The Relationship Between Firearm Availability and Suicide

Summary: Empirical research on the causal effects of firearm availability on the risk of suicide is consistent with the claim that firearms increase suicide risk, but this research cannot yet rule out some other explanations for observed associations between guns and suicide. There are, however, theoretical or logical arguments for believing firearms elevate suicide risk that are sufficiently compelling that individuals and policymakers might reasonably choose to assume that gun availability does increase the risk of suicide.

In 2004, the National Research Council (NRC) concluded:

States, regions, and countries with higher rates of household gun ownership have higher rates of gun suicide. There is also cross-sectional, ecological association between gun ownership and overall risk of suicide, but this association is more modest than the association between gun ownership and gun suicide; it is less consistently observed across time, place, and persons; and the causal relation remains unclear. . . . The risk of suicide is highest immediately after the purchase of a handgun, suggesting that some firearms are specifically purchased for the purpose of committing suicide.

Suicide attempts involving a firearm are more likely to result in death than attempts using any other means (Azrael and Miller, 2016). If firearms are available to a person who is thinking about taking his or her life, the presence of firearms might be linked with a higher likelihood of suicide and higher regional suicide rates. However, if firearms are not available, a person might either not attempt to take his or her life or might do so using other means. In this essay, we examine the empirical evidence on the relationship between firearm availability (or prevalence) and suicide.

Methods

Our literature review strategy was based on the comprehensive search outlined in the methodology description. Although the focus of that search was from 2003 forward, we highlight some highly cited articles published prior to 2003. As we did for the policy discussions, we prioritize the evidence from studies that employ a quasi-experimental approach. However, because this line of scientific inquiry is so much more extensive than most of the other topics reviewed in these syntheses, we take a broader approach referencing noteworthy international studies and cross-sectional studies that were identified in our review.

We categorize these studies as those that examine associations between individual access to firearms and suicide rates and those that examine associations between the regional prevalence of firearms and suicide rates in census regions, states, and cities.

Individual Access to Firearms

A primary conclusion of the NRC report was that although there are limitations of studies that examine suicide outcomes among those with access to guns (e.g., gun purchasers) or those that look at firearm ownership among suicide decedents relative to some other group, these research approaches have generally been “underutilized in the literature” (NRC, 2004, p. 183). These studies are broadly defined as “individual-level studies” and, as described in this section, can be categorized into two groups: those that examine suicide risk among gun owners and those that examine firearm access among suicide decedents.

Our review identified eight U.S.-based individual-level studies conducted since 2003, six of which analyzed data from the 1993 National Mortality Followback Survey (Dahlberg, Ikeda, and Kresnow, 2004; Joe, Marcus, and Kaplan, 2007; Kung, ­Pearson, and Liu, 2003; Kung, Pearson, and Wei, 2005; Shenassa et al., 2004; Wiebe, 2003), one of which examined suicides in the Navy (Stander et al., 2006), and one of which examined suicides in California (Grassel et al., 2003).

Suicide Risk Among Gun Owners

In 2004, NRC identified that the strongest evidence for the effect of firearm availability on individual suicide rates derived from two studies that examined individual outcomes after the purchase of a firearm; we identified no similar studies that have been conducted since NRC published its findings. Cummings et al. (1997b) used a case-control approach in which they linked health insurance records with firearm licenses in Washington state from 1980 to 1992. During this time, those who died by suicide (using any means) were more likely than living, demographically matched controls to have a history of the decedent or somebody in the family having purchased a handgun (24.6 percent versus 15.1 percent, respectively; incidence rate ratio [IRR] = 1.9; 95-­percent confidence interval [CI]: 1.4, 2.5). Compared with the controls, this risk was greatest in the year after the handgun was purchased (3.1 percent versus 0.7 percent; IRR = 5.7; 95-percent CI: 2.4, 13.5); the median interval between the first handgun purchase and any suicide with a firearm was 10.7 years (range: 11 days to 52.5 years). Wintemute et al. (1999) took a prospective study approach in which they linked applications for handgun purchases among California residents in 1991 to death records maintained by the state from 1991 to 1994. Compared with the general mortality trends in the state for the same years and adjusting for age and sex, handgun purchasers had elevated standardized mortality ratios for suicide (4.31) and firearm suicide (7.12). The elevated firearm suicide rate among purchasers was seen across all six years after purchase, although the effect was greatest in the first week after purchase (644 per 100,000) and diminished over longer intervals—specifically, the first month after purchase (350–375 per 100,000) and the first year after purchase (75–100 per 100,000). This pattern may indicate that a subset of handgun purchasers acquire a firearm for the purpose of killing themselves.

Whether the mere availability of a gun increases the risk of suicide is a complex question to disentangle from observational data because some of the association between gun accessibility and suicide is likely attributable to the fact that those who wish to kill themselves may go out of their way to procure a gun or otherwise ensure that a gun is accessible. Others with access to guns may be at higher risk of suicide because their attempt to kill themselves with an available gun is more likely to be fatal than if they had used a less lethal means, such as poison or drug overdose. Experimental studies that could systematically test the effects of gun availability on suicides are unlikely to be performed, because they would almost certainly be found to be unethical. The next-best source of rigorous evidence, quasi-experimental observational studies, may never be able to adequately control for the myriad, sometimes intersecting, reasons why individuals might want guns available and might also wish to kill themselves. Nevertheless, the results of such studies shed some light on this association, as we discuss next.

Firearm Access Among Suicide Decedents

Prior to 2004, a series of U.S.-based studies routinely and consistently found that access to a firearm, particularly a handgun, in one’s home was more prevalent among those who died by suicide than among various comparison groups. These studies were generally based on psychological autopsies, in which ascertainment about the presence of firearms was provided by proxy respondents for the decedent after his or her death and compared with the presence of firearms as reported by comparison or control cases who were matched to the decedent in various ways but who typically had not died. A concern with all such studies is the possibility that cases and controls may not be matched on important characteristics that influence both the person’s decision to acquire firearms and his or her risk of suicide. Relatedly, while proxy respondents are likely to know and acknowledge that the decedent who died by firearm suicide had access to a firearm, it is less certain that all controls would acknowledge having access to a gun. Either bias could result in firearm access appearing to be more closely associated with suicide risk than it really is. (For more on potential biases in psychological autopsy studies, see NRC, 2004, pp. 171–172.) Only three U.S.-based psychological autopsy studies have been conducted since 2005.

The relationship between firearm access and suicide has been shown in studies comparing suicide decedents with those who have died by other causes (Dahlberg, Ikeda, and Kresnow, 2004; Grassel et al., 2003; Kung, Pearson, and Liu, 2003; Kung, Pearson, and Wei, 2005; Shenassa et al., 2004), those living in the same community (Bailey et al., 1997; Brent et al., 1993a; Brent et al., 1993b; Brent et al., 1999; Conwell et al., 2002; Kellermann et al., 1992; Wiebe, 2003), and those with histories of mental illness who have not died by suicide (Brent et al., 1991; Brent et al., 1993a; Brent et al., 1994). This relationship has also been seen in suicides among older adolescents and adults in the general population (Dahlberg, Ikeda, and Kresnow, 2004; Grassel et al., 2003; Kellerman et al., 1992; Kung, Pearson, and Liu, 2003; Kung, Pearson, and Wei, 2005; Shenassa et al., 2004; Wiebe, 2003), as well as specifically among older age groups (Conwell et al., 2002), adolescents (Brent et al., 1991; Brent et al., 1993a; Brent et al., 1993b; Brent et al., 1994; Brent et al., 1999; Bukstein et al., 1993), and women (Bailey et al., 1997). In addition, studies with community-based controls often control for demographic characteristics (through either matching or covariate adjustment) and other family and clinical characteristics (e.g., history of mental illness, alcohol misuse, drug use). Furthermore, studies limited to suicide decedents have shown that prevalence of firearms was higher among those who died by suicide using a firearm than those who used other means (Dahlberg, Ikeda, and Kresnow, 2004; Joe, Marcus, and Kaplan, 2007; Shenassa et al., 2004; Stander et al., 2006).

Eight individual-level studies were published in or after 2003 (Dahlberg, Ikeda, and Kresnow, 2004; Grassel et al., 2003; Joe, Marcus, and Kaplan, 2007; Kung, Pearson, and Liu, 2003; Kung, Pearson, and Wei, 2005; Shenassa et al., 2004; Stander et al., 2006; Wiebe, 2003) (see the table below for details). One of these studies (Grassel et al., 2003) is particularly informative, as it linked California death data with administrative data on handgun purchases. Findings showed that those who died by suicide were more likely to have purchased a handgun in the previous three years, with the relationship even greater between suicide death and purchase of a handgun in the past year, an effect magnified for women. Five studies used the 1993 National Mortality Followback Survey. One compared suicide decedents with living, matched controls from the National Health Interview Survey and found having a gun in the home to be associated with suicide and specifically firearm suicide, but not with nonfirearm suicide (Wiebe, 2003). The other four studies limited their findings to decedents only and found a relationship between having a gun in the home and elevation in the risk of suicide (Kung, Pearson, and Wei, 2005; Shenassa et al., 2004), a relationship generally robust in models that stratify by gender (Dahlberg, Ikeda, and Kresnow, 2004; Kung, Pearson, and Liu, 2003)[1] and race (Kung, Pearson, and Wei, 2005). Two studies limited their analysis of the 1993 National Mortality Followback Survey to suicides and found a relationship between having a gun in the home and firearm suicide (Dahlberg, Ikeda, and Kresnow, 2004; Joe, Marcus, and Kaplan, 2007), an approach similar to that employed by Stander et al. (2006) in analysis of Navy suicides.

With individual-level studies, any observed differences in gun access between groups can be interpreted in at least two ways: The differences could suggest that gun access increases the risk of suicide, or they could suggest that people who are suicidal may obtain guns at a higher rate because they are considering killing themselves with guns. In other words, these studies are criticized for providing little insight into the relationship between firearm access and suicide because they are generally consistent with a wide range of causal models, including models postulating effects in opposite directions. A recent review by Azrael and Miller (2016) suggests that the evidence in support of the former of these two interpretations (that gun access increases the risk of suicide) is strong based on two findings. First, the authors note that a series of studies find that the relationship between household gun ownership and suicide exists not just for the firearm owner but for all other household members. Second, although covariate adjustment for factors related to suicidality could attenuate the relationship between the presence of a firearm and suicide, a number of studies reveal no difference in past suicide attempts (described in the next section), mental illness, and substance use disorders between households with firearms and those without. In addition, an omitted variable analysis suggests that if there is actually some third risk factor associated with both household firearm ownership and suicide, this third factor would need to be a better predictor of suicide than any currently known risk factor to fully account for the association between household firearms and suicide (Miller, Swanson, and Azrael, 2016). While compelling, this does not entirely refute an argument about reverse causation: An individual feeling suicidal may acquire a firearm as a means to take his or her life and thus make the weapon readily available in the household.

Other work has used different control groups to attempt to address this selection bias (that suicidal people are more likely to acquire guns so that they can kill themselves). For example, firearm access was higher among adolescents who had committed suicide than among adolescents in inpatient mental health treatment who had either previously attempted suicide or never attempted suicide (Brent et al., 1991). Additionally, adolescent suicides with no history of a mental health disorder had higher rates of firearm access relative to adolescent suicides with a mental health disorder (Brent et al., 1994). This pattern of results may indicate that access to firearms was a causal factor in the suicidal adolescent’s death or that parents or caretakers removed guns from the homes of adolescents at risk of suicide because of prior attempts or mental health problems, or a combination of the two.

Firearm Storage Among Suicide Decedents

Individual-level studies have examined not only whether decedents had access to firearms in their households but also how those guns were stored. In general, these studies consistently show that, relative to comparison groups of individuals who die other ways or of living community members, those who die by suicide have guns stored less safely (Conwell et al., 2002; Shenassa et al., 2004; Grossman et al., 2005). These studies suggested to one set of researchers a “dose-response” relationship between firearm accessibility and risk for suicide (Azrael and Miller, 2016). However, the relationship is not seen in all studies. Brent et al. (1991; 1993b) found no differences in storage practices in homes with adolescents who died by suicide and a comparison group of adolescents living in the community. Dahlberg, Ikeda, and Kresnow (2004) found no association between storage practices and firearm suicide (versus suicide by other means).

Suicidality (Not Death) as an Outcome

Individual-level studies that conduct postmortem inventories of the presence of firearms may be biased because they rely on proxy respondents who may report incorrect information either purposely or because they do not know the correct information. At times, researchers have used proxy outcomes—most commonly, living individuals’ past suicide attempts and suicide ideation (thinking about suicide), which they can ascertain directly from the individuals whose behavior and firearm access are being studied. Yet, while suicide attempts and ideation are potentially important markers of anguish or distress, they are not reliable proxies for or predictors of suicide deaths.[2]

Since 2005, one longitudinal study (Watkins and Lizotte, 2013) and a series of cross-sectional studies (described in the table below) examined firearm access among those who have attempted suicide (and survived), who have made plans to kill themselves, or who have thought about suicide (suicide ideation). In general, there was not much evidence of a relationship between suicide ideation and firearm access (Ilgen et al., 2008; Miller et al., 2009; Oslin et al., 2004; Simonetti et al., 2015; Smith, Currier, and Drescher, 2015), although Thompson et al. (2006) found that veterans receiving outpatient treatment for opioid dependence and who had suicide ideation were more likely to own a firearm than those in treatment without such thoughts. However, those with a history of suicide attempts are less likely to have access to a firearm in both population-based (Ilgen et al., 2008; Miller et al., 2009; Simonetti et al., 2015) and psychiatric clinical samples (Kolla, O’Connor, and Lineberry, 2011; Smith, Currier, and Drescher, 2015).[3] In another study, firearm access was higher among those who had made a plan to take their lives using a firearm than among those who made a plan involving some other means (Betz, Barber, and Miller, 2011). Although cross-sectional studies examining suicide attempts and ideation are common, they provide little insight into the relationship between firearm access and suicide, because these results are consistent with a wide range of causal models, including ones that postulate effects in opposite directions.

There are similar studies examining suicide attempts and ideation with respect to firearm storage practices. Studies generally find no difference in storage practices between adults who have thought about or attempted suicide versus those who have not (Betz et al., 2016; Ilgen et al., 2008; Oslin et al., 2004; Smith, Currier, and Drescher, 2015).

Although suicide attempts and ideation are not reliable proxies of suicide risk, these studies do yield insights into the differences in suicidality between those who have access to guns and those who do not. These studies find little evidence that firearm access or storage practices are associated with suicidality among household members, which refutes criticism that associations between access and suicide are due to differences in a propensity to take one’s life and whether a person owns or how he or she stores guns. However, other problems in a household might cause poor storage security and increased suicide risk, which could account for their apparent association without storage practice itself contributing to suicide risk. Still, at least one study suggests that such an omitted variable would need to be improbably influential to explain the strong observed association between household firearm access and suicide risk (Miller, Swanson, and Azrael, 2016).

Weapon-Carrying and Suicide Attempts

A third type of individual-level study examined the association between weapon-carrying and suicide attempts. Three such studies fell within the time frame of our literature review (2003–2016), most of which derived from analyses of the Youth Risk Behavior Survey. Two studies documented positive relationships between past suicide attempts and carrying a gun in the past 30 days (Molina and Duarte, 2006; Ruggles and Rajan, 2014), and one found a positive relationship between past suicide attempts and carrying a weapon (though not necessarily a gun) in the past 30 days (Swahn et al., 2012). Again, these results are consistent with a wide range of causal models, including ones that postulate effects in opposite directions (i.e., that suicidality causes one to carry a weapon).

The table below details the studies published in or after 2003 that examined the relationship between firearm access and suicide.

Individual-Level Studies Published in or After 2003 That Examined the Relationship Between Firearm Access and Suicide

Study Sample Cases Controls Results
Case status: Suicide deaths
Grassel et al., 2003 California deaths in 1998 2,798 suicides in California 207,851 noninjury causes of death (with some exclusions) Those who died by suicide were more likely to have purchased a handgun in the past three years (aOR = 6.8; CI: 5.7, 8.1) and in the past year (aOR = 12.5; CI: 10.0, 15.6). The association for purchase in the past three years was especially pronounced for women (aOR = 33.9; CI: 19.3, 59.3).
Kung, Pearson, and Liu, 2003 1993 National Mortality Followback Survey 441 female and 1,022 male suicides 2,337 female and 5,055 male deaths from natural causes Both males and females who died by suicide were more likely to have lived in a home with a gun, regardless of whether they lived alone or with others (female, lived with others: aOR = 2.99; CI: 1.58, 5.65; female, lived alone: aOR = 25.83; CI: 8.36, 77.29; male, lived with others: aOR = 3.53; CI: 2.42, 5.15; male, lived alone: aOR = 16.13; CI: 6.97, 37.25).
Wiebe, 2003 1993 National Mortality Followback Survey 1,959 suicides 13,535 respondents from the 1994 National Health Interview Survey Those who died by suicide were more likely to have lived in a home with a gun (aOR = 3.44; CI: 3.06, 3.86). Having a gun in the home was also associated with firearm suicide (aOR = 16.89; CI: 13.26, 21.52) but inversely associated with nonfirearm suicide (aOR = 0.68; CI: 0.55, 0.84).
Dahlberg, Ikeda, and Kresnow, 2004 1993 National Mortality Followback Survey 1,049 suicides in the home and 687 firearm suicides 535 deaths in the home from other means, excluding suicide, and 362 nonfirearm suicides Males with guns in the home were at a significantly greater risk of suicide than males without guns in the home (OR = 10.4; CI: 5.8, 18.9); the association for females included the null value (= 1.0) in the CI. Among those who died by suicide, those living with a gun in the home were more likely to take their lives using a gun than other means. There was no evidence of an association between suicide method and type or number of guns in the home or between suicide method and storage practices.
Shenassa et al., 2004 1993 National Mortality Followback Survey Firearm suicide Died from other causes Those who died by firearm suicide were more likely to have lived in a home with a firearm (no adjustment).
Kung, Pearson, and Wei, 2005 1993 National Mortality Followback Survey Suicide death among those aged 15–64 Death from natural causes among those aged 15–64 Those who died by suicide were more likely to have lived in a home with a gun in analyses adjusting for race, living arrangements, educational status, marijuana use, excessive alcohol use, depressive symptoms, and past-year use of mental health services.
Stander et al., 2006 1999–2004 Navy suicides Firearm suicide Nonfirearm suicide Among Navy suicides, 66 percent of those with access to a military weapon used a gun to die, compared with 54 percent of those without access. Furthermore, 65 percent of those with training on military weapons used a gun to die, compared with 54 percent of those without training.
Joe, Marcus, and Kaplan, 2007 1993 National Mortality Followback Survey Firearm suicide Nonfirearm suicide In models controlling for demographic, socioeconomic, and clinical variables, having a firearm in the home was associated with firearm suicide in the total sample and when stratified by race.
Case status: Suicide ideation or attempts
Oslin et al., 2004 Older adults receiving primary care treatment Suicide ideation No suicide ideation There was no relationship between suicide ideation and having a gun in the home.
Thompson et al., 2006 Veterans receiving outpatient treatment for opiate addiction Suicide ideation (n = 26) No suicide ideation (n = 75) Owning a firearm was associated with suicide ideation in bivariate analyses.
Ilgen et al., 2008 National Comorbidity Survey Those who report having ever thought about committing suicide, made a plan for committing suicide, or attempted suicide Those who did not meet case criteria There was no significant difference in gun access between those who thought about attempting suicide (31 percent) or made a plan to attempt suicide (31 percent) and those who did not (36 percent for both sets of controls), but those who had attempted suicide were less likely to have access (36 percent versus 24 percent; OR = 0.6; CI: 0.5, 0.8).
Miller et al., 2009 National Comorbidity Survey Replication Past-year suicide ideation, suicide planning, or suicide attempt No past-year suicide ideation, suicide planning, or suicide attempt Living in a home with a firearm was not associated with past-year suicide ideation, planning, or attempts in models that accounted for age, sex, race/ethnicity, educational attainment, and poverty.
Betz, Barber, and Miller, 2011 Second Injury Control and Risk Survey 20 people who, in the past 12 months, had a suicide plan involving a firearm 155 people who, in the past 12 months, had a suicide plan that did not involve a firearm Of those who had a suicide plan involving a firearm, 81 percent lived in a home with a firearm, compared with 38 percent of those whose plan did not involve a firearm (OR = 7.4).
Kolla, O’Connor, and Lineberry, 2011 Psychiatric inpatients Access to a firearm (N = 138) No access to a firearm Females, those with a past suicide attempt, those with a family history of a suicide attempt, and those aged 65 or older were less likely to report access to a firearm in multiple logistic regression. Patients with bipolar disorder diagnoses were more likely to report access in multiple regression analyses.
Simonetti et al., 2015 National Comorbidity Survey: Adolescent Supplement Access to a firearm in the home No access to a firearm in the home There was no relationship between household access to a firearm and lifetime suicide ideation, planning, or attempts, nor in any stratified analyses or multivariable models.
Smith, Currier, and Drescher, 2015 Veterans entering treatment for posttraumatic stress disorder Two samples of veterans with suicidal thoughts or attempts:
  • Sample 1: N = 82 ideators, 62 attempters
  • Sample 2: N = 27 ideators, 23 attempters
Veterans without suicidal thoughts or attempts (Sample 1 = 57, Sample 2 = 22) In Sample 1, attempters were less likely to own a gun at the beginning of treatment (26 percent) relative to ideators (39 percent) or nonattempters/nonideators (32 percent). In Sample 2, there were no significant differences among groups (attempters = 29 percent, ideators = 36 percent, nonattempters/nonideators = 36 percent).
Betz et al., 2016 Seven emergency departments across the United States 1,358 emergency department patients with suicidal thoughts or an attempt None Of patients with suicidal thoughts or an attempt, 11 percent reported having access to a gun at home. Among those with a firearm at home, 58 percent of men and 25 percent of women personally owned at least one gun.

NOTE: All CIs in this table are at the 95-percent level. aOR = adjusted odds ratio; OR = odds ratio.

Regional Availability of Firearms

NRC (2004) concluded that there were regional associations between firearm prevalence and firearm suicide but uncertain relationships between firearm availability and total suicides. The report also concluded that results varied by the age group studied, the covariates included in the models, and the measure of firearm availability used (discussed later in this section). Further, the report noted that there was uncertain evidence that firearm prevalence explained changes in total suicide rates over time. Evidence about change over time derived primarily from studies examining suicide rates in the District of Columbia before and after 1976, when the District established a policy that prohibited the purchase, sale, transfer, and possession of handguns. There was a 23-percent reduction in the frequency of firearm-related suicides following the policy change, and no changes in nonfirearm-related suicides or in firearm-related suicides in the surrounding areas (Loftin et al., 1991), although, as NRC pointed out, this study was sensitive to modeling choices (Britt, Kleck, and Bordua, 1996), and its results may have been caused by other changes in the District of Columbia over the same period (Jones, 1981).

In this discussion, we prioritize longitudinal studies conducted since 2003 that applied a quasi-experimental research design. We describe these studies in the following sections, noting that while some studies are longitudinal, only a handful utilize measures of exposure (firearm prevalence, or a proxy for prevalence) and outcome (suicides) that vary over time, conditions necessary to employ a quasi-experimental design. The studies meeting that criteria are Briggs and Tabarrok (2014), Miller et al. (2006), Phillips and Nugent (2013), and Rodriguez Andrés and Hempstead (2011). Each of these four studies employs unique methods to reach empirical and causal estimates of the effects of changes in firearm prevalence on changes in suicides. This is challenging to estimate empirically because firearm prevalence does not change significantly over regions over time (Smith and Son, 2015) and because, in cross-sectional analyses, firearm prevalence is consistently associated with suicide. Thus, methods need to decompose within-region changes over time from cross-region known associations. In the four studies described here, three (Miller et al., 2006; Briggs and Tabarrok, 2014; and Rodriguez Andrés and Hempstead, 2011) did so in a time-series model with regional fixed effects. Phillips and Nugent (2013) employed a decomposition random-effects model approach that estimated separate between- and within-region effects.

Measures of Firearm Prevalence

One of the biggest challenges to estimating the effects of regional firearm availability (i.e., prevalence) on suicide risk is the lack of valid data on the exposure of interest: household prevalence of firearms or of firearm ownership at the state level. Survey data on firearm ownership collected as part of the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance Survey (BRFSS) for all 50 states are available for three years (2001, 2002, and 2004) and for census regions (and large cities) as part of the General Social Survey (GSS) biannually (though for some periods, annually). Thus, while there are studies examining the relationship between regional prevalence rates and suicide outcomes, researchers interested in examining variability in gun prevalence and its association with suicide at the state level must rely on proxy measures. Sometimes they apply the earlier BRFSS estimates to the current period or apply regional measures to the states within the region.

Some studies validate different proxy measures of firearm prevalence (see, for example, Azrael, Cook, and Miller, 2004; Kleck, 2004; Siegel, Ross, and King, 2014). However, evidence for the validity of these proxies as measures of gun prevalence over time is limited (Kleck, 2004), and establishing such evidence in the absence of survey data, particularly at the state level, over time is challenging. Our goal here is not to review all proxy measures; rather, we describe information on the ones found in the quasi-experimental studies described in this essay, as well as those used in the essay on the relationship between firearm prevalence and violent crime. The proxy measures we discuss are as follows:

  • FS/S. The most frequently utilized measure of firearm prevalence is the proportion of total suicides that are firearm suicides (FS/S). The correlation between FS/S and BRFSS state-based prevalence estimates is 0.80 (Siegel, Ross, and King, 2014), between FS/S and GSS regional-based prevalence estimates is 0.93 (Azrael, Cook, and Miller, 2004), and between FS/S and estimates from large cities is 0.87 (Kleck, 2004). NRC (2004, p. 169), however, emphasized that FS/S could introduce biases in models examining the effects of gun availability on suicide.
  • Hunting licenses per capita. Rodriguez Andrés and Hempstead (2011) used hunting licenses per capita. Kleck (2004) provided only a correlation of this proxy with 45 large cities and estimated a weak correlation of 0.37, although ­Rodriguez Andrés and Hempstead (2011) reported that hunting license per capita has a 0.74 correlation with FS/S.
  • FS/S combined with hunting license rate. In the essay on the relationship between firearm prevalence and violent crime, we review Siegel, Ross, and King (2014), which used a composite measure that includes both FS/S and the hunting license rate. The authors presented evidence that this measure has a 0.95 correlation with BRFSS estimates, although they suggest that the measure overestimates absolute levels of gun ownership and thus its utility should be restricted to a proxy reflecting proportional differences between states.
  • Google searches for gun-related terms. Briggs and Tabarrok (2014) used as a proxy of gun ownership Google searches, aggregated to states, for gun-related terms. The correlation between this measure and the three-year average of the BRFSS estimates is greater than 0.80, although the authors did not present the actual correlation estimate.
  • Composite index of FS/S, the rate of background checks for gun purchases, and the rate of unintentional death by firearm. Briggs and Tabarrok (2014) also used this composite index to “overcome weaknesses” of the measures individually. The correlation between this composite measure and the three-year average of the BRFSS estimates is 0.84.

For other proxy measures—including firearm homicides divided by homicides, subscriptions to firearm-related publications (e.g., Guns & Ammo), membership in the National Rifle Association, percentage of hunters, and carry permits per population—see Azrael, Cook, and Miller (2004) and Kleck (2004).

Quasi-Experimental Results

In the earliest of the four studies in our review, Miller et al. (2006) used data from the GSS on firearm prevalence in census regions over time. Using generalized estimating equations with region-level fixed effects, the authors concluded that a regional reduction in firearms of 10 percent would result in an estimated 4.2-percent reduction in firearm suicides, 2.5-percent reduction in total suicides, and no change in nonfirearm suicides.

Briggs and Tabarrok (2014) used four measures of gun prevalence over time: state-level ownership from the BRFSS in 2001, 2002, and 2004; state-level estimates of searches for gun-related terms on Google from 2004 to 2009; FS/S from 2000 to 2009; and a composite index comprising FS/S, the rate of background checks for gun purchases, and the rate of unintentional death by firearm for 2000 to 2009. In ordinary-least-squares models with time and regional (not state) fixed effects, along with other regional covariate adjustments, all four measures of gun prevalence showed that a 1-percent increase in the prevalence of individuals having firearms in their households in a state is associated with a positive and statistically significant increase in firearm suicides (between 1.3 and 3.1 percent), and three of the four measures found positive and statistically significant increases in total suicides (between 0.7 and 0.9 percent) (see the table below). The effect on total suicide was not significant at p < 0.05 for the direct measure of gun ownership from the BRFSS.

Estimated Effects of a 1-Percent Increase in Firearm Prevalence on Firearm and Total Suicides

Measure of Gun Prevalence Increase in Firearm Suicide Increase in Total Suicide
Gun ownership (from the BRFSS) 1.7 percent 0.5 percent (not significant)
Gun-related Google searches 1.3 percent 0.7 percent
FS/S 3.1 percent 0.9 percent
Composite index (FS/S, rate of background checks for gun purchases, rate of unintentional death by firearm) 2.3 percent 0.8 percent

NOTE: All effects are significant at p < 0.01, except as noted (Briggs and Tabarrok, 2014).

The foregoing findings were correlational, without additional analyses that attempted to determine whether the correlation should be interpreted as evidence that increases in gun prevalence cause an increased suicide rate. However, Briggs and Tabarrok (2014) also reported results using methods that might better support causal interpretation. In these analyses, gun prevalence measures were modeled using “interest in hunting” (based on hunting magazine subscriptions and Google searches for hunting-related terms). This type of “instrumental variable” method can provide evidence of a causal effect if the chosen instrument has no direct effect on suicide but instead can affect suicide only indirectly through its effect on gun prevalence. These models showed suggestive, but nonsignificant, effects consistent with gun prevalence causing suicide. However, the authors provided no empirical evidence for the validity of their instruments, and the instruments’ conceptual validity may also be questioned.

Phillips and Nugent (2013) used a decomposition random-effects model that provided separate estimates for the effect of gun prevalence on suicide between states and on annual suicides within states from 1976 to 2000. The authors measured gun prevalence using GSS data at the regional level (with each state in a region assigned the regional value). They found that gun prevalence was associated with total and firearm suicides across states, but there was no evidence that prevalence explained variation within states (for total, firearm, or nonfirearm suicides) over time.

Rodriguez Andrés and Hempstead (2011) was the only study to find no association between changes in firearm prevalence and total or firearm suicides. The authors used a negative binomial model of suicides between 1995 and 2004 with fixed effects for state and year. However this analysis used one of the weakest proxies of gun ownership: hunting licenses per capita (Kleck, 2004).

The table below details the four longitudinal studies conducted since 2003 that applied a quasi-experimental research design and examined the regional relationship between firearm availability and suicide.

Quasi-Experimental Studies Published in or After 2003 That Examined the Regional Relationship Between Firearm Prevalence and Suicide

Study Details
Miller et al., 2006
Sample
U.S. Census regions
Outcome
Suicide rates, 1981–2002
Measure of Prevalence

GSS gun ownership data (1982, 1984, 1985, 1987–1991, 1993, 1994, 1996–2002; missing years imputed); for sex-specific and child outcomes, gun availability was estimated using responses from these specific groups

Covariates

Age, unemployment, per capita alcohol consumption, poverty, and region of the country

Analytic Approach
Log-log generalized estimating equation regressions with regional fixed effects
Results

Percentage decrease in outcome based on a 10-percent regional decrease in firearm ownership:

  • Total suicides: 2.5 percent (95% CI: 1.4, 3.6)
  • Firearm suicides: 4.2 percent (95% CI: 2.3, 6.1)
  • Nonfirearm suicides: 0.3 percent (95% CI: −1.4, 2.3).

Rate of decline did not vary significantly by gender but was greatest for those aged 0–19.

Rodriguez Andrés and Hempstead, 2011
Sample
U.S. states
Outcome
Number of male suicides, 1999–2004
Measure of Prevalence
Hunting licenses per capita
Covariates
Education, income, alcohol consumption, percentage older than age 65, percentage non-Hispanic white, relevant population size, one index of gun availability (general prohibitions)
Analytic Approach
Negative binomial with state and year fixed effects
Results
There was no statistically significant association between gun availability and outcome.
Phillips and Nugent, 2013
Sample
U.S. states
Outcome
Suicide rates, 1976–2000
Measure of Prevalence
GSS gun ownership (regional) using the three-year moving average
Covariates
Percentage aged 15–24; percentage older than age 65; percentage male; percentage white; population size; percentage living in urban areas; percentage foreign-born; unemployment rate; per capita income; percentage divorced; religious adherence rate per 1,000; percentage Catholic, Episcopalian, or other mainline Protestant; annual alcohol consumption
Analytic Approach
Decomposition model with random effects and regional and year-level fixed effects
Results
Gun ownership rate was associated with increases in total suicide rate across states (0.105 percent, p < 0.05) and firearm suicide rate across states (0.129 percent, p < 0.05) but not across time for either outcome. Also, neither outcome was related to nonfirearm suicide.
Briggs and Tabarrok, 2014
Sample
U.S. states
Outcome
Suicide rates, 2000–2009
Measure of Prevalence
(1) BRFSS gun ownership from 2001, 2002, and 2004; (2) Google searches for gun-related terms (2004–2009); (3) FS/S; (4) composite index comprising FS/S, the rate of background checks for gun purchases, and the rate of unintentional death by firearm
Covariates

Baseline model: population, poverty rate, annual average unemployment rate, percentage urban land area, percentage urban population, Gini coefficient of household income inequality, prevalence of drug and/or alcohol abuse or dependence in the population aged 12+, prevalence of frequent mental distress among noninstitutionalized adults, percentage of males aged 65+, and percentage white

Full model: median household, percentage of children living in a single-mother family, percentage of divorced adults, distance to the nearest hospital emergency room, and a measure of social connectedness

Analytic Approach
Ordinary-least-squares model with time-specific and regional-specific (not state-specific) fixed effects; standard errors account for clustering at the state level. Minimal model excluded Gini, frequent mental distress, drug/alcohol covariates. Used circulation of Field & Stream magazine as an instrumental variable. For Google exposure, the instrumental variable was a Google search for hunting-related terms.
Results

Ownership (BRFSS):

  • Total suicides: 𝛽 = 0.003–0.005, p < 0.10 in baseline and minimal model, not significant in full model
  • Firearm suicides: 𝛽 = 0.014–0.017, p < 0.01
  • Nonfirearm suicides: 𝛽 = –0.008–0.01, p < 0.01 in full model, p < 0.05 in baseline model, p < 0.10 in minimal model

Google searches, baseline model:

  • Total suicides: 𝛽 = 0.007, p < 0.01
  • Firearm suicides: 𝛽 = 0.013, p < 0.01
  • Nonfirearm suicides: 𝛽 = –0.000, p = not significant

FS/S, baseline model:

  • Total suicides: 𝛽 = 0.009, p < 0.01
  • Firearm suicides: 𝛽 = 0.031, p < 0.01
  • Nonfirearm suicides: 𝛽 = –0.012, p < 0.01

Composite index, baseline model:

  • Total suicides: 𝛽 = 0.008, p < 0.01
  • Firearm suicides: 𝛽 = 0.023, p < 0.01
  • Nonfirearm suicides: 𝛽 = –0.007, p < 0.01

When adding a quadratic term to the baseline regressions, they found that it was significant and negative (diminishing effect). The instrumental variable results reported qualitatively similar findings.

Longitudinal, Non-Quasi-Experimental Results

In addition to the four studies just discussed, our search identified two other U.S.-based longitudinal studies that do not meet our criteria for a quasi-experimental design. Desai, Dausey, and Rosenheck (2008) did not use a measure of gun prevalence that varied over time but found that state-level firearm prevalence (measured prior to hospital discharge) is associated with increased risk that a veteran discharged from an inpatient U.S. Department of Veterans Affairs facility with a psychiatric diagnosis will use a firearm to take his or her life relative to not taking his or her life or doing so using some other means. Wadsworth, Kubrin, and Herting (2014) did not employ a control group but found that the suicide rate increase among black males aged 15–34 between 1982 and 1993 was not associated with changes in gun availability (while also controlling for social and economic disadvantage) but that reductions in gun availability during the 1990s had some association with decreasing suicide rates in that group over the same period.

Cross-Sectional Results

Cross-sectional studies that examined regional associations provided little or no evidence for the causal effect of gun availability on suicide. Nonetheless, most such studies since 2003 generally found a positive relationship between gun prevalence and total or firearm suicide in the United States (Duggan, 2003; Miller, Azrael, and Hemenway, 2004; Price, Thompson, and Dake, 2004; Kubrin and Wadsworth, 2009; Miller et al., 2009; Price, Mrdjenovich, and Dake, 2009; Kposowa, 2013; Miller et al., 2013; Smith and Kawachi, 2014; Miller et al., 2015; Kposowa, Hamilton, and Wang, 2016), although there were exceptions (e.g., Shenassa, Daskalakis, and Buka, 2006). Details of these studies are presented in the table below.

Cross-Sectional Studies Published in or After 2003 That Examined the Regional Relationship Between Firearm Availability and Suicide

Study Focal Area Main Findings
Duggan, 2003 U.S. states Firearm prevalence (FS/S and sales rates for Guns & Ammo magazine) was positively correlated with total, firearm, and nonfirearm suicide rates (although there were age groups for which the relationship with nonfirearm suicides was not significant or was negative). Change in firearm prevalence (sales rates for Guns & Ammo magazine, 1980–1998) was correlated with change in firearm suicide, but there was no evidence of a statistically significant association with nonfirearm suicide, while the association with total suicide was dependent on model specification.
Miller, Azrael, and Hemenway, 2004 U.S. states Among seven Northeastern states, prevalence of firearms was positively correlated with suicides (except female suicides) and firearm suicides (but not nonfirearm suicides), as well as suicide attempts (except among those aged 15–64), firearm suicide attempts, and nonfirearm suicide attempts among females.
Price, Thompson, and Dake, 2004 U.S. states Firearm prevalence (FS/S) was positively associated with firearm suicide mortality (1999) in models controlling for number of firearm dealers, race, presence of gun laws, per capita alcohol consumption, level of urbanization, violent crime rate, and socioeconomic status.
Shenassa, Daskalakis, and Buka, 2006 Chicago neighborhoods Neighborhood levels of gun-carrying and gun availability (based on youth self-report) were not associated with the proportion of suicides by firearm.
Kubrin and Wadsworth,
2009
U.S. cities Firearm prevalence (combined FS/S and ratio of homicides that are firearm homicides) was associated with a greater number of suicides among both white males and black males aged 35 or younger aggregated between 1998 and 2001, with some suggestion that gun availability mediates the effect of structural disadvantage and suicide among black males.
Miller et al.,
2009
U.S. states Firearm prevalence (2001 BRFSS) was positively associated with 2000–2002 total and firearm suicides in models that controlled for rates of unemployment, urbanization, poverty, serious mental illness, and alcohol and illicit drug dependence and abuse.
Price, Mrdjenovich, and Dake, 2009 U.S. states Firearm prevalence (2002 BRFSS) was positively associated with firearm suicide mortality (2002) in models controlling for prevalence of serious mental illness, psychotropic medications, access to mental health care, per capita expenditures for mental health services, race/ethnicity, untreated mental health conditions, and educational expenditures and attainment.
Kposowa, 2013 U.S. states Firearm prevalence (2001 BRFSS) was positively associated with death by suicide relative to other causes of death (2000–2004) in models that controlled for individual-level (marital status, sex, race, place of residence, city size, age, year of death) and state-level (2000 suicide rate, percentage voted for George W. Bush, percentage church adherents, percentage immigrants) variables.
Miller et al.,
2013
U.S. states Firearm prevalence (2004 BRFSS) was positively associated with 2008–2009 total and firearm suicide rates in models that accounted for state-level suicide attempt rates. These relationships held in models stratified by gender and age (18–29, 30+).
Smith and Kawachi, 2014 U.S. states Firearm prevalence (2001 BRFSS) was positively associated with 1999–2002 total suicides among all men and all women, as well as in stratified analyses for white men and non-Hispanic white men.
Miller et al.,
2015
U.S. cities Firearm prevalence (BRFSS averaged for 2002 and 2004) was positively associated with firearm and total suicides in U.S. cities (data aggregated from 1999 to 2010).
Kposowa, Hamilton, and Wang, 2016 U.S. states Firearm prevalence (BRFSS) was positively associated with 2011–2013 total and firearm suicide rates in models that controlled for religious adherence, long-term unemployment, percentage of population with a serious mental illness, divorce rate, and percentage rural.

International Evidence

Some of the most suggestive evidence that the prevalence of guns in a community may have a causal effect on suicide rates comes from two international studies published since 2003. Reisch et al. (2013) examined suicide rates in Switzerland between 1995 and 2008, following large-scale reforms in the Swiss military in 2004 that reduced the size of the army by half; lowered the discharge age from 43 to 33; and introduced new policies that, among other things, increased the cost to service members of purchasing their military guns after separation from the service and introduced a gun license requirement. This study showed that suicide rates among men aged 18–43 were lower immediately after the 2004 Army reforms than would have been expected based on the pre-reform trends. The authors reasonably suggested that the two new firearm policies probably had the effect of reducing firearm ownership in the country and that this reduced gun prevalence caused the observed reductions in suicide rates.

The quasi-experimental Reisch et al. (2013) study relied on data from a single treated unit: Switzerland (i.e., there was no control or comparison country or region). To demonstrate that it was specifically the firearm restrictions imposed in 2004 that led to reductions in suicide by younger men, rather than other aspects of the Army reform or other changes in Swiss society around 2004, the authors noted that the observed reductions among younger men were exclusively found for firearm suicides, not other forms of suicide, and that similar reductions were not found among women after 2004. In addition, they found that the effect was more pronounced for younger men (aged 18–43) who would be more directly affected by the firearm restrictions than older men (aged 44–53).

The strength of these findings rests on the question of whether it is plausible that changes other than a reduction in gun prevalence could account for this pattern. For instance, there were, contemporaneously, large-scale changes to the military and, by extension, to Swiss society and the experience of young men after the military reforms. It is plausible that these large social changes affected suicide rates or attitudes toward firearm suicide. If so, then the effect of the additional cost of acquiring a firearm and any consequent effect on firearm prevalence is not well identified. Moreover, other changes in Swiss society must have been responsible for the substantial declines in suicide rates and firearm suicide rates among younger men in the years immediately preceding the Army reforms. Without understanding the factors driving that change, it is not possible to know whether they also shifted around 2004 in ways that further reduced firearm suicides.

Moreover, the comparison group of older men does not offer a strong demonstration that the effect was specific to those who would have been directly affected by the Army’s new gun policies. Specifically, Reisch et al. (2013) found marginally significant reductions in suicide rates after 2004 among older men aged 44–53. Although this effect was no longer significant after Bonferonni corrections, the report did not provide an estimate for whether the reductions found among younger men were significantly different from those found for older men. If the two estimates were not significantly different, then either reducing access to separating soldiers’ service weapons had powerful spillover effects that reduced suicides among older men or, conversely, the Army reforms were not the best explanation of reduced suicides among younger men. If the reductions in suicides among younger and older men were significantly different, then (as the authors argued) changes in firearm policies may well have been the Army reforms' key feature that explains why suicides declined among younger men.

In our assessments of quasi-experimental studies of U.S. law, we raised concerns about any study with fewer than four treated units. This is because, as the number of treated units declines, it becomes increasingly difficult to distinguish the effect of interest from the effects of other contemporaneous events affecting the treated unit or units. Given that only one treated unit was available in the Reisch et al. (2013) natural experiment, stronger evidence for the effect of firearm restrictions on suicide reductions among younger men in Switzerland might include evidence that reductions in suicide rates were disproportionately found among younger men who left the Army in 2004 or later, or that reductions in suicides were disproportionately found among those using their service weapon to kill themselves. Similarly, evidence that Army reforms had a meaningful effect on household gun ownership among younger men could bolster the argument that the effects of Army reforms on suicide were likely to have been mediated by significant changes to gun prevalence among younger men.

A second compelling foreign study examined a 2006 policy implemented by the Israeli Defense Forces, which required soldiers to leave their firearms on base when they returned home on weekends. The Israeli suicide rate among men aged 18–21 (including men both in service and not in service) following this policy decreased by 40 percent, from 28 per year in 2003–2005 to 16.5 per year in 2007–2008—a change largely resulting from weekend firearm suicide rates (ten per year in 2003–2005 to three per year in 2007–2008) (Lubin et al., 2010).

As with the Swiss study, Lubin et al. (2010) investigated an intervention on a single treatment unit (Israeli soldiers), so it must provide a strong argument that it was the weekend firearm policy that accounted for the observed changes, not any other contemporaneous changes that could have affected suicide rates. Because firearm and nonfirearm suicide rates were falling in Israel over the studied period (World Health Organization, 2017), the fact that firearm suicides among those aged 18–21 declined by 40 percent may not itself be distinguishable from declines in firearm suicides in groups that would be less directly affected by the military policy. For instance, firearm suicides among Israelis aged 25–29 also fell by 40 percent over this same period, from 10.7 per year to 6.3 per year (World Health Organization, 2017). On the other hand, the fact that greater reductions in firearm suicide rates among those aged 18–21 were found among weekend suicides rather than weekday suicides suggests that the policy may well have had an influence on suicidal behavior. Whether that involved shifting suicides from the weekend to the weekday or contributing to the ongoing reductions in suicides cannot be answered with the reported analyses.

Both the Swiss and Israeli studies provide some evidence that gun prevalence may have a causal effect on suicides. Both also suffer from studying a single intervention that occurred once in a particular population. The challenge posed by this design is to show persuasively that other events that occurred at the same time, such as the large-scale reform of the Army in Switzerland, do not provide plausible alternative explanations for observed changes in suicide rates. Other relevant international evidence is reviewed in the essay on Australia’s experience banning certain firearms through its National Firearms Agreement. However, that law also does not provide strong evidence of a causal effect of gun prevalence on suicide risk. As we conclude later in the report, although there is some evidence that the 1996 agreement reduced firearm suicides in Australia, studies also found significant reductions in nonfirearm suicides at the same time, calling into question whether the reductions in firearm and nonfirearm suicides were caused by the new law or some other concurrent events.

Conclusions

NRC (2004) concluded that the causal relationship between household gun ownership and suicide is unclear. Since that 2004 report, evidence from U.S.-based studies has substantiated associations that existed then—namely, that

  • people who die by suicide are more likely than matched controls to live in a house known by informants to contain a gun
  • living in a house known by informants to have a gun stored unsafely is associated with higher risk of firearm suicide than living in a house with a safely secured gun, but unsafe storage has no association with nonfirearm suicide
  • changes in firearm prevalence in a region are associated with changes in suicide prevalence in the region.

These observations are all consistent with the conclusion that gun availability increases the risk of suicide. Indeed, there appears to be a consensus among most experts in the public health community that these observed associations, in combination with the results of natural experiments like those in Switzerland and Israel (Reisch et al., 2013; Lubin et al., 2010), provide strong evidence that gun availability has a causal effect on suicide rates. Despite this mounting evidence, quasi-experimental studies providing strong evidence for an effect of gun prevalence on suicide risk have not yet been conducted. Therefore, those who doubt the causal effect can view the observed associations between gun prevalence and suicide rates over time or across regions as indicating that the kinds of people who might consider suicide at some future time may be more likely to purchase a gun (which is a plausible interpretation of, for instance, findings in Wintemute et al., 1999) or that informants in case-control studies may be biased toward describing unsafe storage practices in cases where firearms were used in suicides or may be more likely to incorrectly deny gun availability for control cases in which no firearm injuries occurred.

For example, Kleck (1997) suggests that “one would expect the personality trait of self reliance to encourage both suicide and gun ownership for self-protection, contributing to a spurious correlation between the two” (p. 282). Miller, Swanson, and Azrael (2016) counter this suggestion by noting that any such third-factor explanation (such as a “self-reliance” trait) would have to be as strong a predictor of suicide as are the strongest known predictors (e.g., major depression), as well as “an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor” (p. 1). This, the authors argue correctly, would make explanations of the association based on unmeasured factors highly unlikely. However, their analysis is based on the large gun availability effect sizes produced by the same case-control studies that are subject to methodological concerns about, for instance, whether informants provide unbiased information about gun availability in case versus control homes.

The natural experiments investigated in Switzerland and Israel (Reisch et al., 2013; Lubin et al., 2010) are quite interesting and suggest a possible effect of firearm prevalence on suicide risk but, for reasons described earlier, do not provide especially strong or unambiguous evidence for such an effect. Moreover, even if the studies did provide strong evidence, it is not clear whether similar interventions would have comparable effects in the context of the United States. For these reasons, even though new and important studies have been published since NRC reviewed the case for gun prevalence having a causal effect on suicides, we draw the same conclusion that NRC reached in 2004: Available empirical research does not provide strong causal evidence for the effects of gun prevalence on suicide risk.

Although the empirical research is ambiguous, which suggests that there is more to learn before we can conclude with confidence that gun prevalence has a causal effect of increasing suicide rates, the theoretical or logical arguments for this claim are sufficiently compelling that individuals and policymakers might reasonably choose to assume that gun availability does increase the risk of suicide. These logical considerations include that guns are an especially lethal means of attempting suicide and that suicide attempts are impulsive acts that may never be repeated if the first attempt fails. Because those who impulsively attempt suicide with a gun rarely get a chance to reconsider the decision, it is reasonable to suspect that when guns are less available, fewer suicide attempts will result in fatality, more people will have the chance to reconsider their decisions, and suicide rates will therefore decline. We view this as a logical and reasonably persuasive argument but distinguish it from what empirical research can currently demonstrate persuasively about the net effects of gun prevalence on suicide rates.

Stronger study designs may be available to more persuasively establish the causal effects of gun availability or gun prevalence on suicide risk. However, many such study designs are currently hampered by poor information on the prevalence of gun ownership and the consequent reliance on proxy measures of availability and prevalence. For this reason, we recommend that the Centers for Disease Control and Prevention or another federal agency resume routine collection of voluntarily provided survey data on gun ownership and use.

Notes

  1. For an exception, see Dahlberg, Ikeda, and Kresnow (2004), who found that among suicides in the home, the relationship for women was only marginally statistically significant, as the lower limit of the CI was the null value, 1.0. Return to content
  2. A history of self-injurious thoughts and behaviors is a weak predictor of risk for suicide death (Ribeiro et al., 2016). Return to content
  3. An exception is Borowsky et al. (1999), which found that knowing where to get a gun was associated with lifetime suicide attempts among American Indian youth, particularly girls. Return to content

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  • Swahn, M. H., B. Ali, R. M. Bossarte, M. van Dulmen, A. Crosby, A. C. Jones, and K. C. Schinka, “Self-Harm and Suicide Attempts Among High-Risk, Urban Youth in the U.S.: Shared and Unique Risk and Protective Factors,” International Journal of Environmental Research and Public Health, Vol. 9, No. 1, 2012, pp. 178–191.
  • Swanson, Jeffrey W., “Mental Disorder, Substance Abuse, and Community Violence: An Epidemiological Approach,” in J. Monahan and H. Steadman, eds., Violence and Mental Disorder, Chicago, Ill.: University of Chicago Press, 1994, pp. 101–136.
  • Swanson, Jeffrey W., Michele M. Easter, Allison G. Robertson, Marvin S. Swartz, Kelly Alanis-Hirsch, Daniel Moseley, Charles Dion, and John Petrila, “Gun Violence, Mental Illness, and Laws That Prohibit Gun Possession: Evidence from Two Florida Counties,” Health Affairs, Vol. 35, No. 6, 2016, pp. 1067–1075.
  • Swanson, J. W., E. E. McGinty, S. Fazel, and V. M. Mays, “Mental Illness and Reduction of Gun Violence and Suicide: Bringing Epidemiologic Research to Policy,” Annals of Epidemiology, Vol. 25, No. 5, 2015, pp. 366–376.
  • Swanson, J. W., A. G. Robertson, L. K. Frisman, M. A. Norko, H. Lin, M. S. Swartz, and P. J. Cook, “Preventing Gun Violence Involving People with Serious Mental Illness,” in D. W. Webster and J. S. Vernick, eds., Reducing Gun Violence in America: Informing Policy with Evidence and Analysis, Baltimore, Md.: Johns Hopkins University Press, 2013, pp. 33–51.
  • Swedler, D. I., M. M. Simmons, F. Dominici, and D. Hemenway, “Firearm Prevalence and Homicides of Law Enforcement Officers in the United States,” American Journal of Public Health, Vol. 105, No. 10, 2015, pp. 2042–2048.
  • Tark, Jongyeon, and Gary Kleck, “Resisting Crime: The Effects of Victim Action on the Outcomes of Crimes,” Criminology, Vol. 42, No. 4, 2004, pp. 861–909.
  • Teisl, M. F., K. J. Boyle, and R. E. Record, Jr., “License-Sales Revenues: Understanding Angler and Hunter Reaction to Changes in License Prices,” Human Dimensions of Wildlife, Vol. 4, No. 4, 1999, pp. 1–17.
  • Teplin, L. A., G. M. McClelland, K. M. Abram, and D. A. Weiner, “Crime Victimization in Adults with Severe Mental Illness: Comparison with the National Crime Victimization Survey,” Archives of General Psychiatry, Vol. 62, No. 8, 2005, pp. 911–921.
  • Thompson, R., V. Kane, J. M. Cook, R. Greenstein, P. Walker, and G. Woody, “Suicidal Ideation in Veterans Receiving Treatment for Opiate Dependence,” Journal of Psychoactive Drugs, Vol. 38, No. 2, 2006, pp. 149–156.
  • Thomson Healthcare, Ranking America’s Mental Health: An Analysis of Depression Across the States, Washington, D.C.: Mental Health America, 2007.
  • Tita, G. E., A. A. Braga, G. Ridgeway, and G. L. Pierce, “The Criminal Purchase of Firearm Ammunition,” Injury Prevention, Vol. 12, No. 5, 2006, pp. 308–311.
  • Tondo, Leonardo, Matthew J. Albert, and Ross J. Baldessarini, “Suicide Rates in Relation to Health Care Access in the United States: An Ecological Study,” Journal of Clinical Psychiatry, Vol. 67, No. 4, 2006, pp. 517–523.
  • Tritch, Teresa, “Keep Handguns Away from Teenagers,” New York Times, May 30, 2014. As of June 29, 2017: http://takingnote.blogs.nytimes.com/2014/05/30/keep-handguns-away-from-teenagers/
  • United States Code, Title 18, Section 922, Unlawful Acts.
  • United States Code, Title 18, Section 923, Licensing.
  • United States Code, Title 18, Section 926, Rules and Regulations.
  • United States Code, Title 18, Section 930, Possession of Firearms and Dangerous Weapons in Federal Facilities.
  • United States Code, Title 20, Section 7961, Gun-Free Schools Act.
  • United States Code, Title 26, Section 5801, Imposition of Tax.
  • United States Concealed Carry Association, “Traveling? Know Concealed Carry Permit Info by State,” West Bend, Wisc., August 7, 2013. As of June 29, 2017: https://www.usconcealedcarry.com/traveling-ccw-permit/
  • U.S. Bureau of Labor Statistics, “Current Employment Statistics (National),” 2017. As of May 15, 2017: https://www.bls.gov/web/empsit/ceseeb1a.htm
  • U.S. Census Bureau, Number of Firms, Number of Establishments, Employment, and Annual Payroll by Enterprise Employment Size for the United States, All Industries: 2014, Washington, D.C., December 2016. As of January 15, 2017: https://www.census.gov/data/tables/2014/econ/susb/2014-susb-annual.html
  • U.S. Census Bureau, “U.S. and World Population Clock,” 2017. As of March 22, 2017: https://www.census.gov/popclock/
  • U.S. Department of Homeland Security, Active Shooter: How to Respond, Washington, D.C., October 2008.
  • U.S. Department of Justice, “Violent Crime Control and Law Enforcement Act of 1994 Fact Sheet,” Washington, D.C., October 24, 1994. As of May 30, 2017: https://www.ncjrs.gov/txtfiles/billfs.txt
  • U.S. Department of Justice, “Department of Justice Awards $1 Million to the National Crime Prevention Council to Support Gun Safety Campaign,” press release, March 7, 2013. As of January 10, 2016: https://www.justice.gov/opa/pr/department-justice-awards-1-million-national-crime-prevention-council-support-gun-safety
  • U.S. Department of Labor, Fact Sheet: The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), Washington, D.C., January 29, 2010. As of October 18, 2017: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/mhpaea.pdf
  • U.S. Fish and Wildlife Service, National Hunting License Report, Washington, D.C.: U.S. Department of the Interior, May 5, 2015. As of April 15, 2017: https://wsfrprograms.fws.gov/Subpages/LicenseInfo/HuntingLicCertHistory20042015.pdf
  • U.S. Fish and Wildlife Service, U.S. Department of the Interior, and U.S. Department of Commerce, 2011 National Survey of Fishing, Hunting, and Wildlife-Associated Recreation, Washington, D.C., FH2/11-NAT, 2012.
  • U.S. General Accounting Office, Firearms Purchased from Federal Firearm Licensees Using Bogus Identification, Washington, D.C., GAO-01–427NI, 2001.
  • USA Carry, “Concealed Carry Permit Reciprocity Maps,” web page, April 20, 2017. As of June 29, 2017: http://www.usacarry.com/concealed_carry_permit_reciprocity_maps.html
  • Vernick, J. S., and L. M. Hepburn, “State and Federal Gun Laws: Trends for 1970–1999,” in Jens Ludwig and Philip J. Cook, eds., Evaluating Gun Policy: Effects on Crime and Violence, Washington D.C.: Brookings Institution Press, 2003, pp. 345–402.
  • Vespa, Jonathan, Jamie M. Lewis, and Rose M. Kreider, America’s Families and Living Arrangements: 2012, Current Population Reports, Washington, D.C.: U.S. Census Bureau, P20–570, 2013.
  • Vigdor, E. R., and J. A. Mercy, “Disarming Batterers: The Impact of Domestic Violence Firearms Laws,” in Jens Ludwig and Phillip J. Cook, eds., Evaluating Gun Policy: Effects on Crime and Violence, Washington, D.C.: Brookings Institution Press, 2003, pp. 157–200.
  • Vigdor, E. R., and J. A. Mercy, “Do Laws Restricting Access to Firearms by Domestic Violence Offenders Prevent Intimate Partner Homicide?” Evaluation Review, Vol. 30, No. 3, 2006, pp. 313–346.
  • Violence Policy Center, “Concealed Carry Killers,” web page, 2017. As of March 23, 2017: http://concealedcarrykillers.org/
  • Vittes, K. A., and S. B. Sorenson, “Recreational Gun Use by California Adolescents,” Health Education and Behavior, Vol. 32, No. 6, 2005, pp. 751–766.
  • Vittes, K. A., J. S. Vernick, and D. W. Webster, “Legal Status and Source of Offenders’ Firearms for States with the Least Stringent Criteria for Gun Ownership,” Injury Prevention, Vol. 19, No. 1, June 23, 2012, pp. 26–31.
  • Vyrostek, S. B., J. L. Annest, and G. W. Ryan, “Surveillance for Fatal and Nonfatal Injuries—United States, 2001,” MMWR Surveillance Summary, Vol. 53, 2004, pp. 1–57.
  • Wadsworth, T., C. E. Kubrin, and J. R. Herting, “Investigating the Rise (and Fall) of Young Black Male Suicide in the United States, 1982–2001,” Journal of African American Studies, Vol. 18, No. 1, 2014, pp. 72–91.
  • Wallace, Lacey N., “Castle Doctrine Legislation: Unintended Effects for Gun Ownership?” Justice Policy Journal, Vol. 11, No. 2, Fall 2014.
  • Watkins, Adam M., and Alan J. Lizotte, “Does Household Gun Access Increase the Risk of Attempted Suicide? Evidence from a National Sample of Adolescents,” Youth and Society, Vol. 45, No. 3, 2013, pp. 324–346.
  • Webster, D., C. K. Crifasi, and J. S. Vernick, “Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides,” Journal of Urban Health, Vol. 91, No. 2, 2014, pp. 293–302.
  • Webster, D. W., L. H. Freed, S. Frattaroli, and M. H. Wilson, “How Delinquent Youths Acquire Guns: Initial Versus Most Recent Gun Acquisitions,” Journal of Urban Health, Vol. 79, No. 1, 2002, pp. 60–69.
  • Webster, Daniel W., and Marc Starnes, “Reexamining the Association Between Child Access Prevention Gun Laws and Unintentional Shooting Deaths of Children,” Pediatrics, Vol. 106, No. 6, 2000, pp. 1466–1469.
  • Webster, Daniel W., Jon S. Vernick, and Maria T. Bulzacchelli, “Effects of State-Level Firearm Seller Accountability Policies on Firearm Trafficking,” Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 86, No. 4, 2009, pp. 525–537.
  • Webster, Daniel W., Jon S. Vernick, and Lisa M. Hepburn, “Relationship Between Licensing, Registration, and Other Gun Sales Laws and the Source State of Crime Guns,” Injury Prevention, Vol. 7, 2001, pp. 184–189.
  • Webster, D. W., J. S. Vernick, A. M. Zeoli, and J. A. Manganello, “Association Between Youth-Focused Firearm Laws and Youth Suicides,” JAMA, Vol. 292, No. 5, 2004, pp. 594–601.
  • Webster, D. W., and G. J. Wintemute, “Effects of Policies Designed to Keep Firearms from High-Risk Individuals,” Annual Review of Public Health, Vol. 36, 2015, pp. 21–37.
  • Weil, Douglas S., and Rebecca C. Knox, “Effects of Limiting Handgun Purchase on Interstate Transfer of Firearms,” JAMA, Vol. 275, No. 22, 1996, pp. 1759–1761.
  • Wiebe, Douglas J., “Homicide and Suicide Risks Associated with Firearms in the Home: A National Case-Control Study,” Annals of Emergency Medicine, Vol. 41, No. 6, 2003, pp. 771–782.
  • Wintemute, G. J., D. Hemenway, D. Webster, G. Pierce, and A. A. Braga, “Gun Shows and Gun Violence: Fatally Flawed Study Yields Misleading Results,” American Journal of Public Health, Vol. 100, No. 10, 2010, pp. 1856–1860.
  • Wintemute, G. J., C. A. Parham, J. J. Beaumont, M. Wright, and C. Drake, “Mortality Among Recent Purchasers of Handguns,” New England Journal of Medicine, Vol. 341, No. 21, 1999, pp. 1583–1589.
  • Wintemute, Garen J., Marian E. Betz, and Megan L. Ranney, “Yes, You Can: Physicians, Patients, and Firearms,” Annals of Internal Medicine, Vol. 165, No. 3, 2016, pp. 205–213.
  • Wooldridge, J. M., Econometric Analysis of Cross Section and Panel Data, Cambridge, Mass.: MIT Press, 2002.
  • World Health Organization, Preventing Suicide: A Global Imperative, Geneva, 2014. As of May 8, 2017: http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pdf
  • World Health Organization, World Health Organization Mortality Database, Geneva, 2017. As of October 13, 2017: http://apps.who.int/healthinfo/statistics/mortality/causeofdeath_query/start.php
  • Wright, M. A., and G. J. Wintemute, “Felonious of Violent Criminal Activity that Prohibits Gun Ownership Among Prior Purchasers of Handguns: Incidence and Risk Factors,” Journal of Trauma and Acute Care Surgery, Vol. 69, No. 4, 2010, pp. 948–955.
  • Wright, M. A., G. J. Wintemute, and B. E. Claire, “Gun Suicide by Young People in California: Descriptive Epidemiology and Gun Ownership,” Journal of Adolescent Health, Vol. 43, No. 6, 2008, pp. 619–622.
  • Wright, M. A., G. J. Wintemute, and F. P. Rivara, “Effectiveness of Denial of Handgun Purchase to Persons Believed to Be at High Risk for Firearm Violence,” American Journal of Public Health, Vol. 89, No. 1, 1999, pp. 88–90.
  • Zeoli, A. M., and D. W. Webster, “Effects of Domestic Violence Policies, Alcohol Taxes and Police Staffing Levels on Intimate Partner Homicide in Large U.S. Cities,” Injury Prevention, Vol. 16, No. 2, 2010, pp. 90–95.

View the full project bibliography