Access To Firearms Research Articles

Acceptability of Adolescent Social and Behavioral Health Screening in the Emergency Department

PurposeThe American Academy of Pediatrics recommends routine screening for social and behavioral health risks (SBHR) in adolescents. Because adolescents who seek care in emergency departments (EDs) may have riskier behaviors than adolescents who access primary care, the ED may be a strategic additional setting for screening. We sought to identify acceptable domains for comprehensive SBHR screening in a pediatric ED. MethodsWe conducted a cross-sectional survey to assess adolescent and caregiver acceptance of ED-based SBHR screening across multiple domains. Logistic regression was performed to identify factors associated with screening acceptance. McNemar's test was used to assess agreement within patient/caregiver dyads across domains. ResultsAmong our 516 study participants (347 adolescents and 169 caregivers), those who indicated that they “agree” or “strongly agree” that ED-based screening should be conducted were classified as finding screening acceptable. Acceptability rates ranged from 45.0% (firearm access) to 77.5% (suicidality) among adolescents and 61.5% (firearm access) to 84.0% (substance use) among caregivers. After adjusting for gender, race/ethnicity, and insurance status, adolescents were less accepting than caregivers of screening for: substance use (adjusted odds ratio [aOR]: .51; .31, .83; p < .01); violence (aOR: .63; .41, .97; p = .04); depression (aOR: .65; .42, .99; p = .04); human trafficking (aOR: .58; .39, .86; p < .01); and access to firearms (aOR: .47; .32, .70; p < .01). Shared agreement within adolescent/caregiver dyads ranged from 25.2% to 67.1%. ConclusionsA majority of adolescents and caregivers agree that ED-based SBHR screening should be conducted across most domains. Caregivers generally had higher rates of screening acceptance than adolescents.

“In the Exercise of a Sound Discretion, Who, of This Class of Persons, Shall Have a Right to the License…”: Family, Race, and Firearms in Antebellum North Carolina

In 1841, North Carolina passed a law requiring free black people to acquire firearm licenses from their county court. This essay argues that the license requirement forced free black people to rely on their families’ support to access firearms, which sits contrary to the “individual right” framework that firearms are often viewed through. Family members helped free black people to construct racial identities, highlight trustworthiness, connect individuals to patrons and professional networks, and manage legal fees, all in pursuit of firearm access. This essay contributes to our understanding of antebellum black families and their connections to their broader interracial communities.

Association of Firearm Ownership, Use, Accessibility, and Storage Practices With Suicide Risk Among US Army Soldiers

Since 2004, the suicide rate among US Army soldiers has exceeded the rate of death from combat injury. It is critical to establish factors that increase the risk of acting on suicidal thoughts to guide early intervention and suicide prevention. To assess whether firearm ownership, use, storage practices, and accessibility are associated with increased risk of suicide. In this case-control study, suicide cases (n = 135) were defined as US Army soldiers who died by suicide while on active duty between August 1, 2011, and November 1, 2013. Next-of-kin and Army supervisors of soldiers who died by suicide (n = 168) were compared with propensity-matched controls (n = 137); those soldiers with a suicidal ideation in the past year (n = 118) provided structured interview data. Data were analyzed from April 5, 2018, to April 2, 2019. Firearm ownership, storage, and accessibility were assessed by using items from the World Health Organization Composite International Diagnostic Interview screening scales along with items created for the purpose of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) study. Among the 135 suicide decedents, next-of-kin reported that they had greater accessibility to firearms compared with propensity-matched controls. Specifically, suicide decedents were more likely to own 1 or more handguns compared with propensity-matched controls (odds ratio [OR], 1.9; 95% CI, 1.0-3.7; χ21 = 4.2; false discovery rate [FDR] P = .08), store a loaded gun at home (OR, 4.1; 95% CI, 1.9-9.1; χ21 = 12.2; FDR P = .003), and publicly carry a gun when not required for military duty (OR, 3.2; 95% CI, 1.4-7.3; χ21 = 7.4; FDR P = .02). The combination of these 3 items was associated with a 3-fold increase in the odds of suicide death (OR, 3.4; 95% CI, 1.2-9.4; χ21 = 5.4; FDR P = .05). Storing a loaded gun with ammunition at home or publicly carrying a gun when not on duty was associated with a 4-fold increase in the odds of suicide death (OR, 3.9; 95% CI, 1.9-7.9; χ21 = 14.1; FDR P = .002). In this study, in addition to gun ownership, ease and immediacy of firearm access were associated with increased suicide risk. Discussion with family members and supervisors about limiting firearm accessibility should be evaluated for potential intervention.

Simulating the Suicide Prevention Effects of Firearms Restrictions Based on Psychiatric Hospitalization and Treatment Records: Social Benefits and Unintended Adverse Consequences.

Objectives. To estimate the number of lives saved from firearms suicide with expansions of gun restrictions based on mental health compared with the number who would be unnecessarily restricted. Methods. Agent-based models simulated effects on suicide mortality resulting from 5-year ownership disqualifications in New York City for individuals with any psychiatric hospitalization and, more broadly, anyone receiving psychiatric treatment. Results. Restrictions based on New York State Office of Mental Health-identified psychiatric hospitalizations reduced suicide among those hospitalized by 85.1% (95% credible interval = 36.5%, 100.0%). Disqualifications for anyone receiving psychiatric treatment reduced firearm suicide rates among those affected and in the population; however, 244 820 people were prohibited from firearm ownership who would not have died from firearm suicide even without the policy. Conclusions. In this simulation, denying firearm access to individuals in psychiatric treatment reduces firearm suicide among those groups but largely will not affect population rates. Broad and unfeasible disqualification criteria would needlessly restrict millions at low risk, with potential consequences for civil rights, increased stigma, and discouraged help seeking.

Licensed firearm dealer availability and intimate partner homicide: A multilevel analysis in sixteen states

This paper investigates the association between legal access to firearms in the community through licensed dealers and homicides perpetrated by intimate partners (IPH). We conducted a series of multilevel negative binomial models to assess the relationship between the rate of county-level federally licensed firearm dealers and intimate partner homicides, by gender and age, controlling for leading macro-level correlates of IPH. The rate of county-level federally licensed firearm dealers is significantly associated with intimate partner homicides in urban counties, regardless of gender and age. Although data cannot discern that the rate of licensed firearm dealers is linked to greater legal firearm access, our findings focus attention on the role of community factors, including gun stores, as significant risk factors for violence. Policies to reduce legal options to purchase firearms, especially for those with prior domestic violence offenses, may help to decrease intimate partner homicide, but better data tracking is needed to help us understand how guns move from purchase into the hands of IPH perpetrators.

Increased Violence Involvement and Other Behavioral and Mental Health Factors Among Youth With Firearm Access

PurposeThe purpose of this study was to examine multiple ways youth may access firearms among a sample of urban, mountain west youth, and explore whether youth reporting various types of violence involvement and other behavioral or mental health factors have differential access to firearms compared with youth who do not report these issues. MethodsA cross-sectional community-based survey was conducted among adolescents aged 10–17 years and one of their parents. The main outcomes were youth firearm access and possession and associated violence and behavioral and mental health factors. Bivariate and binomial logistic regression, controlling for demographic factors, was used to determine associations and predictors. ResultsOne thousand one hundred youth and 730 parents participated. Nearly half of youth were male; 58.2% were Hispanic, 24.7% non-Hispanic black, 10.5% multiracial, 3.9% other, and 2.5% white. About 20% were categorized as having potential access to firearms (i.e., youth knows how and/or where to access firearms); 1.9% possessed a firearm. Analyses revealed that being physically aggressive (odds ratio [OR] 2.7), risk for future violence perpetration (OR 2.6), using alcohol (OR 2.0), having internalizing symptoms (OR 1.9), peer problems (OR 1.9), and older age (OR 1.26) predicted youth's possible access to firearms. Marijuana use (OR 9.9), parental gun ownership (OR 6.5), and reported delinquency (OR 8.3) predicted youth's firearm possession. ConclusionsYouth with potential firearm access demonstrate more violence risk and involvement, and other behavioral or mental health issues than youth without potential firearm access. Parental firearm ownership predicts youth firearm possession. It is important for both health-care providers and parents to recognize these potentially lethal associations to provide appropriate counseling.

Possession of Household Firearms and Firearm-Related Discussions with Clinicians Among Veterans Receiving VA Mental Health Care

Objectives: To assess possession of household firearms among veterans receiving mental health care and the frequency of their discussions with clinicians about firearms. Methods: We surveyed random samples of veterans receiving mental health care in each of five purposively chosen, geographically diverse VA facilities; 677 (50% of recipients) responded. Results: 45.3% (95% CI 41.2, 49.3) of veteran respondents reported household firearms; 46.9% of those with suicidal thoughts and 55.6% with a suicide plan had household firearms. Only 27.5% of all veteran respondents and 44% of those with recent suicidal ideation and household firearms had had a firearm-related discussion with a clinician. Discussion: Many veterans receiving mental health care can readily access firearms, a highly lethal means for suicide. Increasing clinician-patient discussions and health system efforts to reduce firearm access might reduce suicide in this clinical population.

Are the Deadliest Mass Shootings Preventable? An Assessment of Leakage, Information Reported to Law Enforcement, and Firearms Acquisition Prior to Attacks in the United States

This study examined the 15 deadliest public mass shootings in the United States from March 1998 to February 2018 to assess (a) leakage of violent thoughts/intent, (b) leakage of specific interest in mass killing, (c) concerning behaviors reported to law enforcement, (d) concerning interest in homicide reported to law enforcement, and (e) firearms acquisition. We then compared our findings on the deadliest public mass shooters with the Federal Bureau of Investigation’s (FBI) findings on active shooters in general. Overall, the results suggest that most incidents were indeed preventable based on information known about offenders in advance, and that the deadliest mass shooters exhibited more warning signs and were more often reported to law enforcement than other active shooters. Future prevention efforts should aim to educate, encourage, and pressure the public to report warning signs to law enforcement, educate and train law enforcement so that they can more effectively investigate potential threats, and limit firearms access for people who have admitted having homicidal or suicidal thoughts or being interested in committing a mass shooting. These relatively straightforward steps could significantly reduce the prevalence of future attacks.

Workplace homicides committed by firearm: recent trends and narrative text analysis

BackgroundFirearm workplace homicides are a significant problem in the United States. We sought to provide a current, national-level examination of these crimes and examine how perpetrators accessed firearms used in workplace homicides.MethodsWe abstracted information on all firearm workplace homicides from the Bureau of Labor Statistics’ Census of Fatal Occupational Injuries from 2011 to 2015. We classified deaths by perpetrator’s relationship to the workplace/victim, motive (robbery v. non-robbery), circumstance (argument v. other circumstances), and firearm access points using narrative text fields.ResultsThere were 1553 firearm workplace homicides during the study period. Robbery crime trended downward from 2011 to 2015. In contrast, non-robbery crimes constituted almost 50% of the homicides and trended upward in recent years. Customers and co-workers were the most frequent perpetrators of non-robbery crimes, most after an argument. While customers and co-workers who commit these crimes were often armed at the time of the argument, some were not and retrieved a firearm from an unspecified location before committing a homicide. Thus, immediate and ready firearm access was commonly observed in argumentative workplace deaths.ConclusionsLimiting firearm access in the workplace is a possible measure for preventing deadly workplace violence and should be considered as part of a comprehensive strategy for addressing this reemerging public health concern.

Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients

ObjectiveAccess to firearms is an independent risk factor for completed suicide and homicide, and the American Academy of Pediatrics recommends that pediatricians screen and counsel about firearm access and safe storage. This study investigates how often pediatric residents screen for access to firearms or counsel about risk-reduction in patients with suicidal or homicidal ideation. MethodsRetrospective chart review of visits by patients younger than the age of 19 years presenting to the pediatric emergency department (ED) of a tertiary academic medical center from January to December 2016. Visits were eligible if there was an ultimate ED discharge diagnosis of “suicidal ideation,” “suicide attempt,” or “homicidal ideation” as identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision codes and the patient was seen by a pediatric resident before evaluation by psychiatry. Descriptive statistics were used to analyze results. ResultsNinety-eight patients were evaluated by a pediatric resident for medical assessment before evaluation by a psychiatry team during the study period and were therefore eligible for inclusion. Screening for firearm access was documented by a pediatric resident in 5 of 98 (5.1%) patient encounters. Twenty-five patients (25.5%) had no documented screening for firearm access by any provider during the ED visit, including in 5 cases when patients were discharged home. ConclusionsPediatric residents rarely document screening for firearm access in patients with known suicidal or homicidal ideation who present to the ED. Additional understanding of the barriers to screening and potential strategies for improving screening and counseling are critical to providing appropriate care for high-risk pediatric patients.

FIREARMS: ACCESS AND IMPLICATIONS IN OLDER ADULTS WITH COGNITIVE IMPAIRMENT: Session 407

In this session, a case will be presented to introduce safety concerns regarding access to firearms in older adults with cognitive impairment. Extant evidence suggests there are particularly high risk times and possible contributing factors for suicide in those with cognitive impairment which will be explored. Homicide rarely occurs in elderly; however, available literature suggests cognitive disorders are among the most prevalent psychiatric diagnoses in elderly homicide perpetrators. Further, when suicides and homicides occur in this population, it is most often by firearm. The epidemiology of suicide and homicide by firearm in older adults with cognitive impairment will be discussed, and risk factors for suicide and homicide will be presented. It has been suggested that a public health approach to gun violence prevention be utilized with physicians having an essential role. Physician and patient attitudes about and strategies for assessing access to firearms will be discussed. Strategies include assessing for firearm access as part of the routine functional or safety assessment and, for those with access to firearms, using a structured approach to explore safety concerns. Firearm safety has been compared to safety concerns related to driving in those with cognitive impairment. Gun laws, like driving evaluations, can vary state to state; however, general legislative measures aimed at reducing gun violence will be explored with an emphasis on persons with cognitive impairment.

“Hey, let me hold your guns for a while”: A qualitative study of messaging for firearm suicide prevention

A recommended component of suicide prevention is encouraging at-risk individuals to voluntarily and temporarily reduce access to firearms and other lethal methods. Yet delivering counseling on the topic can be difficult, given the political sensitivity of firearm discussions. To support such counseling, we sought to identify recommended framing and content of messages about reducing firearm access for suicide prevention. Through qualitative interviews with firearm owners and enthusiasts, we identified key points for use in framing (identity as a gun owner, trust, voluntary and temporary storage, and context and motivation) and specific content (preference for "firearm" over "gun," and legal issues such as background checks for transfers). These findings build on prior work and should enhance efforts to develop and deliver effective, acceptable counseling and-ultimately-prevent firearm suicide.

Impact of licensed federal firearm suppliers on firearm-related mortality.

Legal firearm sales occur largely through suppliers that have Federal Firearm Licensees (FFLs). Since FFL density might reflect ease-of-access to firearm purchases, we hypothesized that the number of FFL dealers would be associated with firearm-related deaths. We further hypothesized that licensee-type subsets would be associated with differential risks for gun-related deaths. We used data from the National Center for Health Statistics National Vital Statistics System (2008-2014) and national data on Federal Firearms Licensees for 2014. Correlation analysis and linear regression analysis were performed to determine the relationship between different licensee types and firearm-related deaths. We controlled for population, number of statewide registered firearms, and the density of other types of FFLs. We identified a total of 65,297 FFLs. There was a moderate correlation (R = 0.53, ρ = 0.48) between total FFL density and firearm-related death rates. Further analysis by type of firearm-related death showed a strong correlation (R = 0.81, ρ = 0.76) between total FFL density and firearm-related suicide rates. No correlation was found between total FFL density and firearm-related homicide rate. Among individual FFL types, FFL02 (firearm dealing pawnshop) density was the only FFL-type found to be correlated with firearm-related death rates. We found a strong correlation between FFL02 density and overall firearm-related death rate (R = 0.69, ρ = 0.78) and firearm-related suicide rate (R = 0.72, ρ = 0.78). Linear regression analysis showed that even while controlling for number of registered firearms and population, the number of firearm-dealing pawnshops remained significantly associated with overall firearm-related deaths and firearm-related suicides. Access to legally distributed firearms is associated with firearm-related death rates, particularly firearm-related suicides. Specifically, firearm-dealing pawnshops were associated with suicide-related deaths. These findings suggest that deeper exploration of legal firearm access and firearm-related injuries would benefit discussion of preventative measures. Therapeutic, Level V.

Acceptability of potential interventions to increase firearm safety among patients in VA mental health treatment.

Veterans in mental health care have high rates of firearm-related suicide; reducing firearm access during high-risk periods could save lives. We assessed veteran patients' attitudes towards voluntary interventions to reduce access. Descriptive data came from surveys mailed to random samples of veterans receiving mental health care in five geographically diverse VA facilities. Survey items inquired about the acceptability of seven voluntary health system interventions to address firearm access, ranging from lower-intensity interventions that addressed safety but might not reduce access (i.e., clinician screening; distribution of gunlocks) to interventions substantially limiting access (i.e., storage of firearms offsite; gun disposal). Mailings occurred between 5/11/15 and 10/19/15; 677 of 1354 veterans (50%) returned the surveys. 93.2% of respondents endorsed one or more health system interventions addressing firearm access; 75.0% endorsed interventions substantially limiting access. Although veterans with household firearms were less likely to endorse interventions, fully 50.4% would personally participate in at least one intervention that substantially limited access. A majority of veterans in VA mental health care endorse voluntary health system interventions addressing firearm access during high-risk periods for suicide. Approximately half of veterans with firearms would personally participate in an intervention that substantially limited firearm access.

'Lock to Live': development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide.

We sought to (1) clarify decision needs among suicidal adults with home firearm access; (2) identify accurate, unbiased and acceptable approaches for content and messaging; and (3) develop a tablet-delivered decision aid for firearm storage options. Following international standards, we used stakeholder interviews to develop a decision aid for the decision, 'what option(s) to choose to reduce home access to firearms for an adult at risk of suicide'. Participants were adults with personal or family history of suicidal ideation or behaviours, firearm ownership or employment in a firearm range or store, involvement in suicide prevention field, or work as emergency department or other healthcare provider. Through 64 interviews, we created the 'Lock to Live' decision aid, which includes (1) introduction specifying the decision, (2) clarification of preferences and logistics, (3) table of storage options and (4) summary with specific next steps. The final tool had high user acceptability. Should the 'Lock to Live' decision aid prove useful in a pilot feasibility trial and subsequent testing, it could enhance lethal means counselling and help prevent firearm suicide.

Firearm Storage Practices Among American Veterans

Interventions that reduce access to highly lethal and commonly used methods of suicide (e.g., limiting firearm access) are considered essential elements of effective suicide prevention programs. Scant epidemiologic data are available to inform such efforts among Veterans. The aim of this study is to describe firearm storage practices and correlates of those practices among a nationally representative sample of U.S. Veteran firearm owners. The authors used a probability-based online survey of Veteran firearm owners in 2015 (data analyzed in 2017; 54.6% response rate). The primary outcome was firearm storage practices. Additional items assessed individual and household-level sociodemographic characteristics, firearm-related characteristics, and risk perceptions related to firearm ownership. One in three (33.3%, 95% CI=28.6%, 38.4%) Veteran firearm owners stores at least one firearm loaded and unlocked. The prevalence of this practice ranges substantially (9%-65%) across individual, household, and firearm ownership characteristics, and is strongly related to other firearm-related behaviors (e.g., carrying handguns); reasons for firearm ownership (e.g., protection versus other); number of firearms owned; and perceptions about the utility of guns stored safely and whether guns make homes safer. Storing a firearm loaded and unlocked is common among Veterans. Storage practices are strongly related to reasons for ownership and potentially malleable perceptions including beliefs about firearm-related risks. Suicide prevention initiatives among Veterans should incorporate communication strategies that address common misperceptions about household firearm risk and whether safe storage practices may better align with reasons most Veterans own firearms (i.e., safety)-especially when someone in their home is at increased risk for suicide.

Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA

BackgroundFirearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested. Materials and MethodsThe Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race. Results27,566 children analyzed in the study. Most were adolescents aged 15–19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R2 = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0–4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0–4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03–1.78), children age 5–9 (2.03, 1.30–3.17) and suicide attempts (15.6, 11.6–20.9) had higher odds of in-hospital mortality. ConclusionsFirearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.

Trigger warning: the causal impact of gun ownership on suicide

ABSTRACTWith a growing debate over tighter firearm regulations, we consider an important social consequence of increased firearm access: increased firearm suicides. Using data from the federal criminal background check system, we consider the impact of firearm ownership on firearm suicide rates. To deal with concerns of identification, we instrument for firearm background checks with state-year-level Google search intensity for phrases that reflect fear of future gun shortages and learning about the constitutional rights of firearm owners. We find that an increase in firearm ownership has a sizable and statistically significant impact on firearm suicide rates. A 10% increase in firearm ownership increases firearm suicide rates by approximately 3%, which is five times larger than non-instrumented estimates. Furthermore, we find no effect of gun ownership on non-firearm suicide rates, suggesting our findings are not simply capturing a suicide method substitution effect. The results are consistent with a variety of validity and robustness tests. Our results make clear the link between firearm ownership and firearm suicide rates, which have increased dramatically over the last decade.

Ammunition leakage from military to civilian markets: market price evidence from Haiti, 2004–2012

ABSTRACTThe increase in the accessibility of firearms and ammunition represents a key factor of destabilization in many countries. It is also commonly associated with an escalation in intensity and organization of collective and interpersonal violence. In some cases, arms are illegally transferred via diversion from existing stores. In this article, we consider the leakage from military to civilian markets as an important source of ammunition available to civilians in Haiti. We employ a unique section-quarterly panel of ammunition prices on the Haitian civilian market over the period July 2004–July 2012. These data are combined with publicly available monthly data on authorized ammunition shipments to the country registered by the United Nations (UN) and Haitian National Police (HNP). We use a standard time-series Ordinary Least Squares (OLS) model to show that the exogenous shocks of UN- and HNP-ordered ammunition exert measurable downward pressure on civilian ammunition markets, which we calculate in terms of adjusted predictions and partial elasticities of demand. These effects constitute econometric evidence that the firewall that should in theory have separated military and civilian markets in Haiti partially broke down. We conclude with a suggestion for using this model to help estimate the specific size of the leakage.

Firearms and Dementia: Clinical Considerations.

Many support limiting firearm access for persons whose mental illness would place them or others at heightened risk, but less attention has been paid to progressive cognitive impairment and firearm...