Gun violence is a critical public health and safety concern in the United States. There is considerable variability in policy proposals meant to curb gun violence, ranging from increasing gun availability to deter potential assailants (e.g., concealed carry laws or arming school teachers) to restricting access to firearms (e.g., universal background checks or banning assault weapons). Many studies use state-level variation in the enactment of these policies in order to quantify their effect on gun violence. In this paper, we discuss the policy trial emulation framework for evaluating the impact of these policies, and show how to apply this framework to estimating impacts via difference-in-differences and synthetic controls when there is staggered adoption of policies across jurisdictions, estimating the impacts of right-to-carry laws on violent crime as a case study.

Introduction: Existing research on medical cannabis patients has often overlooked those younger than 21. This study aimed to detail the frequency and rate of pediatric medical cannabis patients in the US using a large patient database. Methods: Utilizing Leafwell Patient Database data from 2019 to mid-2023, we described demographics and qualifying conditions, employing descriptive statistics and chi 2 tests to discern differences between minors (0-17 years) and young adults (18-20 years). We calculated rates per 100,000 population by state. Results: Analyzing 13,855 patients, 5.7% were minors and 94.3% were young adults. Anxiety emerged as the primary self-reported condition for both groups, yet differences were seen for other conditions. Differences were observed by race/ethnicity, health insurance status, residency in adult-use states, and number of reported conditions. Notably, both groups reported a similar average number of conditions. Conclusion: This study underscores demographic distinctions between minor-aged medical cannabis patients and young adults. There is a need for comprehensive clinical research addressing efficacy, safety, and tailored guidelines specific for pediatric medical cannabis patients. Such insights are pivotal for healthcare providers and policymakers in navigating medical cannabis treatment protocols.

Research SummaryWe utilized the synthetic difference-in-difference method to estimate the impact of adopting a permitless Concealed Carry Weapons (CCW) law on rates of assaults, robberies, and homicides committed with a firearm and by other means, as well as weapons arrests, from 1981 to 2019. We stratified permitless CCW laws by whether they previously prohibited violent misdemeanants from obtaining a CCW permit or previously required live firearm training to obtain a permit prior to law adoption. Findings robust to sensitivity analyses suggest that states that lost a training requirement to obtain a CCW permit had 21 additional gun assaults per 100,000 population (SE = 5.2) (32% increase).Policy ImplicationsIn the wake of the Supreme Court's decision in New York State Rifle & Pistol Association, Inc. v. Bruen, states should implement CCW permitting law provisions that may reduce the risk of firearm violence. Requiring live firearm training prior to carry a concealed weapon may attenuate negative health impacts of deregulation associated with permitless CCW laws.

Research on firearm purchaser licensing laws has found population level reductions in firearm-related mortality. Limited research has been conducted specifically examining the impact of these laws among adolescents and emerging adults. We obtained death data from the National Center for Health Statistics from 1990 to 2019. We generated state-year rates of homicide and suicide, stratified by firearm involvement, for decedents aged 15 to 24. We stratified by race and ethnicity (white, Black, and Hispanic) to assess for differential policy effects. We used stacked difference-in-difference and augmented synthetic control modeling to estimate law repeal or adoption. Repeal of firearm purchaser licensing laws was associated with significantly higher rates of firearm homicide and suicide among those age 15 to 24. The adoption of these laws was associated with significantly lower rates of firearm homicide and suicide among this group. These laws are a promising supply-side intervention to reduce firearm mortality among those with elevated violence vulnerability.

Recent studies suggest that medical cannabis laws may contribute to a relative reduction in health insurance costs within the individual health insurance markets at the state level. We investigated the effects of adopting a medical cannabis law on the cost of employer-sponsored health insurance in the United States. We analyzed state-level data from the Medical Expenditure Panel Survey–Insurance Component (MEPS-IC) Private Sector spanning from 2003 to 2022. The outcomes included log-transformed average total premium costs per employee for single, employee-plus-one, and family coverage plans. We utilized the Sun and Abraham (J Econometr 225(2):175–199, 2021) difference-in-difference (DiD) method, looking at the overall DiD and event-study DiD. Models were adjusted for various state-level demographics and dichotomous policy variables, including whether a state later adopted recreational cannabis, as well as time and unit fixed effects and population weights. For states that adopted a medical cannabis law, there was a significant decrease in the log average total premium per employee for single (−0.034, standard error [SE] 0.009 (−238)) and employee-plus-one (−0.025, SE 0.009 (−348)) coverage plans per year considering the first 10 years of policy change compared with states without such laws. Looking at the last 5 years of policy change, we saw increases in effect size and statistical significance. In-time placebo testing suggested model robustness. Under a hypothetical scenario where all 50 states adopted medical cannabis in 2022, we estimated that employers and employees could collectively save billions on healthcare coverage, potentially reducing healthcare expenditure's contribution to GDP by 0.65

Abstract Background Handgun purchaser licensing (HPL) laws mandate individuals to obtain a license from law enforcement before buying a firearm. Research indicates these laws effectively reduce various forms of fatal firearm violence, including homicides, suicides, and mass shootings. Our study sought to assess the impact of HPL laws on non-fatal firearm violence. Methods Utilizing the augmented synthetic control method (ASCM), we estimated the average treatment effect on the treated (ATT) resulting from a full repeal of an HPL law in Missouri (2007), a partial repeal in Michigan (2012), and an adoption on HPL law in Maryland (2013) on firearm injury hospitalizations. We utilized RAND's healthcare cost and utilization project-based dataset from 2000 to 2016 for our outcome variable. We conducted in-time placebo testing and leave-one-out donor pool testing as sensitivity analyses. Results Maryland’s adoption was associated with a statistically significant 32.3% reduction in firearm-related injury hospitalization (FIH) rates (ATT = − 0.497, standard error (SE) = 0.123); Missouri’s repeal was associated with a statistically significant 35.7% increase in FIH rates (ASCM = 0.456, SE = 0.155); and Michigan’s partial repeal showed no statistically significant associations with FIH rates (ATT = − 0.074, SE = 0.129). Sensitivity analyses confirm the robustness of the estimated HPL effects. Discussion HPL laws appear to be protective against hospitalizations for nonfatal firearm injuries. These findings align with prior research indicating that HPL laws are effective in reducing fatal firearm violence. States without such licensing systems ought to consider these robust policies as a means to address firearm violence.

Teenagers in the United States are at the highest risk of crash during the first year of independent driving. Graduated driver licensing (GDL) policies, vehicle choice, and safety technologies all have an impact on teenager safety, yet more needs to be understood about parent and teenager attitudes and beliefs that affect the choices and decisions surrounding these issues. We conducted six focus groups with teenagers enrolled in a driver education program and their parents. A qualitative thematic analysis was undertaken of the responses of these individuals directly experiencing GDL policies and selecting vehicles for the teenagers to drive. We found parents believed there was a high likelihood teenage drivers would crash and were concerned about the associated financial costs. Parents preferred visual cues for determining vehicle safety and had concerns for the impact of safety technologies on teenager driving skills. Teenagers and parents felt that logging 60 h was a measure of the character of a driver rather than an opportunity for mastering driving skills. There was a debate balancing the intrusiveness with the convenience of recording driving through smartphone applications. Teenagers wanted to learn to drive for independence, but parents did not observe actions related to these desires. Attitudes and beliefs about which vehicles were safest were heavily influenced by personal experiences and perceptions, rather than quantitative evidence, with examples of availability-, substitution-, and outcome cognitive biases. By understanding the influence of cognitive biases on driving safety decisions, community-based educational outreach programs could more effectively improve teenager driver safety.

Introduction Cannabis use for medical purposes has surged in the past decade. However, understanding who medical cannabis patients are and their accompanying health issues remains limited. Methods Utilizing Leafwell patient database (LPD) data from 2022, we describe the demographics and top 15 primary qualifying conditions (PQCs) of medical cannabis patients across 32 states of the United States. We employed descriptive statistics and χ2 tests to discern differences in PQCs across age, sex, and race/ethnicity. We describe the self-reported rank-order (1–5) of co-occurring conditions. Results In 2022, there were 81433 new medical cannabis patients registered in the LPD, 93.2% of whom (n=75904) reported a list of the top 15 PQCs. Leading PQCs were chronic pain (n=24340), anxiety (n=20370), and post-traumatic stress disorder (PTSD) (n=8517). The top 15 conditions varied across all demographics (p<0.001). Notably, a lower percentage of Hispanics reported chronic pain as their PQC compared to other race/ethnicities; a higher percentage of those aged <21 years reported insomnia as their PQC compared to older age groups. Anxiety and chronic pain were either the first or second PQC or rank-order second condition. Insomnia was a more common rank-order third condition (n=3597) and rank-order fourth condition (n=1796). PTSD was the leading rank-order fifth condition (n=784). Conclusions This study underscores demographic differences across PQCs among a large sample of medical cannabis patients representing data from 36 states of the US. We note patients often report more than one medical condition, suggesting that the reasons for using medical cannabis may be more complex medically than previously understood.

The United States faces rapidly rising rates of violent crime committed with firearms. In this study, we sought to estimate the impact of changes to laws that regulate the concealed carrying of weapons (concealed-carry weapons (CCW) laws) on violent crimes committed with a firearm. We used augmented synthetic control models and random-effects meta-analyses to estimate state-specific effects and the average effect of adopting shall-issue CCW permitting laws on rates of 6 violent crimes: homicide with a gun, homicide by other means, aggravated assault with a gun, aggravated assault with a knife, robbery with a gun, and robbery with a knife. The average effects were stratified according to the presence or absence of several shall-issue permit provisions. Adoption of a shall-issue CCW law was associated with a 9.5% increase in rates of assault with a firearm during the first 10 years after law adoption and was associated with an 8.8% increase in rates of homicide by other means. When shall-issue laws allowed violent misdemeanants to acquire CCW permits, the laws were associated with higher rates of gun assaults. It is likely that adoption of shall-issue CCW laws has increased rates of nonfatal violent crime committed with firearms. Harmful effects of shall-issue laws are most clear when provisions intended to reduce risks associated with civilian gun-carrying are absent.

In June 2021, Missouri passed the "Second Amendment Preservation Act" (SAPA). Though SAPA passed easily and had gubernatorial support, many Missouri law enforcement agencies, including the Missouri Sheriff's Association, oppose it. Missing from this policy conversation, and deserving of analysis, is the voice of Missouri citizens. Using qualitative interview data and survey data, we explored what if anything Missouri gun owners knew about SAPA and what they perceived its effects would be on gun-related murders, suicides, gun thefts, and mass shootings. Most Missouri gun owners had not heard about SAPA and were ambivalent about its potential effect on gun safety outcomes. Our findings also indicate that respondents' attitudes toward SAPA and the impact of such policy on safety is driven by gun ownership (i.e., primary versus living in a household with firearms), partisan identification, and attitudes toward government firearm regulation.

Background Fatal and nonfatal shootings by police are a public health issue that warrants additional research. Prior research has documented associations between fatal shootings by police and gun ownership, legislative strength scores, and lax concealed carry weapons laws. Despite research on other firearm-related outcomes, little is known about the impact of permit-to-purchase (PTP) laws on shootings by police. We generated counts of fatal and nonfatal OIS from the Gun Violence Archive from 2015 to 2020. We conducted cross-sectional regression modeling with a Poisson distribution and robust standard errors. In addition to PTP, we included several state-level policies that may be associated with shootings by police: comprehensive background check only (CBC-only) laws, concealed carry licensing laws, stand your ground laws, violent misdemeanor prohibitions, and extreme risk protection orders (ERPO). We controlled for state-level demographic characteristics and included a population offset to generate incidence rate ratios (IRR). Findings PTP laws were associated with a 28% lower rate in shootings by police [IRR = 0.72, 95% confidence interval (CI) 0.64–0.81]. Shall Issue (IRR = 1.34, 95% CI 1.17–1.53) and Permitless (IRR = 1.61, 95% CI 1.35–1.91) concealed carry laws and CBC-only laws (IRR = 1.12, 95% CI 1.01–1.25) were associated with higher rates of shootings by police. Stand your ground, violent misdemeanor prohibitions, and ERPO laws were not associated with shootings by police. Conclusions Our study found that PTP laws were associated with significantly lower rates of shootings by police. Removing restrictions on civilian concealed carry was associated with significantly higher rates. State-level firearm policies may be a lever to address shootings by police.

Objective: This paper aims to understand what general practice physicians (GPs) perceive as facilitators and barriers to initiating anticipatory guidance around firearm safety.Methods: We employ qualitative interviewing to have in-depth conversations with 18 GPs. Participants were randomly selected from a national panel of physicians and screened for specialty (general practice or internist), practice setting (not hospital-based), and time spent on direct patient care (80% +). The sample was stratified at the state level by the presence of safe storage or child access protection laws, with half of the participants selected from each stratum.Results: We identify five physician-perceived barriers to providing secure firearm storage counseling, including inadequate screening mechanisms to trigger conversations, physician perceptions of who is at risk for firearm injury, time pressures, concerns about patient receptivity, and a need for training.Conclusion: Prior to focusing on how to have conversations about firearm safety, interventions designed to increase the incidence of physician-initiated guidance need to address the structural issues of why those conversations typically do not occur.Practice implications: Findings indicate the need for revised screening tools and improved physician education as to who is at risk for gun injury and how to best approach firearm safety conversations.

About 1,000 civilians are killed every year by a law enforcement officer in the USA, more than 90% by firearms. Most civilians who are shot are armed with a firearms. Higher rates of officer-involved shootings (OIS) are positively associated with state-level firearm ownership. Laws relaxing restrictions on civilians carrying concealed firearms (CCW) have been associated with increased violent crime. This study examines associations between CCW laws and OIS. We accessed counts of fatal and nonfatal OIS from the Gun Violence Archive (GVA) from 2014–2020 and calculated rates using population estimates. We conducted legal research to identify passage years of CCW laws. We used an augmented synthetic control models with fixed effects to estimate the effect of Permitless CCW law adoption on OIS over fourteen biannual semesters. We calculated an inverse variance weighted average of the overall effect. On average, Permitless CCW adopting states saw a 12.9% increase in the OIS victimization rate or an additional 4 OIS victimizations per year, compared to what would have happened had law adoption not occurred. Lax laws regulating civilian carrying of concealed firearms were associated with higher incidence of OIS. The increase in concealed gun carrying frequency associated with these laws may influence the perceived threat of danger faced by law enforcement. This could contribute to higher rates of OIS.

Objectives. To examine the impact of the California Occupational Safety and Health Administration's (Cal/OSHA's) 2017 workplace violence (WPV) prevention in health care safety standard on nonfatal violent injuries among health care workers (HCWs). Methods. We accessed estimated counts of WPV from the survey of occupational injuries and illness from 2011 to 2019 specific to HCWs. We used the Current Population Survey estimates of HCWs to create rates per 10 000. We conducted a longitudinal panel analysis and a comparative interrupted time-series analysis to examine the change in incidence and in rates associated with California's new standard. Results. Adoption of the 2017 safety standard led to an additional 3.48 reported WPV injuries per 10 000 HCWs in California, or an additional 473 injuries. Sensitivity analyses suggest other injuries did not change in the same period. Conclusions. It appears that the Cal/OSHA standard increased reporting of WPV injuries among HCWs in the first year of its adoption compared with the United States. Mandating reporting of all WPV incidents in the health care setting may be a means to ensure a more complete understanding of this public health problem. (Am J Public Health. 2022;112(11):1668-1675. https://doi.org/10.2105/AJPH.2022.307029).

BACKGROUND:Recent workplace homicide investigations have noted that the Census of Fatal Occupational Injuries (CFOI) has several limitations that reduce our ability to understand who dies as part of a workplace homicide incident. We sought to assess the magnitude of nonworker deaths associated with workplace homicide incidents.METHODS:Using National Violent Death Reporting System (NVDRS) data from 2003 to 2017, we employed a descriptive epidemiological investigation. The counts of worker and nonworker deaths during a workplace homicide incident were ascertained, as well as other characteristics (e.g., gender, age, mechanism of death, and race/ethnicity). We used multiple logistic regression to estimate the relationship between incident characteristics and the odds of having a nonworker death.RESULTS:Across the study period, there were 2,020 workplace homicides. The number of deaths associated with workplace homicide incidents increased 8.2% when considering nonworker deaths (n = 2,186). Including those nonfatally shot as part of a workplace homicide incident increased causalities by 18.2% (n = 2,388). If a firearm was used during perpetration, the odds that a nonworker was killed during a workplace homicide incident increased 3.76 times (95% confidence interval: 2.03, 6.96).CONCLUSION/APPLICATION TO PRACTICE:Considering nonworkers killed as part of workplace homicide incidents is essential to understanding the true magnitude of violence associated with these incidents. Likely, it is the lethality of firearms that greatly increases the likelihood that nonworkers are killed as part a workplace homicide incident. To best understand the epidemiology of workplace homicide incident, we recommend CFOI adopt an incident-based method for coding workplace deaths.

INTRODUCTION:Recent research suggests that COVID-19 associated stay-at-home orders, or shelter-in-place orders, have impacted intra-and-interstate travel as well as motor vehicle crashes (crashes). We sought to further this research and to understand the impact of the stay-at-home order on crashes in the post order period in Connecticut.METHODS:We used a multiple-comparison group, interrupted time-series analysis design to compare crashes per 100 million vehicle miles traveled (VMT) per week in 2020 to the average of 2017-2019 from January 1-August 31. We stratified crash rate by severity and the number of vehicles involved. We modeled two interruption points reflecting the weeks Connecticut implemented (March 23rd, week 12) and rescinded (May 20th, week 20) its stay-at-home order.RESULTS:During the initial week of the stay-at-home order in Connecticut, there was an additional 28 single vehicle crashes compared to previous years (95% confidence interval (CI): [15.8, 36.8]). However, the increase at the order onset was not seen throughout the duration. Rescinding the stay-at-home order by and large did not result in an immediate increase in crash rates. Crash rates steadily returned to previous year averages during the post-stay-at-home period. Fatal crash rates were unaffected by the stay-at-home order and remained similar to previous year rates throughout the study duration.DISCUSSION:The initial onset of the stay-at-home order in Connecticut was associated with a sharp increase in the single vehicle crash rate but that increase was not sustained for the remainder of the stay-at-home order. Likely changes in driver characteristics during and after the order kept fatal crash rates similar to previous years.

Introduction Understanding how the COVID-19 pandemic has impacted our health and safety is imperative. This study sought to examine the impact of COVID-19’s stay-at-home order on daily vehicle miles travelled (VMT) and MVCs in Connecticut. Methods Using an interrupted time series design, we analysed daily VMT and MVCs stratified by crash severity and number of vehicles involved from 1 January to 30 April 2017, 2018, 2019 and 2020. MVC data were collected from the Connecticut Crash Data Repository; daily VMT estimates were obtained from StreetLight Insight’s database. We used segmented Poisson regression models, controlling for daily temperature and daily precipitation. Results The mean daily VMT significantly decreased 43% in the post stay-at-home period in 2020. While the mean daily counts of crashes decreased in 2020 after the stay-at-home order was enacted, several types of crash rates increased after accounting for the VMT reductions. Single vehicle crash rates significantly increased 2.29 times, and specifically single vehicle fatal crash rates significantly increased 4.10 times when comparing the pre-stay-at-home and post-stay-at-home periods. Discussion Despite a decrease in the number of MVCs and VMT, the crash rate of single vehicles increased post stay-at-home order enactment in Connecticut after accounting for reductions in VMT.

OBJECTIVES Using available literature, our aim was to design a firearm safety counseling protocol tool for dementia patients. DESIGN We conducted a literature review on firearm safety counseling by healthcare providers using several databases to inform the creation of our evidence-based protocol. SETTING Roughly 5.7 million Americans currently live with some form of dementia with approximately 60% of persons with dementia (PWD) owning a firearm. The mental deterioration associated with dementia creates an opportunity for firearm abuse, misuse, and injury. Patient and family safety counseling from a healthcare provider is one potential opportunity for reducing the level of danger. This literature review identifies the available clinical guidelines for firearm safety for PWD and creates a firearm safety counseling protocol based on existing literature. PARTICIPANTS: Persons with dementia and their families or care takers. MEASUREMENTS Databases were searched using variations of the terms "Firearms," "Dementia," and "Alzheimer's disease." Studies were included for review if they provided either recommendations or guidelines for healthcare provider's counseling around firearm safety for PWD or their families. RESULTS Search terms yielded 456 articles, of which 12 met inclusion criteria. Using the available literature, we developed a firearm safety counseling protocol that provides measurable means to assess risk and offer harm mitigation strategies for patients and their families. Mitigation strategies are based on Clinical Dementia Rating scale assessment at time of patient interaction and results of risk assessment. CONCLUSION Providing standardized and effective clinical guidelines to healthcare providers who interact with firearm-owning PWD can act as a means to reduce firearm injury and violence. The protocol proposed in this article needs further testing and validation to determine if it will help reduce firearm-related events in PWD.

Statement of Purpose In the U.S., death by suicide is a leading cause of death and was the 2nd leading cause of death for ages 15 to 24 in 2017. Though incomplete, much of the scientific literature has found associations between cannabis use and death by suicide. As 8 states and the District of Columbia now permit recreational sale of cannabis, we sought to evaluate whether cannabis legalization has impacted suicide rates in Washington State and Colorado, the earliest states to legalize. Methods We used a quasi-experimental research design with annual, state-level deaths by suicide data to evaluate the legalization of cannabis in Washington State and Colorado. Outcome data was from the National Center for Health Statistics-Restricted Vital Statistics. We used synthetic control models to construct policy counterfactuals, controlling for time-invariant and time-variant factors as our primary method of estimating the effect of legalization, stratified by age, gender, and mechanism. Results Preliminary results suggest that 3-years post-implementation of recreational sale of cannabis, Washington state saw 2.8% increase in suicides, while Colorado saw a 6.5% reduction in suicides. However, both states saw increases in deaths by suicide among youth age 15 to 24 years (WA=20.2%; CO=14.9%). Additional results will discuss suicide completion stratified by mechanism and gender. Conclusion Preliminary results suggest that the overall effect of recreational cannabis on deaths by suicide is heterogenous. However, as deaths by suicides among 15 to 24-year olds increased post-implementation in both states, states with legalized cannabis, and states considering similar legislation, may need to consider the mental health implications of cannabis legalization for younger users