Matthew Miller

Background: The World Health Organization (WHO) emphasizes surveillance of suicide and suicide attempts as a core component of national suicide prevention strategies. Aims: In Sri Lanka, police registers serve as the main source for national suicide reporting. This study evaluated the completeness of police suicide records by linking them with hospital and civil registration data and examining the extent to which suicide deaths identified across these sources were captured in police registers. Method: A secondary analysis was conducted on a case series of suicides identified through a prospective surveillance system established for a randomized controlled trial in Anuradhapura District, Sri Lanka (April 2019–September 2023). Police records were linked with hospital and civil registration data. Sensitivity and 95% confidence intervals (CIs) were calculated overall and stratified by hospital admission status and method of suicide. Results: A total of 663 suicide deaths were identified across the three sources, with 310 reported by all. Police registers recorded 615 deaths, with a sensitivity of 91.0% (95% CI: 86.8%–93.8%) for hospital deaths and 94.0% (95% CI: 91.2%–95.8%) for nonhospital deaths. Method-specific sensitivity was 93.2% (95% CI: 89.1%–95.8%) for pesticide ingestion (n = 237), 70.7% (95% CI: 55.5%–82.6%) for nonpesticide poisoning ( n = 41), 97.3% (95% CI: 94.8%–98.7%) for hanging ( n = 336), and 77.6% (95% CI: 63.6%–87.0%) for other methods ( n = 49). Limitations: Findings are limited to one district and may not be generalizable nationally. Conclusions: Police registers are a largely comprehensive source of suicide data in Sri Lanka, although some cases are missed, particularly for less common methods. This underreporting suggests national suicide rates may be slightly underestimated. In countries lacking a WHO-recommended robust civil registration and vital statistics system, police data remain an important source for suicide surveillance and public health planning.

Importance: Children who live in households with firearms are several times more likely to die by suicide and unintentional firearm injury, compared with those in homes without guns. This risk can be mitigated by locking and unloading all household firearms. Objective: To describe firearm storage practices in homes with children overall and by the age of the youngest child in the household, and to estimate the number of children living in homes with firearms that are loaded and unlocked. Design, Setting, and Participants: A probability-based national survey study was conducted between December 18 and December 25, 2024, in the US. Eligible participants were firearm owners living with children younger than 18 years. Survey weights were incorporated to account for nonresponse and to produce nationally representative estimates. Exposure: Whether a child younger than 13 years lives in the household. Main Outcomes and Measures: The outcome of interest was firearm storage practices in the child’s home, categorized as (1) at least 1 gun loaded and unlocked; (2) no guns loaded and unlocked, but at least 1 loaded and locked or unloaded and unlocked; and (3) all guns unloaded and locked. Results: A total of 879 respondents personally owned a gun, lived in a household with 1 or more children younger than 18 years, and provided full information about storage. Among these gun owners, 65.3% were aged 18 to 44 years, 63.8% were male, and 70.2% lived with children aged 0 to 12 years. An estimated 21.1% (95% CI, 18.3%-24.3%) reported at least 1 gun loaded and unlocked; 34.8% (95% CI, 31.4%-38.3%) that all firearms were unloaded and locked; and the remainder otherwise (ie, neither any guns loaded and unlocked, nor all locked and unloaded). Among gun-owning adults whose children were all aged 13 to 17 years, an estimated 26.1% (95% CI, 20.2%-33.0%) stored at least 1 firearm loaded and unlocked, compared with 17.1% (95% CI, 12.9%-22.2%) of those whose children were all younger than 13 years and 17.4% (95% CI, 11.6%-25.2%) of those with both adolescents and younger children. Extrapolating to the 2024 US population, an estimated 32.3 million children younger than 18 years lived in a household with firearms, of whom 6.7 million (95% CI, 5.7-7.5 million) lived in a household with at least 1 loaded and unlocked gun. Conclusions and Relevance: In this survey study of adult firearm owners who lived in households with children younger than 18 years, more than 1 in 5 reported that at least 1 firearm in their household was both loaded and unlocked, a practice more common when all children in the household were teenagers. More effective approaches to motivating parents to make their firearms inaccessible to both their teenagers and their younger children are needed.

Firearm acquisitions in the United States surged after the onset of the pandemic, with an unprecedented increase in the proportion of adults who became new gun owners. This article reports a nation... Visual Firearm Acquisition and New Exposure to Household Firearms After the Initial Pandemic Purchasing Surge: Results From the 2024 National Firearms Survey Firearm acquisitions in the Un... Background: Firearm acquisitions in the United States surged after the onset of the pandemic. The increase, sustained through at least early 2021, resulted from a modest increase in the proportion ...

Importance: Suicide-prevention interventions often recommend removing firearms from the homes of individuals at elevated risk of suicide or, short of removal, locking and unloading all household firearms. The recommendation to remove firearms is based on strong and consistent evidence. For adults, however, the recommendation to lock firearms is based on few studies with inconsistent findings.Objective: To assess the association between firearm storage practices and suicide method by sex and age.Design, Setting, and Participants: This case-control study investigated decedents aged 15 years or older who lived in a home with firearms in the last year of their life and who died by suicide. Data were from the 1993 National Mortality Followback Survey. Analyses were conducted from June 1, 2024, to March 30, 2025.Exposures: The presence of 1 or more unlocked firearm in the decedent’s residence and/or 1 or more loaded firearm.Main Outcomes and Measures: The main outcome was firearm storage practices by suicide method. Logistic models, including both exposures, compared the relative odds of exposure among decedents who died by firearm suicide vs nonfirearm suicide, adjusted for sex, age, and region of residence at the time of death.Results: Among the 725 individuals who died by suicide (mean [SD] age, 47.1 [19.7] years; 554 males [85.0%]), 606 (83.6%) decedents died by firearm suicide and 119 (16.4%) died by nonfirearm suicide. Adult suicide decedents who used firearms were neither more nor less likely than those who used other suicide methods to have lived in a home where all firearms were locked (odds ratio [OR], 1.15 [95% CI, 0.67-1.95]) or unloaded (OR, 0.78 [95% CI, 0.44-1.36]). Corresponding ORs for locked firearms were 1.29 (95% CI, 0.69-2.44) for men and 0.58 (95% CI, 0.24-1.41) for women; for unloaded firearms, ORs were 0.80 (95% CI, 0.41-1.56) for men and 0.61 (95% CI, 0.25-1.51) for women. Among adolescent and young adult (hereinafter adolescent) decedents aged 15 to 20 years, approximately half (26 of 43 [60.5%]) who died by firearm suicide, but none of the 7 who died by nonfirearm suicide, had lived in a home with unlocked firearms. Among adolescents in households in which all firearms were locked, suicide method was not associated with whether any firearm was unloaded (OR, 1.36 [95% CI, 0.10-18.9]).Conclusions and Relevance: In this case-control study, neither locking nor unloading household firearms was associated with whether adults used a firearm in their suicide. By contrast, adolescents who died by firearm suicide were far more likely to have lived in a household with unlocked firearms than were adolescent decedents who died by nonfirearm suicide methods. Suicide-prevention approaches that aim to reduce suicide mortality, especially for adult subpopulations likely to own firearms, should focus on firearm access rather than storage practices.

Background: Unintentional firearm death (UFD) rates are higher among Black children than among White and Hispanic children. Whether disparities in UFD rates among Black as compared to White and Hispanic children vary by other demographic characteristics or by circumstances is unknown. Methods: Data come from the 32 states contributing to the National Violent Death Reporting System (NVDRS), 2015–2021. Our sample comprises children 0–17 who died from unintentional firearm injuries. Race/ethnicity- and age-specific population data at the state and county level were used to calculate rates. UFD rates were compared within and across race-ethnicity groupings by age, sex, urbanization and across four NVDRS coded circumstances. Urbanization was assigned using a six-level urban–rural classification scheme from the National Center for Health Statistics (NCHS) based on the county in which the fatal injury occured. Findings: Of the 568 UFDs, four-fifths of victims were male (82%) and four-fifths died in a home (84%), usually the Victim’s home (55%). Most deaths involved a child playing with a firearm (63%). Overall, UFD rates were 4.6-fold higher for Black children compared with White children. Black children’s rates were more than 6-fold higher than those of White children for females and for children five to nine years of age, and nearly 8-fold higher for children living in large central metro counties. Conclusions: Black children die from unintentional firearm injury at disproportionately high rates, especially young children living in urban centers. The underlying reasons for these racial disparities are unclear and should be a priority for future research.

For a paper that has not yet been through peer review or even been formally published, William English’s “2021 National Firearms Survey” has been remarkably prominent in gun rights advocacy and scholarship. As of December 2024, it has been cited in roughly sixty-five briefs, invoked at oral argument in the Supreme Court and multiple courts of appeals, and regularly cited in public writings and published academic work. This response is offered in the spirit of a peer review. Our focus is on methodological issues, questionable statistical results, and problematic conclusions. Because of serious methodological issues, English’s draft fails to provide a reliable estimate of the number of annual defensive gun uses, the stock of AR-15s, or the actual protective value of or frequency with which AR-15 type firearms have been used. The paper should not be used as an authoritative source. This version of our paper has been updated to account for the response that Prof. English posted on October 23, 2024.

Background: In assigning manner of death (MOD) for inclusion on death certificates, medical examiners and coroners do not always apply uniform criteria. Previous research indicates surveillance statistics based on death certificates, such as the National Vital Statistics System, grossly miscount unintentional firearm deaths. The National Violent Death Reporting System (NVDRS) has taken steps to reduce variability in manner of death coding by providing uniform criteria for assigning an “abstractor manner of death” (AMD). AMD has five categories: unintentional, suicide, homicide, undetermined, and legal intervention homicide. A previous study found good accuracy of AMD coding for unintentional firearm deaths, all ages, 2003–2006, but a more recent study reported that the NVDRS undercounted self- and other-inflicted unintentional firearm deaths in which both the victim and shooter (for other-inflicted injuries) were under age 15 (2009–2018). Findings: We replicated the recent study’s sample population, identifying 924 NVDRS incidents from 2009 to 2018 in which both victim and, for other-inflicted injuries, shooter age was under 15 and AMD was homicide, suicide, unintentional or undetermined (there were no legal intervention deaths to children). We assigned a researcher-adjudicated MOD (RMD) by reviewing incident narratives. RMD was compared with AMD and with manner recorded on the death certificate. Based on RMD as the gold standard, the sensitivity, specificity, and predictive values positive and negative of the AMD for unintentional childhood firearm deaths were, respectively, 90%, 99%, 98% and 96%; 86% (24/28) of false negatives were coded by abstractors as homicides. By contrast, death certificate manner had relatively poor sensitivity (63%). Conclusions: In our sample of 924 deaths, the abstractor manner of death generally agreed with researcher-adjudicated manner of death, though not perfectly, missing 10% of researcher-adjudicated unintentional deaths, mostly because abstractors coded these unintentional deaths as homicides. A sizable minority of false negatives were unintentional deaths where the narrative explicitly noted that adult negligence contributed to a child’s unintentional shooting death. While AMD coding in NVDRS is good, it could be improved if NVDRS coding guidelines explicitly affirmed that potential prosecution for negligent manslaughter is not a contraindication to an AMD of unintentional, provided the firearm was not used to intentionally harm, threaten, or coerce.