Post-pandemic Divergent Trends in Firearm Homicide and Suicide Across Demographic and Urbanization Strata in the United States: A National Ecological Study (2018-2024)

Background: Firearm-associated deaths and injuries represent a major public health issue in the United States.These rates changed during and after the COVID-19 pandemic due to socioeconomic factors.Disparities among different demographic groups are evident in the data.This study seeks to evaluate changes during and after the pandemic.Objective: The aim of this study was to evaluate post-pandemic trajectories, demographic disparities, and urban-rural distributions of firearm homicides and suicides in the United States.Methods: A retrospective, longitudinal ecological study was conducted using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) mortality data (2018)(2019)(2020)(2021)(2022)(2023)(2024).Trends were stratified by intent, age, race, sex, and urbanization level.Multivariable Poisson regression models with robust standard errors estimated annual incidence rate ratios (IRRs).Results: Post-pandemic data revealed a structural divergence between homicides and suicides.Firearm homicides rose 34.4% in absolute deaths between 2019 and 2020 (14,286 to 19,203), peaked in 2021 at 20,808 deaths, and then contracted through 2024 (annual IRR 0.89; 95% CI 0.86-0.91).Relative to the pre-pandemic trend, the homicide incidence rate was 64.3% higher during 2020-2021 (IRR 1.643).Homicides were concentrated primarily among Black or African American individuals and young adults; pediatric homicide incidence was 87.3% above pre-pandemic trend levels (IRR 1.873), with counts peaking in 2022.Suicides followed a chronic, sustained acceleration: the pandemic level shift was null (IRR 1.000), but the post-onset trend showed a 1.8% annual increase in incidence (IRR 1.018; 95% CI 1.002-1.034;p = 0.023), driven predominantly by non-Hispanic White populations.Geriatric suicides increased continuously from 6,327 (2018) to 7,440 (2024).Urban settings drove the acute homicide shock, whereas rural suicides outnumbered rural homicides by more than 3.5 to 1.Conclusions: Firearm homicide acted as a transient, urban-concentrated social shock, whereas firearm suicide represents an escalating, long-term public health crisis.Prevention strategies must move past uniform frameworks to target the unique sociodemographic drivers of each intent.