0204 Safe and Sound: County-Level Associations Between Insufficient Sleep and Gun Violence Across the United States

Abstract Introduction Gun violence is a leading cause of injury and death in the United States, with emerging evidence linking community sleep patterns and violence. Prior work in major cities found that greater violence is associated with insufficient sleep, wherein sleep shows a stronger association with violence than mental health issues. This study examined associations between county-level insufficient sleep, childhood opportunity, and gun violence across all US counties. Methods We analyzed gun violence incidents from The Trace's Atlas of American Gun Violence (1/1/2022-9/30/2025) across 2,186 US counties (all 50 states plus Washington DC). Outcomes included injuries (range: 0-2,440), deaths (range: 0-609), domestic violence incidents (range: 0-331), and drive-by shootings (range: 0-1,379), summed to the county level and merged with 2022 data from the 2025 release of CDC PLACES (insufficient sleep prevalence) and the Childhood Opportunity Index (version 3.0-2023; Noelke et al., 2025). Negative binomial regression models with population offset were used to estimate incident rate ratios (IRR) of violence outcomes. Results Counties with a higher prevalence of insufficient sleep had a 5.1% increased rate of injuries per percentage point increase of insufficient sleep (95% CI [1.037-1.065]), a 5.7% increased rate of drive-by shootings (95% CI [1.035-1.080]), and a 1.9% increased rate of domestic violence incidents (95% CI [1.007-1.030]). Prevalence of insufficient sleep was not associated with deaths (95% CI [0.997-1.017]). Higher childhood opportunity was protective across all violence outcomes (IRRs: 0.986-0.989, all p < 0.001). Conclusion County-level insufficient sleep is associated with higher gun violence, particularly injuries. These findings extend prior city-focused research and suggest community sleep and neighborhood conditions may be promising targets for violence prevention. Support (if any)