Completed Research

2020 Completed Research

Association of minimum age laws for handgun purchase and possession with homicides perpetrated by youth 18-20 years old

Investigators: Caitlin A. Moe, Miriam J. Haviland, Andrew G. Bowen, Ali Rowhani-Rahbar, Frederick P. Rivara

Publication: In press, JAMA Pediatrics


In 1994, the United States government set the minimum age to purchase a handgun from a licensed dealer at 21, to purchase a handgun from an unlicensed dealer at 18, and to possess a handgun at 18. Some states went further and increased the minimum age. Moe et al. examined whether between 1995 and 2017 the passage and implementation of state laws that raised the minimum age required to purchase or possess a handgun had an effect on firearm homicides perpetrated by young adults aged 18 to 20. Twelve states with stricter minimum age laws prior to 1994 were excluded. The researchers found no statistical association between stricter minimum age laws and firearm homicides perpetrated by those aged 18 to 20. Moe et al. speculate that this lack of association may be due to a variety of reasons, namely that firearms used in crime tend to be “acquired from sources unlikely to be affected by statutory restrictions. Additionally, straw purchasing and firearms trafficking from states with less-restrictive gun laws to those with stricter gun laws may also be methods for firearms acquisition among young adults and youth.

Policy implications: While stricter minimum age laws appear to have no effect on firearm homicides committed by young adults, strengthening straw purchase, interstate firearms trafficking, and firearm theft reporting laws may have more of an impact on firearm homicides. Moreover, youth access to firearms within the home should be considered and legislation requiring safe storage of firearms while minors reside in the home may also reduce firearm homicides committed by youth and young adults.

Link to article unavailable

Firearms and Protective Orders in Intimate Partner Homicides

Investigators: Vivian H. Lyons, Avanti Adhia, Caitlin Moe, Mary A. Kernic, Ali Rowhani-Rahbar, Frederick P. Rivara

Publication: In press, Journal of Family Violence


Lyons et al. used 2003-2018 data from the National Violence Death Reporting System (NVDRS) to identify intimate partner homicides (IPH), whether a firearm was used in IPH, and whether a protection order was filed prior to the homicide. The researchers identified 8,375 IPHs with 9,130 victims. Of these, 306 victims were killed with a firearm while an existing protective order was in effect, 4,519 with a firearm with no protective order, 176 without a firearm and with a protective order in effect, and 3,416 without a firearm and without a protective order. While past literature shows that firearms removal in protective orders may reduce IPHs, there was no documentation in the data reviewed that firearm removal was made a condition of the protective orders. The victims were predominantly white females with an average age of 40, while the perpetrators were predominantly white males with an average age of 42. This finding aligns with the proportion of firearm owners in the United States who are white.

Policy implications: Documentation in NVDRS of the conditions of protective orders needs improvement. Additionally, including firearms removal and prohibitions as conditions of protective orders is recommended. As the majority of IPH victims were killed by firearms, restricting perpetrator (or potential perpetrator) access to them may reduce IPHs. Closing the “boyfriend loophole” by allowing nonmarried, non-cohabitating intimate partners to file protective orders may also reduce IPHs.

Link to article unavailable

Age, period, and cohort effects in firearm homicide and suicide in the United States, 1983-2017

Investigators: Miriam J. Haviland, Ali Rowhani-Rahbar, Frederick P. Rivara

Publication: In press, Injury Prevention


Using 1983-2017 data from the Centers for Disease Control and Prevention’s Web-based Injury Statistics Query and Reporting System (WISQARS), Haviland et al. evaluated the intersection of firearm homicides and suicides with temporal trends, age, birth year, and sex of victims. Firearm homicides increased in the late 1980s and early 1990s, possibly due to the prevalence of crack cocaine and related crime during this time period. The peak age for firearm homicide varied, but generally occurred between ages 15 and 29. While firearm homicide victims were typically male, firearm suicides varied by sex. Firearm suicide rates were higher for older males and rates increased with age. Conversely, firearm suicide rates were higher for older females, but rates decreased with age.

Policy implications: According to previous studies, firearm-related laws (e.g., the Brady Handgun Violence Prevention Act and those implementing permit requirements) have been associated with a reduction in firearm suicides in those 45 and older. Legislation restricting access to firearms may reduce firearm homicides and suicides.

Link to article unavailable

Safe Storage Policies and Practices for Firearms Issued to Law Enforcement Officers in Washington State

Investigators: Christopher R. DeCou, Tierney Huppert, Gavin Crowell-Williamson, Kosuke Kume

Publication: June 2020, Journal of Police and Criminal Psychology


Using a survey of 106 Washington law enforcement agencies – including city police departments, Sheriff’s Offices, university police, tribal police, and airport police –, DeCou et al. found that 76% of agencies reported issuing locking devices for agency-issued firearms to their officers while 52% offered cable locks and 36% offered gun safes. Additionally, 76% reported offering firearm safe storage training for their officers. 40% of urban agencies compared to 23% of rural agencies provided multiple locked device options, but this was not calculated to be statistically significant.

Policy implications: Approximately, one-fourth of participating law enforcement agencies in the state of Washington do not provide locking devices to their personnel. Further research into why this may be and an allocation of funding toward safe storage training and the provision of locking devices is recommended.

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Extreme Risk Protection Orders in Washington: A Statewide Descriptive Study

Investigators: Ali Rowhani-Rahbar, M. Alex Bellenger, Lauren Gibb, Heather Chesnut, Madison Lowry-Schiller, Emma Gause, Miriam J. Haviland, Frederick P. Rivara

Publication: June 2020, Annals of Internal Medicine


Rowhani-Rahbar et al. collected and analyzed 242 Extreme Risk Protection Orders (ERPOs) filed in the State of Washington between December 8, 2016 and May 10, 2019, finding that the majority were filed because the respondents (i.e., those who had an ERPO filed for them, resulting in a firearms prohibition) were a possible harm to themselves (n=67), harm to others (n=86), or a harm to themselves and others (n=84). A prior mental health encounter was reported in 49% of cases. A diagnosis of a mental health condition and substance misuse were reported in 40% and 47% of the cases, respectively. Seventy-nine percent of the respondents owned a firearm and firearms were removed from 64% of respondents. Among those who did not own a firearm, 54% expressed intent to obtain a firearm. Most ERPOs were granted with the remaining 19% being dismissed or denied. Three ERPOs were terminated after being granted, because the respondents had received mental health and/or substance use treatment and were deemed no longer a risk of violence. Despite 16 counties not having an ERPO filed, there was a general increase in ERPOs as time passed with an increase in the winter of 2018. This is possibly due to the Parkland shooting in February 2018.

Policy implications: Further research on ERPOs is recommended and forthcoming. The majority of ERPOs were filed by law enforcement but often initiated by concerned family members, indicating a possible need for community education on the order. While 30% of respondents were ordered to complete a mental health evaluation, there is no enforcement of this requirement. Including an enforcement component to the legislation would help ensure that respondents are being evaluated for mental health and/or substance use issues. ERPOs can be a tool for initiating mental health or substance use treatment for respondents. Additionally, completion, filing, and the level of detail in the court record was inconsistent, demonstrating the need for a standardized training, forms, and process. Lastly, a central database for court records would greatly aid in future research on ERPOs and other similar orders.

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Variation in State Laws on Access to Civil Protection Orders for Adolescents Experiencing Intimate Partner Violence

Investigators: Avanti Adhia, Jaron Goddard, Mary Kernic, Mary D. Fan, Monica S. Vavilala, Frederick P. Rivara

Publication: May 2020, Journal of Adolescent Health


Adhia et al. conducted a systematic review of the civil protection orders (CPO) laws in all 50 states and the District of Columbia. The researchers found that 48 states allowed minors to obtain CPOs and 14 allowed them obtain CPOs on behalf of themselves. Forty-four states allowed dating relationships to qualify for a CPO and 22 states included a prohibition against firearm possession with their CPOs. Additionally, the type of abuse (e.g., physical, sexual, stalking, emotional/psychological) that qualified for a CPO varies by state with the majority recognizing physical, sexual, and stalking.

Policy implications: To reduce youth intimate partner violence and provide youth an additional layer of protection, Adhia et al. recommend reducing barriers to obtaining CPOs through expanding the definitions of abuse, recognizing dating relationships, and by allowing minors to obtain a CPO on behalf of themselves.

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Murder-Suicides Perpetrated by Adolescents: Findings from the National Violent Death Reporting System

Investigators: Avanti Adhia, Chris DeCou, Tierney Huppert, Rajiv Ayyargi

Publication: April 2020, Suicide and Life-Threatening Behavior


Adhia et al. used the National Violent Death Reporting System (NVDRS) to evaluate all cases of murder-suicide perpetrated between 2003 and 2016 by those under the age of 21. Forty-seven incidents resulting in 56 homicides were identified. The majority of victims were female and age 12 to 20, whereas perpetrators were predominantly male and age 18 or older. Half of victims were White and over 40% of victims were a current or former intimate partner of the perpetrator. Of those involving an intimate partner, 78.3% of perpetrators had a history of intimate partner violence. Forty-two incidents involved the use of a firearm with 60% involving a handgun. Additionally, half of the murder-suicides occurred at a home.

Policy implications: Consistent with previous studies, the majority of perpetrators of murder-suicides were male, indicating a need to address social and cultural norms surrounding masculinity and violence. Additionally, restricting firearms access to those with a history of intimate partner violence and/or suicidality is suggested. Funding toward adolescent intimate partner violence prevention and intervention programs is recommended as well.

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Risk of Suicide, Homicide, and Unintentional Firearm Deaths in the Home

Investigators: Elissa K. Butler, Hanne M. Boveng; Richard C. Harruff, Jeffrey S. Duchin, Monica S. Vavilala, Frederick P. Rivara, Ali Rowhani-Rahbar

Publication: April 2020, JAMA Internal Medicine


Butler et al. updated a 1986 study of firearm deaths in King County homes, where the primary findings mirror those of the past study. That is, firearm deaths in the home were predominantly suicides or criminal homicides rather than self-defense homicides. Of 647 firearm deaths occurring in the home in King County, 502 died of suicide and 57 of homicide in their own homes. Twenty-three died at a friend or acquaintance’s residence. Of those who committed suicide, 114 used a firearm that was kept in the home whereas in 81.3% (n=74) of the homicide cases, the firearm was brought to the home. There were 99 homicides attributed to self-defense. Butler et al. calculate that for each self-defense homicide, there were 0.9 unintentional deaths, 7.3 criminal homicides, and 44.1 suicides.

Policy implications:

This research demonstrates the need for funding and social programming directed at suicide prevention. Additionally, research into the motives behind the criminal homicides in this study is recommended as it may indicate a need for more robust social services.

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Fidelity Assessment of a Social Work–Led Intervention Among Patients with Firearm Injuries

Investigators: Vivian H. Lyons, Lina R. Benson, Elizabeth Griffin, Anthony Floyd, Sharon W. Kiche, Kevin Haggerty, Lauren Whiteside, Sarah Conover, Daniel B. Herman, Frederick P. Rivara, Ali Rowhani-Rahbar

Publication: March 2020, Research on Social Work Practice


Lyons et al. conducted a fidelity assessment on the implementation of an existing randomized control trial of a social work-led intervention for patients with a firearm injury, Hi-Fi. The Hi-Fi program provided those with a firearm injury “trauma-informed services, hospital- or community-based motivational interviewing, a community-based outreach program, and support by a multidisciplinary team of relevant community agencies to help identify relevant recovery resources.”

The study assesses how well the client-, worker-, and team-based domains were implemented. The intervention met 70% of the fidelity assessment score items, indicating that the intervention was “well-implemented.” However, the client-based and worker-based items averaged a score of three, indicating that they are “fairly implemented.” The fidelity assessment itself increased the fidelity of the program implementation, refocusing efforts on oversight and monitoring of the program.

Policy implications: Allocating funding to monitoring of firearms-related intervention programs can aid in the success of the program.

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Safe Storage Map

Investigators: Frederick P. Rivara, Ali Rowhani-Rahbar, M. Alex Bellenger, Brianna Mills, Andrew Bowen, Lauren Gibb, Amelia Hanron, Parker Leland

Publication: March 2020, HIPRC website

Summary: Replicating efforts from the Colorado Firearm Safety Coalition, the research team identified and contacted potential temporary safe storage sites (e.g., law enforcement, gun retailers, and shooting ranges) across the state of Washington. The intent of this map was to provide the public with a list of sites that can temporarily hold a firearm during a time of crisis, such as suicidal ideation or mental health issue. Fifty-nine sites (50 law enforcement, 8 firearm retailers, and one shooting range) agreed to be on the map. The sites were evenly distributed across the state.

Policy implications: Follow-up with the sites needs to occur to see how often the map is being used to temporarily and voluntarily remove firearms from a home and whether such removal results in fewer firearm injuries and death.

Firearm Storage Practices in Households with Children: A Survey of Community-Based Firearm Safety Event Participants

Investigators: Aisha King, Joseph Simonetti, Elizabeth Bennett, Cassie Simeona, Lauren Stanek, Alison C. Roxby, Ali Rowhani-Rahbar

Publication: February 2020, Preventive Medicine


The researchers conducted a survey in English or Spanish at 10 community-based firearm safety events across the state from 2015 to 2018. Participants completed the survey prior to receiving safe storage counseling, training on the use of storage devices, and a free firearm lockbox or trigger lock. Emphasis of safe storage was on safety to children and families. The majority of participants were male (58.3%) and lived with a spouse (70.1%), at least one child and/or adolescent (57.9%), and had at least one firearm in the household (90%). Reasons for wanting a safety device are most commonly overall safety and child safety. The vast majority of participants chose to receive a lockbox over a trigger lock. Storage practices varied, but only 23.7% of participants practice triple safe storage (i.e., locked and unloaded, and ammunition locked separately). Additionally, four out of ten firearm-owning participants stored their firearms unlocked in their home.

Policy implications: As King et al. find that nationally, 66% of firearm owners agree on the importance of locking up firearms in households with children, funding future research on firearm-owning individuals via firearm safety events is recommended.

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Firearm Violence Affects All of Us, and We Have the Power to Prevent It

Investigators: Frederick P. Rivara, Ali Rowhani-Rahbar

Publication: January 2020, The Seattle Times


Rivara and Rowhani-Rahbar discussed the need for self-education on firearm-related injury and death in the United States in addition to passing legislation directed at reducing firearm injury and death while also respecting the constitutional right of firearm ownership. Seventy-five percent of firearm deaths in the state are attributed to suicides. Additionally, a suicide attempt is fatal approximately 90% of the time when using a firearm.

Policy implications: Rivara and Rowhani-Rahbar suggest passing legislation directed at suicide prevention, restricting access to military-style weapons and high capacity magazines, improving firearm-related data collection and management, requiring firearm safety training, and facilitating access to mental health treatment programs for gun violence victims.

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2019 Completed Research

Legal Liability for Returning Firearms to Suicidal Persons Who Voluntarily Surrender Them in 50 US States

Investigators: Molly J. Gibbons, Mary D. Fan, Ali Rowhani-Rahbar, Frederick P. Rivara

Publication: December 2019, American Journal of Public Health


To prevent suicide, often those at risk will have firearms temporarily removed from their home, whether voluntarily or involuntarily. Gibbons et al. discussed the unintended barriers of legal liability involved in returning those firearms. Temporary transfer laws, such as Extreme Risk Protection Orders, exist to facilitate the transfer of firearms during times of crisis. The issue was when firearms are transferred back to the owner. That is, is the holder of firearm legally liable if the owner later uses the firearm to harm themselves or others?

Policy implications: Gibbons et al. recommends clarifying in the legislation the liability of transferring back the firearms to the owner as well as clarifying the process of transferring back the firearm. Additionally, terms involved in temporary transfer laws are vague in meaning (e.g., “transferor”). Lastly, legislation should consider including the option to extend the holding period.

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Firearm Violence Research: Improving Availability, Accessibility, and Content of Firearm-Related Data Systems

Investigators: Ali Rowhani-Rahbar, M. Alex Bellenger, Frederick P. Rivara

Publication: October 2019, JAMA


In this Viewpoint article, Rowhani-Rahbar et al. highlighted the availability and accessibility of firearms-related data nationally and in the state of Washington. Specifically, there was no registry of firearm ownership, leaving researchers to rely on proxy measures, such as the Behavioral Risk Factor Surveillance System (BRFSS) firearm ownership questions, which have their own limitations. BRFSS does not have firearm storage and ownership questions consistently year-to-year. Other restrictions in firearms-related data included the majority of states not allowing researchers access to firearms purchasing data. The Tiahrt Amendment of 2003 restricted researchers from accessing firearm trace data.

Policy implications: As of 1995, Washington State has disallowed researchers’ access to firearms purchase data that is stored and managed by the Department of Licensing. Allowing access to this discuss would allow researchers to study firearms more accurately in the state of Washington. This data could be de-identified and distributed to researchers via a trusted third party. Additional recommendations include allowing firearm ownership and storage questions into the BRFSS core survey section, requiring recovered firearm data to be deposited with the state Department of Justice and made available to researchers, allowing researcher access to firearm trace data, and conducting surveys in the state to quantify firearm ownership and storage.

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Initiation Age, Cumulative Prevalence, and Longitudinal Patterns of Handgun Carrying Among Rural Adolescents: A Multistate Study

Investigators: Ali Rowhani-Rahbar, Sabrina Oesterle, Martie L. Skinner

Publication: October 2019, Journal of Adolescent Health

Summary: Rowhani-Rahbar et al. used data from the Community Youth Development Study to understand rural youth handgun carrying practices. They found that more male youth than female youth (a higher percentage of female youth carried a handgun only once) in rural areas carried handguns and those that did tended to endorse “prohandgun norms.”

Policy implications: As youth violence is an issue, efforts to reduce firearm carrying in both urban and rural areas are recommended. Additionally, further research should be conducted on the causes, correlates, and consequences of firearm carrying by rural youth.

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The Effects of Violence on Health

Investigators: Frederick P. Rivara, Avanti Adhia, Vivian Lyons, Anne Massey, Brianna Mills, Erin Morgan, Maayan Simckes, Ali Rowhani-Rahbar

Publication: October 2019, Health Affairs


This paper discussed the myriad health problems that arose from exposure to violence, including intimate partner violence, child physical and sexual abuse, elder abuse, bullying, sexual violence, community violence, and other adult and youth interpersonal violence. The possible health consequences associated with these forms of violence included mental illness (e.g., depression, anxiety, etc.), suicidal ideation and attempts, substance use, sexually transmitted infections, obesity, risky sexual behaviors, arthritis, ulcers, migraines and headaches, physical injuries as a result of interpersonal violence, gastrointestinal disorders, chronic pain, posttraumatic stress, sleep problems, loss of productivity (including missed work, loss of job, or housing instability), and social withdrawal among others.

In addition to health effects, exposure to violence had financial impacts as well. For example, it was estimated that intimate partner violence costs victims in the United States approximately $3.6 trillion over their lifetimes with an individual cost of over $100,000.

Policy implications: Rivara et al. recommend addressing violence prevention as a means of reducing the adverse health effects of violence. Allocating funding to violence prevention would also address the negative economic impact. Furthermore, there is a clear racial disparity in many types of violence, therefore emphasizing the correction of systemic discrimination and disfranchisement is also recommended.

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Evaluation of Injury Severity and Resource Utilization in Pediatric Firearm and Sharp Force Injuries

Investigators: Ashley E. Wolf, Michelle M. Garrison, Brianna Mills, Titus Chan, Ali Rowhani-Rahbar

Publication: October 2019, JAMA Network Open


Wolf et al. used National Trauma Data Bank encounter-level trauma data to analyze firearm or other penetration injury (i.e., cut or pierce injuries) in children. Between 2007 and 2016, 25,155 encounters for firearm injuries and 21,270 for other penetration injuries were identified. A larger proportion of those with firearm injuries were male, Black, unintentional injuries, and the result of assault when compared to penetration injuries. Additionally, firearm injuries resulted in more days in the hospital and Intensive Care Unit than did penetration injuries.

Policy implications: Addressing the reasons behind pediatric firearm and penetration injury will help to reduce such injuries. In particular, emphasizing safe storage of firearms in the home will limit child access to firearms. Supporting legislation to remove firearms from homes in which domestic violence occurs is also recommended.

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Firearm Assault Injuries by Residence and Injury Occurrence Location

Investigators: Brianna Mills, Anjum Hajat, Frederick P. Rivara, Paula Nurius, Ross Matsueda, Ali Rowhani-Rahbar

Publication: September 2019, Injury Prevention


Using hospital and death records from 2010 to 2014, Mills et al. determined the location of firearm injuries and deaths in King County in relation to the location of the victims’ residences. The researchers found that 665 people were injured and 165 were killed in 670 firearm assaults in King County during this period. Injury locations were on average 3.9 miles from the victim’s residence, with only 25% of injuries occurring within a half-mile of the victim’s residence. Using victim residence as a proxy for the location of a firearm injury or death may be unreliable. Additionally, missing data was attributed to homelessness or unstable housing, indicating that location of injury or death may be a more reliable measure than residential location for studying firearm injuries and deaths.

Policy implications: Funding allocated to future studies on firearm injuries and death using injury location will yield more accurate results and improve monitoring of such injuries and death.

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Use of Multiple Failure Models in Injury Epidemiology: A Case Study of Arrest and Intimate Partner Violence Recidivism in Seattle, WA

Investigators: Vivian H. Lyons, Mary A. Kernic, Ali Rowhani-Rahbar, Victoria L. Holt, Marco Carone

Publication: August 2019, Injury Epidemiology

Summary: Lyons et al. used multiple failure survival models to measure the association between arrest and intimate partner violence (IPV) recidivism occurring in Seattle between 1999 and 2001. In the 12 months following the arrest, time between arrest and first physical IPV recurrence was reduced by 26%. There was no statistical association between arrest and time to first psychological IPV incident in the year after the arrest. This could be due to psychological IPV being more difficult to define and identify.

Policy implications: This study took place after the implementation mandatory arrest laws for IPV, indicating their effect on reducing physical IPV. Further research should be conducted into the effect of mandatory arrest laws as well as how to reduce psychological IPV.

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Firearm-Related Behaviors following Firearm Injury: Changes in Ownership, Carrying and Storage

Investigators: Vivian H. Lyons, Frederick P. Rivara, Alice Ning-Xue Yan, Cara Currier, Erin Ballsmith, Kevin P. Haggerty, Lauren Whiteside, Anthony S. Floyd, Anjum Hajat, Ali Rowhani-Rahbar

Publication: August 2019, Journal of Behavioral Medicine


Using firearm-related behavior survey supplement data from an ongoing randomized controlled trial at Harborview Medical Center, Lyons et al. found that patients with a recent nonfatal gunshot wound (GSW) may change their firearm carrying, storage, ownership, and exposure behavior following the injury. These changes manifested in increasing their safety around firearms (e.g., through safe storage) and increasing their risks for future firearm-related injury (e.g., through increased firearm carrying in public).

Policy implications: The researchers recommend further research on the topic. Additionally, funding should be allocated toward the development of an intervention focused on decreasing risky behaviors and chance of future injury following a nonfatal GSW.

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School Shootings in the U.S.: What Is the State of Evidence?

Investigators: Ali Rowhani-Rahbar, Caitlin Moe

Publication: June 2019, Journal of Adolescent Health


Challenges in defining “school shootings” lead to a variety of databases created based on these disparate definitions (e.g., including shootings at after-hours events, accidental discharges, every instance a gun is brandished regardless of use, etc.). Using the Washington Post database, another study found that 70% of school shootings did not result in a fatality and that the majority of school shootings occurred in non-majority-white schools. An increase in school shootings lead to an increase in school security; however, their efficacy in preventing or deterring school shootings is debatable. Rowhani-Rahbar and Moe recommend future research focus on risk and protective factors as well as policy analysis to reduce the occurrence of school shootings.

Policy implications: Regarding policy, Rowhani-Rahbar and Moe suggest implementing and enforcing firearm policies (e.g., universal background checks) and allocating educational and mental health funding in a public health approach.

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Limiting Access to Firearms as a Suicide Prevention Strategy Among Adults: What Should Clinicians Recommend?

Investigators: Joseph A. Simonetti, Ali Rowhani-Rahbar

Publication: June 2019, JAMA Network Open


In this commentary, the authors provided a review of existing literature to explain that likely the best method of preventing suicide by firearm is to limit access to firearms by storing them locked and unloaded, locked with an external locking device (e.g., trigger lock), or by removing them from the home during a time of crisis. As clinicians are in a unique position of recommending to their at-risk patients various methods to prevent suicide, further research into this topic is important.

Policy implications: Funding should be allocated to such research. Additionally, clinicians should be provided resources on safe firearm storage, where to locate external locking devices, and possible temporary safe storage sites across the state (see Safe Storage Map), among other methods of suicide prevention.

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Intimate Partner Homicide of Adolescents

Investigators: Avanti Adhia, Mary Kernic, David Hemenway, Monica S. Vavliala, Frederick P. Rivara

Publication: April 2019, JAMA Pediatrics


Adhia et al. used 2003 to 2016 data from the National Violent Death Reporting System to identify 2188 homicides of youth aged 11 to 18. One hundred fifty of these deaths were classified as intimate partner homicides. The majority of victims were female (90%) with the average age being 16.8 years old. 77.9% of the perpetrators were over 18 with an average age of 20.6 years old. The perpetrators were less likely to be current intimate partners than in homicides of youth aged 19 to 24. In 61.2% of homicides, firearms were the most common instrument used and handguns were used in 82.6% of these homicides. According to the researchers, the most commonly cited reasons for the homicide are “broken/desired relationship or jealousy and an altercation followed by reckless firearm behavior and pregnancy related.”

Policy implications: Closing the “boyfriend loophole” (i.e., the definition of intimate partner violence does not also include “nonmarried, noncohabitating intimate partners”, which is the most common type of intimate relationship) in state laws that restrict firearm access is recommended to reduce adolescent partner homicides. Additionally, extending civil protection orders to minors may be effective in reducing intimate partner violence for adolescents.

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Validating the National Violent Death Reporting System as a Source of Data on Fatal Shootings of Civilians by Law Enforcement Officers

Investigators: Andrew Conner, Deborah Azrael, Vivian Lyons, Catherine Barber, Matthew Mills

Publication: April 2019, American Journal of Public Health


The researchers compared the National Violent Death Reporting System (NVDRS) to a number of open-source databases to assess its accuracy and completeness in reporting officer-involved homicide of civilians. For the year 2015, NVDRS was linked at the individual level to the, Gun Violence Archive, Mapping Police Violence, The Counted, and the Washington Post officer-involved homicide databases.  Four-hundred-four unique cases in which an officer fatally shot a civilian while on duty were identified in the NVDRS and five databases. Of these 404,390 were found in both NVDRS and an open-source database. Eleven were found solely in an open-source database and three solely found in NVDRS. Through use of an algorithm, an additional nine fatal officer-involved shootings not originally coded as “legal intervention” were identified in NVDRS. An additional 21 homicides were identified in the open-source databases, of which 11 did not co-occur in the NVDRS database.

Conner et al. conclude that NVDRS is a comprehensive data source for “macro-level analyses” for officer-involved shootings.

Policy implications: As NVDRS only collects data from 27 states, expanding coverage to all 50 states and additional territories will allow researchers to study officer-involved shootings in the county more accurately and comprehensively.

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Firearm Injury Research and Epidemiology: A Review of the Data, their Limitations, and How Trauma Centers Can Improve Firearm Injury Research

Investigators: Ashley Hink, Stephanie Bonne, Marc Levy, Deborah A. Kulhs, Lisa Allee, Peter A. Burke, Joseph V. Sakran, Eileen M. Bulger, Ronald M. Stewart

Publication: April 2019, Journal of Trauma Acute Care Surgery


Hink et al. discussed the various data sources for nonfatal firearm injury and their limitations, which are predominantly due to the use of probability estimates, bias or mistakes in administrative coding, lack of comprehensive data collection, and underrepresentation of firearm injuries in the data. While there are accurate sources for studying firearm fatalities (e.g., Centers for Disease Control Web-based Injury Statistics Query and Reporting System and the National Violence Death Reporting System), there is no system dedicated to recording firearm injuries. Additionally, there is no federal database of firearm ownership in the United States and the Bureau for Alcohol, Tobacco, and Firearms is prohibited from maintain an electronic record of firearm ownership, making firearm ownership data next to impossible to study. The limitations in the data available make firearm injuries difficult to study accurately.

Policy implications: The quality and scope of state and federal firearm injury surveillance systems and the data they collect would greatly improve nonfatal firearm injury research. Additionally, developing a complete database of all firearm purchases and making it available to researchers would similarly improve firearms research.

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Long-lasting Consequences of Gun Violence and Mass Shootings

Investigators: Ali Rowhani-Rahbar, MD, MPH, PhD; Doug Zatzick, MD; Fred Rivara, MD, MPH

Publication: April 2019, JAMA Network Open


In this Viewpoint article, Rowhani-Rahbar et al. discussed the myriad negative effects of mass shootings on survivors’ mental and physical health. For example, posttraumatic stress and major depression were prevalent in up to 91% and 71%, respectively, of mass shooting survivors. Rowhani-Rahbar et al. suggest implementing a population-based health care model, in which community-level intervention is linked with personalized health services.

Policy implications:

To address and mitigate the negative effects associated with mass shootings, programmatic funding and further research into mass shootings are recommended.

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Community Engagement and Education

Firearm Injuries: A Community Conversation

Audience: Bellevue Chinese community

Presenters: Erin R. Morgan, Vivian H. Lyons, Avanti Adhia, Brianna Mills, Anne Massey, Sixtine Gurrey


The presenters discussed firearm injury and death in King County and specifically the Bellevue area. Morgan et al. emphasized safe storage of firearms (i.e., firearms should be stored locked, unloaded, and separate from ammunition), engaging children in conversation about firearms and suicide prevention, discussing firearm storage and access with other parents, educating themselves and others on policies related to firearm access (e.g., universal background checks and waiting periods), and pursuing training on how to stop a bleed if an injury were to occur.

Policy implications: Community engagement and education, especially on recent and relevant firearm-related policies, are important components for reducing firearm injuries and death. Adding a fiscal note to pending legislation for community engagement and education is recommended.

Dr. Brianna Mills on Gun Violence Research (Podcast Interview)

Podcast: “Disagreeable Subjects,” 30 minutes

Interviewee: Brianna Mills


During this podcast, Mills highlighted the limitations of available data contributing to the inability to accurately capture the number and rates of firearm injuries and deaths. Mills iterates the need for further research on warning signs and risks of firearm homicide and suicide, the effectiveness of firearm legislation (e.g., safe storage and child access prevention laws), studies conducted using local level data, firearm product safety, differing levels of attention paid to implementation and enforcement of laws, and the life cycle of a firearm (i.e., from manufacture to purchase to use in a firearm injury or death).

Policy implications: To fill in the gaps in the research, collection and management of firearms-related data should be improved. Moreover, allowing researchers’ access to such data and other relevant data sources (e.g., Department of Corrections data) can provide a more holistic perspective of firearm injury and violence.

Link: Dr. Brianna Mills on Gun Violence Research


Would Greater Access to Behavioral Health Care Help Solve the Firearm Suicide Epidemic?

Investigators: Evan Goldstein, Laura Prater, Thomas Wickizer

Conference: October 2020, APHA Virtual Conference

Summary: Firearms account for most intentional self-harm deaths, and many more Americans take their own lives with a firearm each year than are murdered with one. Internationally, the United States firearm suicide rate is estimated to be eight-times higher than the average firearm suicide rate of 22 other high-income countries. Mental illness is an important risk factor for firearm suicide, though the supply of behavioral health treatment services may only have a modest protective effect on firearm suicide. The study examined behavioral health treatment capacity between states and over time and estimated the potential cost of preventing firearm suicide through expanding the behavioral health workforce in select states. In the talk, Goldstein et al. will identify and quantify a relationship between behavioral health treatment capacity and firearm suicide between states and over time.

Policy implications: The researchers will compare the potential costs of preventing firearm suicide through expanding the behavioral health workforce in select states, and finally, they will discuss policy alternatives for protecting communities against firearm violence, including which firearm control initiatives might offer a greater protective effect for reducing firearm suicide.

Youth Suicide by Firearm and Behavioral Health Treatment Capacity: Is Expanding the Workforce Part of a Comprehensive Solution?

Investigators: Thomas Wickizer, Laura Prater, Evan Goldstein

Conference: October 2020, APHA Virtual Conference

Summary: Suicide is the second leading cause of death for Americans aged 10 to 24 and has increased by approximately 50% from 2000 to 2017. Furthermore, across all ages suicide accounts for approximately two-thirds of gun deaths in the US. Firearms make up approximately 5% of suicide attempts but account for about 50% of deaths. This phenomenon can be explained by the firearm suicide mortality rate of up to 90%. While having a prior attempt is a risk factor for future suicide completion, only 5-10% of those with a prior attempt go on to die from suicide. While individuals who make a suicide attempt with a less lethal mode may be steered into the mental health care system, those using a highly lethal mode such as a firearm often never get this opportunity. In this talk, Wickizer et al. will discuss the study, which assessed whether increasing behavioral health workforce capacity would reduce the firearm suicide rate amongst youth. The researchers did not find a significant relationship between youth firearm suicide rates and behavioral health workforce. Consistent with prior literature, they found that restrictive child access prevention laws were significantly associated with a relatively large reduction in youth firearm suicide rates. They will discuss implications from the results of our study, as well as potential solutions.

Policy implications: Passing and strengthening child access prevention laws can help reduce firearm suicide rates in youth.

Differences in Injury Circumstances and Outcomes Between Firearm Injuries Transported Via EMS and Private Vehicle

Investigators: Brianna Mills, E. Miller, B. Feinstein, L. Barnard, C. Counts, T. Rea, M. Sayre, Monica S. Vavilala

Conference: 2019, Society for the Advancement of Violence and Injury Research annual meeting, Cincinnati, OH

Summary: Prior studies suggest higher survival rates when penetrating injuries are transported to hospital via private vehicle instead of emergency medical services (EMS).  The purpose of this study was to identify differences between EMS and non-EMS transports which may contribute to outcome disparity. Our results identify many factors may influence transport mode, several of which are not well-captured by existing data systems. Evaluation of regional EMS policies on patient outcomes must begin with enhancing data sharing and collaboration.

Policy implications: Access to this data can be facilitated by removing barriers and streamlining data sharing/use agreements and data requests with the specific data sources.

Health Affairs Briefing on Violence and Health

Investigator: Brianna Mills

Conference: October 2019, Health Affairs meeting, Washington, D.C.

Summary: Mills presented an introduction to the topic of “violence and health” (summarizing interpersonal violence, including community violence, sexual violence, intimate partner violence, child abuse, elder abuse, and gun violence) at the release event for the thematic issue on Violence and Health. The briefing was attended by approximately 150 attendees, including agency officials, congressional staff, academics, other health care policy professionals, and members of the news media. The briefing was recorded and is available online via the Health Affairs website.

Policy implications: Mills discussed the mental health, chronic health, and acute health effects associated with the various forms of violence, which can have economic implications. Passing legislation to reduce violence and their related social determinants, as well as funding interventions and follow-up care are recommended.