Abstract
Objective:
It is unclear whether Child Access Prevention (CAP) laws influence firearm storage. We sought to analyze the association of CAP laws with loaded and unlocked firearm storage.
Methods:
We used logistic regressions to analyze survey data of 2,264 firearm owners from a 2023 nationally representative U.S. sample. Secondary analyses disaggregated CAP laws by stringency (i.e., liability thresholds for negligent storage) and examined associations by parental status and county social vulnerability.
Results:
Nearly one-third of U.S. firearm owners reported storing at least one firearm loaded and unlocked (unsecure storage). Residence in a CAP law state was only associated with lower odds of unsecure storage in unadjusted models; however, firearm-owning adults in states with the most stringent CAP laws were less likely to report unsecure storage than those in non-CAP law states even after covariate adjustment. In analyses stratified by county social vulnerability, CAP laws were only associated with lower odds of unsecure storage in the least vulnerable counties.
Conclusions:
Our results suggest that the relationship between CAP laws and firearm storage varies depending on the stringency of the law and county social vulnerability. Understanding how these and other factors drive effect heterogeneity will inform CAP laws and implementation efforts.
Keywords: child access prevention laws, firearm storage, firearm policy, social vulnerability
1. Introduction
Firearm injury is the leading cause of death among children and teens in the U.S.1 While firearm harms comprise a range of intents, firearm access is a shared risk factor across all forms of injury.2–4 Among children and teens, specifically, suicides and unintentional shootings overwhelmingly involve firearms accessed from the victim’s home or that of a relative or acquaintance.5,6 The accessibility of firearms within a household also influences the risk of injury; firearms that are stored locked and unloaded are significantly less likely to be used in suicides and unintentional shootings of children and teens.4 Accordingly, recommended approaches to reduce youth firearm injuries primarily focus on limiting firearm access, in part through increasing secure storage.7
Child access prevention (CAP) laws are one policy approach states have adopted to regulate firearm storage and prevent minors from accessing firearms. These laws are intended to promote secure storage by allowing prosecutors to criminally charge individuals who negligently store a firearm. State CAP laws vary in several ways, including how they define a minor, whether offenses are charged as felonies or misdemeanors, whether the statute regulates firearm storage broadly or the storage of loaded firearms specifically, and the threshold for when negligent storage liability applies (i.e., law stringency). In states with the most stringent CAP laws, firearm owners may face liability for negligent storage if a minor could or is likely to access a firearm. In states with the least stringent CAP laws, liability only applies if a minor gains access and uses a firearm. As of 2025, 26 states and the District of Columbia have negligent storage CAP laws or broader safe storage laws.
Research has generally found that CAP laws are associated with reductions in firearm injury and death among youth,8–14 although some studies have failed to find protective effects.15 A recent synthesis of firearm policy research characterized the evidence that CAP laws reduce multiple firearm-related outcomes among children and teens as “supportive,” the highest evidence rating on the four-item scale that was used to assess each firearm policy.14 Studies have documented associated mortality reductions across a range of intents, including firearm suicide, assault injuries, firearm homicide, and unintentional shootings among youth.8–14 While most studies used a dichotomous measure of CAP laws, Azad et al.9 disaggregated state CAP laws into three levels of stringency based on the thresholds for when negligent storage liability may may apply: if a minor (1) accesses and uses the firearm (least stringent); (2) accesses the firearm; or (3) could access a firearm (most stringent). Each stringency level was associated with reduced firearm mortality (relative to no law), but the most stringent CAP laws were associated with the largest reduction in firearm deaths among children under 14.9
Despite evidence suggesting that CAP laws reduce youth firearm mortality, their potential effect on firearm storage remains inconclusive. In a study using 2005 survey data, parents of 4-year-old children in CAP law states were less likely to lock their firearms than those in non-CAP law states, although the likelihood of unlocked storage decreased as overall state firearm policy strength increased.16 Miller and colleagues found that, in 2019, firearm owners in states with CAP laws were no more likely to lock their firearms than those in non-CAP law states after adjusting for covariates that were imbalanced across CAP and non-CAP law states and plausibly associated with firearm storage.17 Notably, most firearm owners reported not knowing if their state had a CAP law, including nearly half of those in CAP law states.17
In addition to examining the mechanisms through which firearm policies influence injury risk, recent studies also highlight the importance of examining whether potential policy impacts differ across community contexts. Their findings suggest that community-level determinants of health, such as social vulnerability and economic distress, moderate the relationship between state firearm law restrictiveness and firearm injury rates.18,19 It is unknown whether a similar effect modification exists for specific policies, such as those regulating firearm storage. Uncovering whether the association between CAP laws and firearm storage differs based on these community-level characteristics could inform targeted CAP law implementation efforts, such as lock distributions, public awareness campaigns, or other focused initiatives to improve secure storage in underserved communities.
Understanding the possible mechanisms by which CAP laws work is critical. To our knowledge, no study has assessed whether more stringent CAP laws have a larger protective association with firearm storage, or the extent to which social vulnerability modulates the relationship between CAP laws and firearm storage. Given these gaps, we pursued the following research questions:
Does firearm storage vary by state CAP law residence, such that those who live in a CAP law state are less likely to store firearms loaded and unlocked?
Are more stringent CAP laws, characterized by a lower threshold for imposing liability, associated with lower odds of loaded and unlocked firearm storage?
Does the CAP law-firearm storage relationship vary by parent/legal guardian status or community social vulnerability?
2. Methods
2.1. Study Design and Population
We used data from the 2023 National Firearm Attitudes and Behaviors Study, a nationally representative cross-sectional survey of 8,172 U.S. adults recruited from the Gallup Panel. Survey responses were fielded by Gallup from May 23, 2023 to June 30, 2023. Participants were asked about firearm-related attitudes and specific behaviors, including firearm carrying, prior safety training, and firearm storage. A $5 post-paid incentive was provided upon survey completion. Additional information on the survey and sampling procedure can be found in previously published studies.20,21
Our analytic sample is limited to firearm owners who reported storing at least one firearm on their property and indicated how they store their firearm(s). We excluded respondents in states with CAP law changes that coincided with the study period (Michigan, New Mexico, Vermont; n=107). Cap laws in New Mexico and Vermont took effect in June and July of 2023. Michigan’s CAP law took effect in 2024, but there was widespread media coverage of the bill being signed into law in April 2023. We also excluded respondents in the Armed Forces Pacific (n=1) and District of Columbia (n=2) due to lack of CAP laws and firearm ownership data, respectively. The final sample includes 2,264 firearm-owning adults across 47 U.S. states (see the study sample flowchart in Appendix Figure A1). This study was approved by the University of Michigan Institutional Review Board (HUM00165985).
2.2. Measures
2.2.1. Outcome
Our outcome was a dichotomous indicator of storing one or more firearms loaded and unlocked. Respondents were asked separately for each type of firearm they owned: “Of the handguns [long guns] on your property that you personally own, how many are kept in the following ways?” Those who reported storing at least one firearm loaded and unlocked were coded as 1. We assigned respondents a value of 0 if they reported storing zero handguns or zero long guns loaded and unlocked and reported storing at least one firearm in another manner. Respondents were also assigned a value of 0 if they did not answer the loaded and unlocked storage question(s), but the total number of the firearms stored in other ways matched the total number of firearms they reported owning (i.e., all firearms were reported as stored in a manner other than loaded and unlocked).
We focused on loaded and unlocked storage for two reasons. First, storing a loaded firearm unlocked is considered the least safe manner of storage.4,22,23 Second, firearm owners in CAP law states who store a firearm loaded and unlocked would always be subject to potential criminal liability (pending other circumstance requirements, such as access or use), whereas unlocked and unloaded storage would not constitute negligent storage in some states.
2.2.2. Exposure
The primary exposure was a dichotomous variable indicating residence in a state with a CAP law. We defined CAP laws as laws that regulate negligent firearm storage (i.e., excluding reckless provision laws). We obtained statute citations from the RAND State Firearm Law Database,24 Giffords, and Everytown and reviewed statute texts to verify statutory elements and effective dates. Consistent with the approach by Azad and colleagues,9 we conducted secondary analyses that disaggregated CAP laws into three stringency categories based on liability thresholds: 0=no CAP law liability; 1=liability if a child uses the firearm (e.g., possesses, discharges, causes injury); 2=liability if a child gains access to the firearm; 3=liability if a child could or is likely to gain access to the firearm. Some states regulated storage to prevent firearm access by specific prohibited persons, including minors, or by unauthorized individuals more generally. Because these states explicitly or implicitly regulated storage based on the use, access, or potential access by minors, we classified them as CAP law states and coded the stringency of their laws accordingly, as done in prior studies.9,17 Statute texts, classifications, effective dates, and law citations are presented in Appendix Table A1.
2.2.3. Stratification variables
Parental status was assessed using the following survey question: “Are you the parent, legal guardian, or caregiver of a child 17 years old or younger?” We linked FIPS codes from each survey to 2022 Social Vulnerability Index (SVI)25 data to measure social vulnerability in respondents’ counties. The SVI comprises four themes that assess overall vulnerability: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type/transportation.25 ZIP codes were used to determine social vulnerability values in Connecticut, which transitioned to county-equivalent geographic units called “planning regions.” We trichotomized county index scores into low, medium, and high social vulnerability.
2.2.4. Control variables
We used a directed acyclic graph to identify potential confounding pathways at the state level that we hypothesized could bias estimated associations between CAP laws and firearm storage (Appendix Figure A2). Failing to control for factors that would block these confounding pathways would lead to biased estimates of the relationship between residence in a CAP law state and firearm storage. We expected that, in part, regional differences explain varying levels of state firearm ownership,26 which likely influences partisan lean, whether a state has a CAP law, and firearm storage. We did not expect individual-level factors to influence state CAP law status independent of state-level variables. Based on our graph, we controlled for Census region, state government control in 2023 (i.e., divided, Democratic, or Republican control based on the governorship and state legislature majority), and state household firearm ownership prevalence, measured as the proportion of individuals living in a household with a firearm in 2018 (the most recent year for which estimates were available).27
2.3. Statistical Analysis
We used weighted proportions to examine loaded and unlocked firearm storage overall and by CAP law status. We applied post-stratification weights to better represent the U.S. adult population on several characteristics, including firearm ownership, parental status, and region. Unadjusted and adjusted binomial logistic regressions were used to examine associations of CAP laws with loaded and unlocked firearm storage. We conducted analyses that separately stratified the sample by parental status and social vulnerability tertile. As the post-stratification weights were not developed to be representative of county social vulnerability, we used unweighted data in analyses stratified by social vulnerability.
The data were cleaned in R version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria) and analyzed in Stata 18 (StataCorp LP, College Station, TX) using the svy commands for complex survey data.
3. Results
We present weighted percentages of loaded and unlocked firearm storage in Table 1. Overall, 31.2% of U.S. firearm owners stored at least one firearm loaded and unlocked (95% confidence interval (CI)=27.8, 34.5). In CAP law states, 28.1% of respondents (95% CI=23.9, 32.3) stored firearms loaded and unlocked, compared to 34.9% (95% CI=29.6, 40.3) in states without such laws. Proportionally fewer parents (20.3%, 95% CI=15.3, 25.3) stored firearms loaded and unlocked than non-parents (35.3%, 95% CI=31.3, 39.4), and parents residing in CAP law states were the least likely to store firearms in this manner (17.8%, 95% CI=11.9, 23.7). Approximately one-third of respondents in medium and high social vulnerability counties reported loaded and unlocked storage irrespective of state CAP law status. Conversely, 18.6% of respondents residing in low social vulnerability counties within CAP law states reported loaded and unlocked storage (95% CI=12.8, 24.5) compared to 41.1% of respondents in similarly advantaged counties within non-CAP law states (95% CI=29.7, 52.4).
Table 1.
Weighted percentages of loaded and unlocked firearm storage among firearm-owning U.S. adults by state Child Access Prevention law status in May-June 2023.
| Child Access Prevention law state n=1,342 |
Non-Child Access Prevention law state n=922 |
Overall n=2,264 |
|
|---|---|---|---|
| % loaded and unlocked (95% CI) | % loaded and unlocked (95% CI) | % loaded and unlocked (95% CI) | |
| Overall | 28.1 (23.9, 32.3) | 34.9 (29.6, 40.3) | 31.2 (27.8, 34.5) |
| Parental status | |||
| Parent/legal guardian | 17.8 (11.9, 23.7) | 23.7 (15.3, 32.2) | 20.3 (15.3, 25.3) |
| Non-parent/guardian | 32.3 (27.2, 37.5) | 38.9 (32.5, 45.3) | 35.3 (31.3, 39.4) |
| County social vulnerability | |||
| Low | 18.6 (12.8, 24.5) | 41.1 (29.7, 52.4) | 29.2 (22.6, 35.7) |
| Medium | 30.5 (22.5, 38.5) | 31.8 (23.4, 40.3) | 31.2 (25.3, 37.0) |
| High | 31.6 (25.1, 38.2) | 33.5 (25.1, 42.0) | 32.4 (27.2, 37.6) |
| Region | |||
| Northeast | 10.7 (5.0, 16.4) | 23.1 (6.3, 40.0) | 16.5 (7.6, 25.4) |
| Midwest | 20.5 (9.2, 31.8) | 35.1 (25.0, 45.3) | 29.4 (21.8, 37.0) |
| South | 35.6 (28.8, 42.3) | 42.6 (34.2, 51.0) | 38.6 (33.3, 44.0) |
| West | 26.3 (19.2, 33.4) | 23.1 (14.7, 31.5) | 25.3 (19.7, 30.8) |
Abbreviations: CI=confidence interval.
Table 2 presents results from the main logistic regression models. In the unadjusted model, residing in a CAP law state was associated with lower odds of storing a firearm loaded and unlocked (odds ratio (OR)=0.73, 95% CI=0.53, 1.00). After controlling for U.S. region, state firearm ownership, and state political control, the magnitude of the association remained unchanged but was less precise (adjusted odds ratio (AOR)=0.73, 95% CI=0.47, 1.14). In secondary models that disaggregated CAP laws by law stringency, respondents in states with the most stringent CAP laws were less likely to store a firearm loaded and unlocked than those in states without a CAP law (OR=0.51, 95% CI=0.34, 0.77), even after adjusting for other state-level factors (AOR=0.52, 95% CI=0.27, 0.98).
Table 2.
Unadjusted and adjusted associations of residence in a Child Access Prevention law state and loaded and unlocked firearm storage among firearm-owning U.S. adults in May-June 2023 (n=2,264).
| Unadjusted | Adjusted | |
|---|---|---|
| OR (95% CI) |
AOR (95% CI) |
|
| No law | Ref. | Ref. |
| Any Child Access Prevention law | 0.73 (0.53, 1.00) |
0.73 (0.47, 1.14) |
| Law stringency | ||
| No law | Ref. | Ref. |
| If child uses | 0.80 (0.54, 1.19) |
0.72 (0.44, 1.17) |
| If child accesses | 1.14 (0.71, 1.85) |
0.93 (0.52, 1.66) |
| If child could/is likely to access | 0.51 (0.34, 0.77) |
0.52 (0.27, 0.98) |
Notes. Adjusted analyses controlled for Census region, state government political party control in 2023, and state firearm ownership in 2018.
Abbreviations: OR=odds ratio; AOR=adjusted odds ratio; CI=confidence interval.
In unadjusted analyses stratified by parental status, only residence in a state with the most stringent CAP law was associated with lower odds of storing a firearm loaded and unlocked among parents (OR=0.44, 95% CI=0.20, 0.96) and non-parents (OR=0.53, 95% CI=0.33, 0.84) (Table 3). There were no significant associations between CAP laws and firearm storage—irrespective of parental status and law stringency—after adjusting for state-level factors.
Table 3.
Unadjusted and adjusted associations of residence in a Child Access Prevention law state and loaded and unlocked firearm storage among firearm-owning U.S. adults in May-June 2023 stratified by parental status.
| Parent | Non-parent | |||
|---|---|---|---|---|
| n=500 | n=1,763 | |||
| OR (95% CI) |
AOR (95% CI) |
OR (95% CI) |
AOR (95% CI) |
|
| No law | Ref. | Ref. | Ref. | Ref. |
| Any Child Access Prevention law | 0.70 (0.38, 1.29) |
0.60 (0.27, 1.34) |
0.75 (0.52, 1.07) |
0.81 (0.48, 1.35) |
| Law stringency | ||||
| No law | Ref. | Ref. | Ref. | Ref. |
| If child uses | 0.85 (0.38, 1.92) |
0.68 (0.27 1.69) |
0.82 (0.52, 1.28) |
0.77 (0.45, 1.33) |
| If child accesses | 0.98 (0.44, 2.18) |
0.58 (0.20, 1.65) |
1.19 (0.67, 2.10) |
1.10 (0.56, 2.17) |
| If child could/is likely to access | 0.44 (0.20, 0.96) |
0.42 (0.13, 1.33) |
0.53 (0.33, 0.84) |
0.57 (0.27, 1.18) |
Notes. Adjusted analyses controlled for Census region, state government political party control in 2023, and state firearm ownership in 2018.
Abbreviations: OR=odds ratio; AOR=adjusted odds ratio; CI=confidence interval.
Table 4 presents results from analyses stratified by county social vulnerability tertile. In high social vulnerability counties, CAP law status was associated with lower odds of loaded and unlocked storage (OR=0.76, 95% CI=0.58, 1.01). However, in adjusted analyses, the odds of storing a firearm loaded and unlocked for respondents residing in medium (AOR=1.26, 95% CI=0.77, 2.09) or high social vulnerability counties (AOR=1.10, 95% CI=0.72, 1.69) did not differ by state CAP law status, regardless of law stringency. Among the least socially vulnerable (i.e., most advantaged) counties, those who resided in a state with a CAP law were less likely to store firearms loaded and unlocked in unadjusted (OR=0.51, 95% CI=0.34, 0.75) and adjusted analyses (AOR=0.39, 95% CI=0.21, 0.71). This protective association in less socially vulnerable counties also held for the least stringent (AOR=0.37, 95% CI=0.19, 0.72) and most stringent CAP laws (AOR=0.35, 95% CI=0.16, 0.78).
Table 4.
Unadjusted and adjusted associations of residence in a Child Access Prevention law state and loaded and unlocked firearm storage among firearm-owning U.S. adults in May-June 2023 stratified by county social vulnerability tertile.
| Low Social Vulnerability | Medium Social Vulnerability | High Social Vulnerability | ||||
|---|---|---|---|---|---|---|
| n=522 | n=767 | n=973 | ||||
| OR (95% CI) |
AOR (95% CI) |
OR (95% CI) |
AOR (95% CI) |
OR (95% CI) |
AOR (95% CI) |
|
| Child Access Prevention law | ||||||
| No law | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Any Child Access Prevention law | 0.51 (0.34, 0.75) |
0.39 (0.21, 0.71) |
0.82 (0.60, 1.13) |
1.26 (0.77, 2.09) |
0.76 (0.58, 1.01) |
1.10 (0.72, 1.69) |
| Law stringency | ||||||
| No law | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| If child uses | 0.43 (0.24, 0.74) |
0.37 (0.19, 0.72) |
1.02 (0.69, 1.50) |
1.37 (0.80, 2.36) |
0.94 (0.65, 1.36) |
1.26 (0.74, 2.15) |
| If child accesses | 0.97 (0.52, 1.83) |
0.53 (0.21, 1.35) |
0.91 (0.54, 1.54) |
1.11 (0.57, 2.16) |
0.92 (0.63, 1.33) |
1.07 (0.66, 1.73) |
| If child could/is likely to access | 0.43 (0.26, 0.72) |
0.35 (0.16, 0.78) |
0.58 (0.37, 0.92) |
1.12 (0.55, 2.29) |
0.54 (0.37, 0.78) |
1.00 (0.51, 1.97) |
Notes. Adjusted analyses controlled for Census region, state government political party control in 2023, and state firearm ownership in 2018.
Abbreviations: OR=odds ratio; AOR=adjusted odds ratio; CI=confidence interval.
4. Discussion
CAP laws are intended to prevent minors from accessing firearms by allowing prosecution of negligent firearm storage. Although these laws are associated with reductions in pediatric firearm mortality,9–14 the extent to which they influence firearm storage is not well understood. We found that CAP laws were only associated with lower odds of loaded and unlocked firearm storage in models that did not account for other factors. However, respondents who lived in states with the most stringent CAP laws were less likely to store firearms loaded and unlocked even after adjusting for state-level factors. Social vulnerability may also represent an important moderator as CAP laws were only robustly associated with lower odds of loaded and unlocked storage among respondents in low social vulnerability counties.
Our finding that the most stringent CAP laws were associated with the lowest odds of loaded and unlocked firearm storage is broadly consistent with prior research that found more stringent CAP laws to be associated with larger reductions in firearm mortality among children.9 It is unclear why less stringent CAP laws were not associated with lower odds of loaded and unlocked storage. It may be that the most stringent laws elicit greater news coverage and awareness due to their proactive nature; they are the only type of CAP law that can be applied even if a child has not used or gained access to a firearm. Alternatively, such laws may be more effective in influencing social norms around firearm safety, which could lead to more secure storage even if many owners are not aware of their state’s specific liability thresholds. Given the recent finding that many firearm owners reported not knowing whether they lived in a state with a CAP law, more research is needed to identify the mechanism through which more stringent CAP laws may influence firearm storage.
There was not a clear association between CAP laws and firearm storage among parents and non-parents. We expected that the relationship between these laws and firearm storage would be most evident among those with children under 18 years since they are generally at greater risk of negligent storage liability. Nonetheless, this null finding is consistent with recent research that did not find an association between CAP laws and firearm storage among households with children.17 Future work should continue to examine associations among households with children, as well as the potential effect of targeted education to parents about their state’s storage requirements.
Importantly, our results suggest that the association between CAP laws and reduced risk of loaded and unlocked firearm storage is limited to those in the least vulnerable (i.e., most advantaged) communities. Internet access28 and information disparities29 along key SVI dimensions suggest that awareness of CAP laws could be greater in less vulnerable communities. Firearm owners in these communities may also have the means to purchase lock boxes or safes, which are among owners’ preferred devices and generally more expensive than other storage devices.30,31 Moreover, socially vulnerable and resource-deprived communities may experience a diminished benefit from firearm-related policies given other unaddressed drivers of firearm injury, such as community distress and low social capital.18 Those in less vulnerable communities may not face the same pressure to keep firearms accessible for protection as those in more vulnerable communities, which experience significantly higher rates of firearm violence.32 Protection is both the dominant motivation for firearm ownership21 and a key reason why owners do not lock up firearms; inaccessibility in an emergency is among the most commonly cited obstacles to secure storage.33 The immediacy of the threat posed by community violence may more directly shape storage practices in vulnerable communities than the presence of a CAP law. Additional research is needed to investigate whether factors such as awareness, economic stability,34 community firearm violence, and perceived safety explain these heterogeneous associations.
4.1. Limitations
Our work is limited in a few ways. We relied on self-report survey data, which may be subject to response bias. The cross-sectional nature of our data did not allow us to assess changes in storage following CAP law adoption. Additionally, the data were not weighted to match population targets for county social vulnerability. Therefore, results from the unweighted analyses stratified by social vulnerability tertile may not be nationally generalizable. Our directed acyclic graph assumed that no individual-level factors directly influenced both the likelihood of residing in a CAP law state and loaded and unlocked firearm storage; however, our theoretical model, and thus, modeling assumptions, may be incorrect. If individual factors do confound the relationship between CAP laws and firearm storage, our adjusted estimates would not accurately reflect this association. Lastly, we coded respondents who owned handguns and long guns as having no loaded and unlocked storage if they reported storing 0 firearms of one type loaded and unlocked but did not provide a response regarding the other type. Results from sensitivity analyses that excluded these respondents (n=53) remained unchanged; however, our estimates could be biased if actual storage systematically differed by state CAP law status among this group.
5. Conclusion
Nearly a third of U.S. firearm owners stored at least one firearm loaded and unlocked. CAP laws were associated with lower odds of loaded and unlocked firearm storage only in analyses that did not adjust for other factors. However, in the least socially vulnerable counties, and for those in states with the most stringent CAP laws, these laws were associated with decreased risk of storing firearms loaded and unlocked independent of other state-level factors. Future research should further explore this apparent effect heterogeneity with the goal of informing policies and interventions to decrease unsecure firearm storage.
Supplementary Material
Funding:
Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under Award Number T32HD108054. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Conflicts of Interest: The authors have no conflicts of interest to disclose.
Ethical Compliance: This study was approved by the University of Michigan Institutional Review Board (HUM00165985).
CRediT Author Statement: SNO: Conceptualization, Methodology, Formal analysis, Writing – original draft, Writing – review & editing; MDE: Conceptualization, Writing – review & editing; KGH: Conceptualization, Writing – review & editing; HAH: Conceptualization, Writing – review & editing; PFE: Conceptualization, Writing – review & editing; PMC: Conceptualization, Writing – review & editing; RLS: Conceptualization, Writing – review & editing.
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