research paper on gun violence in america

Center for Gun Violence Solutions

• Make a Gift
• Stay Up-To-Date
• Research & Reports

Firearm Violence in the United States

• National Survey of Gun Policy
• The Public Health Approach to Prevent Gun Violence

Firearm violence is a preventable public health tragedy affecting communities across the United States. In 2021 48,830 Americans died by firearms—an average of one death every 11 minutes. Over 26,328 Americans died by firearm suicide, 20,958 die by firearm homicide, 549 died by unintentional gun injury, and an estimated 1,000 Americans were fatally shot by law enforcment. 1,2 In addition, an average of more than 200 Americans visit the emergency department for nonfatal firearm injuries each day. 3 

For each firearm death, many more people are shot and survive their injuries, are shot at but not physically injured, or witness firearm violence. Many experience firearm violence in other ways, by living in impacted communities with high levels of violence, losing loved ones to firearm violence, or being threatened with a firearm. Others are fearful to walk in their neighborhoods, attend events, or send their child to school. In short, firearm violence is public health epidemic that has lasting impacts on the health and well-being of everyone on this country. 

Overwhelming evidence shows that firearm ownership and access is associated with increased suicide, homicide, unintentional firearm deaths, and injuries. These injuries and deaths are preventable, through evidence-based solutions. 

Firearm Ownership 

Firearms remain embedded in American history and modern culture. Americans own 46% of the world’s civilian-owned firearms and U.S. firearm ownership rates far exceed those of other high-income countries. 4,5 Forty-six percent of U.S. households report owning at least one firearm, including 30% of Americans who say they personally own a firearm. 6,7 Firearm ownership varies significantly by state. For example, an estimated 64% of households own a firearm in Montana compared to only 8% in New Jersey. 8   

It has been well-documented that firearm ownership rates are associated with increased firearm-related death rates. Among high-income countries, the United States is an outlier in terms of firearm violence. The U.S. has the highest firearm ownership and highest firearm death rates of 27 high-income countries. 9

The firearm homicide rate in the U.S. is nearly 25 times higher than other high-income countries and the firearm suicide rate is nearly 10 times that of other high-income countries. 10 

The Geography of Gun Violence

Gun death rates vary widely across the United States due to differences in socio-economic factors, demographics, and, importantly, gun policies. In general, the states with the highest gun death rates tend to be states in the South or Mountain West, with weaker gun laws and higher levels of gun ownership, while gun death rates are lower in the Northeast, where gun violence prevention laws are stronger.

* The total number of gun homicide deaths in New Hampshire and Vermont were less than 10 and thus repressed by CDC. Gun homicide deaths are thus listed as “other gun death rate” for these two states. Additionally, “other intents” include legal intervention, unintentional, and unclassified.

Firearm purchases increased during the COVID-19 Pandemic

During the COVID-19 pandemic firearm sales rose at unprecedented levels with an estimated one in five U.S. households purchasing a firearm from March 2020 to March 2022. 11 The FBI reported a record high of 20 million annual firearm sales in both 2020 and 2021, up from an average of 13 million firearms sold from 2010 to 2019. 12  

Knowing the Facts About Firearm Ownership and Safety  

Over four decades of public health research consistently finds that firearm ownership increases the risk of firearm homicide, suicide, and unintentional injury. Nevertheless, more than 6 in 10 Americans believe that a firearm in the home makes the family safer—a figure that has nearly doubled since 2000. 13 This increase in perceived safety is reflected in shifting reasons for firearm ownership. In a 2023 Pew Research survey, more than two-thirds (71%) of firearm owners cited protection as a major reason for ownership. 14 This represents a notable increase from the mid-1990s, when the majority of American firearm owners cited recreation as their primary reason for ownership and fewer than half owned firearms primarily for protection. 15 

Research runs counter to these changing public perceptions of firearms providing safety.  It shows that firearm ownership puts individuals and their families at higher risk of injury and death. Individuals who choose to own a firearm can mitigate many of the risks associated with ownership by always storing their firearms unloaded and locked in a secure place, and refraining from carrying their firearms in public places. 

Firearm owners can make their homes safer through secure firearm storage practices. Unfortunately, the majority of U.S. firearm owners choose to leave their firearms unlocked, allowing children or persons, who are at risk for violence to self or others, to access them. 16 An estimated 4.6 million children live in households with at least one firearm that is loaded and unlocked. 17 These unsafe storage practices lead to countless suicides, homicides, and unintentional injuries by individuals who should not have access to a firearm. This includes children, prohibited persons with a history of violence, and family members who may be suicidal or temporarily in crisis.   

Leaving firearms unsecured also fuels theft—a primary avenue in which firearms are diverted into the illegal market and used in crime. There are an estimated 250,000 firearm theft incidents each year resulting in about 380,000 firearms stolen annually. 18 In recent years, as more Americans carry firearms in public, theft from cars has skyrocketed. Firearms stolen from cars now make up the majority of thefts. In fact, one analysis of crime data reported to the FBI found that on average, at least one firearm is reported stolen from a car every 15 minutes. 19 

Carrying firearms in public also increases the risk for violence by escalating minor arguments and increasing the chances that a confrontation will become lethal. Research has found that even the mere presence of a firearm increases aggressive thoughts and actions. 20 

Some believe that carrying a firearm will act as a deterrent and help prevent conflicts or minimize harm. While there are specific examples where this was true, there are many more cases where firearm carrying escalates conflict and leads to firearm injury or death. In aggregate, research shows firearm carrying increases levels of violent crime. 21  

It’s important for individuals to know the risks of firearm ownership, and the reality that higher levels of firearm ownership and carrying do not reduce violence or enhance public safety.  

How does access to firearms affect deaths? 

Higher levels of firearm ownership and permissive firearm laws are associated with higher rates of suicide, homicide, violent crime, unintentional firearm deaths, and shootings by police.  

More than 55% of all firearm deaths are suicides. 22 Evidence consistently shows that access to firearms increases the risk of suicide. 23,24 Access to a firearm in the home increases the odds of suicide more than three-fold. 25 Firearms are dangerous when someone is at risk for suicide because they are the most lethal suicide attempt method. Eighty-five percent of suicide attempts with a firearm are fatal compared to the most widely used suicide attempt methods, which have case fatality rates below 5%. 26 

Research shows that individuals often do not substitute means for suicide if their preferred method is not available. In other words, when individuals who have planned a suicide by firearm cannot access a one, they often not do attempt suicide by another method. 27 Even if they substitute firearms with another method they increase their chances of survival because virtually every other method is less lethal than firearms. 28 Delaying a suicide attempt can also allow suicidal crises to pass and lead to fewer suicides. Ninety percent of individuals who attempt suicide and survive do not go on to die by suicide. 29 The use of a firearm in a suicide attempt often means there is no second chance. Reducing access to lethal means, such as firearms, is critical to saving lives.  

Policies and practices that temporarily restrict access to someone at elevated risk for suicide can save lives. These interventions include Extreme Risk Protection Orders, safe and secure firearm storage practices, and lethal means safety counseling.  

Homicide and violent crime 

Over 40% of all firearm deaths are homicides. 30 Access to firearms—such as the presence of a firearm in the home—is correlated with an increased risk for homicide victimization. 31 Studies show that access to firearms in the household doubles the risk of homicide. 32 States with high rates of firearm ownership consistently have higher firearm homicide rates. 33   Firearms drive our nation’s high homicide rate, accounting for 8 out of every 10 homicides committed. 34    

Lax public carry laws which allow individuals to carry firearms in public places with little oversight are linked to increases in firearm homicides and assaults. 35 Similarly, states with permissive firearm laws have higher rates of mass shootings. 36 Firearms also contribute to domestic violence with over half of all intimate partner homicides committed with firearms. 37 A women is five times more likely to be murdered when her abuser has access to a firearm. 38  

Firearm homicide is a complex issue that includes different types of firearm violence—domestic violence, community violence, and mass shootings—and requires an array of policies. These policies include: firearm purchaser licensing laws which build upon universal background checks, firearm removal laws, safe and secure storage laws, community violence intervention programs, and strong public carry laws. 

Unintentional Shootings 

Each year more than 500 people are killed and thousands more are injured by unintentional shootings, also commonly referred to as accidental shootings. 39,40  

Easy access to unsecured firearms increases the risk of unintentional injury and death by firearm. Children are often impacted by unintentional firearm injuries by gaining access to an unsecured firearm owned by a parent. In fact, every six days a child under the age of 10 is killed by an unintentional shooting. 41  

Laws that promote safe and secure firearm storage practices can prevent unintentional shootings. For example, state Child Access Prevention laws, which hold gun owners accountable if a child accesses an unsecured firearm, are linked to reductions in unintentional shootings among children and teens and may also reduce unintentional shootings among adults. 42,43   

Shootings by Police 

Each year, more than 1,000 people are shot and killed by police officers, and thousands more are injured. 44,45 Black people are disproportionately impacted by this physical violence. Unarmed Black people are over three times more likely to be shot and killed by police compared to white people. 46 

Permissive firearm laws are associated with increases in shootings by police. Specifically, research finds that state permitless concealed carry laws increase shootings by police by 13%. 47 Conversely, strong state firearm laws, like Firearm Purchaser Licensing laws, are linked to reductions in shootings by police. 48 

Better data on police-involved injuries and deaths are sorely needed. Compulsory and comprehensive data collection at the local level, reporting to the federal government, and transparency in public dissemination of data will be critical for understanding this unique kind of firearm violence and developing evidence-based solutions to minimize police-involved shootings. 

1. Davis A, Kim R, & Crifasi CK. (2023).  A Year in Review: 2021 Gun Deaths in the U.S. Johns Hopkins Center for Gun Violence Solutions . Johns Hopkins Bloomberg School of Public Health. 

2. Tate J, Jenkins J, & Rich S. (2021). Fatal Force.  Washington Post . 

3. Schnippel K, Burd-Sharps S, Miller T, Lawrence B, Swedler DL. (2021). Nonfatal firearm injuries by intent in the United States: 2016-2018 Hospital Discharge Records from the Healthcare Cost and Utilization Project.  Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health .

4. Bangalore S & Messerli FH. (2013). Gun ownership and firearm-related deaths.  American Journal of Medicine.

5. Karp A. (2018). Estimating global civilian-held firearms numbers. Small Arms Survey.

6. One in Five American Households Purchased a Gun During the Pandemic. (2022). NORC at the University of Chicago.  

7. Schaeffer K. (2023). Key facts about Americans and guns. Pew Research Center.  

8. Gun Ownership in America, 1980-2016. (2020). RAND Corporation.

9. Bangalore S & Messerli FH. (2013). Gun ownership and firearm-related deaths.  American Journal of Medicine.  

10. Grinshteyn E & Hemenway D. (2019). Violent death rates in the US compared to those of the other high-income countries, 2015.  Preventive Medicine .

11. One in Five American Households Purchased a Gun During the Pandemic. (2022). NORC at the University of Chicago.  

12. One in Five American Households Purchased a Gun During the Pandemic. (2022). NORC at the University of Chicago. 

13. McCarthy J. (2014). More than six in 10 Americans say guns make homes safer. Gallup.  

14.  Doherty C, Kiley J, Oliphant B, Hartig H, Borelli G, Daniller A, Van Green T, Cerda A, Gracia S, and Lin K. (2023). For most U.S. gun owners, protection is the main reason they own a gun. Pew Research Center.  

15. LaFrance A. (2016). The Americans who stockpile guns.  The Atlantic . 

16. Webster DW, Vernick JS, Zeoli AM, and Manganello JA. (2004). Association between youth-focused firearm laws and youth suicides.  JAMA Network .

17. Miller M and Azrael D. (2022). Firearm storage in US households with children.  JAMA Network . 

18. Hemenway D, Azrael D, and Miller M. (2017). Whose guns are stolen? The epidemiology of gun theft victims.  Injury Epidemiology.   

19. O’Toole M, Szkola J, and Burd-Sharps S. (2022). Gun thefts from cars: the largest source of stolen guns. Everytown Research and Policy. 

20. Benjamin Jr AJ, Kepes S, and Bushman BJ. (2018). Effects of weapons on aggressive thoughts, angry feelings, hostile appraisals, and aggressive behavior: A meta-analytic review of the weapons effect literature.  Personality and Social Psychology Review.    

21.  Donohue JJ, Aneja A, & Weber KD. (2019). Right‐to‐carry laws and violent crime: A comprehensive assessment using panel data and a state‐level synthetic control analysis.  Journal of Empirical Legal Studies.

22. Three-year average, 2019-2021. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death.  

23. Anglemyer A, Horvath T, and Rutherford G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis.  Annals of Internal Medicine.

24. Siegel M and Rothman EF. (2016). Firearm ownership and suicide rates among US men and women, 1981–2013.  American Journal of Public Health . 

25. Anglemyer A, Horvath T, and Rutherford G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis.  Annals of Internal Medicine.

26. Harvard T.H. Chan School of Public Health. (2000). Lethality of suicide methods: Case fatality rates by suicide method, 8 U.S. states, 1989-1997.  

27. Daigle MS. (2005). Suicide prevention through means restriction: Assessing the risk of substitution. A critical review and synthesis.  Accident Analysis and Prevention .

28.  Lethality of suicide methods . Means Matter. Harvard T.H.Chan School of Public Health. 

29. Owens D, Horrocks J, & House A. (2002). Fatal and non-fatal repetition of self-harm. Systematic review.  British Journal of Psychiatry . 

30. Three-year average, 2019-2021. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death. 

31,32. Anglemyer A, Horvath T, and Rutherford G. (2014). The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis.  Annals of Internal Medicine. 

33.  Siegel M, Ross CS, and King C. (2014). Examining the relationship between the prevalence of guns and homicide rates in the USA using a new and improved state-level gun ownership proxy.  Injury Prevention .

34. Three-year average, 2019-2021. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death.

35. Doucette ML, McCourt AD, Crifasi CK, & Webster DW. (2023). Impact of changes to concealed-carry weapons laws on fatal and nonfatal violent crime, 1980–2019.  American Journal of Epidemiology .

36. Reeping PM, Cerdá M, Kalesan B, Wiebe DJ, Galea S, and Branas CC. (2019). State gun laws, gun ownership, and mass shootings in the US: Cross sectional time series.  British Medical Journal . 

37. Zeoli AM, Malinski R, & Turchan B. (2016). Risks and targeted interventions: Firearms in intimate partner violence.  Epidemiologic Reviews .

38. Campbell JC, Webster D, Koziol-McLain J, Block C, Campbell D, Curry MA, Gary F, Glass N, McFarlane J, Sachs C, Sharps P, Ulrich Y, Wilt SA, Manganello J, Xu X, Schollenberger J, Frye V, & Laughon K. (2003). Risk factors for femicide in abusive relationships: Results from a multisite case control study.  American Journal of Public Health . 

39. Three-year average, 2019-2021. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death. 

40. Barber C, Cook PJ, Parker ST. (2022). The emerging infrastructure of US firearms injury data.  Preventive medicine . 

41. Three-year average, 2019-2021. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death.

42. Webster DW, Starnes M. (2000). Reexamining the association between child access prevention gun laws and unintentional shooting deaths of children.  Pediatrics . 

43. DeSimone J, Markowitz S, Xu J. (2013). Child access prevention laws and nonfatal gun injuries.  Southern Economic Journal.

44.  Kaufman EJ, Karp DN, and Delgado MK. (2017). US emergency department encounters for law enforcement-associated injury, 2006-2012.  Jama Surgery . 

45, 46. Tate J, Jenkins J, & Rich S. (2021). Fatal Force.  Washington Post . 

47. Doucette ML, Ward JA, McCourt AD, Webster D, Crifasi CK. (2022). Officer-involved shootings and concealed carry weapons permitting laws: analysis of gun violence archive data, 2014–2020.  Journal of urban health.

48.  Crifasi CK, Ward J, McCourt AD, Webster D, Doucette ML. (2023).The association between permit-to-purchase laws and shootings by police.  Injury epidemiology.

Support Our Life Saving Work

MAKE A GIFT

Search form

• Find Stories
• For Journalists

Image credit: Getty Images

Reducing gun violence: Stanford scholars tackle the issue

After 19 children and two teachers were slaughtered by a gunman at Robb Elementary School in Uvalde, Texas, many Americans are asking, yet again, how to prevent future acts of senseless violence from occurring. What gun laws need to be changed? Why is it so difficult to pass regulations? How can Second Amendment rights be balanced with firearm safety? 

Stanford scholars have been studying these issues from a range of perspectives, including law, politics, economics, and medicine. Here are some of their findings.

Update: May 25, 2022: This story was originally published on Feb. 26, 2018, and has been updated to include new content.

Causes, impacts of gun violence

Uncovering the causes of gun violence has been a challenge, in part because research is limited by federal legislation that constrains research funding on the issue. Scholar Nigam Shah at the Stanford School of Medicine has written about how this has affected empirical study. But that has not deterred scholars from examining its impacts. David Studdert, also at the School of Medicine, has studied the devastating consequences of gun violence, particularly the risks it poses to public health.  

Maya Rossin-Slater, an associate professor of medicine and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR), has also looked at the long-term impact of gun violence, specifically among American children who experienced a shooting at their school. Rossin-Slater found that they have higher rates of absenteeism, lower high school and college graduation rates, and by their mid-twenties, earn lower incomes.

Below is some of that research. 

Californians living with handgun owners more than twice as likely to die by homicide, study finds

Residents who don’t own a handgun but live with someone who does are significantly more likely to die by homicide compared with those in gun-free homes, research shows.

New study of gun violence in schools identifies long-term harms

Research from SIEPR’s Maya Rossin-Slater finds that students exposed to school shootings face “lasting, persistent” adversity in their educational and long-term economic outcomes.

Shirin Sinnar on the Buffalo shooting, hate crimes, and domestic terrorism

In the wake of the Buffalo shooting, Stanford Law School’s Shirin Sinnar discusses the scale of white supremacist violence in the U.S. and the rise of hate crimes.

Disconnect: The gap between gun violence and research in numbers

Gun violence is much discussed but little studied, largely due to federal decisions governing research funding. A new analysis highlights just how big the gap between the violence and our knowledge of it is. The answer? It’s huge.

Supporting students exposed to school shootings

Maya Rossin-Slater talks about her research into the mental health impact of severe school violence.

Panel discusses how shootings affect those unscathed by bullets

A panel of faculty members at the School of Medicine said shootings can affect the mental health of people close to the violence.

California handgun sales spiked after two mass shootings

In the six weeks after the Newtown and San Bernardino mass shootings, handguns sales jumped in California, yet there is little research on why – or on the implications for public health, according to a Stanford researcher.

Mass shootings: Public face of a much larger epidemic

While mass shootings have become the public face of gun violence, they account for less than 1% of the 40,000 firearm deaths each year.  

Short-term hospital readmissions for gun injuries cost $86 million a year

A study from Stanford researchers has found that readmissions account for 9.5% of the $911 million spent annually on gun-injury hospitalizations.

Supporting children through loss

Rabbi Patricia Karlin-Neumann talks about how to help young people experiencing grief.

Firearm injuries in children, teens costly for U.S. health care system, Stanford study finds

The average cost of initial hospitalization to treat pediatric gun injuries is about $13,000 per patient and has risen in recent decades, a Stanford Medicine study found.

Investigating psychiatric illnesses of mass shooters

Ira Glick and his collaborators studied the psychiatric state of 35 mass shooters in the United States who survived the incidents, which took place between 1982 and 2019.

The silent cost of school shootings

SIEPR’s Maya Rossin-Slater finds the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred.

New study analyzes recent gun violence research

Consensus is growing in recent research evaluating the impact of right-to-carry concealed handgun laws, showing that they increase violent crime, despite what older research says.

Handgun ownership associated with much higher suicide risk

Men who own handguns are eight times more likely to die of gun suicides than men who don’t own handguns, and women who own handguns are 35 times more likely than women who don’t.

Advice on how to cope with the threat of school shootings

Victor Carrion offers advice on how families can cope with the stress of school safety.

Reducing gun violence

Many Americans are demanding practical steps to reduce gun crime. One way is to have more stringent gun safety policies, such as legislation requiring guns to be stored safely, more stringent background checks, or as President Biden announced Tuesday, a federal ban on assault weapons and high-capacity magazines. 

Research has shown that states with tighter policies save lives: One study by Stephanie Chao found that states with stricter gun laws have lower rates of gun deaths among children and teenagers, and states with child prevention access laws are linked with fewer gun suicides in this age group.

“If you put more regulations on firearms, it does make a difference,” said Chao, assistant professor of surgery and senior author of the study. “It does end up saving children’s lives.” Her analysis found that states with the strictest laws had a mortality rate of 2.6 per 100,000 and for states with the least strict laws, mortality rate was almost double at 5.0 per 100,000.  

John Donohue: One tragic week with two mass shootings and the uniquely American gun problem

In a Q&A, Stanford Law School gun law expert John J. Donohue III discusses mass shootings in the U.S., the challenges facing police when confronting powerful automatic weapons and the prospect of gun safety laws.

Lax state gun laws linked to more child gun deaths

States with strict gun laws have lower rates of gun deaths among children and teenagers, and laws to keep guns away from minors are linked with fewer gun suicides in this age group, a Stanford study found.

Improved gun buyer background checks would impede some mass shootings, Stanford expert says

Stanford Law Professor John Donohue says a background check system that was universal and effectively operated could impede gun acquisition by people who commit mass shootings.

How to solve more gun crimes without spending more money

Simple tweaks to how police process bullet casings could dramatically improve their forensic data.

Reducing civilian firepower would boost police and community safety, Stanford expert says

In addition to restricting the firepower a person can amass, Stanford law Professor John J. Donohue advocates efforts to build trust between communities and law enforcement agencies as a way to enhance both police and citizen safety.

Stricter gun laws reduce child and adolescent gun deaths, Stanford study finds

Laws that keep guns away from young people are especially strongly linked to lower rates of gun suicides in youth.

Gun legislation and policy

For nearly three decades, law Professor John Donohue III has studied what can be done to prevent gun violence in the United States. A lawyer and economist, Donohue explores how law and public policy are connected to gun violence, including how gun laws in the U.S. compare to other countries, as well as how legislation varies across the states, to better understand the effect that has on rates of violence. 

“The U.S. is by far the world leader in the number of guns in civilian hands,” Donohue explained . “The stricter gun laws of other ‘advanced countries’ have restrained homicidal violence, suicides and gun accidents – even when, in some cases, laws were introduced over massive protests from their armed citizens.” 

Here are some of his findings, and other research related to legislating gun safety in the U.S.

Stanford’s John Donohue on guns, mass shootings and the law in the U.S.

On Nov. 30, American students were once again the victims of a school shooting. Stanford law Professor John Donohue discusses the case and gun violence in the U.S.

How U.S. gun control compares to the rest of the world

While deaths from mass shootings are a relatively small part of the overall homicidal violence in America, they are particularly wrenching. The problem is worse in the U.S. than in most other industrialized nations. And it’s getting worse.

4 gun control steps U.S. needs now

John Donohue pens an opinion piece for CNN laying out four steps the United States should take to strengthen gun legislation.

Violent crime increases in right-to-carry states

Stanford Law School Professor John Donohue found that states that adopted right-to-carry concealed handgun laws have experienced a 13 to 15 percent increase in violent crime in the 10 years after enacting those laws.

Another mass shooting: An update on U.S. gun laws

In a Q&A, John Donohue discusses gun safety law and legislative developments.

Stanford GSE holds teach-in on research into gun violence in schools

Education scholars look at the evidence behind policy ideas to address school shootings.

Will Americans ever think differently about guns?

Stanford medicine and law professor David Studdert thinks more public health evidence is needed before cultural attitudes around gun safety and violence will change.

Subscribe or renew today

Every print subscription comes with full digital access

Science News

Mass shootings and gun violence in the united states are increasing.

The United States is the only country with more civilian-owned firearms than citizens

Law enforcement officers look at a memorial following a mass shooting at Robb Elementary School on May 26, 2022, in Uvalde, Texas, where 19 students and 2 adults were killed. 

Brandon Bell / Staff / Getty Images News

Share this:

By Nikk Ogasa

May 26, 2022 at 6:00 pm

On May 24, at an elementary school in Uvalde, Texas, 19 children and two teachers were killed by a shooter. Just 10 days earlier, a white gunman was accused of a racially motivated shooting in a grocery store in Buffalo, N.Y., that left 10 Black people dead. These tragic incidents are among the latest mass shootings to rattle the United States, the only country with more civilian-owned firearms than citizens .

Sadly, mass shootings — the definitions of which vary — are just a fraction of the story. In the United States, gun violence incidents are on the rise. In 2021, nearly 21,000 people were killed by firearms (not including suicides), according to the Gun Violence Archive , an online database of U.S. gun violence incidents. That’s a 33 percent increase from 2017, the year that firearm-related injuries usurped motor vehicle crashes as the most common cause of death among children and adolescents. 

In that same time frame, active shooter incidents nearly doubled. The FBI designates an active shooter as “one or more individuals who are engaged in killing or attempting to kill in a populated area.” In 2021, 61 such incidents in the United States killed 103 people. In 2017, the number of incidents was 31, though deaths totaled 143.

“I can’t think of an issue that requires more urgency and attention,” says Sonali Rajan, a school violence prevention researcher from Columbia University. “Gun violence is a solvable problem.”

Active shooters

Data collected by the FBI reveal a steady increase over the past 20 years in active shooter incidents, which the Bureau defines as “one or more individuals who are engaged in killing or attempting to kill in a populated area.”

In 2020, the U.S. Centers for Disease Control and Prevention and the National Institutes of Health awarded a combined $25 million in grants for research on gun violence prevention, ending a 25-year paucity of federal funding in the field ( SN: 5/3/16 ). During that decades-long financial drought, research on gun violence prevention relied on funds from private foundations and state grants. 

One of the few state-funded institutions in the country is the New Jersey Gun Violence Research Center at Rutgers University in Piscataway. The center conducts interdisciplinary research on the causes and prevention of gun violence, including homicides and suicides. Richard Barnes, the center’s assistant director, manages research projects that focus on suicide prevention and how social disparities relate to violence in Black and brown communities

Science News spoke with Barnes and Rajan about U.S. gun violence, ways to help reduce it and what research is needed. The following conversations have been edited for length and clarity.

SN : What recent trends in gun violence in the United States stand out to you?

Rajan: Gun violence as a problem has only gotten worse over the past several years. There are on average about 100,000 Americans who are shot with a firearm every single year and an estimated 40,000 of those individuals die from their firearm-related injuries. [These numbers include suicides.] In the last couple of years, that number has gone up. 

Barnes: In the last two years, during the pandemic, there was a significant surge in gun purchasing. And we’ve seen increasing rates of homicides and interpersonal violence in our cities across the country. 2021 was a record-breaking year, with the most gun deaths period, including suicide. It was also record-breaking in the sense that a lot of Black and brown communities throughout the country experienced a significant increase in gun violence. [According to the CDC, the nearly 35 percent increase in overall firearm homicides from 2019 to 2020 – rising from 4.6 to 6.1 deaths per 100,000 people – hit Black communities particularly hard.] 

This American problem of gun violence is significant, and I’m hoping soon that we are able to distance ourselves from this trend of increased gun violence, which is so devastating.

SN : Why is gun violence so much worse in the United States than in so many other countries?

Barnes: We have to consider our unique difference in terms of gun ownership. We have way more guns than a lot of other countries. And where you have a lot of firearms, you are going to have more gun violence. 

Gun ownership

The United States has more than twice the number of guns per 100 people than any other country, data from the Small Arms Survey show. With 120.5 firearms per 100 residents, that means there are more guns in the United States than people. 

SN : What does research suggest can help reduce gun violence?

Barnes: Again, where there are more firearms, there is more gun violence. So the first thing to consider is access to firearms. I’m not advocating that we shouldn’t have firearms, but that’s one way.

We also have violence interruption organizations ( SN: 11/4/19 ). Their role is to work locally with other organizations — a lot of times they work with law enforcement — to gather information about the effectiveness of outreach programs and do their best to prevent and intervene in those skirmishes that might lead to gun violence. We know that when those organizations run right, they can have an impact on reducing gun violence. It really focuses on and encourages investment in public safety within those communities. That’s not a cheap course of action, it takes resources. And it’s been really difficult to get those needed resources for folks in the community, and also the research.

SN : Does increasing police presence help quell gun violence? 

Rajan : Increasing police is not a solution to gun violence. There is no evidence that that works. In fact, I think it’s important to underscore that police violence is a form of gun violence. Rather than increasing funding to the police, there are a number of things that we could do, such as investing in communities and in schools in ways that are far more effective at deterring gun violence.

SN: In the wake of the Texas school shooting, there’s been talk about increasing campus security and arming teachers . Is that effective? 

Rajan: There’s actually evidence that shows that criminalizing a school space [by increasing police presence] is hugely detrimental both for children and their learning outcomes, and it also disproportionately impacts children of color in very negative ways. That to me is a really good example of our school districts investing lots of money into practices that are not doing anything productive, and may in fact be having unintended negative consequences.

In the context of schools, there are a lot of things that actually have no evidence to support their effectiveness: metal detectors, zero tolerance policies, anonymous threat reporting systems and arming teachers with firearms. There is absolutely no scientific evidence that any of these kinds of safety strategies are actually effective at deterring gun violence in a school.

Rising gun violence

In 2021, there were nearly 21,000 gun-related deaths in the United States, not counting suicides. That’s a 35 percent increase from just two years earlier, and part of an ongoing rise in U.S. firearm deaths, data from the Gun Violence Archive show.

SN : What kind of research is needed to reduce gun violence?

Barnes: [At the New Jersey Gun Violence Research Center], we’re speaking to people who have owned a firearm illicitly within the last five years. Our question is very different from the criminal question, which is where you get your firearms from. That question is fine, but we’re aiming to better understand the lived experience of illicit firearm owners, to better understand why they own guns. What is it about where they live, how they live and why they think they need a firearm?

I think a lot of times, people discount the lived experience, because they start and end with the question over whether it’s legal to own guns. They don’t ask the question of whether you should own a firearm. But if you’re living in an area that’s dangerous, where people get shot, how are you going to protect yourself, your family, your loved ones? So, we’re trying to answer that question, in hopes of being able to suggest: Here’s some meaningful things that can be done.

SN : What other kinds of information can help prevent gun violence?

Barnes: Social determinants of health are the factors that either contribute or hinder communities from thriving [such as economic stability, social support, education and health care access]. There are so many similarities among communities that are struggling the most from gun violence. I think the conversation around gun violence has to include questions around how much [these social determinants] contribute to or impact what we understand about gun violence. And in particular, the increase or uptick in gun violence.

SN: What is a major misconception in gun violence prevention?

Rajan: That the solution to gun violence is entirely based on gun laws. The gun laws are an extremely important part of the gun violence prevention puzzle. But it is not the only part. We need to think about all of the ways in which we are attending to the health and well-being of children and adults. Like, why would a 14-year-old choose to carry a firearm to begin with? They fundamentally don’t feel safe and we as a society are failing our children. What are the big systemic factors that are driving this level of violence? We need to reimagine what gun violence prevention looks like. 

SN : What challenges do gun violence prevention researchers face?

Barnes: Funding is the biggest one, but also having partners on the ground is important. 

We’re a research institution, so there’s a lot of distrust that needs to be overcome when we enter a community. A lot of Black and brown communities feel like they’ve been poked and prodded, they’ve seen this before. We need to have relationships on the ground that start with trust, to figure out how we can get at some of the questions that may lead to recommendations and prevention methods that work. 

To do that, organizations on the ground need to be funded as well. Because if they go away, it makes it nearly impossible for us to penetrate those communities that have a well-reasoned fear of outsiders, in particular researchers. That’s the only way that you really get under the issue of gun violence in the community.

More Stories from Science News on Science & Society

Separating science fact from fiction in Netflix’s ‘3 Body Problem’ 

Language models may miss signs of depression in Black people’s Facebook posts

Aimee Grant investigates the needs of autistic people

In ‘Get the Picture,’ science helps explore the meaning of art

What  Science News  saw during the solar eclipse

​​During the awe of totality, scientists studied our planet’s reactions

Your last-minute guide to the 2024 total solar eclipse

Protein whisperer Oluwatoyin Asojo fights neglected diseases

Subscribers, enter your e-mail address for full access to the Science News archives and digital editions.

Not a subscriber? Become one now .

An official website of the United States government, Department of Justice.

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock A locked padlock ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

The Fight Against Rampant Gun Violence: Data-Driven Scientific Research Will Light the Way

A data point will not stop a bullet, but evidence-based research grounded in reliable science is a proven pathway for addressing the gun violence crisis in the United States.

For a quarter century, studies supported by the National Institute of Justice (NIJ) have made clear that multifaceted, data-driven, strategic approaches to firearms violence research have the potential to stem gun traffic, cut down on shootings, and save lives. In several communities, they have already done so.

A recent exhaustive study of motivations for gun possession and use by young people in violence-torn sections of three New York City boroughs confirms that fear and the desire for physical safety, more than any criminal inclination, drive young people to carry and use firearms. Another recent NIJ-supported study, made possible by quantum leaps in computing power, has harnessed big data to help measure the impact of socioeconomic factors and specific physical features of an urban environment—like gas stations and overgrown lots—on gun violence.

More new research has examined how delinquent youths’ firearm involvement influences later criminal gun use and their own victimization in young adulthood. And yet another recent NIJ-supported project has helped illuminate the illicit procurement path of guns used in street crimes. The vast majority of those guns come from illegal sources, and the study traced how they move through underground markets, with an eye toward refined interdiction strategies.

On many fronts, the research continues, bolstered by an influx of new federal resources responding to a national gun violence epidemic. A second straight year of surging firearms violence on U.S. streets, leaving thousands dead and many more injured, underscores the magnitude of the task of finding effective policy and practice solutions.

In response, the administration unfurled a comprehensive strategy on gun violence designed to put more police on the streets to fight crime, invest in community policing, fight the inflow of illicit weapons used in crimes, and rebuild police legitimacy and trust in the communities they serve. New initiatives are designed to better address the root social causes of crime, such as poverty, educational inequities, and the lack of jobs and training in urban communities.

Of the many program elements the U.S. Department of Justice will spearhead, a centerpiece is an enhanced Project Safe Neighborhoods (PSN). PSN brings together local, state, and federal law enforcement officials, prosecutors, and community stakeholders. The project’s purpose is to identify the most pressing violent crime issues in an area and collaborate on comprehensive solutions.

PSN is a gun violence abatement tool ready for use today because past federally backed scientific research verified its potential and identified ways to improve. The PSN model was implemented in 2001; a second version, recently adopted, incorporates findings from rigorous evaluation research on the original design. Evaluations of the original PSN model established it as a promising evidence-based crime prevention tool, while identifying areas for improvement.

Both the new insights from recent NIJ-supported research and the lessons distilled from the agency’s research archive point to the foundational role science must play in justice stakeholders’ collective response to street violence. Evidence-based research on who carries guns in high-crime areas, how they get them, and how and where they use them, as well as the personal damage done by firearms, will continue to inform real-world solutions to the gun epidemic and the needs of violence victims.

The research archive also points to the value of gun violence incident reports as a window to solutions. [1] NIJ staff scientists reviewing the archive concluded that incident review teams can significantly advance the understanding of gun violence and help law enforcement identify patterns of people, groups, places, and contexts driving that violence. That approach is particularly effective in understanding how criminal, nonfatal shootings relate to gun homicides, mainly because of insufficient administrative data on nonfatal shootings, according to the research. The lessons drawn from incident reports suggest that criminal, nonfatal shooting analyses should be part of a larger crime reduction strategy. [2] Comprehensive nonfatal shooting data can assist law enforcement in understanding the context of local gun violence and inform policy and practice, the research suggests.

For all the research progress to date, significant gaps persist. Still lacking in the NIJ-supported research literature, for instance, are theoretical generalizations about those circumstances that lead some elements of society to engage in and persist in firearms violence.

This article first selectively focuses on results of more recent gun violence research managed by NIJ, the scientific research, development, and evaluation branch of the U.S. Department of Justice. It then concisely reviews representative lessons gained from NIJ-supported firearms violence research begun in the 25 years from 1991 to 2016, highlighting scientific evaluations of the original Project Safe Neighborhoods and other program models found to be promising against gun violence. It concludes by reflecting on the lessons to be broadly drawn from both micro- and macro-level studies of gun violence. Micro-level research focuses on individuals who perpetrate crimes and victims. Macro-level studies, on the other hand, tend to point to the benefits of, and need for, high-level cross-collaborations that can drive policy and practice reforms and make a systemic impact on gun culture.

Motivations for Gun Possession and Use in NYC

Recent comprehensive research on the motivations of youth who carry and use guns in high-crime New York City neighborhoods offers compelling evidence that fear, not criminal interest, is their motivator.

The study of youth who use guns was unprecedented for a scientific study in the largest U.S. city (by population), in terms of both sample size and the extent of measures taken to build trust between subjects and community-based research staff. It was designed to address the gap in generalizable studies on youth gun culture, a traditionally hidden group.

The research, conducted by the Center for Court Innovation, with results reported in 2020, examined 330 city youth at high risk for gun violence. Subjects had to have owned or carried a gun or been shot or shot at. The study population was 94 percent Black and Latino, and 79 percent lived in public housing. A history of violent victimization was a near-universal experience among study subjects.

Through in-depth interviews of participants, the study established that most possessed or used guns out of a generalized fear of being victimized or a specific fear of retaliation. A history of violence victimization also informed the decision to carry a firearm. Many also reportedly felt a pervasive fear of the state, particularly law enforcement.

In the end, the study report concluded, most participants said they carried guns to increase their feelings of safety. “They held a widespread belief that they could be victimized at any time, and guns served to protect them from real or perceived threats from other gun carriers.”

The study’s parsing of motivations behind young people’s resorting to firearms also plainly supports a conclusion that people of limited means want the same things as people of means and resort to crime to attain them.

On the basis of their findings, the study team recommended specific approaches to working with young people to reduce gun violence. Key recommendations include

• Organizations should bring services to spaces important to youth, such as project courtyards.
• Organizations should hire credible messengers for interactions with youth.
• Community safety strategies that do not involve law enforcement should be adopted.
• Jobs should be created specifically for this youth population, with concrete pathways to jobs that pay a living wage.

Firearm Involvement in Delinquent Youth and Collateral Consequences in Young Adulthood

A team of researchers from the Northwestern University recently examined the association between firearm involvement by youth involved in the juvenile justice system and subsequent firearm violence in adulthood. [3] The research advanced the work of the federally funded Northwestern Juvenile Project, a large-scale longitudinal study of delinquent youth’s lives after detention. That study looked at the gun involvement of nearly 2,000 people who entered the juvenile justice system as adolescents in Cook County, Illinois.

The researchers found that, for the urban sample of Cook County youth who were both arrested and detained, involvement with firearms during adolescence—including victimization—is a significant risk factor for criminal firearm perpetration and ownership during adulthood. The authors concluded that there is a need for programs that target high-risk youth, in addition to targeting the neighborhoods where they live. Expanding prevention and intervention programs for individuals and communities enhances firearm violence reduction efforts when carried out by law enforcement in tandem with the public health system, researchers emphasized.

Underground Markets as a Supply Chain of Guns to People at the Highest Risk of Using Them in Violent Crimes

A study of underground gun markets examined how firearms are funneled to people in Chicago who are at the highest risk of using them in violent crimes. [4] Through the collection and analysis of several unique sources of qualitative and quantitative data, the research team from the University of Chicago Crime Lab determined the following:

• Guns confiscated by the police from gang members tend to be quite old, with an indication that they move through a series of transactions before being acquired by the current owner, according to an examination of crime gun trace data provided to the Chicago Police Department by the federal Bureau of Alcohol, Tobacco, Firearms and Explosives. Most gang guns come from out of state or through intermediaries in the underground market, including straw purchasers, brokers, and traffickers.
• Data derived from semi-structured interviews with 221 males sentenced for gun or weapons charges and incarcerated in Illinois revealed that respondents were extensively involved with guns and violence, albeit virtually none were eligible for an Illinois gun license. Most reported obtaining guns from voluntary transactions involving purchases, trades, loans, gifts, or sharing arrangements with their close and trusted social network. Theft also played a role (7 percent reported stealing a firearm). Ammunition was also mainly acquired from trusted street sources or straw purchases. Guns and ammunition are easy to obtain, the interviews established. Lastly, respondents expressed mistrust of law enforcement and unwillingness to cooperate.
• Another study component examined the details of gun transactions between first sale and last acquisition by someone who used the gun in a criminal act. The study element used structured interviews of key players in gun distribution, including gang members, gun brokers who sell guns to the public, and “gun runners” who move large quantities of guns between areas. The research found that underground gun markets may be thought of as social webs of individuals who play varied, but crucial, roles in the illegal distribution of firearms. The connections are built on familiarity and trust, with individuals often required to provide references to gain entry to the network.
• Notably, although gang cohesion in Chicago was dropping, gangs were becoming more engaged in gun distribution to both gang members and individuals not in gangs.
• Another noteworthy finding was that a resigned attitude about gun violence occurring in a community was most prevalent among those residing outside the community. Those living inside the affected neighborhoods tended to look forward to a positive social change and to actively working toward creating safer neighborhoods.
• The research team also documented the revival of a historic practice, that is, engagement of at-risk individuals in ancillary gun-related activity, such as storing weapons, providing safe spaces for gun transactions, and acting as a lookout for police. These services can enable cash-strapped individuals to obtain immediate off-the-books revenue. Nearly all subjects were unemployed or working part-time in menial jobs.

These findings, the authors concluded, suggest a fundamental shift in the ways that crime guns are acquired. In contrast to the old pattern, when guns were often purchased through federally licensed dealers, it is now very rare for a crime gun to be bought new from a gun dealer in a documented sale. [5] Because other intermediaries in the underground market are now in place—straw purchasers, brokers, and traffickers—it is important for law enforcement to focus on those groups, the research suggests, in order to reduce gang access to guns. Further, by partnering and collaborating with other key stakeholders, law enforcement could advance strategies aimed at reducing gun violence. Building trust between law enforcement and affected neighborhoods will be essential to effective collaboration, the study concluded.

The Built Environment and Gun Violence

Another significant newer study, completed for NIJ in June 2021 by the RAND Corporation, was developed to give cities a new tool for fighting firearms violence through a better understanding of commonalities among the “built environment” (gas stations, overgrown lots, bars, convenience stores, etc.), the socioeconomic traits of a neighborhood population, and violence.

The RAND team sought to build on the established fact that fatal shootings tend to be heavily clustered in urban neighborhoods. The goal was to develop insights on geospatial associations between the built environment and gun violence, a connection previously not well understood due to a lack of adequate data. Powerful new computing capacity and data-sharing capabilities enabled the research team to generate the volumes of data needed for a close analysis of many built features in relation to socioeconomic traits.

One study element of interest, identified as ripe for more research, was local perceptions by community members of the influence of the built environment and socioeconomic factors on gun violence. To that end, in each of four cities—Detroit, Los Angeles, New Orleans, and Pittsburgh—two focus groups of community members were convened to identify those factors that the community members associate with firearm violence and general crime and that urban planners would favor preventive measures to address.

The researchers found dissimilar community views across cities on the relation to the built environment features to firearm crime. For example, participants in Pittsburgh, New Orleans, and Los Angeles discussed violence as a function of poor lighting, but those in Pittsburgh and Los Angeles also associated gun violence with broad daylight. Perceptions differed widely on a number of violence-related factors across the four cities.

There were reported common themes, however. Participants had concerns about overgrowth in lots, lack of lighting, and loitering in all four cities. Participants viewed both isolation and crowded areas as dangerous for different reasons. In all cities, participants associated activities such as prostitution, drugs, and violence with built environment features that lead to firearm violence specifically.

A key implication of the research, given the absence of specific similarities relating violent crime to the built environment, is that there will not be a one-size-fits-all solution. As a result, the research report noted, each city’s separate findings will be important when that city’s urban planners and law enforcement determine how the built environment and socioeconomic factors should inform solutions to gun violence.

Lessons from the NIJ Archive: Collaborative, Multifaceted Programs Built on Data-Driven Research Can Work

Since the 1980s, NIJ has supported scientific evaluations of the effectiveness of programs and policies to reduce firearms violence. Those programs and policies, developed for adoption or enhancement by state and local justice agencies often working with federal partners, have included the following:

• Collaborative strategic approaches to reducing violence through prevention, disruption, deterrence, or a combination of factors.
• Community-based firearm violence prevention and intervention programs.

Findings from 92 identified final study reports, including basic research and program evaluations, and related publications on firearms research supported by NIJ and initiated between 1991 and 2016, were the subject of a recent agency science staff analysis. That review broke down research focus areas by subject and assessed common themes and findings. [6]

On balance, the retrospective review revealed that the more strategic, aggressive approaches grounded in data, research, collaboration, and partnerships are implemented, the fewer instances of firearms-related crimes and homicides are reported. [7]

Challenging Stereotypes

The reviewed research primarily examined the prevalence of firearms among inner-city youth populations at the highest risk of gun violence. Final reports from relevant projects challenged then-common stereotypes regarding gun possession and use by urban youth. One persistent stereotype was the notion that juveniles arm themselves primarily because of the needs of criminal activity, drug trafficking, and gang affiliations. More often, the studies suggested, juveniles seek firearms out of fear rather than criminal need. (The newer New York City study, discussed above, substantially reinforces that conclusion, backed by unprecedented data volume and new research methods creating a critical trust factor for participants.)

An overarching theme of the reviewed scientific studies was that the gun and gang culture gripping U.S. inner cities is largely a function of the social alienation of young people. Guns, drugs, gangs, crime, and violence are all expressions of the pervasive alienation of youth from the conventions of the larger society. The NIJ reviewers also observed a common conclusion among researchers that inner-city youths’ perception of guns as necessary to survival will endure unless attention is given to conditions that promote insecurity and fear and breed feelings such as hostility and hopelessness.

The reviewed catalog of research also shows that illegally acquired firearms are disproportionately related to firearm violence in the United States, as compared to those acquired legally. A shift in the means of acquiring guns by prohibited persons has also been noted. (The newer University of Chicago Crime Lab study, discussed above, substantially reinforces that conclusion.)

Examples of Evaluated Programs That Made Inroads Against Gun Possession and Use

The archival review highlighted research-validated program successes in reducing gun possession and violent crime. A prominent example follows:

Original Project Safe Neighborhoods. Partnerships led by the U.S. attorney in each of the nation’s 94 federal judicial districts to reduce violent crimes by, among other measures, addressing criminal gangs and felony firearm possession.

In May 2021, the U.S. Department of Justice announced a strategy to strengthen Project Safe Neighborhoods by adopting new core principles, including fostering trust and legitimacy in communities, supporting community organizations that help prevent violence, setting strategic enforcement priorities, and measuring results. The announcement emphasized that the project’s goal is to reduce crime and not to increase arrests and prosecutions, as if they were ends in themselves.

In 2012, CrimeSolutions, the online NIJ resource that rates justice system programs and practices on the basis of scientific evaluations, rated the original Project Safe Neighborhoods as “Promising.” The long-standing program has not been evaluated in more than a decade, and the program has changed significantly since then. Currently, an NIJ-funded, rigorous, national evaluation of the enhanced program, with a focus on 10 program sites, is being carried out by RTI International. The research team aims to pin down how Project Safe Neighborhoods affected violent crime across the United States, in individual districts, and in targeted enforcement areas.

Other landmark interventions evaluated through NIJ-funded projects include Operation Ceasefire, the Kansas City (MO) Gun Experiment, and Strategic Approaches to Community Safety Initiative (SACSI). Their promise for reducing gun violence has been established through rigorous evaluations. [8]

Taken as a whole, nearly 100 reports and publications populating the NIJ firearms violence research archive represent both micro- and macro-level examinations of the U.S. gun violence problem. Micro-level research examines individual needs, actions, and impacts in relation to gun violence. At the macro- or community level, research drawing from those individual findings probes the societal implications and impacts of firearms activity as a critical step toward forging collaborative programs and partnerships that can make a lasting difference.

As both the NIJ research archive and newer studies suggest, the criminal justice system is in a unique position to help prevent firearm violence by focusing on high-risk individuals in gun crime-ridden communities. Yet, decades of data-driven research instructs that the justice system must collaborate with other systems, such as urban planning, the public health system, and key community stakeholders contributing to the socioeconomic health of communities, in order to make a lasting impact on street violence.

Micro- and macro-level approaches are equally important to maintaining a scientifically sound basis for advancing gun violence policy and practice. In the end, only evidence-based science on who carries guns illegally, why they carry and use them, and how they get them can produce the answers law enforcement, the justice system, and community groups need to take clear aim at the gun violence crisis.

[note 1] Natalie Kroovand Hipple et al., “ Gun Crime Incident Reviews as a Strategy for Enhancing Problem Solving and Information Sharing ,”  Journal of Crime and Justice  40, no. 1 (2017): 50–67.

[note 2] Edmund F. McGarrell et al., “ The Importance of Nonfatal Shooting Data to Inform Violence-Prevention Policy, Practice, and Research ,”  Translational Criminology  (Fall 2019): 4–6.

[note 3] Linda A. Teplin,  Firearm Involvement in Delinquent Youth and Collateral Consequences in Young Adulthood: A Prospective Longitudinal Study , October 2019, National Institute of Justice. See, also, Linda A. Teplin et al., “ Association of Firearm Access, Use, and Victimization During Adolescence With Firearm Perpetration During Adulthood in a 16-Year Longitudinal Study of Youth Involved in the Juvenile Justice System ,”  JAMA Network Open  4, no. 2 (2021): e2034208.

[note 4] Philip J. Cook, Harold A. Pollack, and Kailey White, “The Last Link: From Gun Acquisition to Criminal Use,”  Journal of Urban Health  96, no. 5 (2019 Oct): 784–791.

[note 5] Philip J. Cook et al., “ Some Sources of Crime Guns in Chicago: Dirty Dealers, Straw Purchasers, and Traffickers ,”  Journal of Criminal Law and Criminology  104, no. 4, Symposium on Guns in America (Fall 2015).

[note 6] The aim of the agency’s historical research review was to assess what has been learned about firearms violence and to identify research gaps yet to be filled. NIJ science staff examined the content of grant solicitations as well as awards from both closed and still-open grants. Forensics and technology-related research on firearms violence was excluded. A limitation on the staff review was a lack of full access to all awards and final reports from the period.

[note 7] Key examined research reports on point are Deborah Azrael, Anthony Braga, and Mallory O’Brien,  Developing the Capacity to Understand and Prevent Homicide: An Evaluation of the Milwaukee Homicide Review Commission , January 2013, National Institute of Justice; Timothy S. Bynum, Eric Grommon, John D. McCluskey,  Evaluation of a Comprehensive Approach to Reducing Gun Violence in Detroit , February 2014, National Institute of Justice; Edmund McGarrell et al.,  Project Safe Neighborhoods – A National Program to Reduce Gun Crime: Final Project Report , April 2009, National Institute of Justice; Edmund McGarrell et al., “Project Safe Neighborhoods and Violent Crime Trends in US Cities: Assessing Violent Crime Impact,”  Journal of Quantitative Criminology  26 no. 2 (June 2010): 165–190; Wesley G. Skogan et al.,  Evaluation of CeaseFire-Chicago , June 2009, National Institute of Justice; Jeremy Wilson, Steven Chermak, and Edmund McGarrell,  Community-Based Violence Prevention: An Assessment of Pittsburgh’s One Vision One Life Program , June 2010, National Institute of Justice; Julie H. Goldberg and William Schwabe,  How Youthful Offenders Perceive Gun Violence , December 2000, National Institute of Justice.

[note 8] Evaluations of the three programs are found at these links:

• Operation Ceasefire
• Kansas City Gun Experiment
• Strategic Approaches to Community Safety Initiative (SACSI)

About the author

Basia E. Lopez is a social science research analyst in the Office of Research, Evaluation, and Technology at the National Institute of Justice. Paul A. Haskins is writer/editor with Leidos, supporting the National Institute of Justice.

Cite this Article

Read more about:.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Front Public Health

Gun Violence in United States: In Search for a Solution

Muni rubens.

1 Health Promotion and Disease Prevention, Florida International University, Miami, FL, USA

Nancy Shehadeh

2 Health Administration Program, Florida Atlantic University, Boca Raton, FL, USA

Introduction

The Navy Yard shooting at Washington DC, with 12 victims and gunman killed, after the deadly Sandy Hook massacre, has again reopened the debate on gun-shooting violence in the United States over the last 15 years; though in reality, a total of 62 episodes in schools and other sites occurred since 1982 ( 1 ). Who could have imagined that Columbine, CO, USA (15 died) in 1999 would fail to be an anomaly and initiate a series of shootings at such schools as Red Lake High School, MN, USA (10 died), Virginia Tech, VA, USA (33 died), Chardon High School, OH, USA (3 died), and Amish School, Lancaster, PA, USA (6 died). These incidences create an unsettling atmosphere for the affected families and the empathetic public. A closer look at mass murders and shooters reveals some trends and possible interventions. Although the events in Newtown, Connecticut raised a renewed dialog on preventing similar tragedies in the future and focused the discussion on the mentally ill, violence in individuals, the ability to access mental health services, gun control, and the association between the media and violence, the shooting at Navy Yard has proven that nothing much has changed.

Theoretical Framework of Social Ecological Model

From the public health perspective, the issue of gun violence could be evaluated based on the theoretical framework of social ecological model (SEM) by the Center for Disease Control and Prevention (CDC) ( 2 ). The SEM uses four levels of influence to describe a framework that identifies factors that either places a person at-risk for or guards them from being subjected to or causing a health problem such as violence. The levels of influence in the SEM structure include the individual or intrapersonal, relationships or interpersonal, community, and society (see Figure ​ FigureA1 A1 in Appendix). Each level represents a key point in the process of violence, and thereby, offers an opportunity to intervene in violence for prevention. The framework also provides a tool to use in evaluation of public health issues of firearm violence.

Components of SEM for Gun Violence Intervention

According to researchers, mental illness fails to be a sufficient reason for mass murder ( 3 ). Many individuals suffer from mental health problems, but fail to commit homicide. An individual’s attributes remain inexplicably complex. Numerous factors converge to create the rare event of public shootings ( 1 ). A more recent review found possible mental issues in individuals going on rampage shootings ( 4 ). The researchers found mental problems to be related to trauma from broken homes with prior physical or sexual abuse, psychotic behavior with symptoms of schizophrenia or schizotypal personality disorders with paranoid delusions and psychopathic behavior of narcissism, a lack of empathy, a lack of conscience, and sadistic behavior. Violence occurred more frequently with individuals with a history of being socially ostracized, exhibiting poor anger management, a fascination with violence, and possessing a strong attraction and easy access to guns. Unfortunately, the perpetrators rarely perceive an individual need for counseling or mental health services.

Individual or intrapersonal level influence

A forensic scientist describes some of these mass murders as “pseudocommandos” who massacre in public, formulate their attack well in advance and arrive with an arsenal of firearms at the scene ( 5 ). Withdrawn demeanor, social isolation, and poor impulse control appear in individuals perpetuating gun violence ( 3 ). The individuals possess a long history of strong feelings of anger and resentment from a lifetime or long interval of collecting injustices. Some mass murderers become preoccupied with themes of violence and death that come to light in writings, drawings, threats, and bullying. The person goes on a highly personal mission to obtain revenge from a rejecting world and this individual leaves a communication of some kind to the public or news media ( 6 ). Providing mental health services to individuals with risks for harming others is an example of intervention at individual or intrapersonal level of SEM.

Relationships or interpersonal level influence

In many of the multiple victim incidents, the perpetrator made comments about an attack to more than one other person before its occurrence, but the information known to the peers or significant others failed to be passed on to an adult or followed up on by a responsible adult. Comments tend to be general in nature such as “something bad is going to happen” rather than explicit threats such as “I’m going to kill you” ( 4 ). Third parties, particularly teachers and family members, usually possess the ability to identify the individual needing help and to locate resources through such organizations as the National Alliance on Mental Illness ( 7 , 8 ). In our opinion, the role of the social networks of peers and individuals could provide relationships or interpersonal level opportunity to direct an individual exhibiting the withdrawn demeanor and hints of a violent tendency into counseling or mental health services.

Community level influence

Knoll advocates teaching compassion, non-violence, and personal responsibility at a young age in order to go beneath the problem and implement primary prevention ( 8 ). The virtue of responsibility requires cultivating the mind during growth and development. We think that both parents and teachers carry an obligation for this training. Organizations such as schools, workplaces, recreational facilities, and other social gathering places implement zero tolerance for violence. These organization are examples of community level opportunities, which can play a pivotal role in diverting these individuals into programs for anger management, counseling or other interventions, and preventing killing sprees ( 9 ).

Society level influence

The media represents a significant communication platform that shapes the viewing or listening audience. One’s perception arises from the images on the television and the internet, photos in blogs and in newspapers, thousands of face-to-face dialogs, emails, and on Twitter and Facebook. Some perpetrators became motivated by news coverage of the infamy of previous homicidal tragedies. The news media exploited the violent and tragic acts of the murderers after the Columbine and Virginia Tech events. However, the media provided an appropriate coverage of Newtown by keeping the public informed and not glorifying or demonizing the wrongdoer ( 8 ). A further positive action by some of the news channels involved using mental health professionals to advise the public on the psychological issues to work through. Offering guidance provides a proactive method to assist teachers, parents, and others directly and indirectly affected by the social disaster ( 10 ). When leadership at the scene provides a key spokesperson to impart factual information in a timely manner to the public, the communication reduces panic and uncertainty. In our opinion, the best approach involves providing open dialog to eliminate misconceptions and reduce anxiety about topics that involve horrendous subjects like the killing of innocent children and adults. Table ​ Table1 1 presents the four levels of influence of SEM with possible interventions and corresponding formative research questions which could be answered.

Social ecological model of influence a .

a Adapted from the framework used by the CDC to address the concept of violence .

Levine and colleagues report the United States homicide rate for 15–24 years old to be 42.7 times higher than in other high-income countries ( 11 ). Firearms represent the mechanism of injury in 83% of the homicides and males commit 86% of the lethal shootings in the United States. Unfortunately, the debate about firearms remains an emotional and political issue with the focus on bans to rapidly firing assault weapons and more back ground checks ( 12 ). The problem continues to be more fundamental than gun ownership and the Second Amendment. A paucity of scientific information exists and prevents sound judgment by the people who need to make the decisions. We think that this major problem exists at the society level due to the lack of research on firearms related to violence. Congress stipulated that no CDC injury-prevention funds or the Department of Health and Human Services funds may be utilized to advocate or promote gun control (Who calls the shots? 2012). Society desperately needs peer-reviewed and evidence based research to address even basic questions about firearm violence registration and licensing of guns to perpetrators of gun violence ( 13 ). The American Academy of Pediatrics supports the funding of research on surveillance of firearm injuries, evaluation of healthcare screening and intervention, and identifying and disseminating violence prevention resources ( 14 ). Politicians need to focus on renewed support for research into gun violence.

Controlling gun violence is a complex and formidable task. It is well established that multi-level approach is needed to end gun violence. We provided some suggestions for policymakers and practitioners based on the SEM. The association between violence and the interaction between different factors, from individual to societal, suggest that addressing risk factors or devising prevention plans across various levels of the SEM may lead to decrease in incidences like Sandy Hook massacre and Navy Yard shooting. However, we acknowledge that implementing all these suggestions at a time is practically impossible. Since we don’t have a false proof mechanism to identify and intervene with people who might be potential culprits, the initial step should be to prevent the weapons getting into the hands of these people. This initial steps could be achieved by changing the social norms on guns and implementing some immediately workable policies ( 15 ). As the norm on the propriety of driving has changed over time, there is no reason to believe that norms about guns will not change. One such norm should be keeping the guns in safe and secure places as many perpetrators used guns which were stolen. Some of the policy changes we recommend are stricter provisions in obtaining gun license and its periodic renewal. In addition, people should undergo rigorous background checks and extensive gun safety trainings before obtaining gun. However, the challenges remain and require long term solutions.

Social ecological model levels (adapted from the framework used by the CDC to address the concept of violence) .

Gun Violence, Prevention of (Position Paper)

Introduction.

Gun violence is a national public health epidemic that exacts a substantial toll on the U.S. society. Gun violence includes homicide, violent crime, attempted suicide, suicide, and unintentional death and injury. According to the Centers for Disease Control and Prevention (CDC), more than 38,000 deaths from firearms (including suicides) occurred in the United States in 2016, 1  and nearly 85,000 injuries from firearms occurred in 2015. 2  That’s an average of 105 deaths and more than 230 injuries from firearms each day. 1,2

In addition to the thousands killed or injured, myriad families must also cope with the consequences of this violence. In terms of the financial toll, although the estimates vary, it’s generally held that gun violence expenses—medical charges, loss of income, daily care/support, and criminal justice expenditures—cost the U.S. economy approximately $229 billion annually. 3

Gun violence should be considered a public health issue, not a political one—an epidemic that needs to be addressed with research and evidence-based strategies that can reduce morbidity and mortality. Gun violence affects people of all ages and races. Family physicians care for victims of gun violence and their families every day. These physicians, who witness the substantial impact firearm-related violence has on the health of their patients, families, and communities, have the power to help improve the safety and wellbeing of those groups.

The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be a key strategy used to prevent future harm and injuries. This approach focuses on three elements: scientific methodology to identify risk and patterns, preventive measures, and multidisciplinary collaboration. 4  The AAFP encourages this public health approach and supports research that identifies which policies and interventions effectively reduce morbidity and mortality, while also respects the Constitutional right to bear arms.

Call to Action The American Academy of Family Physicians joined the American Academy of Pediatrics, American College of Physicians, American College of Obstetricians and Gynecologists, and the American Psychiatric Association urging the president and Congress to take the following three concrete steps to address gun violence:

• Label violence caused by the use of guns as a national public health epidemic.
• Fund appropriate research as part of the federal budget.
• Establish constitutionally appropriate restrictions on the manufacturing and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity. 5

This call to action from physician groups emphasizes the need to treat gun violence as a public health epidemic.

Family physicians can further address gun violence in their practices and communities by following these office- and community-based steps.

Office-based:

• Know the rates of gun violence in your area to help understand the impact on your patient population ( http://www.gunviolencearchive.org/charts-and-maps ). 6
• Ask patients and their families if there are guns in the home. If “yes,” discuss safe storage of firearms and ammunition. Encourage participation in gun safety classes.
• The AAFP  recommends  screening for depression in the general adult population, including pregnant and postpartum women ( https://www.aafp.org/patient-care/clinical-recommendations/all/depression.html ). 7

o   Patients who screen positive should undergo additional assessment that considers severity of depression and comorbid psychological problems, alternate diagnoses, and medical conditions. Patients with depression should be treated with antidepressant medication and/or psychotherapy.

• The AAFP  recommends  that clinicians screen women of childbearing age for intimate partner violence (IPV), such as domestic violence, and provide or refer women who screen positive to intervention services ( https://www.aafp.org/patient-care/clinical-recommendations/all/domestic-violence.html ). 8

o   The presence of guns in the home increases the risk that a woman will die due to an IPV-related homicide eight-fold. 9

Community-based:

• Know the rates of gun violence in your area to better understand the impact on your community ( http://www.gunviolencearchive.org/charts-and-maps ) 6
• Participate in programs that address violence in your community.
• Communicate with your local, state, and federal officials about gun violence as a public health concern. These conversations should specifically address:

o   Funding research to identify effective measures to increase the safety of firearms; o   Gun safety legislation; o   Strict enforcement of current gun laws; o   Constitutionally-appropriate restrictions on the manufacture and sale, for civilian use, of large-capacity magazines and firearms; and o   Appropriate funding for mental health services.

Gun Violence: A Public Health Epidemic Gun violence is a public health epidemic and should be treated accordingly. While mass shootings are horrific and capture the attention of the media, they are only part of the gun-violence picture—more than half of all suicides are firearm-related, 10  and firearms are used in more than 50% of female homicides. 3,11

Similarly to females, firearm-related deaths are a particular threat to children in the U.S. They are the third-leading cause of death in children overall, 1  and the U.S. accounts for more than 90% of all firearm deaths among children in developed, high-income nations. 12

Public health professionals are trained to create and test interventions to reduce death and injury. However, limited federal funding is available to research this leading cause of death. Introduced in 1996, the Dickey Amendment prohibits federal funding allocated to the Centers for Disease Control and Prevention (CDC) be used to advocate for or promote gun control, which essentially ended all CDC funding research on gun violence or gun control measures. 13

Appropriate research funding is the first step to understand gun violence and is essential to develop programs to prevent premature death from guns. An inconsistent collection of epidemiologic data is another impediment to this research. Currently, not all U.S. states report surveillance data to the National Violent Death Reporting System. 14 International Classification of Disease (ICD) codes are often used to collect data on a national scale, but do not provide the same level of detail. Creating a comprehensive data collection surveillance system will provide public health researchers with comprehensive and consistent information to study gun violence.

An example of such a system in place with data to study a public health issue is research on motor vehicle accidents. The number of deaths caused by motor vehicle accidents is comparable to gun violence, but motor vehicle deaths have declined significantly over the past decade despite more motorists on the road. Extensive research has improved motor vehicle safety with multiple evidence-based interventions contributing to decreased mortality. Implementation of vehicle safety features, stricter enforcement of traffic laws, and public awareness campaigns effectively addressed high morbidity and mortality associated with motor vehicles.

The National Highway Traffic Safety Administration (NHTSA) operates with a budget of more than $1 billion annually, and is committed to the continued improvement of the safety of motor vehicles and motorists. 15  Research and development for the agency alone had a budget of nearly $146 million in 2017. 15

Similarly, almost all other leading causes of death, whether accident or disease, receive substantially more funding for research than gun violence. 16  One study found that, “in relation to mortality, gun violence research was the least-researched cause of death and the second-least funded cause of death after falls.” 16  When a similar approach to research on motor vehicle accidents is suggested for gun violence, it is often considered political, instead of an evidence-based, data-driven approach to prevent morbidity and mortality.

As whole-person health care providers, family physicians see the effect of gun violence on their patients and in their communities. Using a public health perspective, family physicians can incorporate evidence-based strategies to treat their patients and guide their communities on this important issue. With that in mind, the AAFP:

• Continues to oppose legislation that would prohibit the CDC and other agencies from conducting and distributing research on gun violence as a public health problem;
• Advocates for systems to allow accurate reporting of surveillance data; and
• Encourages the evaluation and implementation of evidence-based research and approaches that addresses gun violence to improve the health and lives of all patients.

Suicide In 2016, almost 45,000 individuals committed suicide in the U.S. 1  Suicide accounts for nearly 60% of all firearm-related deaths in the U.S., with men overwhelmingly choosing firearms as their primary method to commit suicide. 1 Alarmingly, suicide was the second-leading cause of death for adolescents ages 15-19, with firearms as the leading method of suicide (50.7%) in this age group. 1

Firearms are the most lethal method of attempting suicide. Between 85 to 91% of firearm suicide attempts result in death, compared to 3% or less for other common ways of attempting suicide. 17  Suicide is often an impulsive decision. The majority of those who survived a suicide attempt reported that less than one hour had passed between the time they decided to commit suicide and when they took action. 18  The use of a firearm to commit suicide rarely allows for intervention or reconsideration, so increased access to firearms is associated with increased rates of completed suicide. 19  Evidence suggests unsafe gun storage may also pose a higher risk for committing suicide using a firearm. 19  The impulsive nature of suicide, in combination with often times easy access to guns, can result in a completed suicide—one that might have been preventable if another method had been attempted.

Opportunities for Prevention Reducing the availability of firearms is one of the most effective mechanisms for suicide prevention. Waiting periods for purchasing handguns, mandatory background checks, gun locks, and restrictions on open-carry policies are also associated with a reduction in suicide by firearm. 20

Waiting periods may allow for a “cooling off” time for individuals to reconsider suicide. 17  Background checks limit access by creating a second barrier at the point of purchase. 20  Safely securing guns places a barrier on immediate access and open-carry regulations decreases exposure to firearms. 20  These mechanisms have been shown not only to decrease suicide by firearm, but also to decrease overall rates of suicide (by any method). 20

In addition to decreasing access to firearms, increased access to mental health services is associated with a decrease in overall rates of suicide. 19  The majority of patients with mental health issues access the health care system through primary care physicians. 21  Appropriate access to primary care and payment for mental health services are critical to care for individuals with depression, substance abuse, and other mental illnesses, and can ultimately prevent attempted suicide through firearms and other means.

Domestic Violence Among developed nations, the U.S. has the most gun violence against women. Women are nearly 16 times more likely to die by firearm when compared to other developed nations. 12  The majority of these deaths are the result of intimate partner violence (IPV). For example, in 2015, more than 3,500 women and girls were victims of homicide. More than half of those deaths were related to IPV. 11  These rates are even greater in subgroups defined by race. Non-Hispanic black and American Indian/Alaskan Native women have the highest rates of IPV-related homicide. 11

Compared to homes without guns, households with guns are associated with a nearly three-fold increase for the risk of homicide occurring in the home. 22  There is a nearly eight-fold increased risk associated with gun ownership and homicide when the perpetrator is the intimate partner or a relative of the victim. 22  If the gun owner has a history of domestic violence, the risk of homicide is 20 times higher. 22  Women who are physically abused by current or former partners are seven times more likely to be murdered if the partner owned a handgun compared to women whose partner does not own a handgun. 9

Opportunities for Prevention A proven strategy to protect women from IPV-related homicides includes reducing the availability of firearms. The AAFP recommends screening all women of childbearing age for IPV, and referring women who screen positive for IPV to intervention services. 8  A step that family physicians can take after a positive assessment for IPV is to refer female patients to organizations which have resources for crisis intervention and counseling, and finding safe housing, medical care, and legal advocacy. 11

Intimate partner violence is higher in communities experiencing severe disadvantage, such as poverty and low-social cohesion. 23  System-level changes to reinvest in communities of poverty can reduce violence of many forms, including IPV-related homicide. Legislative policy change is an essential component to the reduction of IPV-related homicide.

Restricting firearm purchases for individuals convicted of domestic violence-related crimes or under a domestic violence-related restraining order is an effective way to prevent IPV-related homicide. 24  States with systems to screen for restraining orders prior to firearm purchases have an 8-19% reduction in all IPV homicides and a 9-25% reduction in the rate of IPV homicide with a firearm. 25  However, these safeguards must apply to all purchases to be effective. Currently, federal law only requires background checks for firearm purchases with licensed dealers. 19 Firearms purchased through unlicensed sellers and at gun shows, commonly referred to as the “gun-show loophole,” do not require a background check, allowing for individuals with a history of domestic violence unfettered access to guns. States requiring universal background checks on handgun sales from all sources experienced a 47% reduction in victims of IPV-related firearm homicide. 26

Homicide and Violent Crime with a Firearm In 2016, there were more than 14,400 homicides with a firearm, accounting for nearly three-quarters of all homicides. 1  In contrast to IPV, the majority (80%) of homicide victims are men. 1

In the U.S., individuals are 25 times more likely to be killed by a firearm than in other high-income nations. 12 Disparities exist across racial and ethnic lines, as well. Non-white individuals are more likely to die by homicide than whites. For individuals 10-29 years, homicide is the leading cause of death in non-Hispanic blacks and Hispanics. 27 This is substantially higher than non-Hispanic whites, where homicide is the fifth-leading cause of death. 27

Opportunities for Prevention Not surprising, a lack of research has resulted in a scarcity of evidence regarding prevention of homicide and violent crime. Limited evidence suggests that reducing access to illegal guns through programs that have demonstrated success can reduce homicide and violent crime rates. One program implemented in Baltimore used a system of “hot-spotting,” where detectives were placed in areas at high risk for gun violence. Between 2007 and 2012, areas of “hot spotting” experienced a 12-13% reduction in homicides and an 18-20% reduction in shootings. 28

Background checks may also contribute to decreased rates of both homicide and overall violent crime. 19  Moderate evidence suggests a decrease in violent crime with mental health background checks. 19  However, much of this data is reported voluntarily by states and may vary depending on which conditions prohibit gun ownership. 19  It is important to note that there is evidence that certain policies may actually increase violent crime. There is moderate evidence that stand your ground laws increase rates of homicide, and some evidence that states with concealed carry laws see increased rates of violent crime. 19

Mass Shootings Given no standard definition of “mass shooting,” data on the subject, as well as mass murder is inconsistent. After the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, the U.S. Congress defined “mass killing” as “3 or more killings in a single incident.” 29  This definition does not include information about the weapon(s) used, the number of perpetrator(s), or the location of the shooting. Mass murder is defined by the Federal Bureau of Investigation (FBI) as a “multiple homicide in which four or more victims are murdered, within one event, and in one or more locations in close geographical proximity.” 29  This does not include injuries, nor is this a formal definition used for data collection purposes. Developing standard definitions through consensus among researchers will be crucial for quality, consistent research regarding gun violence.

Mass shootings account for only a small portion of gun violence deaths, but generally garner media attention due to the public and horrific nature of the incidents. In recent years, mass shootings have, by and large, been perpetrated by men using assault-style, semi-automatic weapons, often modified to mimic fully-automatic versions via high-capacity magazines and “bump stock” technology. These shootings have occurred in public places, such as schools, nightclubs, churches, and music venues.

Opportunities for Prevention While a lack of research hinders the development of evidence-based strategies to prevent mass shootings, even small changes—banning modification devices, such as bump stocks and high-capacity magazines—could potentially reduce the number of injuries and deaths that occur.

Congress’s 1994 assault weapons ban, which included 18 types of assault weapons, weapons with military-style features, and weapons with high-capacity magazines (10 or more bullets), lapsed in 2004. In that 10-year period, “gun massacres” (six or more gun deaths) declined compared to the decade prior.

From 2004-2014, after the assault weapons ban lapsed, the number of gun massacre deaths during the ban (89) increased more than three times (302). Also, the number of gun massacre incidents during the ban (12) nearly tripled (34) during the same 10-year period. 30

Unintentional Death and Injury by Firearm Unintentional deaths and injuries by firearms are largely preventable. In 2016, 495 people died from unintentional firearm incidents. 1  Of those, 127 (25.7%) were children and adolescents (0-19 years). 1  Most of those deaths were among two age groups: 15-19 years (53 deaths) followed by 0-4 years (23 deaths). 1  Young adults (20-24 years) had the most deaths by age group, with 68 unintentional firearm deaths. 1

Unintentional injury by firearm also disproportionately affects adolescents and young adults. Of the 17,311 unintentional injuries by firearm in 2015, nearly 8,000 (50%) occurred in individuals between 15-29 years. 2  The rate of unintentional injury by firearm was the highest among individuals between 20-24 years (21.9). 2

Opportunities for Prevention Research suggests clinical interventions and public health campaigns focused on safe storage are effective at preventing unintentional injuries and deaths by firearms. 19  One study found that family physicians and pediatricians who ask patients (mostly those with children) about access to firearms, and are counseled on safe storage and provided a free safe storage device, it results in increased safe storage behaviors. 19  Another study, following the same protocol without a providing a free safe storage device, also found improvements in safe storage of firearms. Safe storage of firearms decreases immediate access to guns, especially for children. 19  Child access prevention (CAP) laws are designed to protect children by legally prosecuting adults who intentionally or carelessly create situations in which children have unsafe and negligent access to guns. 19

These laws often mandate safe storage of firearms, and some states stipulate that firearms must be unloaded when stored. 19  CAP laws also prohibit providing children with unsupervised, reckless access to firearms. 19  Strong evidence suggests CAP laws decrease firearm-related self-injuries (intentional and unintentional) among all ages, and decrease unintentional firearm injuries and death among children. 19,31  Evidence also suggests that classifying violations of CAP law as felonies may further reduce unintentional death and injuries by firearms among children. 19

Policy Strategies to Address Gun Violence Other potential avenues to address gun violence are consistent with common prevention strategies employed in other public health interventions. Two of the most effective public health strategies employed to reduce tobacco use—price increases and taxation—have proven effective deterrents to initiating tobacco use and encouraging the decline and cessation of tobacco use. 32  Applying this economic strategy to the purchase of firearms could potentially reduce gun ownership, and as a result, decrease gun violence.

For example, background checks for ammunition purchases, limits on ammunition purchases, and identification requirements for firearms, have been shown to reduce firearm deaths. 33  Reinstating the 1994 federal assault weapons ban could decrease access to dangerous semi-automatic weapons. Requiring microstamping—microscopic, laser-generated engravings on guns and ballistic materials—contribute to a higher solve rate for homicides and other violent crimes. 34

Call for Research The AAFP calls for increased research funding on gun violence, and identifying key areas that must be addressed. These areas could begin to be addressed by answering the following questions:

• What specific counseling (regarding gun safety and given by physicians) reduces the likelihood of gun violence?
• Does gun safety training reduce gun violence?
• What policies and interventions (including legal remedies and prevention strategies) reduce gun violence?
• What are the most effective interventions for securing public venues to minimize the risk of mass shootings and minimize resulting casualties?

AAFP Efforts to Address Firearm Safety and Violence Family physicians frequently find themselves on the frontlines on public health issues and discussions. This role provides them an opportunity to address and guide conversations about public health issues, such as gun violence, in both the exam room and their communities. By advancing policies that promote safety and discourage violence, family physicians are instrumental in the gun violence debate.

To assist family physicians in this effort, the AAFP has policies and advocacy efforts relating to violence to help equip family physicians as they serve the needs of their patients. The AAFP recognizes violence as a public health concern, and the impact of violence has on immediate and long-term health outcomes. The AAFP acknowledges that violence occurs in the context of a broad range of human relationships and complex interactions. These encompass social, cultural, and economic risk factors, including but not limited to, the influence of the media, substance abuse, interpersonal violence, fragmentation of family life, and the increased availability of weapons.

Moreover, the AAFP recognizes that violence disproportionately affects vulnerable populations, such as women, children, lesbian, gay, bisexual, transgender, questioning, and intersex individuals, as well as those living in poverty, among other populations. The AAFP has outlined multi-faceted issues surrounding violence in position papers, and describes both the challenges and opportunities for family physicians to address the health consequences, as well as to help prevent a continued cycle of violence.

• Violence Position Paper : This paper discusses the incidence and prevalence of violence, the impact it has on health, causes of violence, and the family physician’s role in preventing violence and serving patients who have been impacted by violence (www.aafp.org/about/policies/all/violence.html).
• Violence as a Public Health Concern : This policy discusses the AAFP’s stance on violence as a public health concern (www.aafp.org/about/policies/all/violence-public-health.html).
• Firearms and Safety Issues: This policy covers the AAFP’s stance on firearms, guns, and violence as a public health issue (www.aafp.org/about/policies/all/weapons-laws.html).
• Prevention of Gun Violence : This policy discusses the AAFP’s stance on background checks as a mechanism to prevent gun violence (www.aafp.org/about/policies/all/prevention-gun-violence.html).

As clinicians, family physicians can help prevent gun violence in their practice and within their communities by proper screening and treatment of depression, screening for IPV, referring patients to appropriate services, and talking with patients about the safe storage and handling of guns.

Outside of the exam room, family physicians can help prevent suicide and intentional injuries and deaths by advocating for gun violence research funding and gun control legislation at the community, state, and federal levels. To gain a better understanding of gun violence and potential solutions, it is essential that the U.S. Congress implements research funding to create evidence-based strategies to combat and prevent gun violence.

Gun violence in the U.S. is a public health epidemic. Using comprehensive, interdisciplinary approaches, and working in collaboration with other public health professionals, family physicians can play an imperative role in the reduction of gun violence.

• Web-based Injury Statistics Query and Reporting System. Fatal injury reports, national, regional and state (RESTRICTED) , 1999 – 2016. Centers for Disease Control and Prevention. Accessed April 2, 2018.
• Web-based Injury Statistics Query and Reporting System. Nonfatal injury reports, 2000 – 2015 . Centers for Disease Control and Prevention. Accessed April 2, 2018.
• Follman M, Lurie J, Lee J, West J. The true cost of gun violence in America . The data the NRA doesn’t want you to see. Mother Jones. Accessed April 2, 2018.
• Institute of Medicine. National Research Council. Priorities for research to reduce the threat of firearm-related violence. Washington, DC. The National Academies Press. Accessed April 2, 2018.
• American Academy of Family Physicians. Physician groups demand action now on gun violence . AAFP joins call for president, Congress to start with three steps. Accessed April 2, 2018.
• Gun Violence Archive. Charts and maps.  Accessed April 2, 2018.
• American Academy of Family Physicians. Clinical preventive service recommendation. Depression . Accessed April 2, 2018.
• American Academy of Family Physicians. Clinical preventive service recommendation. Intimate partner violence and abuse of vulnerable adults . Accessed April 2, 2018.
• Campbell JC, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: results from a multistate case control study. Am J Public Health. 2003;93(7):1089-1097.
• National Center for Health Statistics. Suicide and self-inflicted injury. Centers for Disease Control and Prevention. Accessed April 2, 2018.
• Petrosky E, Blair JM, Betz CJ, et al. Racial and ethnic differences in homicides of adult women and the role of intimate partner violence – United States, 2003-2014. MMWR. 2017;66(28):741-746.
• Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273.
• Jamieson C. Gun violence research: history of the federal funding freeze. Newtown tragedy may lead to lifting of freeze in place since 1996. American Psycholigal Association. Accessed April 2, 2018.
• National Violent Death Reporting System. Violence prevention. Centers for Disease Control and Prevention . Accessed April 2, 2018.
• National Highway Traffic Safety Administration. Budget estimates. Fiscal year 2017. U.S. Department of Transportation . Accessed April 3, 2018.
• Stark DE, Shah NH. Funding and publication of research on gun violence and other leading causes of death. JAMA. 2017;317(1):84-85.
• Brady Center to Prevent Gun Violence. The truth about suicide & guns.  Accessed April 3, 2018.
• Drexler M. Guns & suicide. The hidden toll. Harvard Public Health . Accessed April 3, 2018.
• RAND Corporation. The science of gun policy. A critical synthesis of research evidence on the effects of gun policies in the United States . Accessed April 3, 2018.
• Anestis MD, Anestis JC. Suicide rates and state laws regulating access and exposure to handguns. Am J Public Health. 2015;105(10):2049-2058.
• American Academy of Family Physicians. Mental health care services by family physicians (position paper). Accessed April 3, 2018.
• Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med. 1993;329:1084-1091.
• Beyer K, Wallis AB, Hamberger LK. Neighborhood environment and intimate partner violence: a systematic review. Trauma Violence Abuse. 2015;16(1):16-47.
• Center for Gun Policy and Research. Intimate partner violence and firearms. Johns Hopkins Bloomberg School of Public Health . Accessed April 3, 2018.
• Zeoli AP, Malinski R, Turchan B. Risks and targeted interventions: firearms in intimate partner violence. Epidemiol Rev. 2016;38(1):125-139.
• Everytown for Gun Safety. Guns and domestic violence. Accessed April 3, 2018.
• Web-based Injury Statistics Query and Reporting System. Leading causes of death reports, national and regional , 1999 – 2015. Centers for Disease Control and Prevention. Accessed April 3, 2018.
• Samuels A. Hot spot policing focusing on guns is most effective strategy for reducing gun violence in Baltimore, stud finds . Accessed April 3, 2018.
• Congressional Research Service. Mass murder with firearms: incidents and victims, 1999-2013 . Accessed April 3, 2018.
• Ingraham C. It’s time to bring back the assault weapons ban, gun violence experts say. The Washington Post. Accessed April 3, 2018.
• Dowd MD, Sege RD. Firearm-related injuries affecting the pediatric population. Council on Injury, Violence, and Poison Prevention Executive Committee. Pediatrics. 2012;130(5):e1416-e1423.
• Public Health Law Center at Mitchell Hamline School of Law. Taxation and product pricing. Accessed April 3, 2018.
• Kalesan B, Mobily ME, Keiser O, Fagan JA, Galea S. Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study. The Lancet. 2016; 387(10030):1847-1855.
• Giffords Law Center to Prevent Gun Violence. Microstamping & ballistics . Accessed April 3, 2018.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

Opinion: It’s been 25 years since Columbine. This is what we’re still getting wrong about school shootings

• Show more sharing options
• Copy Link URL Copied!

Twenty-five years ago on April 20, 1999, one teacher and 12 students were shot and killed by two seniors at Columbine High School in Littleton, Colo. Another 21 members of the Columbine school community were injured in this shooting and countless lives devastated. That kind of mass violence — and in a school no less — was unthinkable at the time. Yet the past quarter-century has tragically and frustratingly shown that we have failed to keep schoolchildren safe .

The communities of Newtown, Conn., Parkland, Fla., and Uvalde, Texas, like Littleton, were subsequently forced to contend with the unimaginable. And so too have hundreds of others that have not made the national news despite gun violence in their schools.

Data from the Washington Post allow us to estimate that more than 370,000 K-12 students have been exposed to firearm violence since Columbine. And data my colleagues and I are gathering show that there have been nearly 350 intentional school shootings in K-12 public schools since 2015, meaning these events have taken place during school hours and with a perpetrator’s intent to harm someone else. Firearms are now the leading cause of death among all children and teens in the U.S. and for nearly 20 years prior were the leading cause of death among Black children, reflecting significant disparities that have recently gotten worse .

Op-Ed: I lived through Columbine. Here’s what I have to say to survivors of mass shootings

Our country has mass shootings almost daily. I wish I could tell you after your incident that it will all be OK soon. But that would be a lie.

July 3, 2022

Indeed, 25 years after Columbine — alongside the rise of school shootings and the corresponding rise of a multibillion dollar school security industry — it is the anticipation of firearm violence that overwhelmingly shapes many aspects of a school, including its safety policies, disciplinary strategies, physical layout and budget. Research estimates that $14.5 billion per year is now spent on school resource officers and security guards. And various states have pushed for structural changes such as installing physical barriers around school grounds, implementing bulletproof windows and increasing the use of metal detectors as ways to safeguard campuses. But there is no evidence these efforts work. Moreover, they often take resources away from the kinds of investments children and schools would actually benefit from.

Instead of investing in the meaningful prevention of shootings, schools have been organized around the inevitability of this kind of violence. An increasing number of districts are arming their teachers with firearms, despite the lack of evidence guiding the effectiveness of such policies. Lockdown drills are now ubiquitous in schools across the U.S., and 1 in 4 teachers reported that their school experienced a firearm-related lockdown within the past year.

School shootings shouldn’t be an inevitability, yet schools are forced to treat them like they are. As research has shown, ready access to firearms increases the likelihood of intentional shootings on school grounds. There is also a rigorous evidence base that provides clear guidance as to which specific policy measures could significantly reduce acts of firearm violence in schools: bans on large-capacity magazines , the implementation of safe storage and child access prevention laws and extreme risk protection orders , among others. But over the past 25 years there have been limited efforts by elected officials to implement the policies that we know would have a meaningful effect.

Op-Ed: Why our response to school shootings is all wrong

So many children are dying in school shootings because the U.S. doesn’t focus on prevention. There are ways we can stop these horrific massacres.

May 25, 2022

Encouragingly, and following more than two decades of no federal funding for research on gun violence prevention, Congress is now helping finance this rapidly growing field that is actively contributing additional solutions and insights. New research is highlighting the promise of anonymous reporting systems that allow students to privately provide tips about potential gun violence, as well as the effects of gun-free school zones . It is also showing how school and community investments in public libraries, bystander interventions and universal school-based violence prevention programs, among others, together contribute to safer schools. This groundswell of new science is providing guidance for policymakers to help scale solutions that work.

There is undoubtedly much still to be done. And the best research can only accomplish so much without significant gun safety legislation. But 25 years after Columbine, it’s clear that our nation can do better. Just as the U.S. is making significant strides to “ end cancer as we know it ” and has set the goal for motor vehicle road deaths at zero , a goal must be established for the country to eradicate school shootings. In another 25 years, and hopefully sooner, schools should be spaces free from firearm violence, where all children can thrive.

Sonali Rajan is a professor at Teachers College, Columbia University and the inaugural president of the Research Society for the Prevention of Firearm-Related Harms.

More to Read

25 years after Columbine, trauma shadows survivors of the school shooting

April 18, 2024

Editorial: Some schools are overdoing it with frightening active-shooter drills

Feb. 14, 2024

Abcarian: The pathetic lessons of the Uvalde school shooting in Texas

Jan. 19, 2024

A cure for the common opinion

Get thought-provoking perspectives with our weekly newsletter.

You may occasionally receive promotional content from the Los Angeles Times.

More From the Los Angeles Times

Opinion: California law requires police to fix these bad policies. So why haven’t they?

April 24, 2024

Doris Kearns Goodwin and husband Dick Goodwin lived, observed, created and chronicled the 1960s

Abcarian: Criminalizing homelessness is unconscionable, but is it unconstutitional?

April 23, 2024

Column: The Republican Party can still do what’s rational and right. Here’s the proof

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

• Publications
• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

Gun deaths among U.S. children and teens rose 50% in two years

The number of children and teens killed by gunfire in the United States increased 50% between 2019 and 2021, according to a Pew Research Center analysis of the latest annual mortality statistics from the Centers for Disease Control and Prevention (CDC).

In 2019, before the coronavirus pandemic , there were 1,732 gun deaths among U.S. children and teens under the age of 18. By 2021, that figure had increased to 2,590.

The gun death rate among children and teens – a measure that adjusts for changes in the nation’s population – rose from 2.4 fatalities per 100,000 minor residents in 2019 to 3.5 per 100,000 two years later, a 46% increase.

Both the number and rate of children and teens killed by gunfire in 2021 were higher than at any point since at least 1999, the earliest year for which information about those younger than 18 is available in the CDC’s mortality database .

In the wake of a fatal school shooting in Tennessee on March 27 , Pew Research Center conducted this analysis to find out how gun deaths among U.S. children and teens have changed in recent years. Gun deaths include homicides, suicides, accidents and all other categories where firearms are listed on death certificates as the underlying cause of death. Children and teens are defined as those under the age of 18, while adults are defined as those ages 18 and older.

Data on the annual number and rate of gun deaths among children and teens comes from the WONDER database of the Centers for Disease Control and Prevention (CDC). Crude rates, rather than age-adjusted rates, are used in this analysis because age-adjusted rates are not available when analyzing those under the age of 18. Black, White and Asian children and teens include only those who are single-race and not Hispanic; Hispanic children and teens include those who are of any race.

This analysis also includes data on the estimated number of nonfatal gun injuries sustained by children and teens. This information is drawn the CDC’s WISQARS database , which relies on information collected from a representative sample of U.S. hospitals.

To examine parental worries about their children being shot, Pew Research Center surveyed 3,757 U.S. parents with at least one child younger than 18 from Sept. 20 to Oct. 2, 2022. Most parents who took part are members of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. The survey also included an oversample of Black, Hispanic and Asian parents from Ipsos’ KnowledgePanel, another probability-based online survey web panel recruited primarily through national, random sampling of residential addresses.

Address-based sampling ensures that nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology . Here are the questions asked in this survey , as well as its methodology .

The rise in gun deaths among children and teens is part of a broader recent increase in firearm deaths among Americans overall . In 2021, there were 48,830 gun deaths among Americans of all ages – by far the highest yearly total on record and up 23% from the 39,707 recorded in 2019, before the pandemic.

The total number of gun deaths among children and teens in 2021 includes homicides, suicides, accidents and all other categories where firearms are listed on death certificates as the underlying cause of death. It does not include deaths where firearms are listed as a contributing, but not underlying, cause of death.

Homicide was the largest single category of gun deaths among children and teens in 2021, accounting for 60% of the total that year. It was followed by suicide at 32% and accidents at 5%. Among U.S. adults, by contrast, suicides accounted for a 55% majority of gun deaths in 2021.

In addition to data on gun fatalities, the CDC publishes estimates on nonfatal gun-related injuries sustained by children and teens. In 2020 – the most recent year with available data – there were more than 11,000 emergency-room visits for gunshot injuries among children and teens under the age of 18 – far higher than in other recent years. An exact count is not possible, however, because the CDC’s estimate is based on a sample of U.S. hospitals, not all U.S. hospitals, and is subject to a large margin of error.

Gun deaths are much more common among some groups of children and teens

In the U.S., some groups of children and teens are far more likely than others to die by gunfire. Boys, for example, accounted for 83% of all gun deaths among children and teens in 2021. Girls accounted for 17%.

Older children and teens are much more likely than younger kids to be killed in gun-related incidents. Those ages 12 to 17 accounted for 86% of all gun deaths among children and teens in 2021, while those 6 to 11 accounted for 7% of the total, as did those 5 and under. Still, there were 179 gun deaths among children ages 6 to 11 and 184 among those 5 and under in 2021.

For all three age groups, homicide was the leading type of gun death in 2021. But suicides accounted for a significant share (36%) of gun deaths among those ages 12 to 17, while accidents accounted for a sizable share (34%) of gun deaths among those 5 and under.

Racial and ethnic differences in gun deaths among kids are stark. In 2021, 46% of all gun deaths among children and teens involved Black victims, even though only 14% of the U.S. under-18 population that year was Black. Much smaller shares of gun deaths among children and teens in 2021 involved White (32%), Hispanic (17%) and Asian (1%) victims.

Looked at another way, Black children and teens were roughly five times as likely as their White counterparts to die from gunfire in 2021. There were 11.8 gun deaths per 100,000 Black children and teens that year, compared with 2.3 gun deaths per 100,000 White children and teens. The gun death rate among Hispanic children and teens was also 2.3 deaths per 100,000 in 2021, while it was lower among Asian children and teens (0.9 per 100,000).

There are also major racial and ethnic differences in the types of gun deaths involving children and teens. In 2021, a large majority of gun deaths involving Black children and teens (84%) were homicides, while 9% were suicides. Among White children and teens, by contrast, the majority of gun deaths (66%) were suicides, while a much smaller share (24%) were homicides.

In this analysis, Black, White and Asian children and teens include only those who are single-race and not Hispanic, while Hispanic children and teens are of any race.

Nearly half of U.S. parents worry about their children getting shot

A sizable share of American parents are worried about their kids getting shot. In a fall 2022 Pew Research Center survey , 22% of parents with children under 18 said they were extremely or very worried about any of their children getting shot at some point, while another 23% said they were somewhat worried. Still, more than half said they were not worried about this.

The survey found demographic differences in these concerns. Around four-in-ten Hispanic parents (42%) and about a third of Black parents (32%) said they were extremely or very worried about their children getting shot, compared with smaller shares of Asian (23%) and White (12%) parents.

Parents in self-described urban communities (35%) were considerably more likely than those in rural (19%) or suburban (17%) areas to be extremely or very worried about any of their children being shot. And lower-income parents (40%) were far more likely than middle-income (16%) and upper-income (10%) parents to be extremely or very worried.

Partisan differences were evident, too. Democratic and Democratic-leaning parents were roughly twice as likely as Republican and Republican-leaning parents to say they were extremely or very worried about their children getting shot at some point (27% vs. 14%).

Note: Here are the questions asked in this survey , as well as its methodology .

• Medicine & Health
• Teens & Youth

John Gramlich is an associate director at Pew Research Center

About 1 in 4 U.S. teachers say their school went into a gun-related lockdown in the last school year

Striking findings from 2023, key facts about americans and guns, for most u.s. gun owners, protection is the main reason they own a gun, gun violence widely viewed as a major – and growing – national problem, most popular.

1615 L St. NW, Suite 800 Washington, DC 20036 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Age & Generations
• Coronavirus (COVID-19)
• Economy & Work
• Family & Relationships
• Gender & LGBTQ
• Immigration & Migration
• International Affairs
• Internet & Technology
• Methodological Research
• News Habits & Media
• Non-U.S. Governments
• Other Topics
• Politics & Policy
• Race & Ethnicity
• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of  The Pew Charitable Trusts .

Copyright 2024 Pew Research Center

Terms & Conditions

Privacy Policy

Cookie Settings

Reprints, Permissions & Use Policy