Rural-Urban Variation in the Association of Adolescent Violence and Handgun Carrying in the United States, 2002-2019

IMPORTANCE Adolescent handgun carrying is associated with increased risk of firearm-related violence. Most evidence on adolescent handgun carrying is from urban areas, but these findings may not generalize to rural areas. OBJECTIVE To examine differences in associations of adolescent interpersonal violence with handgun carrying across the rural-urban continuum. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used nationally representative data from the US National Survey on Drug Use and Health among adolescents aged 12 to 17 years from 2002 to 2019 to estimate time-varying prevalence ratios (PRs) and prevalence differences (PDs) between interpersonal violence and handgun carrying across the rural-urban continuum. Analyses were conducted in April to July 2022. EXPOSURES Any past-year serious fighting, group fighting, and attacking with intent to harm. MAIN OUTCOMES AND MEASURES Any past-year handgun carrying. Associations were estimated within county rural-urban strata using the US Department of Agriculture's Rural-Urban Continuum Codes. RESULTS In each year, the sample included a weighted count of almost 25 million adolescents, with 50.9%(95% CI, 50.2%-51.6%) males and 24.7%(95% CI, 23.8%-25.6%) Hispanic adolescents, 13.5% (95% CI, 12.8%-14.2%) non-Hispanic Black adolescents, and 51.8%(95% CI, 50.8%-52.8%) non-Hispanic White adolescents in 2019. More rural counties had less racial and ethnic diversity. For example, 81.1% (95% CI, 75.9%-85.4%) of adolescents were non-Hispanic White in the most rural counties vs 43.1% (95% CI, 41.7%-44.6%) of adolescents were non-Hispanic White in the most urban counties in 2019. Adolescent handgun carrying increased over time, with the largest increases in the most rural counties, where the prevalence of adolescent handgun carrying increased from 5.2% (95% CI, 3.8%-7.0%) in 2003 to 12.4%(95% CI, 8.9%-16.9%) in 2019. PRs for the association of violence and handgun carrying were greater in more urban counties. For example, in the most urban counties in 2019, adolescents involved in a group fight had 3.7 (95% CI, 2.9-4.8) times the prevalence of handgun carrying vs those not involved in a group fight; this PR was 3.1 (95% CI, 1.6-5.6) in the most rural counties. PDs were similar and, in some cases, larger in rural areas. For example, in the most urban counties in 2019, handgun carrying prevalence was 7.5%(95% CI, 5.7%-9.5%) higher among adolescents who were involved in a group fight compared with those who were not; this PD was 21.8%(95% CI, 8.2%-37.8%) in the most rural counties, where handgun carrying was more common. CONCLUSIONS AND RELEVANCE This cross-sectional study found that associations of interpersonal violence with handgun carrying were stronger in relative terms in urban areas than in rural areas; however, a higher percentage of rural than urban adolescents carried handguns, resulting in a greater absolute prevalence of handgun carrying associated with violence in rural areas than in urban areas. These findings suggest opportunities for preventing handgun carrying-related harms may differ between rural and urban communities.