safety in rural areas should start early. Potential high-risk trajectories, including carrying at high frequencies, should be the focus of future work to explore the antecedents and consequences of handgun carrying in rural areas.

Unemployment and violence both increased during the coronavirus pandemic in the United States (US), but no studies to our knowledge have examined their association. Using data for 16 US cities from January 2018 to July 2020, we estimated the association between acute changes in unemployment during the coronavirus pandemic and violent and acquisitive crime. We used negative binomial regression models and parametric g-computation to estimate average differences in crime incidents if the highest and lowest levels of unemployment observed in each city had been sustained across the exposure period (March-July 2020), compared with observed unemployment in each city-month. During the pandemic, the percentage of the adult population who were unemployed was 8.1 percentage points higher than expected, on average. Increases in unemployment were associated with increases in firearm violence and homicide. For example, we estimated an average increase of 3.3 firearm violence incidents (95% CI: - 0.2, 6.7) and 2.0 homicides (95% CI: - 0.2, 3.9) per city-month from March to July 2020 if all cities experienced their highest versus observed level of unemployment. There was no association between unemployment and aggravated assault or any acquisitive crime. Findings suggest that the sharp rise in unemployment during the pandemic may have contributed to increases in firearm violence and homicide, but not other crime. Additional research is needed on mechanisms of association, generalizability, and modifying factors., (© 2022. The New York Academy of Medicine.)

Background: Variation in drug policies, norms, and substance use over time and across countries may affect the normative sequences of adolescent substance use initiation. We estimated relative and absolute time-varying associations between prior alcohol and tobacco use and adolescent marijuana initiation in Argentina and Chile. Relative measures quantify the magnitude of the associations, whereas absolute measures quantify excess risk., Methods: We analyzed repeated, cross-sectional survey data from the National Surveys on Drug Use Among Secondary School Students in Argentina (2001-2014) and Chile (2001-2017). Participants included 8th, 10th, and 12th grade students (N = 680,156). Linear regression models described trends over time in the average age of first use of alcohol, tobacco, and marijuana. Logistic regression models were used to estimate time-varying risk ratios and risk differences of the associations between prior alcohol and tobacco use and current-year marijuana initiation., Results: Average age of marijuana initiation increased and then decreased in Argentina and declined in Chile. In both countries, the relative associations between prior tobacco use and marijuana initiation weakened amid declining rates of tobacco use; e.g., in Argentina, the risk ratio was 19.9 (95% CI: 9.0-30.8) in 2001 and 11.6 (95% CI: 9.0-13.2) in 2014. The relative association between prior alcohol use and marijuana initiation weakened Chile, but not in Argentina. On the contrary, risk differences (RD) increased substantially across both relationships and countries, e.g., in Argentina, the RD for tobacco was 3% (95% CI: 0.02-0.03) in 2001 and 12% (95% CI: 0.11-0.13) in 2014., Conclusion: Diverging trends in risk ratios and risk differences highlight the utility of examining multiple measures of association. Variation in the strength of the associations over time and place suggests the influence of environmental factors. Increasing risk differences indicate alcohol and tobacco use may be important targets for interventions to reduce adolescent marijuana use., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Research on violence exposure emphasizes discrete acute events such as direct and witnessed victimization. Little is known about the broad range of experiences of violence (EVs) in daily life. This study assesses the prevalence and patterns of distribution of 6 EVs in an adult general population., Methods: California state-representative survey administered online (English and Spanish), July 14-27, 2020. Adult (age ≥ 18 years) California resident members of the Ipsos KnowledgePanel were eligible to participate. Two EVs concerned community environments: (1) the occurrence of gunshots and shootings in the neighborhood and (2) encounters with sidewalk memorials where violent deaths occurred. Four concerned social networks: direct personal knowledge of individuals who (1) had purposefully been shot by someone else or (2) had purposefully shot themselves, and direct personal knowledge of individuals whom respondents perceived to be at risk of violence, either (3) to another person or (4) to themselves. Main outcome measures, expressed as weighted percentages with 95% confidence intervals (CIs), were the prevalence and extent (or dose) of each EV and of EVs in combination and associations between EVs and respondents' sociodemographic characteristics and firearm ownership status., Results: Of 2870 respondents (57% completion rate), 52.3% (95% CI 49.5-55.0%) were female; mean [SD] age was 47.9 [16.9] years. Nearly two-thirds (64.6%, 95% CI 61.9-67.3%) reported at least 1 EV; 11.4% (95% CI 9.7-13.2%) reported 3 or more. Gender was not associated with the prevalence of any experience. Non-owners of firearms who lived with owners reported more extensive EVs through social networks than did firearm owners or non-owners in households without firearms. Knowledge of people who had been shot by others was most common among Black respondents, 31.0% (95% CI 20.9-43.3%) of whom knew 2 or more such persons. Knowledge of people who had shot themselves was greatest among respondents aged ≥ 60 years, but knowledge of persons perceived to be at risk of violence to themselves was greatest among respondents aged 18-29 years., Conclusions and Relevance: Experiences of violence in daily life are widespread. They occur in sociodemographic patterns that differ from those for direct victimization and suggest new opportunities for research and intervention., (© 2021. The Author(s).)

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

Background: Firearms are the most lethal method of suicide and account for approximately half of all suicide deaths nationwide. We describe associations between firearm purchasing characteristics and firearm suicide., Methods: Data on all legal handgun transactions in California from 1996 to 2015 were obtained from the California Department of Justice Dealer's Record of Sale database. Handgun purchasers were linked to mortality data to identify those who died between 1996 and 2015. To account for variation in timing and duration of observation time, analyses were stratified by birth cohort. The primary analysis focused on those aged 21-25 in 1996. A secondary analysis tested associations among those aged 50-54 in 1996. Using incidence density sampling, purchasers who died by firearm suicide (cases) were each gender-matched to 5 purchasers (controls) who remained at risk at the case's time of death. We examined the characteristics of purchasers and transactions, focusing on the transaction closest in time to the case's death. Data were analyzed with conditional logistic regression., Results: There were 390 firearm suicides among the younger cohort and 512 firearm suicides among the older cohort. Across both cohorts, older age at first purchase and the purchase of a revolver were associated with greater risk of firearm suicide. For example, among the younger cohort, those who purchased a revolver versus semiautomatic pistol had 1.78 times the risk of firearm suicide (95% CI 1.32, 2.40) in multivariable models. Other associations varied across cohorts, suggesting cohort or age effects in purchasing patterns., Conclusions: Findings add to the evidence on firearm suicide risk and may help inform prevention strategies and future research., (© 2021. The Author(s).)

Firearm access is a risk factor for firearm suicide; substance use may confer additional risk. In this retrospective cohort study, we estimated the associations between prior alcohol and drug charges at the time of handgun purchase and subsequent suicide among men in California. The sample comprised all men who legally purchased a handgun in California in 2001 and who were age ≥ 21 at the time of acquisition (N = 101,377), identified in the California Department of Justice (CA DOJ) Dealer's Record of Sale database. Exposures included alcohol and drug criminal charges and convictions accrued January 1, 1990 until the first ('index') handgun acquisition in 2001, recorded in the CA DOJ Criminal History Information System. Outcomes included suicide and firearm suicide occurring after the index purchase and before January 1, 2016. A total of 1907 purchasers had alcohol charges, 1248 had drug charges, and 304 had both; 594 purchasers died by suicide (516 by firearm suicide). Compared with those with neither alcohol nor drug charges, those with alcohol charges had 2.20 times the hazard of suicide (95% confidence interval [CI], 1.39-3.46) and 2.22 times the hazard of firearm suicide (95% CI, 1.36-3.62). Risk was most elevated among those with more recent charges and those with 2 or more charges, and in the time period closest to the purchase. The associations for drug charges and the combination of alcohol and drug charges were not distinguishable from the null. Firearm owners with alcohol offenses may benefit from intervention to reduce firearm access and alcohol use., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Violent crime increased and most property crime decreased in many United States (US) cities during the coronavirus pandemic. Using negative binomial regressions, we examined the association between physical distancing (a central coronavirus containment strategy) and crime within 16 large cities (in 12 US states and the District of Columbia) through July 2020. Physical distancing was measured with aggregated smartphone data and defined as the average change in the percentage of the population staying completely at home. Outcome data were obtained from the Gun Violence Archive and city open data portals. In multivariable models, increases in the percentage of the population staying home were associated with decreases in reported incidents of aggravated assault, interpersonal firearm violence, theft, rape, and robbery, and increases in arson, burglary, and motor vehicle theft. Results suggest that changes in the frequency of interpersonal interactions affected crime during the coronavirus pandemic. More research is needed on the specificity of these assocations and their underlying mechanisms., (© 2021. The New York Academy of Medicine.)

Background: Uptake of gun violence restraining orders (GVROs), which temporarily prohibit the possession and purchase of firearms and ammunition from individuals at particularly high risk of harming themselves or others with a firearm, has been slow and heterogenous across California. Insights into the implementation process and perceived effectiveness of the law could guide implementation in California and the many states that have enacted or are considering enacting such a law., Methods: We conducted 21 semi-structured interviews with 27 key informants, including judges, law enforcement officers, city and district attorneys, policy experts, and firearm violence researchers. Analysis of transcripts was guided by grounded theory and the Consolidated Framework for Implementation Research (CFIR)., Findings: The following constructs emerged within 4 CFIR domains as salient features of implementation: 1) implementation characteristics: risk of violence, cost, and adaptability; 2) outer setting: interagency coordination and local firearm ideology; 3) inner setting: readiness for implementation and law enforcement firearm culture; and 4) implementation process: planning and engaging with those involved in implementation. Key informants perceived the law to be effective, particularly for preventing firearm suicide, but agreed that more research was needed. While most indicated that the law resulted in positive outcomes, concerns about the potential for class- and race-based inequities were also raised., Conclusions: Implementation of the GVRO law in California was hampered by a lack of funding to support local proactive implementation efforts. This resulted in ad hoc policies and procedures, leading to inconsistent practices and widespread confusion among those responsible for implementation. In states that have not begun implementation, we recommend dedicating funding for implementation and creating local procedures statewide prior to the law's rollout. In California, recommendations include providing training on the GVRO law-including an explication of agency-specific roles, responsibilities, and procedures-to officers, city attorneys, and civil court judges., Competing Interests: The authors have declared that no competing interests exist.

Background: Firearm violence is a significant public health problem in the United States. A surge in firearm purchasing following the onset of the coronavirus pandemic may have contributed to an increase in firearm violence. We sought to estimate the state-level association between firearm purchasing and interpersonal firearm violence during the pandemic., Methods: Cross-sectional study of the 48 contiguous states and the District of Columbia from January 2018 through July 2020. Data were obtained from the National Instant Criminal Background Check System (a proxy for firearm purchasing) and the Gun Violence Archive. Using negative binomial regression models, we estimated the association between cumulative excess firearm purchases in March through July 2020 (measured as the difference between observed rates and those expected from autoregressive integrated moving average models) and injuries (including nonfatal and fatal) from intentional, interpersonal firearm violence (non-domestic and domestic violence)., Results: We estimated that there were 4.3 million excess firearm purchases nationally from March through July 2020 and a total of 4075 more firearm injuries than expected from April through July. We found no relationship between state-level excess purchasing and non-domestic firearm violence, e.g., each excess purchase per 100 population was associated with a rate ratio (RR) of firearm injury from non-domestic violence of 0.76 (95% CI: 0.50-1.02) in April; 0.99 (95% CI: 0.72-1.25) in May; 1.10 (95% CI: 0.93-1.32) in June; and 0.98 (95% CI: 0.85-1.12) in July. Excess firearm purchasing within states was associated with an increase in firearm injuries from domestic violence in April (RR: 2.60; 95% CI: 1.32-5.93) and May (RR: 1.79; 95% CI: 1.19-2.91), though estimates were sensitive to model specification., Conclusions: Nationwide, firearm purchasing and firearm violence increased substantially during the first months of the coronavirus pandemic. At the state level, the magnitude of the increase in purchasing was not associated with the magnitude of the increase in firearm violence. Increases in purchasing may have contributed to additional firearm injuries from domestic violence in April and May. Results suggest much of the rise in firearm violence during our study period was attributable to other factors, indicating a need for additional research.

Objective: To examine whether firearm ownership and ownership-related motivations and practices can be classified into reasonably distinct types., Methods: Cross-sectional data on firearm owners (n=429) were obtained from the 2018 California Safety and Well-Being Survey, a state-representative web-based survey. We conducted a latent class analysis using six self-reported indicators of firearm ownership: (1) number of firearms owned, (2) types of firearms owned, (3) primary reason for firearm ownership, (4) firearm storage, (5) loaded handgun carrying and (6) high-capacity magazine ownership., Results: We identified five markedly different classes of firearm ownership. There were two classes of single-firearm owners and three classes of multiple-firearm owners. Only members of one class (9% of owners) were likely to have carried a loaded handgun and to own high-capacity magazines or assault-type weapons. Members of this class were also likely to own 5+ firearms, own for protection against people, and store a firearm in the least secure manner (loaded and unlocked)., Conclusion: There were distinct classes of firearm ownership in California, and all higher-risk behaviours studied were exhibited disproportionately by members of a single class. This latent class structure, which may help identify higher-risk groups of firearm owners, could inform future research on risk assessment and on focused interventions to reduce firearm injury and death., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite evidence that firearm access in the home is a strong risk factor for firearm injury, firearms are owned more often for self-protection than for any other reason. In this cross-sectional study, we describe the association between firearm ownership and perceived risk of personal firearm injury using logistic regressions applied to data from the 2018 California Safety and Well-being Survey. Most respondents (57.7%) reported being very/somewhat worried about gun violence happening to them. Compared with non-owners in households without firearms, firearm owners were 60% (adjusted OR (aOR) 0.40, 95% CI: 0.27 to 0.58) less likely to be worried about gun violence happening to them; non-owners living in homes with firearms were 46% (aOR 0.54, 95% CI: 0.33 to 0.88) less likely. This suggests an underestimation of actuarial risk that conflicts with the available evidence, with important implications for public health messaging., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: A total of 19 states and the District of Columbia now have extreme risk protection order (ERPO) or similar policies, and others are considering them; however, little research exists describing their use., Objective: To characterize early use of California's ERPO policy by providing the first aggregate, statewide description of ERPOs, individuals subject to them, and petitioners., Design, Setting, and Participants: This cross-sectional study analyzed 1076 respondents to ERPOs recorded in the California Department of Justice California Restraining and Protective Order System from 2016 to 2019. Descriptive analyses of orders issued between January 1, 2016, and December 31, 2019 in California were performed, and univariate Moran I was calculated to examine county-level spatial autocorrelation of the policy's use., Main Outcomes and Measures: The primary study outcomes included the characteristics of ERPO respondents (demographic characteristics), petitioners (law enforcement vs family or household members), and orders (type and service) as well as temporal and spatial variation in policy use during the first 4 years of implementation., Results: Of 1076 respondents during the study period, most were men (985 [91.5%]) and white individuals (637 [59.2%]), with a mean age of 41.8 years (range, 14 to 98 years). A law enforcement officer was the petitioner in 1038 cases (96.5%). The number of respondents increased during the study period from 70 in 2016 to 700 in 2019, and there was substantial county-level variation in ERPO use (ranging from 0 to 354 respondents), with significant spatial clustering in counts of ERPO respondents among neighboring counties (observed Moran I, 0.18, mean [SD] Moran I from reference distribution, -0.01 (0.05); z value, 3.58; P = .004)., Conclusions and Relevance: This study, among the first to describe the early utilization of an ERPO or similar policy, found a substantial increase in the use of ERPOs in California from 2016 to 2019. These results could inform policy makers and other stakeholders involved in policy implementation and outreach in California and elsewhere. Similar studies in other states would be useful to understand variation.

Urgent, individualized interventions to reduce firearm access, such as extreme risk protection orders (ERPOs, colloquially known as "red flag" orders), provide a rapid, focused response when risk for imminent firearm violence is high. Studies to date suggest such interventions are most commonly used to prevent suicide and are effective. Authorizing legislation has often been enacted after public mass shootings but, to our knowledge, there have been only 2 reported cases of ERPO use in efforts to prevent mass shootings. California enacted the nation's first ERPO statute, which took effect in January 2016. The authors are evaluating that statute's implementation and effectiveness and are seeking to obtain court records for all 414 cases occurring in 2016 to 2018. Based on 159 records received thus far, this article presents an aggregate summary and individual histories for a preliminary series of 21 cases in which ERPOs were used in efforts to prevent mass shootings. Most subjects were male and non-Hispanic white; the mean age was 35 years. Most subjects made explicit threats and owned firearms. Four cases arose primarily in relation to medical or mental health conditions, and such conditions were noted in 4 others. Fifty-two firearms were recovered. As of early August 2019, none of the threatened shootings had occurred, and no other homicides or suicides by persons subject to the orders were identified. It is impossible to know whether violence would have occurred had ERPOs not been issued, and the authors make no claim of a causal relationship. Nonetheless, the cases suggest that this urgent, individualized intervention can play a role in efforts to prevent mass shootings, in health care settings and elsewhere. Further evaluation would be helpful.

Aims: Amid changing marijuana policies in the Southern Cone, we examined relationships between marijuana-related risk factors and marijuana use among adolescents in Argentina, Chile, and Uruguay from 2001 to 2016., Methods: Using cross-sectional surveys from 8 th , 10 th , and 12 th graders and weighted time-varying effect models, we estimated associations between perceived risk (no/low risk versus moderate/great risk) and perceived availability (easy/very easy versus difficult/very difficult/not able to obtain) of marijuana, and any past-month marijuana use., Results: In all countries, marijuana use increased over time and adolescents who perceived no/low risk and easy availability had higher odds of use. In Argentina, the bivariate risk/use association weakened from 2001 (OR = 15.24, 95%CI = 9.63, 24.12) to 2004 [OR = 3.86 (2.72, 5.48)] and strengthened until 2011 [OR = 8.22 (7.56, 10.30)]; the availability/use association strengthened from 2005 [OR = 5.32 (4.05, 6.98)] to 2009 [OR = 20.77 (15.57, 27.70)] and weakened until 2014 [OR = 11.00 (9.11, 13.27)]. In Chile, the risk/use association weakened from 2001 [OR = 7.22 (6.57, 7.95)] to 2015 [OR = 5.58 (4.82, 6.48)]; the availability/use association weakened from 2001 [OR = 5.92 (4.96, 7.06)] to 2015 [OR = 4.10 (3.15, 5.34)]. In Uruguay, the risk/use association weakened from 2003 [OR = 34.22 (22.76, 51.46)] to 2016 [OR = 6.23 (4.96, 7.83)]; the availability/use association weakened from 2005 [OR = 29.13 (13.39, 63.39) to 2007 [OR = 9.42 (3.85, 23.07)], and strengthened until 2016 [OR = 22.68 (12.03, 42.76)]., Conclusions: Overall, the association between risk and use weakened in all countries, suggesting risk perceptions became a weaker determinant of marijuana use. Perceived availability remained strongly associated with use and may become an increasingly important driver of use (particularly in Uruguay and Argentina)., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States., Purpose: To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs., Data Sources: Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists., Study Selection: Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses., Data Extraction: 2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention., Data Synthesis: Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation., Limitation: Few studies, high ROB, and heterogeneous analytic methods and outcome measurement., Conclusion: Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences., Primary Funding Source: National Institute on Drug Abuse and Bureau of Justice Assistance.