Content uploaded by Nestor D Kapusta
Author content
All content in this area was uploaded by Nestor D Kapusta on Dec 22, 2013
Content may be subject to copyright.
BackgroundBackground The availability ofThe availability of
firearmsin homes and at aggregate levelsfirearmsin homes and at aggregate levels
is a risk factor for sui cide and homi cide.is a risk factor for sui cide and homi cide.
One method of reducing access to suicidalOne method of reducing access to suicidal
meansis the restriction of firearmmeans is the restr i ction of fi r earm
availabil i ty through more stri ngentavai labi l ity through more stri ngent
legis lation.legis lation.
AimsAims To eval uate the impact of fi rearmTo evaluate the impact of f irearm
legislationreform on firearm suicides andlegislationreform on firearm suicides and
homi c i des as well as on the ava il ability ofhomi c i des as well as on the av a ilabili ty of
firearmsin Austria.firearms in Austria.
MethodMethod Official statistics on suicides,Official statistics on suicides,
firearm homicides and firearmlicencesfirearm homicides and firearmlicences
issued from1985 to 2005 were examined.issued from1985 to 2005 were examined.
To assess the eff ect ofthe new fi r earmlaw,To assess the effect of the new fi rearm law ,
enacted in1997, linear regression andenacted in1997, linear regression and
Poisson regressions were performed usi ngPo i ssonregress i ons wer e perfo r med usi n g
data from before and af ter the law reform.data from before and aft er the law reform.
ResultsResults The rate of firearm suicidesThe rate of fi rearm suicides
among some age groups, percentage ofamong some age groups, p ercentage of
f irearm suicides, as wellas the rate offi rearm suicides, as wel l as the rat e of
firearm homicides and the rate of firearmfirearmhomicides and the rate of firearm
licences, significantly decreased after alicences, significantly decreased after a
more stringent firearm law had beenmore str ingen t fi r earm law had been
i mp lemen t ed.i mp lemen t ed.
ConclusionsConclusions Our fi ndi ngs pro v ideOur fi nd i ngs prov i de
ev idence that the in t roduction ofev idence that the in troduction of
restr ictive fir earm legis lation effectivel yrestricti ve fi rearm legis lation effective ly
reduced the rat es of firearm suicide andreduced the rates of fi rearm suicide and
homi c i de .The dec li ne in fi r earm-re l a tedhomi c i de .The dec li ne i n fi r earm-related
deaths seems to have been mediated bydeaths seems to have been mediated by
the legal restr iction of fi rearm availabi l i ty.the legal restri ction of fi rearm avai labi l i ty.
Restr ictive f irearm legis lation shou ld be anRestri ctive firearm legis lation should be an
i n t egra l part of national su ic ide preven t ionintegral part of national suicide prevention
programmesin countries with highprogrammesin countries with high
firearm suiciderates.fi rearm suicide rates.
Declaration of interestDeclaration of interest None.None .
A recent study (World Health Organiza-A recent study (World Health Organiza-
tion, 2006) has pointed to the possibilitytion, 2006) has pointed to the possibility
of preventing disease by controlling envir-of preventing disease by controlling envir-
onmental factors; it has been estimated thatonmental factors; it has been estimated that
more than 20% of total suicides in Northmore than 20% of total suicides in North
America and Europe can be attributed toAmerica and Europe can be attributed to
environmental factors, one of which isenvironmental factors, one of which is
access to firearms. Suicide preventionaccess to firearms. Suicide prevention
measures include the training of primarymeasures include the training of primary
healthcare personnel, school-based pro-healthcare personnel, school-based pro-
grammes, improvement of the availabilitygrammes, improvement of the availability
of telephone hotlines and crisis centres, im-of telephone hotlines and crisis centres, im-
plementation of guidelines for the media’splementation of guidelines for the media’s
portrayal of suicide, and the restriction ofportrayal of suicide, and the restriction of
access to methods and means of suicideaccess to methods and means of suicide
(Bertolote, 2004). One of the methods of(Bertolote, 2004). One of the methods of
reducing access to suicidal means is thereducing access to suicidal means is the
restriction of firearm availability throughrestriction of firearm availability through
more stringent firearm legislation (Mannmore stringent firearm legislation (Mann
et alet al, 2005). Generally, studies on the im-, 2005). Generally, studies on the im-
pact of firearm availability and legislationpact of firearm availability and legislation
on suicide rates can be divided into threeon suicide rates can be divided into three
categories: cross-sectional comparisons ofcategories: cross-sectional comparisons of
firearm availability and suicide rates infirearm availability and suicide rates in
different countries; cross-sectional correla-different countries; cross-sectional correla-
tions of the stringency of firearm controltions of the stringency of firearm control
and suicide rates in the USA; and quasi-and suicide rates in the USA; and quasi-
experimental studies examining the impactexperimental studies examining the impact
of changes in firearm legislation on suicideof changes in firearm legislation on suicide
rates (Brent, 2001).rates (Brent, 2001).
The availability of firearms in homesThe availability of firearms in homes
has been shown to be a risk factor for sui-has been shown to be a risk factor for sui-
cide (Kellermanncide (Kellermann et alet al, 1992) and homicide, 1992) and homicide
(Dahlberg(Dahlberg et alet al, 2004). Furthermore, peer-, 2004). Furthermore, peer-
reviewed publications provide vast evidencereviewed publications provide vast evidence
to support the view that changes in firearmto support the view that changes in firearm
legislation have influenced the rate of fire-legislation have influenced the rate of fire-
arm suicidesarm suicides in the USA (Ludwig & Cook,in the USA (Ludwig & Cook,
2000), Canada2000), Canada (Caron, 2004), Australia(Caron, 2004), Australia
(Ozanne-Smith(Ozanne-Smith et alet al, 2004) and New, 2004) and New
Zealand (BeautraisZealand (Beautrais et alet al, 2006), whereas, 2006), whereas
there is only some evidence from continentalthere is only some evidence from continental
Europe and Britain to suggest the sameEurope and Britain to suggest the same
(Hawton(Hawton et alet al, 1998; Haw, 1998; Haw et alet al, 2004)., 2004).
Other researchers have shown that differentOther researchers have shown that different
state firearm regulations across the USA havestate firearm regulations across the USA have
influenced suicide (Conner & Zhong, 2003)influenced suicide (Conner & Zhong, 2003)
and homicide rates (Rosengartand homicide rates (Rosengart et alet al, 2005)., 2005).
METHODMETHOD
We examined suicide and homicide rates inWe examined suicide and homicide rates in
Austria recorded before and after a newAustria recorded before and after a new
firearm law came into effect. We expandedfirearm law came into effect. We expanded
a longitudinal approach from a recent studya longitudinal approach from a recent study
which evaluated the association betweenwhich evaluated the association between
changes in firearm availability and suicidechanges in firearm availability and suicide
rates in the USA (Millerrates in the USA (Miller et alet al, 2006) and, 2006) and
accounted for the availability of firearms.accounted for the availability of firearms.
Since the accuracy of survey data and otherSince the accuracy of survey data and other
proxy variables of firearm availability haveproxy variables of firearm availability have
recently been questioned (Millerrecently been questioned (Miller et alet al,,
2004), the number of officially issued fire-2004), the number of officially issued fire-
arm licences was used to assess the avail-arm licences was used to assess the avail-
ability of firearms.ability of firearms.
Austrian firearm legislationA ustrian firearm legislation
The Austrian firearms law was adapted inThe Austrian firearms law was adapted in
July 1997 after the European Council Di-July 1997 after the European Council Di-
rective 91/477/EEC on the control of therective 91/477/EEC on the control of the
acquisition and possession of weaponsacquisition and possession of weapons
was implemented in European Union mem-was implemented in European Union mem-
ber states. The transposition of the Eur-ber states. The transposition of the Eur-
opean directive into Austrian national lawopean directive into Austrian national law
brought changes concerning the acquisitionbrought changes concerning the acquisition
of firearms over 60 cm in length, which hadof firearms over 60 cm in length, which had
previously enjoyed a more liberal regime.previously enjoyed a more liberal regime.
Moreover, the new law abolished the pre-Moreover, the new law abolished the pre-
vious possibility of obtaining a firearmvious possibility of obtaining a firearm
without specifying a reason. In addition towithout specifying a reason. In addition to
the European Directive, other restrictionsthe European Directive, other restrictions
were implemented in Austria. The legalwere implemented in Austria. The legal
criteria for obtaining a category B weaponcriteria for obtaining a category B weapon
(handguns, semi-automatic firearms or(handguns, semi-automatic firearms or
repeating firearms) for the first time nowrepeating firearms) for the first time now
include psychological testing, being at leastinclude psychological testing, being at least
21 years of age, and background checks.21 years of age, and background checks.
Furthermore, the new legislation alsoFurthermore, the new legislation also
specifies safe firearm storage regulationsspecifies safe firearm storage regulations
and a 3-day ‘cooling-off’ waiting periodand a 3-day ‘cooling-off’ waiting period
for category C and D weapons (includingfor category C and D weapons (including
long firearms with smooth bore and rifledlong firearms with smooth bore and rifled
barrels) (Commission of the Europeanbarrels) (Commission of the European
Communities, 2000).Communities, 2000).
Data collectionDa ta collection
Records for each year between 1985 andRecords for each year between 1985 and
2005 in Austria were examined. The start-2005 in Austria were examined. The start-
ing year was set at 1985 because of record-ing year was set at 1985 because of record-
ing restrictions at the Ministry of theing restrictions at the Ministry of the
Interior, where data on firearm licencesInterior, where data on firearm licences
were obtained. Data on the number of sui-were obtained. Data on the number of sui-
cides per year and the number of firearmcides per year and the number of firearm
homicides per year (with external cause-homicides per year (with external cause-
of-death codes according to ICD–9 andof-death codes according to ICD–9 and
ICD–10), as well as data on the size of theICD–10), as well as data on the size of the
general population and on unemploymentgeneral population and on unemployment
rates, were obtained from Statistics Austria.rates, were obtained from Statistics Austria.
253253
BRITISH JOURNAL OF PSYCHIATRYBRITISH JOURNAL OF PSYCHIATRY (2007), 191, 253^257. doi: 10.1192/bjp.bp.106.032862(2007), 191, 253^257. doi: 10.1192/bjp.bp.106.0328 62
Fi rearm legisl ation refo rm i n the E uropean Uni on:Fi rearm legislati on refo rm in the Eur opean Uni on:
i mpact on firearm a vail ability, fi r earm suici d ei mpact on firearm a vailab ility, fi r earm suici d e
and homicide rates in Austriaand homicide rates in Austria
NESTOR D. KAPUSTA, ELMAR ETZERSDORFER, CHRISTOPH KRALLNESTOR D. KAPUSTA, ELMAR ETZERSDORFER, CHRISTOPH KRALL
anda nd GERNOT S ONNECKGER NOT SONNECK
AUTHOR ’ S P ROOFAUTHOR ’ S P ROOF
KAPUSTA ET ALKAPUSTA ET AL
Details on these data have been describedDetails on these data have been described
elsewhere (Etzersdorferelsewhere (Etzersdorfer et alet al, 2006). The, 2006). The
figures on alcohol consumption per capitafigures on alcohol consumption per capita
were obtained from the Austrian Alcoholwere obtained from the Austrian Alcohol
Coordination and Information CentreCoordination and Information Centre
(Uhl(Uhl et alet al, 2006)., 2006).
Statistical analysisStatistical analysis
To assess the effect of the enactment of theTo assess the effect of the enactment of the
1997 firearm law, a regression of the num-1997 firearm law, a regression of the num-
ber of firearm licences per 100 000 inhabi-ber of firearm licences per 100 000 inhabi-
tants per year was performed with antants per year was performed with an
autoregressive error model of first orderautoregressive error model of first order
to compare time trends before and afterto compare time trends before and after
enactment. Similarly, Poisson regressionsenactment. Similarly, Poisson regressions
were performed to compare time trends ofwere performed to compare time trends of
firearm suicides, of firearm suicides as afirearm suicides, of firearm suicides as a
percentage of total suicides and of the totalpercentage of total suicides and of the total
number of homicides, before and after thenumber of homicides, before and after the
law was enacted (using SAS/STAT versionlaw was enacted (using SAS/STAT version
8 for Windows). Because of underdisper-8 for Windows). Because of underdisper-
sion, we allowed the variance estimate insion, we allowed the variance estimate in
both models to depend on an underdisper-both models to depend on an underdisper-
sion factor estimated from the data. Datasion factor estimated from the data. Data
on total suicides indicated overdispersion,on total suicides indicated overdispersion,
hence total suicides were modelled with ne-hence total suicides were modelled with ne-
gative binomial distribution. The regressiongative binomial distribution. The regression
model included linear time trends allowingmodel included linear time trends allowing
for a change point in 1998. Changing popu-for a change point in 1998. Changing popu-
lation sizes were taken into account bylation sizes were taken into account by
including the respective changes in theincluding the respective changes in the
model. To distinguish between the effectsmodel. To distinguish between the effects
of the new legislation and other factorsof the new legislation and other factors
known to influence rates of suicide and ho-known to influence rates of suicide and ho-
micide, unemployment rates and averagemicide, unemployment rates and average
alcohol consumption per capita were in-alcohol consumption per capita were in-
cluded in the analysis as covariates. In thecluded in the analysis as covariates. In the
calculation of the regression model ofcalculation of the regression model of
homicide rates, the ratio of young men inhomicide rates, the ratio of young men in
the population was also included as athe population was also included as a
covariate. All parameter estimates are re-covariate. All parameter estimates are re-
ported with 95% confidence intervals.ported with 95% confidence intervals.
The analysis is based on figures for firearmThe analysis is based on figures for firearm
licences, suicide, firearm suicide, firearmlicences, suicide, firearm suicide, firearm
homicide and population sizes in the periodhomicide and population sizes in the period
1985–2005. The two-tailed significance1985–2005. The two-tailed significance
level was set at 5%.level was set at 5%.
RESULTSRESULTS
During the observation period 6071 fire-During the observation period 6071 fire-
arm suicides were counted. Of these,arm suicides were counted. Of these,
95.1% were by men and 4.9% by women.95.1% were by men and 4.9% by women.
When firearm suicides by men are split intoWhen firearm suicides by men are split into
age groups, 3.3% of all firearm suicidesage groups, 3.3% of all firearm suicides
were by men aged under 19 years, 62.9%were by men aged under 19 years, 62.9%
by men aged 20–64, and 28.8% by menby men aged 20–64, and 28.8% by men
aged 64 or older. Of all suicides, 0.2% wereaged 64 or older. Of all suicides, 0.2% were
by females aged 19 years or younger, 3.8%by females aged 19 years or younger, 3.8%
by women aged 20–64 and 0.9% byby women aged 20–64 and 0.9% by
women aged 64 or older.women aged 64 or older.
Figure 1 shows the trend of the firearmFigure 1 shows the trend of the firearm
suicide rate, prior to and after enactment ofsuicide rate, prior to and after enactment of
the legislation. We observed no significantthe legislation. We observed no significant
time trend in the total number of firearmtime trend in the total number of firearm
suicides between 1985 and 1997suicides between 1985 and 1997
((ww
22
¼0.04, d.f.0.04, d.f.¼18,18, PP¼0.84). During this0.84). During this
period the mean firearm suicide rate wasperiod the mean firearm suicide rate was
3.96 per 100 000 (s.d.3.96 per 100 000 (s.d.¼ 0.19). In the period0.19). In the period
1998–2005, we observed a significant nega-1998–2005, we observed a significant nega-
tive trend (tive trend (ww
22
¼88.0,88.0, PP550.0001) with a0.0001) with a
steady decline in the firearm suicide ratesteady decline in the firearm suicide rate
of 4.7% each year (Table 1). The firearmof 4.7% each year (Table 1). The firearm
suicide rate reached a low of 2.67 persuicide rate reached a low of 2.67 per
100 000 in the year 2005. The change in100 000 in the year 2005. The change in
the time trend after 1998 is significantthe time trend after 1998 is significant
((ww
22
¼46.0,46.0, PP550.0001) even when adjusted0.0001) even when adjusted
for unemployment and alcohol consump-for unemployment and alcohol consump-
tion (tion (ww
22
¼19.9,19.9, PP550.0001).0.0001).
When the firearm suicide rates wereWhen the firearm suicide rates were
analysed by age group and gender, the onlyanalysed by age group and gender, the only
significant trend changes after the legisla-significant trend changes after the legisla-
tion reform could be found in the grouption reform could be found in the group
of women aged 20–64 years (of women aged 20–64 years (ww
22
¼9.9,9.9,
PP¼0.0016), in men aged 20–64 years0.0016), in men aged 20–64 years
((ww
22
¼81.7,81.7, PP550.0001) and in men 65 years0.0001) and in men 65 years
old or older (old or older (ww
22
¼6.4,6.4, PP¼ 0.01). The group0.01). The group
of persons aged under 19 years and womenof persons aged under 19 years and women
more than 64 years old showed no signifi-more than 64 years old showed no signifi-
cant trend change in suicide by firearmscant trend change in suicide by firearms
after enactment of the law. When all agesafter enactment of the law. When all ages
were pooled for each gender, the trend ofwere pooled for each gender, the trend of
firearm suicides after enactment changedfirearm suicides after enactment changed
significantly among both women and mensignificantly among both women and men
(women:(women: ww
22
¼12.5,12.5, PP¼0.0004; men:0.0004; men: ww
22
¼
28.9,28.9, PP 550.0001).0.0001).
We observed a significant negative timeWe observed a significant negative time
trend in the total number of suicides beforetrend in the total number of suicides before
1998 (1998 (ww
22
¼131.0, d.f.131.0, d.f.¼ 18,18, PP550.0001), as0.0001), as
well as in the period 1998–2005 (well as in the period 1998–2005 (ww
22
¼23.4,23.4,
PP550.0001). The overall suicide rate de-0.0001). The overall suicide rate de-
creased from 27.6 per 100 000 in 1985 tocreased from 27.6 per 100 000 in 1985 to
16.7 per 100 000 in 2005. The change in16.7 per 100 000 in 2005. The change in
the trend was not significant (the trend was not significant (ww
22
¼0.3,0.3,
PP¼0.590), even when adjusted for unem-0.590), even when adjusted for unem-
ployment and alcohol consumptionployment and alcohol consumption
((ww
22
¼0.03,0.03, PP¼0.870).0.870).
During the examined pre-legislationDuring the examined pre-legislation
period, a significant positive time trend inperiod, a significant positive time trend in
firearm suicides as a percentage of totalfirearm suicides as a percentage of total
suicides was observed (suicides was observed (ww
22
¼68.5, d.f.68.5, d.f.¼18,18,
PP550.0001). During this period the per-0.0001). During this period the per-
centage of firearm suicides increased fromcentage of firearm suicides increased from
14.3% in 1985 to 19.3% in 1997. Con-14.3% in 1985 to 19.3% in 1997. Con-
versely, during the post-implementationversely, during the post-implementation
period, a significant negative time trendperiod, a significant negative time trend
was observed (was observed (ww
22
¼30.5,30.5, PP550.0001), with0.0001), with
a decrease to 16.8% in 2005 (Fig. 2). Thea decrease to 16.8% in 2005 (Fig. 2). The
growth factor of the percentage of firearmgrowth factor of the percentage of firearm
suicides per year, derived from Poisson re-suicides per year, derived from Poisson re-
gression analysis, was +2.6% prior to andgression analysis, was +2.6% prior to and
772.9% following the change in legislation2.9% following the change in legislation
(Table 1). Consequently, with 1998 set as(Table 1). Consequently, with 1998 set as
offset, the change in trend was significantoffset, the change in trend was significant
((ww
22
¼53.5,53.5, PP550.0001). Figure 3 shows the0.0001). Figure 3 shows the
course of suicide methods in the examinedcourse of suicide methods in the examined
period. After the implementation of theperiod. After the implementation of the
firearm law, no increase in other methodsfirearm law, no increase in other methods
was observed.was observed.
Figure 4 shows the time trend of the to-Figure 4 shows the time trend of the to-
tal number of firearm homicides, indicatingtal number of firearm homicides, indicating
no significant trend before 1998 (no significant trend before 1998 (ww
22
¼0.04,0.04,
d.f.d.f.¼18,18, PP¼0.840) with a mean of 0.390.840) with a mean of 0.39
(s.d.(s.d.¼ 0.08) firearm homicides per0.08) firearm homicides per
100 000. The growth factor during this per-100 000. The growth factor during this per-
iod was a modest +0.2% per year. A nega-iod was a modest +0.2% per year. A nega-
tive time trend was observed in the post-tive time trend was observed in the post-
1998 period (1998 period (ww
22
¼23.6,23.6, PP550.0001); the0.0001); the
growth factor wasgrowth factor was 772.3% per year. Fire-2.3% per year. Fire-
arm homicides reached a 20-year low ofarm homicides reached a 20-year low of
0.16 per 100 000 in the year 2005. The0.16 per 100 000 in the year 2005. The
change in the firearm homicide trend pre-change in the firearm homicide trend pre-
and post-legislation was significantand post-legislation was significant
((ww
22
¼14.3,14.3, PP¼ 0.0002). When adjusted for0.0002). When adjusted for
unemployment, alcohol consumption andunemployment, alcohol consumption and
the proportion of young men in the popu-the proportion of young men in the popu-
lation, the trend change remained signifi-lation, the trend change remained signifi-
cant (cant (ww
22
¼3.9,3.9, PP¼ 0.049) (Table 1).0.049) (Table 1).
Finally, we observed a significant posi-Finally, we observed a significant posi-
tive time trend in firearm licences pertive time trend in firearm licences per
100 000 before 1998 (Fig. 5) with an esti-100 000 before 1998 (Fig. 5) with an esti-
mated increase of 140 per year (mated increase of 140 per year (tt¼ 6.85,6.85,
PP550.0001) and a significant negative time0.0001) and a significant negative time
trend after the law with an estimated de-trend after the law with an estimated de-
crease of 125 per year (crease of 125 per year (tt¼773.52,3.52,
254254
AUTHOR ’ S P ROOFAUTHOR’S PROOF
Fig. 1Fig. 1 Firearm suici de rates before and after theFirearm suicide rates before and after the
1 997 firearm leg islati on (squares ind icate counted1997 firearm legislat ion (squares indicate counted
numbers, line shows numbers predicted throughnumbers, line shows numbers predicted through
regression models).regression models).
IMPACT OF FIREARM LEGISLATION ON SUICIDEIMPACT OF F IREARM LEGISL ATION ON SUICIDE
PP¼0.0026). Hence, the change in the trend0.0026). Hence, the change in the trend
of firearm licence rates is also significantof firearm licence rates is also significant
((tt¼ 775.28,5.28, PP550.0001). Significant positive0.0001). Significant positive
autocorrelation (autocorrelation (PP¼0.0015) was observed0.0015) was observed
(Table 1).(Table 1).
DIS CUSSIONDISCUSSION
More stringent firearm legislation has beenMore stringent firearm legislation has been
suggested as an evidence-based suicide pre-suggested as an evidence-based suicide pre-
vention strategy (Mannvention strategy (Mann et alet al, 2005). We ex-, 2005). We ex-
amined the effects of a firearm legislationamined the effects of a firearm legislation
reform in Austria over a period of 12 yearsreform in Austria over a period of 12 years
prior to and 8 years following its enact-prior to and 8 years following its enact-
ment. The results show that the firearmment. The results show that the firearm
suicide rate decreased among women agedsuicide rate decreased among women aged
20–64 years, men aged 20–64 years and20–64 years, men aged 20–64 years and
men aged 65 years or older; firearmmen aged 65 years or older; firearm
suicides as a percentage of total suicidessuicides as a percentage of total suicides
decreased; the firearm homicide ratedecreased; the firearm homicide rate
decreased; and the overall firearm licencedecreased; and the overall firearm licence
rate decreased after enactment of the newrate decreased after enactment of the new
law. These results hold true even when ad-law. These results hold true even when ad-
justing for common confounders of suicidejusting for common confounders of suicide
rates such as unemployment and average al-rates such as unemployment and average al-
cohol consumption per capita as well as thecohol consumption per capita as well as the
proportion of young men in the population.proportion of young men in the population.
The observed decline in the number ofThe observed decline in the number of
firearm suicides among some age groupsfirearm suicides among some age groups
after enactment of more stringent legislationafter enactment of more stringent legislation
is in congruence with previous studies. Inis in congruence with previous studies. In
the USA, the Brady Handgun Violencethe USA, the Brady Handgun Violence
Prevention Act has been shown to havePrevention Act has been shown to have
reduced suicide rates among people agedreduced suicide rates among people aged
55 years and over (Ludwig & Cook,55 years and over (Ludwig & Cook,
2000). In Canada, Leenaars & Lester2000). In Canada, Leenaars & Lester
(1997) observed a decrease in firearm sui-(1997) observed a decrease in firearm sui-
cides, but this effect was not apparent forcides, but this effect was not apparent for
those over 65 years old. In Australia a de-those over 65 years old. In Australia a de-
cline in the firearm suicide rate, especiallycline in the firearm suicide rate, especially
among younger men, was observed inamong younger men, was observed in
metropolitan and provincial cities aftermetropolitan and provincial cities after
legal restrictions were introduced in 1992legal restrictions were introduced in 1992
(Cantor & Slater, 1995). The decline in(Cantor & Slater, 1995). The decline in
255255
AUTHOR ’ S P ROOFAUTHOR ’ S P ROOF
Ta b l e 1Ta b l e 1 Parameter estimates derived from the Poisson regression model.Parameter estimates derived from the Poisson regression model.
Growth factor (95% CI)Growth factor (95% CI)
11
Change inChange in
growth factorgrowth factor
Test for trend changeTest for trend change
Before 1998Before 1998 After 1998After 1998 % (95% CI)%(95%CI) ww
22
PP
Model 1 (unadjusted)Model 1 (unadjusted)
Per centage of firearm suicide sPer cen tage of firear m sui cid es
among all suicidesamong all suicides
1.026 (1.01.026 (1.019 to 1.032)19 to 1.032) 0.9710.97 1
(0.961 to 0.981)(0.961 to 0.981)
775.2 (5.2 (776.7 to6.7 to 773.9)3.9) 53.053.0 550.0000.00011
Firearm suicide rateFirearm suicide rate 1.000 (0.994 to 1.01.000 (0.994 to 1.010)10) 0.949 (0.935 to 0.964)0.949 (0.935 to 0.964) 774. 9 (4.9 (775.9 to5. 9 to 773.9)3.9) 45.745.7 550.0000.00011
Total suicide r ateTotal suicide rate 0.975 (0.971 to 0.979)0.975 (0.971 to 0.979) 0.978 (0.971 to 0.985)0.978 (0.971 to 0.985) 0.3 (0.3 (771.0 to 1.3)1.0 to 1.3) 0.280.28 0.590.59
Firearm homicide rateFirearm homicide rate 1.002 (0.977 to 1.029)1.002 (0.977 to 1.029) 0.877 (0.832 to 0.923)0.877 (0.832 to 0.923) 7712.5 (12.5 (7718.2 to18.2 to 77 6.2)6.2) 14.314.3 550.0000.00011
Model 2 (adjusted)Model 2 (adjusted)
Per centage of firearm suicide sPer cen tage of firear m sui cid es
among all suicidesamong all suicides
22
1.026 (1.01.026 (1.016 to 1.038)16 to 1.038) 0.978 (0.963 to 0.993)0.978 (0.963 to 0.993) 774.8 (4.8 (776.7 to6.7 to 772.8)2.8) 21.821.8 550.0000.00011
Firearm suicide rateFirearm sui cid e rate
22
1.00 (0.968 to 1.01.00 (0.968 to 1.013)13) 0.953 (0.937 to 0.969)0.953 (0.937 to 0.969) 774.8 (4.8 (776.9 to6.9 to 772.7)2.7) 19.919.9 550.0000.00011
Total suicide r ateTotal suicide rate
22
0.975 (0.969 to 0.982)0.975 (0.969 to 0.982) 0.974 (0.964 to 0.984)0.974 (0.964 to 0.984) 770.1 (0.1 (771.4 to 1.3)1.4 to 1.3) 0.030.03 0.870.87
Firearm homicide rateFirearm homicide rate
33
0.994 (0.894 to 1.10)0.994 (0.894 to 1.10) 0.895 (0.791 to 1.00.895 (0.791 to 1.013)13) 779.9 (9.9 (7718.9 to18.9 to 770.1 )0.1) 3.93.9 550.0000.00011
1. A growth factor of e.g. 1.05 indicates an increase in the suicide rate of 5% per year.1. A growth factor of e.g. 1.05 indicates an increase in the suicide rate of 5% per year.
2. Adj usted for unem plo y ment and per capita alcohol consumpt ion.2. Adj usted for unemp lo y ment and per capita alcohol consum ption.
3. Adjusted for unemployment, per capita alcohol consumption and proportion of young men in the population.3. Adj usted for unemploy ment, per capita alcohol consumption and propor tion of young men in the population.
Fig. 2Fig. 2 Firearm suicides as a percentage of totalFirearm suicides as a percentage of total
suicides.suicides.
Fig. 3Fig. 3 Course of suicide methods before and after the1997 firearm legislation.Course of suicide methods before and after the 1997 firearm legislation.
KAPUSTA ET ALKAPUSTA ET AL
firearm suicides in Australia was further ac-firearm suicides in Australia was further ac-
celerated after the enactment of a morecelerated after the enactment of a more
stringent firearm law in 1996 (Goldney,stringent firearm law in 1996 (Goldney,
2006). Data from New Zealand showed2006). Data from New Zealand showed
that the mean firearm suicide rate de-that the mean firearm suicide rate de-
creased after assessment of firearm reliabil-creased after assessment of firearm reliabil-
ity and licence tests were introduced inity and licence tests were introduced in
1992 (Beautrais1992 (Beautrais et alet al, 2006). Besides this, 2006). Besides this
decline in firearm suicides, a decrease indecline in firearm suicides, a decrease in
firearm suicides as a percentage of totalfirearm suicides as a percentage of total
suicides was also observed, similar to thesuicides was also observed, similar to the
decrease observed in our findings. Thedecrease observed in our findings. The
decrease in the percentage of firearm sui-decrease in the percentage of firearm sui-
cides has been discussed as ruling out thecides has been discussed as ruling out the
possibility that the decline in firearm-possibility that the decline in firearm-
related suicides is due to changes in overallrelated suicides is due to changes in overall
suicide rates (Beautraissuicide rates (Beautrais et alet al, 2006)., 2006).
A series of studies is also available fromA series of studies is also available from
Canada, where the criminal code wasCanada, where the criminal code was
amended in 1977 (Bill C-51). Some studiesamended in 1977 (Bill C-51). Some studies
reported a decrease in firearm suicide ratesreported a decrease in firearm suicide rates
after enactment of the reform (Richafter enactment of the reform (Rich et alet al,,
1990; Carrington & Moyer, 1994; Leenaars1990; Carrington & Moyer, 1994; Leenaars
et alet al, 2003). Although Rich, 2003). Although Rich et alet al (1990) sug-(1990) sug-
gested possible switching effects from firearmgested possible switching effects from firearm
suicides to suicides by jumping, comparing 5-suicides to suicides by jumping, comparing 5-
year periods before and after the reform, ayear periods before and after the reform, a
subsequent study (Carrington & Moyer,subsequent study (Carrington & Moyer,
1994) with a longer observation period1994) with a longer observation period
found this trend to be insignificant. Thefound this trend to be insignificant. The
findings on the effects of legal restrictionfindings on the effects of legal restriction
in Canada have been replicated by a furtherin Canada have been replicated by a further
study, after two additional firearm lawsstudy, after two additional firearm laws
(Bills C-17 and C-68) were enacted in(Bills C-17 and C-68) were enacted in
1991 and 1995; subsequent to this legisla-1991 and 1995; subsequent to this legisla-
tion, firearm suicides, the percentage oftion, firearm suicides, the percentage of
firearm suicides and firearm homicidesfirearm suicides and firearm homicides
further decreased (Bridges, 2004). How-further decreased (Bridges, 2004). How-
ever, when re-examining these Canadianever, when re-examining these Canadian
data, Leenaarsdata, Leenaars et alet al (2003) found evidence(2003) found evidence
of switching for men but not women. Sinceof switching for men but not women. Since
firearm suicide rates among women ac-firearm suicide rates among women ac-
counted for a small proportion of all fire-counted for a small proportion of all fire-
arm suicides in our study, switchingarm suicides in our study, switching
effects for each gender were not calculated.effects for each gender were not calculated.
The potential switch to other suicideThe potential switch to other suicide
methods is a complex phenomenon whichmethods is a complex phenomenon which
is often misinterpreted. Since firearm sui-is often misinterpreted. Since firearm sui-
cides (as a percentage of all suicides) declinecides (as a percentage of all suicides) decline
after an effective law, the proportion ofafter an effective law, the proportion of
other methods of suicide logically increases.other methods of suicide logically increases.
But this does not explain a possible switch-But this does not explain a possible switch-
ing phenomenon – one has to consider theing phenomenon – one has to consider the
course of suicide rates. Accordingly, acourse of suicide rates. Accordingly, a
switching phenomenon would be reflectedswitching phenomenon would be reflected
in an increase in absolute suicides by allin an increase in absolute suicides by all
other methods (or some of the methods)other methods (or some of the methods)
after the enactment of a more stringent fire-after the enactment of a more stringent fire-
arm law, which was not observed in ourarm law, which was not observed in our
work.work.
Besides cross-sectional studies on theBesides cross-sectional studies on the
association of firearm availability and fire-association of firearm availability and fire-
arm suicides in the USA (Dahlbergarm suicides in the USA (Dahlberg et alet al ,,
2004; Miller2004; Miller et alet al, 2004) and Austria, 2004) and Austria
(Etzersdorfer(Etzersdorfer et alet al, 2006), longitudinal, 2006), longitudinal
studies have shown that firearm suicidesstudies have shown that firearm suicides
are associated with household firearm own-are associated with household firearm own-
ership (Millerership (Miller et alet al, 2002; Haw, 2002; Haw et alet al, 2004)., 2004).
Our results support and supplement theseOur results support and supplement these
findings, additionally demonstrating that afindings, additionally demonstrating that a
change in firearm legislation has an impactchange in firearm legislation has an impact
on firearm availability. A change in firearmon firearm availability. A change in firearm
legislation simultaneously alters the num-legislation simultaneously alters the num-
ber of firearm licences and the firearmber of firearm licences and the firearm
suicide rate, and this emphasises thesuicide rate, and this emphasises the
hypothesised association between bothhypothesised association between both
variables.variables.
In a cross-sectional study we have re-In a cross-sectional study we have re-
cently shown that there is a trend towardscently shown that there is a trend towards
higher firearm suicide rates in counties withhigher firearm suicide rates in counties with
higher firearm licensing rates (Etzersdorferhigher firearm licensing rates (Etzersdorfer
et alet al, 2006). These findings have been de-, 2006). These findings have been de-
scribed as representing an urgent publicscribed as representing an urgent public
health issue (Leenaars, 2006). Along withhealth issue (Leenaars, 2006). Along with
the results of the longitudinal analysis re-the results of the longitudinal analysis re-
ported here, there is even more evidenceported here, there is even more evidence
to support the view that a reduction in fire-to support the view that a reduction in fire-
arm suicides and firearm homicides can bearm suicides and firearm homicides can be
achieved by restriction of firearm availabil-achieved by restriction of firearm availabil-
ity through implementation of more strin-ity through implementation of more strin-
gent firearms legislation.gent firearms legislation.
Limitations of the studyLi m itations of the study
Because of the limiting ecological design ofBecause of the limiting ecological design of
this study, it must be noted that the de-this study, it must be noted that the de-
creasing firearm homicide and suicidecreasing firearm homicide and suicide
trends we observed – although having sig-trends we observed – although having sig-
nificantly changed in and after the year ofnificantly changed in and after the year of
the legal reform – may be attributable to so-the legal reform – may be attributable to so-
cio-economic or other factors. The influ-cio-economic or other factors. The influ-
ence of well-known confounders such asence of well-known confounders such as
consumption of alcohol per capita and un-consumption of alcohol per capita and un-
employment did not significantly diminishemployment did not significantly diminish
the positive effects of the new law as ob-the positive effects of the new law as ob-
served in our study. This has also beenserved in our study. This has also been
found in earlier multivariate models, wherefound in earlier multivariate models, where
the association of firearm availability andthe association of firearm availability and
firearm suicide rates has not been ruledfirearm suicide rates has not been ruled
out (Ludwig & Cook, 2000; Lenaarsout (Ludwig & Cook, 2000; Lenaars et alet al,,
2003; Miller2003; Miller et alet al, 2006)., 2006).
Since the accuracy of survey data andSince the accuracy of survey data and
other proxy variables of firearm availabilityother proxy variables of firearm availability
are questionable (Millerare questionable (Miller et alet al, 2004), the, 2004), the
number of officially issued firearm licencesnumber of officially issued firearm licences
was used to assess the availability of fire-was used to assess the availability of fire-
arms. We acknowledge that this measurearms. We acknowledge that this measure
is an underestimation of firearm availabil-is an underestimation of firearm availabil-
ity, but it is the only available measure fority, but it is the only available measure for
Austria. Another limitation of our resultsAustria. Another limitation of our results
is that aggregated data analyses allow nois that aggregated data analyses allow no
direct conclusion about individuals. Millerdirect conclusion about individuals. Miller
et alet al (2002) discussed the possibility that(2002) discussed the possibility that
individuals who die by suicide may notindividuals who die by suicide may not
share the characteristics (level of income,share the characteristics (level of income,
available firearm) of the group from whichavailable firearm) of the group from which
they were drawn. However, this does notthey were drawn. However, this does not
limit the growing evidence that morelimit the growing evidence that more
stringent firearm legislation reduces firearmstringent firearm legislation reduces firearm
deaths in the overall population.deaths in the overall population.
Finally, it could be argued that the de-Finally, it could be argued that the de-
crease in firearm suicide rates observed increase in firearm suicide rates observed in
our study might be a randomly found effectour study might be a randomly found effect
of an overall decline in suicide rate and notof an overall decline in suicide rate and not
due to the change in legislation. This isdue to the change in legislation. This is
found to be improbable when the declinefound to be improbable when the decline
in post-legislation firearm homicides is alsoin post-legislation firearm homicides is also
taken into consideration. We could showtaken into consideration. We could show
that, along with a decline in the numberthat, along with a decline in the number
256256
AUTHOR ’ S P ROOFAUTHOR ’ S P ROOF
Fig. 4Fig. 4 Firearm homicide rates.Firearm homicide rates.
Fig. 5Fig. 5 Firearm licence rates before and after theFirearm licence rates before and after the
1 997 firearm leg isl ation.1997 fi rearm legislation.
IMPACT OF FIREARM LEGISLATION ON SUICIDEIMPACT OF F IREARM LEGISL ATION ON SUICIDE
of firearm suicides, the number of firearmof firearm suicides, the number of firearm
homicides also decreased after enactmenthomicides also decreased after enactment
of the new legislation. The firearm homi-of the new legislation. The firearm homi-
cide rate trend had previously been steady,cide rate trend had previously been steady,
but it decreased after enactment, whereasbut it decreased after enactment, whereas
the overall suicide rate was in continuousthe overall suicide rate was in continuous
decline both before and after the legal re-decline both before and after the legal re-
form. We argue that the effect of changesform. We argue that the effect of changes
in firearm laws can be observed in twoin firearm laws can be observed in two
different measures: firearm suicides anddifferent measures: firearm suicides and
firearm homicides. Restrictive firearm legis-firearm homicides. Restrictive firearm legis-
lation has previously been shown to reducelation has previously been shown to reduce
firearm suicides as well as homicides infirearm suicides as well as homicides in
cross-sectional (Conner & Zhong, 2003;cross-sectional (Conner & Zhong, 2003;
RosengartRosengart et alet al, 2005) and longitudinal, 2005) and longitudinal
studies (Loftinstudies (Loftin et alet al, 1991; Leenaars &, 1991; Leenaars &
Lester, 1994; LeenaarsLester, 1994; Leenaars et alet al, 2003; Bridges,, 2003; Bridges,
2004).2004).
Implications of the studyImplications of the study
Suicide prevention plans encounter resis-Suicide prevention plans encounter resis-
tance when they demand more stringenttance when they demand more stringent
firearm laws, because national firearm re-firearm laws, because national firearm re-
strictions inevitably affect many people, in-strictions inevitably affect many people, in-
cluding those who are not at risk of suicide.cluding those who are not at risk of suicide.
Yet it should also be remembered that thoseYet it should also be remembered that those
who are at risk will be more effectively pro-who are at risk will be more effectively pro-
tected by such laws. Some researchers statetected by such laws. Some researchers state
that suicide prevention strategies are basedthat suicide prevention strategies are based
on two different approaches, which shouldon two different approaches, which should
be balanced – namely, the restriction of thebe balanced – namely, the restriction of the
means of suicide and the prevention ofmeans of suicide and the prevention of
mental disorders (Gunnell & Lewis,mental disorders (Gunnell & Lewis,
2005). They rightly point to the fact that re-2005). They rightly point to the fact that re-
striction of means does not address the rootstriction of means does not address the root
cause of the problem. However, until thecause of the problem. However, until the
effective prevention of mental disorderseffective prevention of mental disorders
realistically becomes our long-term aim,realistically becomes our long-term aim,
we should recall that the restriction ofwe should recall that the restriction of
means very probably does prevent suicidemeans very probably does prevent suicide
in the short term, thereby increasing thein the short term, thereby increasing the
likelihood of people who are suicidal re-likelihood of people who are suicidal re-
ceiving professional help in time. Despiteceiving professional help in time. Despite
its limitations, this study provides evidenceits limitations, this study provides evidence
from a European country that firearm sui-from a European country that firearm sui-
cides and homicides may indeed be pre-cides and homicides may indeed be pre-
vented through legal restriction of thevented through legal restriction of the
availability of firearms. Therefore, we re-availability of firearms. Therefore, we re-
commend that further steps be taken incommend that further steps be taken in
Austria and in other countries to reduceAustria and in other countries to reduce
the availability of firearms.the availability of firearms.
REFE RENCE SREFERENCES
Beautrais, A. L., Fergusson, D. M. & Horwood, L. J.Beautrais, A. L., Fergusson, D. M. & Horwood, L. J.
(2006)(2006)
Firearms legislation and reductions in firearm-Fi rearms legis lation and reductions in firearm-
re l a ted su i c ide deaths in New Zealand.re l a ted su i c i de deat hs i n New Zealand. Austra lian andAustral i an and
New Zealand Journal of PsychiatryNew Zealand Journal of Psychiatry,, 4040, 253^259., 253^259.
Bertolote, J. M. (2004)Bertolote, J. M. (2004) Suicide prevention: at whatSuic ide prevention: at what
leve l does it work?level does it work? World Psychia tr yWorld Psychia try ,, 33, 147^151., 147 ^151.
Brent, D. A. (2001)Brent, D. A. (2001) Firearms and suicide.Fi rearms and suicide. Annals of theAnnals of the
New York Academy of ScienceNew York Academy of Sc ienc e,, 932932, 225^239, 225^2 39
Bridges, F. S. (2004)Bridges, F. S. (2004) Gun control law (Bi l l C-1 7),Gun control law (Bill C-1 7),
suicide, and homicide in Canada.suicide, and homicide in Canada. Psychological ReportsPsychologi cal Reports,,
9494,819^826., 819^826.
Cantor, C. H. & Slater, P. J. (1995)C a ntor, C . H. & S la te r, P. J . (1 9 9 5) The impact ofThe im pact of
firearm cont rol legislat ion on suicide in Queensland:f i rearm control legislation on sui cide in Queensland:
preliminary f indings.preliminary f indings. Medical Journal of AustraliaMedical Journal of Australia,, 162162,,
583^585.583^585.
Caron, J. (2004)Caron, J. (2004) Gu n contr o l and suicide: possibleGun control and suicide: possible
impact of Canadian legislation to ensure safe storage ofimpact of Canadian legislation to ensure safe storage of
firearms.firearms. Archives of Suicide ResearchArchives of Suicide Research,, 88, 361^374., 361^374.
Carrington, P. J. & Moyer, S. (1994)Carrington, P. J. & Moyer, S. (1994) Gun contro l andGun control and
suicide in Ontario.sui cide in Ontario . American Journal of PsychiatryAmerican Journal of Psychiatry,, 15 1151,,
6 0 6^608.606^608.
Comm issi o n of the European Commun it ies (2000)Commission of the European Communities (2000)
Report from the Commission to the European ParliamentReport from the Commission to the European Parliament
and the Council: The Implementation of Council Directiveand the Council: The Implementation of Council Directive
9 1/477/EEC, of 18 June 199 1, on Control of the Acquisition9 1/477/EEC, of 18 June 1 99 1, on Control of the Acquis ition
and Possession of Weaponsand Possession of Weapons. Office for Official. Office for Official
Pub licat i ons of the Eur opean Com m u nities.Publications of the European Communities.
Conner, K. R. & Zhong, Y. (2003)Conner, K. R. & Zhong, Y. (2003) State f irearm lawsState f irearm laws
and rates of suicide in men and women.and rates of suicide in men and women. American JournalAmerican Journal
of Preventive Medicineof Preventive Medicine,, 2525, 320^324., 320^324.
Dahlberg,L.L.,Ikeda,R.M.&Kresnow,M.J.(2004)Dahlberg,L.L.,Ikeda,R.M.&Kresnow,M.J.(2004)
Gu ns i n the home and risk of a vi o lent death in the home:Guns i n the hom e and ri sk of a vi olent death in the home:
find ings from a national st ud y.f indi ngs from a national study. American Journal ofAmerican Journal of
EpidemiologyEpidemio logy,, 160160, 929^936., 929^936.
Etzersdorfer, E., Kapusta, N. D. & Sonneck, G.Etzersdorfer, E., Kapusta, N. D. & Sonneck, G.
(2006)(2006)
Suicide by shooting is correlated to rate of gunSu icide by shooti ng is correlated to rate of gun
licenses in Austrian counties.licenses in Austrian counties.Wiener Kli n i scheWiener Klinische
Wochen schriftWochen schrift,, 118118, 4 64^4 68., 4 6 4^468.
Goldney, R. D. (2006)Goldney, R. D. (2 006) Sui cide in Austral ia: some goodSuicide in Australia: some good
news.news. Medical Journal of AustraliaMedical Journal of Australia,, 185185, 304.,304.
Gunnell, D. & Lewis, G. (2005)Gunnell, D. & Lewis, G. (2005) Studying suicide fromS tud ying sui c ide from
the life course perspective: implications for prevention.the l i fe course perspecti ve: i m plications for preven t i on .
British Journal of PsychiatryBritish Journal of Psychiatry,, 187187 , 20 6^208., 20 6^2 0 8.
Haw,C., Sutton, L., Simkin, S.,Haw, C., Sutton, L., Simkin, S., et alet al (2004)(2004) Sui cide bySuicide by
gu nshot i n the United King dom: a review of thegu nshot i n the United King dom: a revie w of the
literature.literature. Medicine, Science and the LawMedicine, Science and the Law ,, 4444, 295^310., 295^310.
Hawton, K., Fagg, J., Simkin, S. ,Hawton, K., Fagg, J., Simkin, S., et alet al (19 9 8)(19 9 8) MethodsMethods
used for suicide by farmers in England and Wales. Theused for suicide by farmers in England and Wales. The
contri buti on of availability and its relevance tocontribution of availability and its relevance to
preven t i on.preven tion. British Journal of PsychiatryBritish Journal of Psychiatry,, 173173, 320^324., 320^324.
K ell ermann, A. L., Rivara, F. P., Somes, G.,Kellermann, A. L., Rivara, F. P., Somes, G., et alet al
(19 9 2)(19 9 2)
Su icide in the home i n rel a tion to gun owne rship.Su icide in the home i n rel a tion to gun owne rship.
New England Journal of MedicineNew England Journal of Medicine,, 327327, 467^472., 4 67^472.
Leenaars, A. A. (2006)Leenaars, A. A. (2006) Suicide by shooting and gunSuic ide by shooti ng and gun
ownership (licenses) in Austria: would gun restrictionownership (licenses) in Austria: would gun restriction
help?hel p? Wiener Klinische WochenschriftWiener Klinische Wochenschrift,, 118118, 439^441.,439^441.
Leenaars, A. A. & Lester, D. (1994)Leenaars, A. A. & Lester, D. (1994) Effects of gunEffects of gun
con trol on homicide in Canada.control on homicide in Canada. Psychological ReportsPsychological Reports,, 7575,,
81^ 82.81^82.
Leenaars, A. A. & Lester, D. (1997)Leenaars, A. A. & Lester, D. (1997) The i m pact of gunThe im pact of gun
cont rol on suicide and homicide across the life span.contro l on suicide and homicide across the l ife span.
Canadian Journal of Behavioral ScienceCanadian Journal of Behavioral Science,, 2929,1^6., 1^6.
Leenaars, A. A., Moksony, F., Lester, D.,Leenaars, A. A., Moksony, F., Lester, D., et alet al (2003)(2003)
The impact of gun control (Bill C-51) on suicide inThe impact of gun control (Bill C-51) on suicide in
Canada.Canada. Death StudiesDeath Studies,, 2727, 103^124., 103^124.
Loftin, C., McDowall, D., Wiersema, B.,Loftin, C., McDowall, D.,Wiersema, B., et alet al (19 91)(19 91)
Effects of restrictive licensing of handguns on homicideEffects of restrictive licensing of handguns on homicide
and suici de in the Distr ict of Col umbia.and suicide in the District of Columbia. New Eng l andNew Engl and
Journal of MedicineJournal of Medicine,, 325325,1615^1620.,1615^1620.
Ludwig, J. & Cook, P. J. (2000)Ludwig, J. & Cook, P. J. (2000) Impact of the Brady actImpact of the Brady act
on homici de and suicide rates.on hom i cide and su icide rates. JAMAJAMA,, 284284, 2718^ 27 21 ., 2718^2721.
Mann, J. J., Apter, A., Bertolote, J.,Mann, J. J., Apter, A., Bertolote, J., et alet al (2005)(2005)
Sui c ide prevent i on strat eg ies: a syste mat i c rev iew.Suic ide prevent i on strat eg i es: a systematic rev iew. JAMAJAMA,,
294294, 20 64^2074., 2064^2074.
Miller , M., Azrael, D. & Hemenway, D. (20 02)Miller, M., Azrael, D. & Hemenway, D. (2002)
Household firearm ownership and suicide rates in theHousehold firearm ownership and suicide rates in the
United States.United States. Epidemiol ogyEpidemiology,, 1313,517^524., 517^524.
Miller, M., Hemenway, D. & Azrael, D. (2004)Miller, M., Hemenway , D. & Azrael, D. (20 04)
Firearms and suicide in the northeast.Firearms and suicide in the northeast. Journal of TraumaJour na l of Trauma,,
5757, 626^632.,626^632.
Miller, M., Azrael, D., Hepburn, L.,Miller, M., Azrael, D., Hepburn, L ., et alet al (2006)(2006) TheThe
associa tion between changes in househo ld fir earmassocia tion between changes in house ho ld fir earm
ownership and rates of suicide in the United States,ownership and rates of suicide in the United States,
1981^2002.1981^2002. Injury PreventionInjury Prevention,, 1212, 178^182., 178^182.
Ozanne-Smith, J., Ashby, K., Newstead, S.,Ozanne-Smith, J., Ashby, K., Newstead, S., et alet al
(2004)(2004)
Firearm related deaths: the impact of regulatoryF irearm related deaths: the impact of regulatory
reform.reform. Injury PreventionInjury Prevention,, 1010, 280^286., 280^28 6.
Rich, C. L.,Young, J. G., Fowler, R. C.,Rich, C. L.,Young, J. G., Fowler, R. C., et alet al (1990)(19 9 0 )
Guns and suicide: possible effects of some specificGuns and suicide: possible effects of some specific
legis lation.legislation. American Journal of PsychiatryAmerican Journal of Psychiatry,, 14 714 7 , 342^346., 342^346.
Rosengart, M., Cummings, P., Nathens, A.,Rosengart, M., Cummings, P., Nathens, A., et alet al
(2005)(2005)
An evaluation of state firearm regulat ions andAn evaluation of state f i rearm regulat ions and
hom i c ide and su i c i de deat h rates.homicide and suicide death rates. Injury PreventionInjury Prevention,, 1111,,
77^83.7 7^83.
Uhl, A . , Kopf, N. , Spring er, A. ,Uhl, A., Kopf, N., Springer, A. , et alet al (2006)(2006)
Handbuch: Alkohol ^ sterreich: Zahlen, Daten, Fakten,Handbuch: Alkohol ^ sterreich: Zahlen, Daten, Fakten,
Trends 2005Trends 2005.BMAGS..BMAGS.
WorldHealthOrganization(2006)World Health Organization (2006) Preventing DiseasePreventing Disease
Through Healthy Environments. Towards an Estimate of theThrough Healthy Environments. Towards an Estimate of the
Environmental Burden of Disease.WHO.Environmental Burden of Disease.WHO.
257257
AUTHOR ’ S P ROOFAUTHOR ’ S P ROOF
NESTOR D .KA PUSTANESTOR D.KAPUSTA, MD, Department of Psychoanalysis and Psychotherapy and Institute for Medical, MD, Department of Psychoanalysis and Psychotherapy and Institute for Medical
Psychology, Medical University of Vienna, Austria;Psychology, Medical University of Vienna, Austria; ELMAR ETZERSDORFERELMAR ETZERSDORFER, MD, Furtbach Hospital for,MD,FurtbachHospitalfor
Ps ychiatry and Ps ychot he rapy, S tutt gart, Germany;Psychiatry and Psychotherapy, Stuttgart,Germany; CHRISTOPH KRALLCHRISTOPH KRALL, PhD, Section of Medical Statistics,, PhD, Section of Medical Statistics,
Medical University of Vienna, Austria;Medical University of Vienna, Austria; GERNOT SONNECKGERNOT SONNECK, MD, Institute for Medical Psychology, Medical, MD, Institute for Medical Psychology, Medical
University of Vienna, AustriaUniversity of Vienna, Austria
Correspondence: Dr Nestor D.Kapusta , Medical Univer sity of Vienna,Depar tment of PsychoanalysisCorrespondence: Dr Nestor D.Ka pusta, Medical University of Vienna,D epartment of Psychoa nalysis
and Psychotherapy,Waehringer Guertel 18^20, A-109 0 Vienna, Austria. Tel: +43 1 4 04 0 0 3 064;and Psychotherapy,Waehringer Guertel18^20, A-10 90 Vienna,Austria.Tel: +43 1 4 04 0 0 306 4;
fax: +43 1 427 7 9656; email: n estor.kapustafax: +43 1 4277 9656; email: nestor.kapusta@@meduniwien.ac.atmeduniwien.ac .at
(First received 30 October 2006, final revision 29 March 2007, accepted 12 April 2007)(First received 30 October 2006, final revision 29 March 2007, accepted 12 April 2007)
