Disrupting Access: Addressing Firearm Suicide in the U.S.

September 10, 2018

Executive Summary

Claiming the lives of nearly 22,000 Americans every year, firearm suicide is a significant public health crisis in the U.S.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A yearly average was developed using five years of most recent available data: 2012-2016. The conversation around gun violence in the U.S. tends to focus on homicides, especially in the context of mass shootings and school shootings. But nearly two-thirds of all gun deaths in the U.S. are suicides: an average of 59 deaths a day.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). Firearm suicide to total suicide ratio and daily average developed using five years of most recent available data: 2012-2016. And the problem is only getting worse: over the past decade, the U.S. firearm suicide rate has increased by 19 percent.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A percent change was developed using 2007-2016 age-adjusted rates for all ages. Addressing firearm suicide is an essential element of any strategy to reduce suicide and gun violence in this country.

2/3 of all gun deaths, 1/2 of all suicides

Amongst commonly used methods of self-harm, firearms are by far the most lethal, with a fatality rate of approximately 85 percent.Miller M, Azrael D, Hemenway D. The epidemiology of case fatality rates for suicide in the northeast. Annals of Emergency Medicine. 2004; 43(6): 723-30.,Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57. Conversely, less than 5 percent of people who attempt suicide using other methods will die,Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57.,Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. and the vast majority of all those who survive do not go on to die by suicide.Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: Systematic review. British Journal of Psychiatry. 2002; 181: 193-199. While firearms are used in less than 6 percent of suicide attempts, over half of suicide deaths are with firearms.Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. Research suggests that a reduction in suicide attempts by firearm would result in an overall decline in the suicide rate by an estimated 20 to 38 percent.Soffen K. To reduce suicides, look at guns. The Washington Post. July 13, 2016. https://wapo.st/2I7MCUx,Yip PS, Caine E, Yousuf S, Chang SS, Wu KC, Chen YY. Means restriction for suicide prevention. The Lancet. 2012; 379(9834): 2393-2399.

Access to firearms — meaning personal or household gun ownership — increases the risk of suicide by three times.Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110. Researchers overwhelmingly agree that household firearm ownership rates are strongly associated with rates of firearm and overall suicide, even when controlling for other factors associated with suicide like poverty, unemployment, serious mental illness, and substance abuse.Miller M, Lippman SJ, Azrael D, Hemenway D. Household firearm ownership and rates of suicide across the 50 United States. The Journal of Trauma Injury, Infection, and Critical Care. 2007; 62(4): 1029-35. This is why states with high rates of household gun ownership also have high rates of firearm and overall suicide.Ibid.

Access to a gun increases the risk of death by suicide by three times.

Policies and practices that focus on disrupting access to firearms can reduce firearm suicides. These include:

  • Building public awareness about the suicide risk posed by firearm access.
  • Limiting the easy and immediate acquisition of firearms.
  • Encouraging the responsible storage of firearms in the home to prevent access by children and other unauthorized users.
  • Creating mechanisms to temporarily remove firearms from individuals in moments of crisis.

Firearm Suicide in the U.S.

A growing problem

Suicide attempts by gun - 85% result in death. Suicide attempts by all other means - less than 5% result in death

Nearly 43,000 Americans die by suicide every year,Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A yearly average was developed using five years of most recent available data: 2012-2016. and the rate of suicide has increased by 19 percent over the past decade.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A percent change was developed using 2007-2016 age-adjusted rates for all ages. The dynamics of suicide are complex, involving factors like poverty, unemployment, substance abuse, and mental illness.Risk Factors and Warning Signs. American Foundation for Suicide Prevention Website. https://bit.ly/2bmWnQx. But one thing is clear: means matter and, amongst commonly used methods of self-harm, firearms are the most lethal means.Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57.,Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. Across all suicide attempts not involving a firearm, less than 5 percent will result in death,Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57.,Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. and the vast majority of those who survive do not go on to die by suicide.Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: Systematic review. British Journal of Psychiatry. 2002; 181: 193-199. For example, 98 percent of people who try to kill themselves through poisoning/overdose — the most common method of attempted suicide — will survive the attempt.Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57.,Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. For gun suicide, those statistics are flipped: approximately 85 percent of gun suicide attempts end in death.Vyrostek SB, Annest JL, Ryan GW. Surveillance for fatal and nonfatal injuries - United States, 2001. Morbidity and Mortality Weekly Report. Surveillance Summaries. 2004; 53(7): 1-57.,Miller M, Azrael D, Barber C. Suicide mortality in the United States: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health. 2012; 33: 393-408. While firearms are used in less than 6 percent of suicide attempts, over half of suicide deaths are with firearms.Ibid.

Joyce and Khary

Nearly 22,000 Americans die by firearm suicide every year — including over 950 children and teens.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A yearly average was developed using five years of most recent available data: 2012-2016. Children defined as 0-19. The U.S. firearm suicide rate is eight times that of other high-income countries.Grinshteyn E, Hemenway D. Violent death rates: The US Compared with other High-Income OECD Countries, 2010. The American Journal of Medicine. 2016; 129(3): 266-273. Like the overall suicide rate, the firearm suicide rate has increased by 19 percent over the past decade.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A percent change was developed using 2007-2016 age-adjusted rates for all ages. This trend has been of particular concern for children and teens, with the rate of firearm suicide up by 61 percent over the past decade.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A percent change was developed using 2007-2016 crude rates for children and teens (0-19).



The demographics of firearm suicide

Men represent 86% of firearm suicide victims

A demographic analysis of firearm suicide victims reveals several key patterns:

Men represent 86 percent of firearm suicide victims, and are over six times more likely than women to die by firearm suicide.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). Developed using five years of most recent available data (2012-2016) and age-adjusted rates.

Rates of firearm suicide are much higher for adults than for children and teens.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). A yearly average was developed using five years of most recent available data: 2012-2016. Children and teens (0-19) die of firearm suicide at a rate of 1.16 per 100,000 compared to 8.75 per 100,000 among adults age 20 and over. For women, firearm suicide rates are highest in the 45 to 60 age range.Ibid. For men, firearm suicide rates largely increase with age,Ibid. and are especially high for male senior citizens (65 and older).

White Americans represent 87 percent of all firearm suicide victims, and have the highest rate of firearm suicide by race.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). Race and ethnicity breakdowns developed using five years of most recent available data (2012-2016) and age-adjusted rates. White defined as non-hispanic white. American Indians and Alaska Natives also have a disproportionately high rate of firearm suicide.Centers for Disease Control and Prevention. National Centers for Injury Prevention and Control, Web-based Injury Statistics Query and Reporting System (WISQARS). Racial and ethnic breakdowns developed using five years of most recent available data: 2012-2016.

Firearm suicide by rate

Finally, Americans living in rural areas experience higher rates of firearm suicide than those living in urban areas.Centers for Disease Control and Prevention. National Center for Health Statistics, Wide-ranging Online Data for Epidemiologic Research Tool (WONDER). A yearly average of each CDC classified urbanization level was developed using five years of most recent available data: 2012-2016. The CDC classifies all U.S. counties according to their level of urbanization,Centers for Disease Control and Prevention. 2013 NCHS Urban-Rural Classification Scheme for Counties. Published April 2014. and the average firearm suicide rate increases as counties become more rural.Centers for Disease Control and Prevention. National Center for Health Statistics, Wide-ranging Online Data for Epidemiologic Research Tool (WONDER). A yearly average was developed using five years of most recent available data: 2012-2016. County urbanization levels given by CDC. The rate of firearm suicide in the most rural counties is over two times higher than in the most urban.Centers for Disease Control and Prevention. National Center for Health Statistics, Wide-ranging Online Data for Epidemiologic Research Tool (WONDER). A yearly average was developed using five years of most recent available data: 2012-2016.

The average firearm suicide rate increases as counties become more rural

The Relationship Between Firearm Access and Suicide

Access to firearms is strongly associated with an increased risk of suicide.Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110. This reflects a broad consensus among academic researchers, medical professionals, and other public health experts. When it comes to suicide, a meta-analysis of 14 different scientific studies concluded that having access to a firearm triples one’s risk of death by suicide.Ibid. This elevated risk applies not only to the gun owner, but everyone in the household.Ibid.

People who live in states with high rates of household gun ownership are almost four times more likely to die by gun suicide than in states where fewer households own guns.Miller M, Lippman SJ, Azrael D, and Hemenway D. Household firearm ownership and rates of suicide across the 50 United States. The Journal of Trauma Injury, Infection, and Critical Care. 2007; 62(4): 1029-35. Again, this relationship remains strong even when controlling for other factors associated with suicide, like poverty, unemployment, serious mental illness, and substance abuse.Ibid. In fact, the relationship between firearm ownership and firearm suicide is so strong that researchers use the prevalence of firearm suicide in a given state as a proxy for the rate of firearm ownership in that state.Siegel M, Ross CS, King C 3rd. A new proxy measure for state-level gun ownership in studies of firearm injury prevention. Injury Prevention. 2014; 20(3): 204-7.

This is why populations most at risk for firearm suicide are also those with the highest rates of firearm ownership and access. A nationally representative survey of U.S. gun owners found that gun owners overall are disproportionately male, white, older, and non-urban.Azrael D, Hepburn L, Hemenway D, Miller M. The stock and flow of U.S. firearms: Results from the 2015 national firearms survey. The Russell Sage Foundation Journal of the Social Sciences. 2017; 3(5): 38-57. And as noted previously in this report, this demographic makes up the vast majority of firearm suicides in the U.S.

“Although some persons suggest that firearms provide protection, substantial evidence indicates that firearms increase the likelihood of homicide or, even more commonly, suicide.”

Informed by this overwhelming body of research, eight national organizations of health professionals and the American Bar Association jointly released a 2015 report stating: “Although some persons suggest that firearms provide protection, substantial evidence indicates that firearms increase the likelihood of homicide or, even more commonly, suicide. Access in the home and general access to firearms have also been shown to increase risk for suicide among adolescents and adults.”Weinberger SE, Hoyt DB, Lawrence HC, et al. Firearm-related injury and death in the United States: A call to action from 8 health professional organizations and the American Bar Association. Annals of Internal Medicine. 2015; 162: 513-516. As the report notes, “reducing availability [of firearms] to persons who may pose a threat to themselves or others” is necessary to properly address “firearm-related violence.”Ibid.

Don and Debbie

The relationship between firearm access and suicide makes sense given what we know about the nature and dynamics of suicide. While there may be warning signs leading up to suicide attempts, almost half of all survivors report less than 10 minutes of deliberation between the thought of suicide and the actual attempt.Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: How much time is left for intervention between consideration and accomplishment of a suicide attempt? The Journal of Clinical Psychology. 2007; 70(1): 19-24.,Simon TR, Swann AC, Powell KE, Potter LB, Kresnow M, O’Carroll PW. Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior. 2001; 32(supp): 49-59. Therefore, the method used in this moment of crisis can mean the difference between life and death, and firearms are an especially lethal means of self-harm.

“If we had a shift in the number of people who attempt to end their life with a firearm — who chose other means — we would very greatly reduce our suicide rate.”

Based on this data, researchers believe that reducing the number of suicide attempts involving firearms should reduce suicide rates overall. According to an analysis by the Washington Post, if the percentage of suicides in the U.S. involving firearms were similar to that of other high-income countries, researchers estimate that suicides overall could decrease by 20 to 38 percent.Soffen K. To reduce suicides, look at guns. The Washington Post. July 13, 2016. https://wapo.st/2I7MCUx Dr. E. Michael Lewiecki, a professor at the University of New Mexico School of Medicine, told the Washington Post: “If you have an impulse for suicide and you have easy access to a gun, you’re very likely to [die by suicide]. But if access to that means is not there, then the impulse may pass.”Ibid. Similarly, Dr. Daniel Webster, a professor at the Johns Hopkins Bloomberg School of Public Health and a leading researcher on gun violence has said, “If we had a shift in the number of people who attempt to end their life with a firearm — who chose other means — we would very greatly reduce our suicide rate.”Ibid.

Policy Solutions

The evidence points to a clear conclusion: America’s outsized rate of firearm suicide is directly related to its high rate of firearm ownership and access. It is not surprising, therefore, that policies and practices focused on disrupting access to firearms have been shown to reduce firearm suicide rates. A comprehensive approach to disrupt access should have several key elements:

  • Building public awareness about the inherent risks of firearm access
  • Limiting the easy and immediate acquisition of firearms
  • Responsibly storing firearms to prevent access by children and other unauthorized users
  • Temporarily removing firearms from at-risk individuals

Building public awareness

Most Americans do not think that having a gun in the home increases the risk of suicide.Connor A, Azrael D, Miller M. Public opinion about the relationship between firearm availability and suicide: Results from a national survey. Annals of Internal Medicine. 2018; 168: 153-155. In fact, most gun-owning Americans simply think their firearms make them safer — 67 percent of gun owners report owning a gun for protectionIgielnik R, Brown A. Key takeaways on Americans’ views of guns and gun ownership. Pew Research Center. June 22, 2017. https://pewrsr.ch/2sZzPjv. — and may not factor in the reality that access to a firearm increases the risk of suicide for people in the household.Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110. While 61 percent of American gun owners report having some formal firearms training, suicide prevention is not frequently covered in those training programs.Rowhani-Rahbar A, Lyons VH, Simonetti JA, Azrael D, Miller M. Formal firearm training among adults in the USA: Results of a national firearm survey. Injury Prevention. 2018; 24: 161-165. Among respondents who had received training, only 15 percent reported being trained on suicide prevention.Ibid.

Although firearm suicide is addressed in a 2012 U.S. Surgeon General report on a national strategy for suicide prevention,US Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. US Department of Health and Human Services; 2012. the federal government should do more to build awareness about this public health risk. In its reporting on suicide in the U.S., the Centers for Disease Control and Prevention (CDC) barely mentions firearms, and does not directly address how they elevate the risk for suicide.Stone D, Simon TR, Fowler KA, et al. Vital Signs: Trends in state suicide rates - United States, 1999-2016 and circumstances contributing to suicide - 27 states, 2015. Centers for Disease Control and Prevention. 2018; 67(22): 617-624.,Ibid. And the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) does not disclose key pieces of data on firearm suicides, including: the types of guns primarily used; the length of time between the purchase of a gun and a suicide attempt; and whether guns used in suicides are typically in the possession of their original buyers.Everytown for Gun Safety Support Fund v. Bureau of Alcohol, Tobacco, Firearms, and Explosives. [2018]. (United States District Court, Southern District of New York).

Scott and Jennifer

In the absence of public health campaigns led by the federal government, local leaders have taken the initiative to educate people on the connection between firearms and suicide. Trusted experts like law enforcement, gun dealers, and medical professionals have all launched campaigns that help inform Americans about the risks of firearms in the home and how to mitigate those risks.

Several law enforcement agencies run campaigns that provide new or prospective gun owners (or permit holders) with information about the risks of firearm access — particularly as it pertains to suicide. The Multnomah County Sheriff’s Office in Oregon is one such agency. As a part of the process for obtaining a concealed carry permit, applicants in Multnomah County are provided materials and given training on the relationship between suicide and firearms. “Firearms are the leading method for suicide,” the literature notes. “They’re also the deadliest … Access to guns raises the risk of suicide for people in crisis.”Is your safety on? Firearms and suicide. Multnomah County Health Department. https://bit.ly/2lwa7h4.

A similar campaign exists in New York City, where the New York Police Department presents permit applicants with a warning about the risks posed by firearms in the home: “The presence of a firearm in the home has been associated with an increased risk of death to self and others, including an increased risk of suicide, death during domestic violence incidents, and unintentional deaths to children and others.”New York City firearm permit application “warning”. Email correspondence with New York Police Department.

Some gun dealers have taken proactive steps to educate their customers on the suicide risk posed by firearms. In New Hampshire, in 2009, firearms used in three separate suicides within one week were traced back to a single store: Riley’s Sports Shop in Hooksett. Then-owner Ralph Demicco was troubled by the pattern, and he set up a series of meetings with various interest groups, from suicide prevention advocates to pro-gun organizations, to determine what could be done to minimize the risk for future customers.Van Brocklin E. Can Gun Stores Play a Role in Suicide Prevention? The Trace. January 4, 2016. https://bit.ly/2t6FWBD

In 2011, this group launched the Gun Shop Project, which encourages gun stores and gun ranges to display and distribute materials about firearms and suicide. A recent evaluation found that nearly half of the gun shops in New Hampshire were displaying these materials, which include information like: “Suicides far outnumber homicides in New Hampshire … Firearms are the leading suicide method in our state.”Vriniotis M, Barber C, Frank E, Demicco R, New Hampshire Firearm Safety Coalition. A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior. 2015; 45(2): 157-163. This program has not otherwise been evaluated for impact.,Harvard T.H. Chan School of Public Health. Gun Shop Project. https://bit.ly/2c4QKah. The Gun Shop Project has since expanded nationwide, with similar initiatives underway in 21 states.Ibid.

Physicians and other medical professionals are also crucial sources of information about the risk of firearm access. Research shows that a majority of Americans (64 percent) who attempted suicide made a visit to a healthcare professional in the month before the attempt.Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. Medical Care. 2015; 53(5): 430-435. But, physicians do not routinely talk to patients about firearm access and the risk of suicide.Price JH, Thompson A, Khubchandani J, Wiblishauser M, Dowling J, Teeple K. Perceived roles of Emergency Department physicians regarding anticipatory guidance on firearm safety. Journal of Emergency Medicine. 2013; 44(5): 1007-1016. One issue is a lack of training: a study of emergency physicians found that over 95 percent report never having been formally trained on firearm safety counseling.Ibid.

Of particular concern, the gun lobby has backed legislation specifically aimed at restricting doctors’ ability to discuss firearms with their patients. In 2011, Florida passed a law to prohibit doctors from discussing firearms with their patients, and Montana and Missouri followed with their own laws that interfere with the doctor-patient relationship. While the Florida prohibition has since been struck down, the clear intent of these laws is to discourage doctor counseling on gun safety.

By asking their patients about firearm access and counseling about firearm suicide risk, medical professionals may help prevent these deaths. Elaine Frank, with the Harvard Injury Control Research Center and the New Hampshire Firearm Safety Coalition, leads a program called Counseling on Access to Lethal Means, or C.A.L.M.CALM: Counseling on Access to Lethal Means. Suicide Prevention Resource Center Website. https://bit.ly/2OvUN1B. This program trains medical professionals on how to explain the differing lethality of various suicide methods, and to “help clients at risk for suicide and their families reduce access to lethal means, particularly firearms.”Ibid. Medical providers who have received this training are more likely to counsel clients on the importance of restricting access to lethal means.Sale E, Hendricks M, Weil V, Miller C, Perkins S, McCudden S. Counseling on Access to Lethal Means (CALM): An evaluation of a suicide prevention means restriction training program for mental health providers. Community Mental Health Journal. 2018; 54(3): 293-301.,Johnson RM, Frank EM, Ciocca M, Barber CW. Training mental healthcare providers to reduce at-risk patients' access to lethal means of suicide: Evaluation of the CALM Project. Archives of Suicide Research: Official Journal of the International Academy for Suicide Research. 2011; 15(3): 259-264. There are several other organizations engaged in this type of work, including the Zero Suicide Initiative,Zero Suicide Toolkit. Zero Suicide Initiative. https://bit.ly/2vtVRKs. and the Veterans Health Administration.Department of Veterans Affairs & Department of Defense. Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. 2013.

Limiting the easy and immediate acquisition of firearms

A study in California found that the rate of suicide among new gun owners in the first week after buying a gun was 57 times higher than the state’s population as a whole.Wintemute GJ, Parham CA, Beaumont JJ, Wright MA, Drake C. Mortality among recent purchasers of handguns. The New England Journal of Medicine. 1999; 341(21): 1583- 1589. Policies and practices that disrupt the easy and immediate acquisition of firearms may save lives. This begins at the point of sale, with strong background check and permitting laws.

Research has shown that, in states requiring an individual to obtain a permit in addition to a background check during the process of buying a handgun, the laws are associated with a reduction in firearm suicide.Federal law requires criminal background checks for all guns purchased from a licensed firearms dealer, and does not cover any sales by unlicensed sellers. A total of 20 states (and Washington D.C.) have closed that critical gap for handguns, passing laws that require some form of a background check before a handgun purchase. Seven of those states require the check only pursuant to a purchase permitting process, nine require a background check only at the point of purchase, and four require background checks both in order to obtain a permit and also at the point of sale.,Crifasi CK, Meyers JS, Vernick JS, Webster DW. Effects of changes in permit-topurchase handgun laws in Connecticut and Missouri on suicide rates. Preventive Medicine. 2015; 79: 43-49. This type of enhanced background check law, which is often referred to as permit-to-purchase (PTP), mandates that an applicant must pass a background check before obtaining their permit and often requires an in-person application at a law enforcement agency. As of 1994 and 1995, Connecticut required both a PTP and a comprehensive point-of-sale background check—laws that were associated with a 15 percent decline in the firearm suicide rate over the following decade.Ibid. By contrast, when Missouri repealed its PTP law in 2007, this repeal was associated with a 16 percent increase in the firearm suicide rate over the following five years.Ibid.

Mikey and Alexandria

Beyond PTP laws, a mandatory waiting period may also help prevent firearm suicides by delaying firearm acquisition. A waiting period law requires a certain number of days to elapse between the purchase of a firearm and when the purchaser can actually take possession of that firearm. In delaying immediate access to a firearm, waiting periods insert a buffer between impulse and action. Policies that create this buffer are associated with reduced rates of firearm suicide.Luca M, Malhotra D, Poliquin C. Handgun waiting periods reduce gun deaths. Proceedings of the National Academy of Sciences of the United States of America. 2017; 114(46): 12162-12165.,Anestis MD, Anestis JC, Butterworth SE. Handgun legislation and changes in statewide overall suicide rates. American Journal of Public Health. 2017; 107(4): 579-581.

While legal mechanisms to limit or delay firearm acquisition may have an impact, gun dealers also have a critical role to play. The Gun Shop Project educates staff members at firearm dealers and firing ranges about the warning signs of suicidal individuals.Van Brocklin E. Can Gun Stores Play a Role in Suicide Prevention? The Trace. January 4, 2016. https://bit.ly/2t6FWBD Demicco, co-founder of The Gun Shop Project, said: “If they manifest [signs of distress] outwardly, that’s where we come in. If they don’t make eye contact, if they’re in distress, shut the sale down.” Which is exactly what he did when he sensed something wrong after a woman came into his shop. After Demicco asked her if buying a gun was a good idea, the woman broke down into tears and admitted she was considering taking her own life. Demicco halted the sale and connected her with medical help. “We can put a little stumbling block in the way of their intentions,” Demicco said, “and possibly give ’em just a little bit of time to realize that a long-term solution to a short-term problem is not the way to go.”Ibid.

Responsibly storing firearms

Access to a firearm increases the risk of death by suicide for everyone in the household, regardless of how that firearm is stored.Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110. However, research shows that responsible firearm storage can help mitigate the risks of firearm suicide, especially for children.Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA: The Journal of the American Medical Association. 2015; 293(6): 707-714.

4.6 million American children live in households with at least one loaded, unlocked firearm.Azrael D, Cohen J, Salhi C, Miller M. Firearm storage in gun-owning households with children: Results of a 2015 national survey. Journal of Urban Health. 2018; 95(3): 295-304. Study defined children as under the age of 18. And 17 percent of American high school students report seriously considering a suicide attempt.Centers for Disease Control and Prevention. High School Youth Risk Behavior Surveillance System. 2017 data. This combination of suicidal ideation and easy firearm access can be lethal. When American children die by gun suicide, they overwhelmingly use guns they find at home. In fact, one study revealed that over 80 percent of child firearm suicides involved a gun belonging to a family member.Johnson RM, Barber C, Azrael D, Clark DE, Hemenway D. Who are the owners of firearms used in adolescent suicides? Suicide and Life-Threatening Behavior. 2010; 40(6): 609-611. Study defined children as under the age of 18.

The American Academy of Pediatrics (AAP) concludes: “the most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.” But if there are guns in the home, AAP notes that responsible storage practices — storing guns locked and unloaded, with ammunition kept in a separate place — can mitigate the risk of child firearm suicide.Council on Injury, Violence, and Poison Prevention Executive Committee. Firearm-related injuries affecting the pediatric population. American Academy of Pediatrics. 2012; 130(5): e1416-e1423. Indeed, research indicates that responsible gun storage practices are associated with reduced rates of child firearm suicide. One study evaluated individual-level household storage practices, including storing household guns locked, unloaded, or separate from the ammunition. Each one of these storage practices was associated with reductions in the risk of self-inflicted and unintentional firearm injuries among children and teenagers — up to 85 percent depending on the type of storage practice.Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional injuries. JAMA: The Journal of the American Medical Association. 2005; 293(6): 707-714. Study found households that locked both firearms and ammunition had an 85 percent lower risk of unintentional firearm deaths than those that locked neither.

Drawing on this data, Everytown for Gun Safety and Moms Demand Action for Gun Sense in America launched Be SMART,Be SMART Website. https://bit.ly/1PUZX1H a public health campaign that educates 25,000 Americans every year on how to prevent child firearm suicides and unintentional deaths. The Be SMART presentation — delivered by volunteers in communities across the country — shares research on how guns in the home pose a risk to children, and how to mitigate this risk through practices like firearm storage and temporary firearm removal.

Recognizing the public safety benefits of responsible firearm storage, many cities and states have laws that require or encourage responsible storage. Four states and the District of Columbia have passed laws mandating that owners responsibly store their firearms.California (Cal. Pen. Code §§ 25000-25110); Massachusetts (ALM GL ch. 140, § 131L); Minnesota (Minn. Stat. § 609.666); Virginia (Va. Code Ann. § 18.2-56.2); District of Columbia (D.C. Code § 7-2507.02) And 14 states have passed Child Access Prevention (CAP) laws, which impose criminal penalties on adults when a child gains unsupervised access to their firearms.Connecticut (Conn. Gen. Stat. §§ 29-37i, 53a-217a); Delaware (11 Del. C. § 1456; 11 Del. C. § 603); Florida (Fla. Stat. §§ 790.174; 790.175; 784.05); Illinois (720 ILCS § 5/24-9); Iowa (Iowa Code § 724.22(7)); Hawaii (HRS §§ 134-10.5; 707-714.5); Maryland (Md. Crim. Law Code Ann. § 4-104); Nevada (Nev. Rev. Stat. § 202.300); New Hampshire (RSA § 650-C:1); New Jersey (N.J. Stat. § 2C:58-15); North Carolina (N.C. Gen. Stat. § 14-315.1); Rhode Island (RI Gen. Laws § 11-47-60.1); Texas (Tex. Pen. Code § 46.13); Wisconsin (Wis. Stat. § 948.55) States with safe storage or CAP laws have seen reductions in firearm suicide rates for children.Gius M. The impact of minimum age and child access prevention laws on firearm-related youth suicides and unintentional deaths. The Social Science Journal. 2015; 52(2): 168-175.,Webster DW, Vernick JS, Zeoli AM, Manganello JA. Association between youth-focused firearm laws and youth suicides. JAMA: The Journal of the American Medical Association. 2004; 292(5): 594-601.,Grossman DC, Mueller BA, Riedy C, et al. Gun storage practices and risk of youth suicide and unintentional injuries. JAMA: The Journal of the American Medical Association. 2005; 293(6): 707-714.

Despite evidence that these laws save lives, the NRA—which claims to support safe storage —has sued to block responsible storage and CAP laws.According to their website, the “NRA’s longstanding rule of gun storage is to store your guns so that they are inaccessible to any unauthorized users, especially your children and the children that visit your home.” Frequently asked questions about Eddie Eagle. NRA Eddie Eagle Gunsafe Program Website. https://bit.ly/2wmZZx9. In 2009, the NRA sued the City and County of San Francisco for enacting legislation that required responsible storage in the home. A federal court of appeals upheld the law, rejecting the NRA’s arguments that San Francisco’s law violated the Second Amendment. The NRA sued the City of Seattle in July and the City of Edmonds, Washington in August 2018, seeking to block enforcement of their newly enacted CAP and responsible storage laws. As of publication, the lawsuits are still pending.

Temporarily removing firearms from at-risk individuals

In February 2018, a man in Portland, Oregon dialed 911 and threatened suicide with a gun. A Portland Police Bureau officer responded to the call, and when he arrived at the residence, he found 10 firearms — including a loaded handgun lying on the floor that was easily accessible to both the man and his three-year-old son. Using Oregon’s recently enacted Red Flag Law, the officer immediately petitioned a court to temporarily remove the firearms from the home and to temporarily prohibit the man from acquiring any new ones. The petition was granted by a judge; the officer then collected all the weapons for safekeeping.Multnomah County ERPO case file, on file with Everytown. Received from Oregon State Court Administrator. By intervening at a clear moment of crisis, this officer may have prevented the man from taking his own life.

To protect individuals in crisis, several states have passed Red Flag Laws as a way to temporarily remove firearm access. These laws—which establish extreme risk protection orders (ERPOs), or gun violence restraining orders (GVROs)—allow immediate family members and/or law enforcement officers to petition a court to temporarily block gun possession by individuals who have exhibited behavior suggesting they are a risk to themselves or others. In states without Red Flag Laws, friends or family members must pursue other options if they wish to have firearms removed from an at-risk individual. According to a survey in several U.S. states, a majority of local law enforcement agencies are willing to temporarily store guns during a crisis; many gun dealers offer this service too.Runya CW, Brooks-Russell A, Brandspigel S, et al. Law enforcement and gun retailers as partners for safely storing guns to prevent suicide: A study in 8 Mountain West states. American Journal of Public Health. 2017; 107(11): 1789-1794. If this is not an option, friends or family may be willing to temporarily store the firearms, though this kind of transfer comes with its own potential risks. In these instances, to prevent the at-risk individual from regaining access, the firearms should be securely locked and any key or code to the lock withheld. This is why Everytown has made passing Red Flag Laws a legislative priority.

At the time of publication, 13 states had Red Flag Laws in place.California (Cal. Pen. Code § 18100, et. seq.); Connecticut (Conn. Gen. Stat. § 29-38c); Delaware (10 Del. C. § 7701, et. seq.); Florida (Fla. Stat. § 790.401); Illinois (2017 IL House Bill 2354); Indiana (Ind. Code § 35-47-14-1, et seq); Maryland (Md. Public Safety Code Ann. § 5-601, et seq); Massachusetts (Mass. Gen. Laws ch. 140, §§ 121, 129B(C), 131(C), 131R-Z); New Jersey (2018 NJ Assembly Bill 1217); Oregon (O.R.S. § 166.525, et seq.); Rhode Island (RI Gen. Laws § 8-8.3-1, et seq.); Vermont (13 VSA § 4051, et seq.); Washington (Rev. Code Wash. § 7.94.010, et seq.) “We’ve actually had three people, specifically, that when they came in for their [ERPO] court hearing … actually thank us in court for securing their firearms from them,” Seattle Police Sergeant Eric Piconski recently said in an interview. “They acknowledged and recognized that it was probably not a good idea that they had access to firearms.”MyNorthwest.com. How Seattle is using ERPO laws to remove guns from at-risk people. KIRO Radio. March 6, 2018. https://bit.ly/2HYWIad.

The impact of Red Flag Laws have been studied in two states: Indiana and Connecticut, and the evidence shows that these laws work to reduce firearm suicides.Kivisto AJ, Phalen PL. Effects of risk-based firearm seizure laws in Connecticut and Indiana on Suicide Rates, 1981-2015. Psychiatric Services. 2018; 69(8): 855-862. In the 10 years after Indiana passed its Red Flag Law, the state’s firearm suicide rate decreased by 7.5 percent.Ibid. In Connecticut, the Red Flag Law was associated with a 14 percent reduction in firearm suicide rate in the period after the 2007 shooting at Virginia Tech, when enforcement of the law increased significantly.Ibid. Another study in Connecticut found that one suicide was averted for approximately every 11 gun removals carried out under the law.Swanson JW, Norko M, Lin H, et al. Implementation and effectiveness of Connecticut's risk-based gun removal law: Does it prevent suicides? Law and Contemporary Problems. 2017; 80: 179-208. Researchers have noted implementation gaps in Connecticut may have blunted the initial impact of the state’s Red Flag Law, underscoring the importance of awareness campaigns aimed at educating the public and law enforcement agencies about the availability of ERPO as a tool to temporarily remove firearm access from a person at risk.

Conclusion

Claiming the lives of nearly 22,000 Americans every year, firearm suicides have a devastating impact on our communities — from the victims themselves, to their surviving loved ones, to the public at large. Access to firearms is strongly associated with increased risk for suicide.Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110. This is why U.S. states with high rates of household gun ownership also have high rates of firearm and overall suicide.Miller M, Lippman SJ, Azrael D, Hemenway D. Household firearm ownership and rates of suicide across the 50 United States. The Journal of Trauma Injury, Infection, and Critical Care. 2007; 62(4): 1029-35.

Americans should be educated on the prevalence of firearm suicide, how having access to a gun increases the risk of suicide, and steps they can take to mitigate risk. Given the unique lethality of firearms as a means of suicide, policies and practices that limit or disrupt access to firearms have been shown to save lives. This includes disrupting the easy and immediate acquisition of firearms, encouraging the responsible storage of firearms in the home, and temporarily removing firearms from individuals in moments of crisis.

Survivor Stories

Joyce & Khary

Joyce was 27 years old, with a new baby son.This narrative is derived from an interview with Khary Penebaker, a member of the Everytown Survivor Network. She was living back home after separating from her husband and struggling with alcoholism and depression.

At some point, her father bought her a handgun for self-defense. He took her to a shooting range so she could practice using it. According to her now-grown son, Khary, nobody considered the risk of giving Joyce access to firearms — despite the fact that Joyce had a history of suicide attempts.

A few months after acquiring the handgun, Joyce wrote a note to her parents asking them to take care of Khary, who was just 20 months old at the time. She climbed into her car, drove onto the freeway, pulled over to the side, and took out the handgun her father had given her. “Then she listened to the lies depression told her and killed herself,” says Khary.

His mother’s story should not have ended this way. “I don’t know how she would have responded, because from what I’m told my mom was very headstrong, but removing access would have saved her life.”

For his entire childhood, Khary was told that his mother had died of an illness. His family “didn’t want to face it,” Khary says. It wasn’t until he was 18, looking through his father’s things, that he found copies of Joyce’s death certificate and learned the truth. “It really messed me up,” he recalls. “I know where my mom is: she’s in a grave in Cincinnati. I have no way of getting to know her, or of finding out what her voice is like, or what her touch was like. No way of remembering what it was like for her to say, ‘I love you’ — stuff that other people take for granted.”

For Khary, who has struggled with anger and pain and his own suicidal impulses over the years, his mother’s story should not have ended this way. “I don’t know how she would have responded, because from what I’m told my mom was very headstrong, but removing access would have saved her life,” he says. “I really think that if someone would have put a barrier in between my mom and that gun, my mom would still be here.”

Don and Debbie

Don was a veteran — he’d served during the Vietnam War — and he lived with his wife on a farm in Virginia that had been in the family for five generations.This narrative is derived from an interview with Debbie, a staff member at Everytown and a member of the Everytown Survivor Network. People could count on Don — if somebody got sick, he would be the one to take them to the doctor. “He was a very hands-on caregiver,” recalls his daughter, Debbie.

At 72, Don got cancer, and the treatment took a tremendous toll on him. “He never really recovered to the point where he was totally independent and could do all the things he wanted to do on the farm,” Debbie says. The sudden reversal of dependence left him at a loss. “I think the thought of someone having to care for hi­m … I don’t think he could tolerate it.”

Don owned shotguns which he used to shoot groundhogs that were getting into the crops. The shotgun he used to take his own life had belonged to his great-grandfather. He did it in a way that nobody would be home when the suicide happened, and so none of his family members would be the one to find him.

Debbie noted, “I think my dad looked at himself like, ‘I’m in pain, and I don’t want to be a burden, and I’ve lived a good life.’ What he didn’t think about, though, was the immense pain that he would leave behind for everybody.”

Scott and Jennifer

Scott had one handgun, which he told his wife he wanted for protection.This narrative is derived from an interview with Jennifer, a member of the Everytown Survivor Network. They argued about it — Jennifer didn’t want to live in a home with a firearm, but he managed to convince her by offering a compromise. The gun would be kept locked in a safe, and he would only take it out when they went to the woods in North Carolina, where he liked to set up targets and practice his aim.

Scott was a great father to his two daughters. He worked for a medical device company and he liked to go hiking in the mountains of Utah and Nevada. He also struggled with depression.

At the age of 42 Scott made a suicide attempt using alcohol and pills. He was taken to the emergency room, treated in an intensive care unit, and then held for supervision. “Then they send you away with a bunch of worksheets encouraging you to seek help,” Jennifer says. “It’s all very overwhelming and you don’t really know what to do.” One of the worksheets directed family members to remove all firearms. Jennifer bought a different safe for the gun, and hid it inside the house. When Scott arrived home, he was furious at her. “He said he was fine now, and why didn’t I trust him? It became a thing.”

Three weeks later, Scott made another suicide attempt with pills. This time, when Scott woke up in the hospital, he was “his old self” again, Jennifer recalls. “He asked me to go to the bookstore and get him all of these books on depression. He felt sure that if he could just learn enough about what was going on, he could solve it.”

Scott soon convinced Jennifer to return his firearm. They were planning a trip to the woods in North Carolina, and he told her that shooting would make him “feel normal” again. “He hated feeling like the patient all the time,” she recalls. But Scott’s depression returned, and he used his gun to kill himself.

Thinking back, Jennifer thinks it could have been different if Red Flag Laws and extreme risk protection orders had existed as a resource. “The gun was a thing between us,” she says. “When he was feeling paranoid, and when he was not at his best and was suspicious of me, he would not consider me an ally.” For Jennifer, removing the gun herself was a difficult proposition; it might have caused an “event” with Scott if she’d tried. But if there had been a legal option to have police remove the gun? “He definitely had a complicated mental illness,” Jennifer says. “I’m not saying it would have helped him forever. But it could have helped him through one more crisis, and maybe then he would have got the help that finally started to work better.”

Mikey and Alexandria

At 13 years old, Mikey was a friendly and engaged boy. He was an expert bowler, a quarterback for the football team, and he loved to play video games.This narrative is derived from an interview with Alexandria, a member of the Everytown Survivor Network. His older sister, Alexandria described him as the type of child “who would befriend the new kid and introduce them to his friends.”

Mikey’s father kept three guns at his home in upstate New York. For years, Mikey’s mother had asked him to get rid of the guns, or at least lock them up so Mikey wouldn’t be able to access them. After the shooting at Sandy Hook in December 2012, she renewed her pleas — “but he would not listen,” recalls Alexandria.

On January 13, 2013 Mikey shot and killed himself with one of his father’s unsecured guns. He seemed happy, says Alexandria, so his suicide came as a shock. “He must have gotten angry for some reason,” she says, and “at that age you’re not thinking how final a gun is.”

“He must have gotten angry for some reason,” she says, and “at that age you’re not thinking how final a gun is.”

Mikey’s community was devastated by the sudden loss. His mother was inconsolable. Exactly nine months to the day after Mikey’s death, she died by suicide. “She was so grief stricken over the death of her son,” Alexandria says, “and the guilt of not being able to protect him was something she could no longer live with.”


Everytown for Gun Safety would like to acknowledge the American Association of Suicidology and our academic research partners for reviewing this report.

If you or someone you know is in crisis, please contact the National Suicide Prevention Lifeline, a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24/7. 1-800-273-TALK (8255) suicidepreventionlifeline.org

You may also contact the Crisis Text Line, which provides trained crisis counseling services over text 24/7. Text HOME to 741741 from anywhere in the U.S. crisistextline.org