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Official websites use. Share sensitive information only on official, secure websites. Correspondence to Dr. Gun-related violence is a public health concern. This study synthesizes findings on associations between substance use and gun-related behaviors. Most studies found a significant bivariate association between substance use and increased odds of gun-related behaviors. However, their association after adjustment was mixed, which could be attributed to a number of factors such as variations in definitions of substance use and gun activity, study design, sample demographics, and the specific covariates considered. The significant association between nonsubstance covariates e. Particularly, the strength of association between substance use and gun activities tended to reduce appreciably or to become nonsignificant after adjustment for mental disorders. Some studies indicated a positive association between the frequency of substance use and the odds of engaging in gun-related behaviors. Overall, the results suggest a need to consider substance use in research and prevention programs for gun-related violence. Prior studies suggest that the prevalence of gun-related violence is influenced by substance use behaviors 1 , 2. In the past 2 decades, the decline of household firearm ownership rates paralleled the decrease in the rates of firearm homicides and nonfatal firearm victimizations in the United States Figure 1 3 — 7. The most marked decline occurred during the s. The number of firearm homicides decreased from 18, or 7 per , persons in to 10, or 3. During the s, there was also a decline in firearm-related suicide rates. The number of nonfatal firearm victimizations in , or 1. After the major decline, there were fluctuations in firearm ownership rates and firearm-related homicides and injuries during the s and early s, though they largely followed a downward trend. However, the death rates from firearm suicides have increased since In , the household firearm ownership rate was about In , nonfatal firearm victimizations, firearm suicides, and homicide deaths totaled , or 1. Household firearm ownership rate and firearm violence in the United States, — Data were compiled from different sources 3 — 7. From a macro perspective, it was suggested that the decline of gun-related homicides in the s was related to the changes in the crack cocaine market 8. During the mid to late s, there was an increase in the demand for crack cocaine. Guns were acquired by drug dealers who used them for the protection of their lucrative businesses and diffused to other people who used them for self-protection in the larger community, potentially leading to escalated gun violence 8 , 9. Conversely, the shrinking of the crack cocaine market might be one of the factors that was associated with the decline of gun violence in the s 8. This hypothesis was consistent with a number of ecological studies using data for New York City 1 , 2 , Specifically, it was found in these studies that cocaine consumption was positively associated with firearm-related homicide rates. From a micro perspective, psychopharmacological effects of alcohol and drug use may induce or trigger violent behaviors. Compared with less violent forms of death such as poisoning, firearm use is a violent method Acute and chronic alcohol consumption may suppress inhibitions, detect less threat, and produce violent impulses It may impair subjects' executive functioning, leading to incorrect assessment of risks Cocaine and crack cocaine use may trigger paranoid or psychotic symptoms when violence is likely to occur Substance abusers are likely to be involved in more than one type of substances. The joint effects of multiple substances may increase the odds of violent behaviors. The above explanations are consistent with Goldstein's 15 tripartite framework, which states that the link between substance use and gun violence may be psychopharmacological, economically compulsive i. The General Strain Theory posits that people may engage in deviant behaviors or crimes to alleviate negative emotions brought by stressful experiences Building on the General Strain Theory, previous studies have found that either indirect e. In addition to explanations based on a bidirectional causal relationship, the association between substance use and gun activities may also reflect clustering of multiple risk behaviors that may enhance the likelihood of engaging in the violent context 19 — For instance, 4 articles reported different conclusions, although all of them used the — National Comorbidity Survey Replication data set 25 — Casiano et al. Conversely, such an association was not significant, after adjustment for both demographics and other mental disorders 25 , When individual disorders were grouped into broad categories, any substance use disorder was associated with gun threats, even after adjustment for demographics and other disorder categories Sample demographics such as sex, age, and racial composition may also contribute to mixed findings for the associations between substance use and gun activities. Results stratified by sex differed across studies. Anteghini et al. On the other hand, Callanan and Davis 30 didn't find a significant association between drug abuse and suicide by firearm either for men or women. Goldberg et al. Although positive blood alcohol content was not associated with suicide by firearm, Conner et al. Specifically, during young and middle adulthood, positive blood alcohol content was associated with increased odds of suicide by firearm vs. The association between substance use and psychiatric disorders also complicates the interpretation of findings for substance use and gun-related behaviors 25 , Bovasso 25 found that the association between drug abuse and gun threats was suppressed by the introduction of ASPD in the adjusted logistic regression model. Given the diversity in measures and definitions for substance use behaviors and gun-related activities, the aim of this study is to help synthesize findings from previous studies of associations between substance use and gun-related activities. We also reviewed the associations between nonsubstance covariates including demographic characteristics i. We searched through PubMed, Embase, and PsycINFO for observational studies investigating the association between substance-related behaviors, including substance use, abuse, and dependence, and gun-related behaviors. Additional records were identified through reference lists of relevant articles. We excluded 1 review articles, 2 studies without a comparison group e. Records identified through the 3 databases were initially screened for duplication and then by titles, abstracts, and full texts sequentially. After removing duplicates, we excluded irrelevant titles and abstracts primarily on the basis of the 3 inclusion criteria. Full-text files of the remaining articles were retrieved and reviewed systematically. Data from eligible studies were extracted to a standardized form that contains the following information if available : geographical location of the study; study period or year of data collection; sample demographics sample size, mean age, age range, sex, and racial composition ; mental health status of subjects; explanations for measures of substance use and gun-related outcome; and primary results regarding the association between these 2 variables. In cases where multiple types of substance use and gun-related behaviors were examined by the study, we recorded all the information. We further grouped estimated adjusted odds ratios for gun-related outcomes from individual studies by each combination of a substance category and a gun-related behavior type to facilitate comparisons across studies. Studies examining firearm access 35 or possession 36 — 43 were grouped into the first category. The second category included studies investigating gun carrying 29 , 32 , 41 , 44 — Third, gun handling included unsupervised gun handling among adolescents 19 , 49 and households with loaded and unlocked firearms Fourth, gun violence contained studies investigating subjects that actually used a gun including child gun use 51 , gun threat or assault 25 , 26 , 40 , 41 , 52 , 53 , firearm homicide 54 — 56 , and self-inflicted gun injury or suicide 11 , 14 , 57 — They were included in the analysis as broad categories. Other studies used different measures such as positive blood alcohol content 54 , 57 , 64 and alcohol abuse or dependence 25 , A total number of 2, records were retrieved from 3 databases and the reference lists of relevant studies Figure 2. After removal of duplicate records, there were 1, records left for screening. Reading through titles and abstracts identified 1, irrelevant records. Out of full-text articles, did not meet the inclusion criteria. Finally, 66 studies including 45 cross-sectional studies, 19 cohort studies, and 2 case-control studies were included in our review. However, low compliance was found in several items that included using commonly used terms to indicate study design in the title and abstract item 1a , describing efforts to address potential sources of bias item 9 , sensitivity analyses item 12e , and so on. The reporting quality, sample characteristics, and relevant results of each study were summarized in Web Table 2. With 4 exceptions, almost all of the studies included in this review used substance use as an independent variable for gun activity in a multivariate framework. Markowitz 48 used 2-stage least squares to adjust for the bias associated with the possibility of reverse causality or an unobserved factor contributing to the association. Contrary to most studies, the one by Wintemute 43 used firearm-related behaviors as an independent variable for alcohol consumption and found that people who engaged in firearm-related behaviors were more likely to consume alcohol than those who did not. Marzuk et al. Using the California Health Interview Survey, Vittes and Sorenson 42 found that, compared with adolescents who were able to get a handgun within 2 days, those who were unable to get a handgun were less likely to engage in a set of health risk behaviors including various measures of substance use. The majority of measures for bivariate association without adjustment for potential confounders indicated that there was a significantly positive association between substance use and gun activity. However, there were also findings indicating a nonsignificant relationship even without adjustment 46 , 67 — A number of studies compared the results before versus results after controlling for demographic characteristics and other behavioral risk factors. Some found that the association was no longer significant after adjustment 32 , 37 , 38 , 59 , while others showed that the odds ratio estimates decreased but remained statistically significant in some cases 22 , 64 , Both types of studies used multivariate logistic models to control for the covariates. They differed mainly in terms of specific covariates adjusted in the models the covariates for each study were described in Web Table 2. Studies that found no significant association tended to control for more behavioral risk factors than those that did find a significant association. Statistical significance based on P values reported from individual studies was obtained. Where P values were not available, they were calculated by using the formula from Altman and Bland The majority of studies indicated that there was a significant association between heavy drinking and gun carrying. However, the adjusted odds ratios varied substantially across studies. For example, it was found by Bergstein et al. All 3 studies included in Table 1 indicated a significant association between alcohol use and unsafe gun handling after adjustment. Findings regarding the association between alcohol use and gun violence are mixed. Two case-control studies 52 , 58 took population-based random samples from people at risk of being shot to match cases who were actually involved in gun assault or self-inflicted gunshot injury in Philadelphia, Pennsylvania. Branas et al. The study by Branas et al. Using data for adult suicide decedents from the — National Violent Death Reporting System database, Conner et al. Further analyses, though, with a subsample of decedents whose blood alcohol content was equal to or greater than 0. Miller et al. Three studies found that smokers had higher odds of carrying a gun than did nonsmokers. For example, Simon et al. In terms of gun handling, both Miller and Hemenway 49 and Bergstein et al. Using data from the and College Alcohol Study, respectively, Miller et al. On the other hand, Loh et al. The majority of studies found that marijuana users had higher odds of gun carrying than did nonusers. Similar to findings regarding the association between tobacco use and gun carrying, Simon et al. Another 3 studies 20 , 76 , 77 suggested that the odds for marijuana users were 3—4 times the odds for nonusers in carrying a gun. Although Miller et al. Narvaez et al. Two other studies found only a less significant 39 or insignificant 40 association. After adjustment for a number of demographics and personal lifestyle risk factors, Johnson et al. DuRant et al. Vaughn et al. Two of the 3 studies 28 , 78 listed in Table 1 did not find a significant association between drug use in general and access to or possession of guns. Tewksbury et al. Two studies 45 , 82 found that substance use in the past 30 days was associated with increased odds of gun carrying. Other studies listed in Table 1 did not find a significant association between substance use in general and gun-related behaviors after adjustment. The studies included in this review invariably showed that males were more likely to engage in gun-related behaviors than females were. The association between age and gun-related behaviors was less consistent across studies. Two studies 22 , 53 found that older adolescents were more likely to engage in gun-related behaviors than were younger adolescents. Three studies 25 , 66 , 80 used adult samples and found a negative association between age and gun-related behaviors. However, age was found to be positively associated with firearm suicide vs. Findings regarding racial disparities in gun-related behaviors are mixed. It is worth noting that several studies 11 , 53 , 64 , 79 found that blacks had higher odds of involvement in gun-related behaviors than non-Hispanic whites had. The majority of studies reported adjusted measures of association between various types of substance use and gun activity. They differed greatly with respect to the specific mental health conditions adjusted in the models. Mental health conditions, such as post-traumatic stress disorder 32 , 60 , depression 30 , 32 , 60 , 63 , 77 , and anxiety 77 , identified by prior studies were included in this review. The association between a mental health condition and gun violence tended to depend on model specifications. For instance, post-traumatic stress disorder and depression were associated with gun carrying behaviors in bivariate models, but not in the multivariate model The associations between substance use and gun-related behaviors tended to be less significant or insignificant in most of the studies controlling for mental disorders other than substance use disorders 25 , 26 , 30 , 32 , 35 , 59 , 60 , This was particularly true when ASPD was included in a model 25 , 26 , Compared with substance use disorders, diagnosis of ASPD was much more strongly associated with gun-related behaviors 25 , Many studies examined the association between different levels of alcohol consumption and gun-related behaviors. A unanimous finding indicated that binge or heavy drinking was more likely to be associated with heightened risk of gun activity, compared with nonexcessive or light drinking 40 , 44 , 52 , 58 , One study reported a significant association between nonexcessive drinking and gun suicide Most of the studies found a significantly positive association between heavy drinking and gun activity, except for 1 study 53 that didn't find a significant association for either heavy or light drinking. Simon et al. The finding generally indicated a positive association between the frequency of substance use and carrying a handgun. Another study 83 also found that more frequent use of hard drugs was associated with a higher frequency of gun-related victimization. Sevigny and Allen 80 divided drug quantity into 4 quartiles and found that only the fourth quartile was associated with increased odds of gun possession during commission of an offense, compared with the first quartile. Two studies 45 , 82 found that day substance use in general was associated with gun carrying. Without consideration of potential confounders, most of the prior findings indicated that substance use was associated with increased odds of gun-related behaviors. Findings regarding their association were mixed after adjusting for various covariates, such as sociodemographic factors, mental health status, and other behavioral risk factors. The association could hardly be detected, especially when psychiatric conditions were being controlled for. Past studies also suggested a dose-response relationship between substance use and gun activity. It has been found consistently that binge or heavy drinking is more likely to be associated with increased odds of gun activity, compared with nonexcessive or light drinking; and that there is a positive association between the frequency of substance use and gun-related behaviors. As mentioned at the beginning of this paper, violent behaviors may be promoted by psychopharmacological effects of substance use. Gun possession itself is not a violent outcome in the sense that it does not necessarily lead to gun misuse. There was substantial heterogeneity in adjusted odds ratios between studies in each substance group and in almost every subgroup of gun activity. The inconsistent findings could be attributed to a number of factors including variations in definitions of substance use and gun activity, differences in study design, and study-specific sample demographics. There was no clear pattern as to which substance was consistently found to have a stronger association with a specific gun-related behavior. This may be related to the fact that there are high co-occurrences between different types of substance use. Compared with other study designs, the 2 case-control studies 52 , 58 identified a stronger association between alcohol use and gun violence. The strong association between male sex and gun activity is consistent with existing laboratory evidence that the substance-aggression relationship is stronger for men than women 84 — The findings that older adolescents and young adults were more likely to be involved in gun-related behaviors are generally consistent with nonfatal and fatal firearm violence prevalence by age in the United States 4. Persons aged 18—24 years almost always had the highest rate of fatal and nonfatal firearm violence from to In , the firearm homicide death rate was In , the nonfatal firearm violence rate was 5. Historically, adolescents aged 12—17 years had the second highest rate of nonfatal firearm violence from to , in , , and , among the age groups abovementioned. The findings that blacks were more likely to engage in gun activities are consistent with national statistics, which show that the rates of firearm homicide and nonfatal firearm violence are higher among blacks than the other major racial groups examined 4. The strong association between nonsubstance covariates and gun activity may have contributed to varied odds ratio estimates after adjustment. For example, Bovasso 25 found that the association between alcohol abuse and gun threats was suppressed after adding sex into the logistic regression model. A spectrum of mental disorders may have attenuated the association between substance use and gun activity. Both studies were based on the samples from the general population 25 , 26 , and samples from various population subgroups 30 , 32 , 35 , 59 , 60 , 66 indicated that the association between substance use and gun activity was suppressed when mental disorders, especially ASPD, were included in the adjusted analyses. This inclination toward violence may have contributed to the strong association between ASPD and gun-related behaviors. In addion to the observational findings on the association between substance use as well as other psychiatric covariates and gun activities in this review, there has been experimental evidence showing that successful treatment of substance use and mental disorders is likely to decrease the level of aggression and violence in general. For instance, Zatzick et al. Mauri et al. Several randomized clinical trials indicated that behavioral interventions on persons with a substance use disorder improved their outcomes in aggression and violence 90 — This study had several limitations. First, the study data included in this review were subject to measurement errors, especially for studies relying on self-reported data. Delinquency and crimes were likely to be under- or overreported depending on factors such as sex, race, and frequency of arrests Overreporting of arrests may be more likely to happen among adolescents than adults Second, the substantial heterogeneity in study designs, sample characteristics, measures of substance use, gun-related behaviors, and other covariates limits the use of meta-analysis to identify potential sources of mixed findings. Third, as most of the studies included in this review were cross-sectional and the majority of cohort studies identified were retrospective, causality and the direction of causation cannot be inferred. In addition, the screening of search results and data extraction were done by a single researcher D. It was consistently found that there was a significant bivariate association between substance use and increased odds of gun-related behaviors; however, there was substantial heterogeneity in their associations after adjustment e. The mixed findings could be attributed to a number of factors, such as differences in definitions of substance use and gun activity, study design, sample demographics, and the specific covariates considered in the analysis. The strong association between nonsubstance covariates such as demographic covariates and other behavioral risk factors, especially psychiatric conditions and gun-related outcomes might have moderated or attenuated the association between substance use and gun activities. Nonetheless, some studies suggested a dose-response relationship between substance use and gun-related behaviors e. The nature of observational designs of the available studies precludes causal inference. The majority of studies included in this review merely regress gun-related outcomes on a series of independent variables specific to the objectives of the studies, without considering possible interactions between them. Additional research is needed to better characterize substance use patterns severity, frequency, type and the level of gun-related violence. Well-designed longitudinal studies are needed to clarify the temporal relationship between substance use and gun-related behaviors. For instance, future research should evaluate the long-term impact of preventing substance use among young people on subsequent gun-related behaviors. Unlicensed private sellers are not legally obliged to verify whether firearm purchasers meet the federal eligibility criteria. This suggests a need to increase compliance inspections on potential violations of gun sales laws and to expand background checks to private sellers. More stringent law enforcement would potentially reduce gun violence by people with a substance use disorder or other serious mental disorders However, there are a number of practical and legal hurdles that may impede the reporting of individuals with a substance use disorder or a severe mental illness to federal databases, such as a lack of technical infrastructure, concerns about data confidentiality, and variations in state policies In order to help improve the reporting of high-risk individuals to federal databases, it may be necessary to establish a better technical infrastructure with enhanced confidentiality protection and to develop policies for removing unnecessary legal barriers to reporting substance use disorders or serious mental illnesses Violence risk assessment could be incorporated into assessments for psychiatric diagnoses to evaluate the risk for future violence Current federal law does not prohibit alcoholics from possessing firearms Given the evidence linking excessive drinking to gun-related behaviors, the severity of problem drinking or alcohol use disorder could be considered as a disqualification criterion. In particular, individuals with multiple convictions of driving under the influence of alcohol or other drugs and who may be at higher risk for violence or injuries should be prohibited from purchasing or possessing firearms Mechanisms for restoring firearm rights should be in place for those under the influence of temporary prohibitions 97 , In addition, research is needed to inform whether and how gun restriction policies may stigmatize people with a substance use disorder or mental illness and deter their treatment seeking To date, many states set 18 years as the minimum legal age for firearm purchase. As studies indicate that young adults are more likely than older adults to engage in gun-related behaviors, raising the minimum legal age for gun purchase to 21 years across the country may reduce the rates of gun activities among young adults Moreover, school- and community-based initiatives for gun violence should be implemented to identify high-risk persons and offer treatment options for problem behaviors The sponsoring agency had no further role in the study design and analysis, the writing of the report, or the decision to submit the paper for publication. The opinions expressed in this paper are solely those of the authors. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Epidemiol Rev. Accepted Sep 15; Issue date All rights reserved. For permissions, please e-mail: journals. Open in a new tab. First Author, Year Reference No. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Miller, Loh, Simon, 74 female. Nelson, Simon, 74 male. Johnson, Cunningham, Bergstein, Carlini-Marlatt, Peleg-Oren, DuRant, Live in households with firearms always or sometimes loaded and unlocked. Branas, Reid, Sevigny, Conner, Piper, Hemenway, Bovasso, Casiano, Tewksbury, Lester, Ever smoked cigarettes regularly at least 1 cigarette every day for 30 days. Steinman, Vaughn, Narvaez, Pelucio, Carter, Illicit drug use cocaine, methamphetamine, inhalants, hallucinogens, marijuana, or street opioids in past 6 months. Anteghini, 29 female. Anteghini, 29 male. Ilgen, Kolla, Williams, Any substance use past 30 days, including alcohol; tobacco; or marijuana and other illegal drugs. Hempstead, Callanan, 30 mixed sexes. History of drug abuse recently abused alcohol, prescription drug, and illicit drug. Callanan, 30 male. Callanan, 30 female. Martone,

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