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EVIDENCE BASED PUBLIC HEALTH POLICY AND PRACTICE
Safer storage of firearms at home and risk of suicide: a
study of protective factors in a nationally representative
sample
Edmond D Shenassa, Michelle L Rogers, Kirsten L Spalding, Mary B Roberts
...............................................................................................................................
See end of article for
authors’ affiliations
.......................
Correspondence to:
Assistant Professor, E D
Shenassa, Department of
Community Health and
Centers for Behavioral and
Preventive Medicine,
Brown Medical School,
One Hoppin Street, Suite
500, Providence, RI
02903, USA;
Edmond_Shenassa@
Brown.edu
Accepted for publication
4 February 2004
.......................
J Epidemiol Community Health 2004;58:841–848. doi: 10.1136/jech.2003.017343
Objective: To estimate the protective effect of storing firearms locked or unloaded, or both, on the risk of
suicide by firearms among people with relatively low intention to die.
Design and setting: Cross sectional survey. The 1993 National Mortality Followback Survey of 22 957
deaths in the United States, representing 2.2 million people, conducted by the National Center for Health
Statistics.
Participants: Decedent’s next of kin answered questions regarding various aspects of decedent’s life to
supplement information from death certificates.
Main results: Compared with decedents who stored their firearm unlocked or loaded, those who stored
their firearms locked or unloaded, or both, were less likely to commit suicide by firearms (locked:
OR = 0.39, 95% CI = 0.24 to 0.66; unloaded OR = 0.30, 95% CI = 0.18 to 0.49).
Conclusions: This study further supports the utility of devices and practices intended to reduce the
likelihood of unauthorised or impulsive use of firearms.
R
eady access to firearms at home is an international
phenomenon. Many nations, both developing and
developed, have high levels of per capita firearm
ownership.
12
In the US, where 41% to 49% of households
own a firearm, about 75% of handgun owners and 38% of all
firearm owners claim protection of themselves, their families,
and their property as the main reason for storing firearms at
home.
3–5
However, far from being a source of protection,
access to firearms at home has been repeatedly linked with
household members’ risk of violent death.
6–11
This link is
particularly well reported for suicide. Ecological studies
(table 1) have consistently linked state, regional, and
national levels of firearm availability with firearm related
suicide rates among various demographic groups
2 12–28
as well
as overall suicide rates,
2121820212324
particularly among
people under age 25.
22 23 29
More convincingly, individual level studies also evince a
link between firearm ownership and risk of suicide (table 2).
Among adults, purchase of a handgun is linked with an
increased risk of suicide, an association that can persist for
five years after the purchase.
30–32
On the balance, individual
level studies also suggest a positive independent association
between access to firearms at home and risk of suicide among
adults. While two of these studies
33 34
found firearm owner-
ship to be independent of risk of suicide, three regional and
two national studies have linked household access to
firearms with the risk of suicide.
7 8 35–37
These findings among
adults are further corroborated by studies of adolescents that
have uniformly found a positive association between access
to firearms at home and risk of suicide.
38–44
Even more convincingly, individual level studies that have
specifically examined firearm related suicides uniformly
report a positive association between household access to
firearms and risk of suicide by firearms. Regional studies
have found that adults’ risk of suicide by firearm is 3 to 12
times higher among handgun purchasers as compared with
controls.
30–32
Similarly, adolescents with access to firearms at
home are four times as likely to commit suicide by firearm
than other adolescents.
39
Most persuasively, in a nationally
representative sample, household access to firearms was
associated with a 17-fold increase in the risk of suicide by
firearm relative to those without such access.
8
Despite the ubiquity of firearms in several nations across
the globe and the abundant evidence linking access to
firearms at home with the risk of violent death—particularly
suicide by firearm—information on factors that may protect
against household members’ risk of suicide by firearm (for
example, placement of lock triggers) is conspicuously sparse,
and the sum of the available information is inconclusive.
Seven studies have examined the link between risk of suicide
and the manner in which firearm(s) are stored (table 3). In
two studies of adult suicide victims and community controls,
unsafe firearm storage independently predicted suicide.
36 37
In
a study comparing seven adolescent suicide victims with no
apparent psychopathology to 60 suicide victims with a
psychiatric disorder and 38 community controls with no
disorder, the presence of a loaded firearm in the home was
significantly associated with suicide completion.
43
In four
other studies, risk of suicide among adolescents was
independent of the manner in which firearms were stored
in their residences.
38 39 41 42
While these studies provide useful
preliminary information, they are limited by their focus on
small geographical areas, small sample sizes, and in some
instances, under-representation of racial and ethnic mino-
rities (see Miller and Hemenway
45
and Brent
46
for reviews).
These studies are further compromised by not considering
study participants’ intention to die.
Here we present the first study to address these short-
comings by using a nationally representative sample to
estimate the protective effect of storing firearms locked and/
or unloaded. We greatly, but not completely, reduce the bias
introduced when intention to die is not considered by
including in the analyses proxies for intention to die.
Furthermore, our focus is on suicides that are likely to have
been impulsive. There is compelling evidence that a
considerable proportion of suicides are impulsive acts.
841
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Internationally, 24% to 53% of suicides are contemplated for
as little as five minutes.
47–51
Clearly, any measure that can
prolong the period between the initial decision to commit
suicide and the suicidal act can potentially decrease the
fleeting intention to die and possibly prevent the suicidal
behaviour. Reducing ease of access to firearms through safer
storage practices is potentially one such method. Our aim is
to estimate the protective effect of safer firearm storage
practices (that is, storing firearms locked and/or unloaded)
on the risk of suicide by firearm among people with relatively
low intention to die.
METHODS
Sample
We use data from the 1993 National Mortality Followback
Survey (NMFS
52
). This is a survey of social, medical, and
lifestyle practices of the decedent as reported by the next of
kin (hereafter, informant). The 1993 NMFS is based on a
sample of 22 957 deaths representing 2 215 000 people. A
10% random sample of death certificates from all states in the
union (except South Dakota), and independent vital regis-
tration areas of the District of Columbia and New York City
were drawn from the 1993 Current Mortality Sample.
Informants were identified either on the death certificate as
having provided information or were identified by the funeral
director. When an informant was not identified in this
manner or could not be located, another person familiar with
the decedent’s life history was recruited by personalised
letter. Eighty three per cent of informants participated in the
survey.
To reduce the likelihood of misinformation provided by
respondents not well acquainted with the decedent, we
included in the analyses only information reported by the
spouse (38%), parent (32%), sibling (14%), or offspring
(14%). As an added precaution, we further focused the study
sample to decedents who had resided with their informant
Table 1 Ecological studies of the link between firearm availability and suicide
Authors
Unit of analysis/ population and
measure of suicide Measure of firearm availability Findings
Birckmayer and Hemenway,
2001
22
Suicide and firearm suicide rates
in 9 US census regions (1979–94)
Proportion of households with
firearms
Prevalence of household firearm ownership
predicted firearm suicide rate.
Clarke and Jones, 1989
15
US suicide and firearm suicide rates
(1959–84)
Proportion of households with
handguns
Prevalence of handgun ownership predicted
rate of firearm suicides.
Hemenway and Miller, 2002
21
Suicide and firearm suicide rates in
9 US census regions (19 88–97)
Proportion of households with
handguns
Household handgun ownership rates predicted
firearm suicide and overall suicide rates.
Kaplan and Geling, 1998
13
Firearm suicide and homicide rates
in 9 US census regions (1989–91)
Prevalence of firearm ownership Prevalence of firearm ownership predicted
firearm suicide among white and black men
Kellermann and Reay, 1986
6
Number of firearm suicides relative
to all firearm deaths that occurred at
home (King County, Washington:
1978–83).
Whether a firearm was kept in
the home
For every self protection homicide involving a
firearm kept in the home, there were 37
suicides involving firearms
Kellermann et al, 1998
10
Number of firearm related attempted
and completed suicides relativ e to all
shootings in/around a home in three
US cities (Nov 1992–May 1994).
Whether the gun involved was
kept in the home
For every legally justifiable shooting, there
were 11 attempted or completed suicides
Killias, 1993
2
Proportion of suicides with a firearm,
rate of firearm suicide, and overall
suicide rate in 14 countries
(1983–86)
Proportion of households with
firearms (1989)
Prevalence of household gun ownership
predicted proportion of suicides with a gun ,
rate of firearm suicide, and overall suicide rate
Kleck and Patterson, 1993
24
Suicide and firearm suicide rates in
170 US cities (1979–81).
Proportion of firearm related
homicides (1979–82); other crimes
(1979–80), and the dollar value of
stolen property attributable to
firearms thefts (1979–81)
Gun prevalence predicted total suicide and
firearm suicide rates
Lester, 1988
16
Rates of suicide by firearm and
other methods in 9 US census
regions (1970)
Proportion of homicides and suicides
committed with firearms; accidental
death rate from firearms; state
handgun control laws, and subscription
rates to firearm magazines
States with a higher availability of firearms had
higher firearm suicide rat es.
Lester, 1989
12
Suicide and firearm suicide rates
in the 48 continental US states (1980)
Per capita circulation of Shooting
Times, Guns & Ammo, and American
Handgunner
States with a higher per capita circulation of
firearm magazines had higher suicide and
firearm suicide rates.
Lester, 1990
17
Suicide rates by firearm and other
methods in 20 countries—1980
Proportion of homicides committed
by firearms
Proportion of homicides committed by firearms
predicted firearm suicide rate.
Lester, 2000
25
Firearm suicide rates in 36 nations
(1993)
Accidental firearm mortality rate;
proportion of homicides involving
firearms
Accidental firearm mortality rate was
independent of firearm suicide rate; proportion
of homicides involving firearms predicted
firearm suicide rate.
Lester, 2001
27
Percentage of suicides using firearms
among total Canadian population
(1970–95)
Rate of accidental death from
firearms
Rate of accidental death from firearms
predicted percentage of suicides using firearms
for all age groups except 55+.
Bridges, 2002
28
Replicated Lester, 2001, using 3
additional years of data (1996–98)
Rate of accidental death from
firearms
Rate of accidental death from firearms
predicted percentage of suicides using firearms
for all age groups except 55+.
Miller et al, 2002
18
Suicide and firearm suicide rates
for all US women (1988–97)
Household gun ownership rates;
Cook’s Index, and fraction of all
suicides that involved a gun
States with relatively lower availability of
firearms had relatively lower rates of suicides,
and firearm suicides.
Miller et al, 2002
23
Suicide and firearm suicide rates
for all US 5–14 year olds (1988–97)
Household gun ownership rates;
Cook’s Index; and fraction of all
suicides that involved a gun
States with relatively lower availability of
firearms had relatively lower rates of suicides,
and firearm suicides.
Miller et al, 2002
20
Suicide and firearm suicide rates
for all US states, 9 census regions
(1988–97)
Proportion of households with
firearms (NORC); fraction of all
suicides that involved a gun
States with relatively lower availability of
firearms had relatively lower rates of suicides,
and firearm suicides.
842 Shenassa, Rogers, Spalding, et al
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for at least a year. To focus on impulsive suicides, we further
focused our study sample to decedents who, according to the
informant, had not expressed a wish to die during the last
month of life. Finally, the study sample included only records
with complete information on all variables of interest.
Recognising that there may be residual confounding by
intention to die, we identified two groups in addition to the
study sample just described. The first group is comprised of
decedents who did not have any of the three strongest
correlates of suicide (other than demographics) in the study
Table 2 Individual level studies of the link between firearm availability and suicide
Authors
Number of suicide victims
(cases)* Comparison group Outcome assessed/exposure OR (CI)/p value
(A) Adult individual level studies
Bailey et al,1997
7
120 females 120 matched community
dwelling controls
RS among women/ > one gun in
home
4.6 (1.2 to 17.5)
Beautrais et al.,
1996
34
197 1028 community dwelling
controls
RS/access to a firearm at home 1.4 (0.96 to 1.99)
Conwell et al,
2002
37
86, ages 50 and over 86 matched community
dwelling controls
RS/ > one gun in home 3.23 (1.15 to 11.20)
Cummings et al,
1997
30
353 1756 matched community
dwelling controls
RS/history of family handgun
purchase
1.9 (1.4 to 2.5)
Grassel et al,
2003
32
887 suicide victims and
1546 gun suicide victims
208738 non-injury deaths -RS 6.8 (5.7 to 8.1)
-RFS/handgun purchase 12.5 (10.4 to 15.0)
Kellermann et al,
1992
36
438 438 matched community
dwelling controls
RS/ > one gun in home 4.8 (2.7 to 8.5)
Kung et al, 2003
35
22772 448710 decedents with natural
causes of death
RS/any firearms in or around
decedent’s home during last
year of life
Men living with others
3.53 (2.42 to 5.15)
Women living with others
2.99 (1.58 to 5.65)
Wiebe, 2003
8
1959 13535 community dwelling
controls
-RS 3.44 (3.06 to 3.86)
-RFS/having a gun in home 16.89 (13.26 to 21.52)
Wintemute et al,
1999
31
238,292 handgun purchasers
in California—observed
1991–1996
General adult population of
California
-RS in first year after handgun
purchase
SMR 4.31
-RFS in first year after handgun
purchase
SMR 7.12
(B) Adolescent individual level studies
Brent et al, 1988
42
27 56 suicidal psychiatric inpatients RS/firearms available in home 2.7 (1.1 to 6.4)
Brent et al, 1991
41
47 (a) 47 suicide attempters RS/gun available in home a: 2.1 (1.2 to 3.7)
(b) 47 never suicidal psychiatric
controls
b: 2.2 (1.4 to 3.5)
Brent et al, 1993
38
7, all with no apparent
psychopathology
(a) 60 adolescent suicide victims
with psychiatric disorder
RS/gun available in home a: none reported
(b) 38 community controls with
no psychiatric disorder
b: p = 0.04
Brent et al, 1993
43
67 67 matched community dwelling
controls
RS/any gun available in the home 3.3 (1.4 to 7.7)
Brent et al, 1994
44
63, all with a history of
affective illness
23 community dwelling controls
with a history of affective illness
RS/handgun available in the home p,0.01
Brent et al, 1999
40
140 131 community dwelling controls RS/gun in home 4.00 (1.30 to 14.70)
Shah et al, 2000
39
36 firearm suicide victims 36 matched community dwelling
controls
RFS/household access to firearms 3.91 (1.11 to 13.80)
*Suicide victims in all studies cited in this table were community dwellers. Odds ratio (OR) = 95% confidence interval (CI). RS, risk of suicide; RFS, risk of firearm
suicide; SMR, standardised mortality ratio.
Table 3 Studies of firearm storage practices and suicide risk
Authors Cases Controls Measures of firearm storage Odds ratio (CI)*/p value
Brent et al, 1988
42
27 56 suicidal psychiatric inpatients Firearms stored loaded NS
Firearms stored locked NS
Brent et al, 1991
41
47 (a) 47 suicide attempters Guns stored locked NS
(b) 47 never suicidal psychiatric
controls
Guns stored together NS
with ammunition NS
Guns stored loaded
Brent et al, 1993
38
7, all with no apparent
psychopathology
(a) 60 adolescent suicide victims
with psychiatric disorder
Loaded gun in the home Cases v a: p,0.01
(b) 38 community controls with no
psychiatric disorder
Cases v b: p,0.01
Brent et al, 1993
43
67 67 matched community dwelling
controls
Loaded gun in the home NS
Conwell et al,
2002
37
86, ages 50 and over 86 matched community dwelling
controls
>1 gun kept unlocked 9.52 (1.52 to 58.82)
>1 gun kept loaded 6.41 (1.17 to 35.71)
Kellermann et al,
1992
36
438 438 matched community dwelling
controls
Any gun kept loaded 9.2 (4.1 to 20.1)
All guns kept unloaded 3.3 (1.7 to 6.1)
Any gun kept unlocked 5.6 (3.1 to 10.4)
All guns kept locked up 2.4 (1.0 to 5.7)
Shah et al, 2000
39
36 firearm suicide victims 36 matched community dwelling
controls
>1 unlocked gun in the home p = 0.05
Crude OR 2.57 (0.98 to 6.70)
*Odds ratios = 95% confidence interval. NS, not significant; p values not reported.
Protective effect of saf er firearm s torage 843
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sample: (1) consumed alcohol in the last year of life, (2)
experienced an employment change in the last year of life,
and (3) visited a mental health professional in the last year of
life. The second group is comprised of only suicide victims.
We reasoned that, on average, compared with the study
sample, intention to die is relatively lower among decedents
who did not have any of the three strongest correlates of
suicide, and relatively higher among those who died of
suicide. Thus, for this analysis, we make the simplifying
assumption that if the risk associated with unsafe firearm
storage is highest among those with the highest intention to
die, and lowest among those with the lowest intention to die,
then we have reasonably succeeded to group decedents by,
and partially control for, their intention to die within
limitations imposed by the data.
Measurement
The dependent variable in this study is an indicator of
whether the decedent committed suicide with a firearm
according to the cause of death stated on the death
certificate. Use of firearms in the suicide was determined
based on the following ICD-9 codes for external cause of
injury (E-codes): E955.0 (suicide by handgun) and E955.1–
E955.4 (suicide by all other and unspecified firearms)*. The
primary exposures of interest are whether the decedent kept
any firearm(s) in or around home during the last year of life,
and whether the firearms were stored unloaded and/or
locked in the decedent’s home. We consider firearms stored
in a locked drawer, cabinet, or closet and those stored with a
trigger lock or other locking mechanism as locked, and
disassembled firearms to be unloaded.
The regression models include the following variables
that refer to the last year of life, except where, as will
be noted, the question refers to the last month of life.
Table 4 Descriptive statistics by cause of death
Decedent’s characteristics
Study sample
(n = 4996)
Committed suicide
by firearm
(n = 190)
Died from other
causes
(n = 4806)
Sociodemographic characteristics
Mean age, y (SE) 70.9 (0.4) 50.3 (1.4) 71.0 (0.4)*
Male, % 57.1 87.3 56.9*
Education, %
Less than high school 38.0 35.8 38.0
High school 35.6 40.0 35.6
College 26.3 24.1 26.3
Race/ethnicity, %
White non-Hispanic and other 87.1 84.7 87.1
Black non-Hispanic 10.7 9.4 10.7
Hispanic 2.2 6.0 2.2*
Region of residence
Northeast 17.2 9.7 17.2*
Midwest 29.8 23.5 29.8
South 34.6 49.3 34.5*
West 18.5 17.5 18.5
Correlates of mental wellbeing and stress
Frequency engaged in religious activities, %
Never 37.0 57.2 36.9*
Less than once per month, 1–3 times per month,
1–2 times per week 56.2 36.5 56.3*
3–6 times per week, every day 6.8 6.3 6.8
Frequency engaged in moderate/vigorous physical
activities, %
Never 45.1 22.2 45.2*
Less than once per month, 1–3 times per month,
1–2 times per week 19.9 22.7 19.9
3–6 times per week, every day 35.0 55.1 34.9*
Frequency of contact with family or friends, %
Never 5.3 3.9 5.3
Less than once per month, 1–3 times per month,
1–2 times per week 24.6 23.0 24.6
3–6 times per week, every day 70.1 73.1 70.1
Consumed 1+ alcoholic drinks per occasion, %` 24.2 58.9 24.0*
Experienced employment change, % 1.6 17.1 1.5*
Avoided or refused needed health care, % 14.2 22.5 14.2*
Visited a psychiatrist/psychologist, % 4.9 14.5 4.8*
Number of depressive symptoms, %1
None 23.3 32.1 23.2*
1–2 34.9 27.6 34.9*
3–4 25.0 24.5 25.0
5+ 16.9 15.9 16.9
Possession and storage of firearms
Firearm(s) kept in/around the home, % 35.7 91.3 35.4*
Firearm(s) kept locked, %` 43.3 29.1 43.5
Firearm(s) kept unloaded, %` 81.2 61.8 81.4*
Source: 1993 National Mortality Followback Survey (NMFS). Reference group. `Reference group is non-
drinkers, which includes lifetime abstainers and former drinkers. 1Depressive symptoms include: (1) seeming
drowsy or sluggish, (2) seeming unresponsive or withdrawn, (3) seeming impatient or annoyed, (4) expressing
feelings of worthlessness, (5) crying for long periods for no apparent reason, (6) having trouble sleeping or
sleeping more or less than usual, (7) eating more or less than usual, and (8) having trouble concentrating or
difficulty making decisions. Statistics are presented only for those who own firearms (n = 1608). *p,0.05—test of
difference between those who committed suicide by firearm and those who died from other caus es.
*In the NMFS, suicide by airgun (E955.6) was included in a category
containing E-codes E954, E955.5-E959, and therefore could not be
classified with suicides by firearm.
844 Shenassa, Rogers, Spalding, et al
www.jech.com
(1) Sociodemographic characteristics—gender, age, educa-
tion level, and race/ethnicity
53–57
; US region of residence,
13
(2)
Correlates of mental wellbeing and stress—three categorical
variables reflecting the frequency of religious activities,
58–61
moderate and/or vigorous physical activities (for example,
heavy housework, jogging,),
62 63
and interaction with family
or friends.
61 64
Also included were indicators of whether or not
the decedent consumed alcohol
35 57 65
; experienced a demo-
tion, job loss, quit a job, or retired
66–68
; avoided or refused
needed health care
69 70
; or saw a mental health profes-
sional.
35 57 71
Categorical variables reflecting the number of
depressive symptoms during the last month of life
35 71–74
were
also included. Up to eight depressive symptoms were
endorsed, allowing a possible range of 0–8; the a reliability
for this scale is 0.77.
Analysis
Using logistic regression, we first estimated the risk of suicide
by firearm associated with having access to firearm(s) at
home, and then estimated the protective effect of safer
storage practices among decedents with relatively low,
medium, and high intention to die. All covariates deemed
relevant based on our review of the literature were
simultaneously included in the models. Observations are
weighted to account for the study design and for non-
response of proxy respondents
75 76
using SUDAAN (version
8.0.1, Research Triangle Institute, Research Triangle Park,
NC) and the weights provided with the NMFS.
52
RESULTS
The study sample consists of 4996 decedents representing
721 436 people aged 15 and older. Compared with the
original NMFS sample, decedents in our study sample are
slightly younger (71 years v 72 years) and somewhat over-
representative of males (57% v 51%), decedents with a college
education (26% v 23%), non-Hispanic whites (87% v 85%),
and residents of the North east (17% v 21%). Midwestern
residents are under-represented (30% v 24%).
Table 5 Logistic regression models of the risk of suicide by firearm relative to death from other causes
Decedent’s characteristics
(A) Study sample (B) Only firearm owners
OR (95% CI) OR (95% CI)
Sociodemographic characteristics
Age 0.96 (0.95 to 0.96) 0.96 (0.95 to 0.97)
Gender
Female* 1.00 1.00
Male 2.75 (1.82 to 4.13) 1.85 (1.09 to 3.14)
Education
Less than high school* 1.00 1.00
High school 0.88 (0.58 to 1.32) 1.09 (0.60 to 1.99)
College 0.67 (0.40 to 1.12) 1.11 (0.56 to 2.20)
Race/ethnicity
White non-Hispanic and other* 1.00 1.00
Black non-Hispanic 0.51 (0.31 to 0.83) 0.70 (0.37 to 1.34)
Hispanic 0.94 (0.43 to 2.06) 2.36 (0.84 to 6.61)
Region of residence
Northeast* 1.00 1.00
Midwest 1.55 (0.80 to 3.02) 1.71 (0.71 to 4.14)
South 2.44 (1.30 to 4.60) 2.63 (1.14 to 6.06)
West 1.32 (0.66 to 2.65) 0.85 (0.34 to 2.13)
Correlates of mental wellb eing and stress
Frequency engaged in religious activities
Never* 1.00 1.00
Less than once per month, 1–3 times per month, 1–2 times per week 0.36 (0.25 to 0.53) 0.20 (0.12 to 0.34)
3–6 times per week, every day 0.70 (0.37 to 1.35) 0.56 (0.23 to 1.37)
Frequency engaged in moderate/vigorous physical activities
Never* 1.00 1.00
Less than once per month, 1–3 times per month, 1–2 times per week 1.45 (0.82 to 2.57) 1.05 (0.46 to 2.41)
3–6 times per week, every day 1.98 (1.14 to 3.44) 2.83 (1.35 to 5.91)
Frequency of contact with family or friends
Never* 1.00 1.00
Less than once per month, 1–3 times per month, 1–2 times per week 0.77 (0.29 to 2.00) 0.89 (0.21 to 3.74)
3–6 times per week, every day 0.53 (0.21 to 1.35) 0.49 (0.12 to 2.00)
Consumed 1+ alcoholic drinks per occasion 2.38 (1.63 to 3.48) 2.28 (1.33 to 3.91)
Experienced employment change 4.05 (2.29 to 7.16) 4.13 (2.12 to 8.05)
Avoided or refused needed health care 1.23 (0.78 to 1.96) 1.19 (0.66 to 2.17)
Visited a psychiatrist/psycholo gist 2.75 (1.51 to 5.01) 5.29 (2.38 to 11.74)
Number of depressive symptoms`
None* 1.00 1.00
1–2 0.88 (0.55 to 1.41) 1.23 (0.65 to 2.33)
3–4 1.08 (0.63 to 1.85) 1.15 (0.52 to 2.51)
5+ 0.89 (0.48 to 1.64) 1.37 (0.63 to 2.99)
Number 4996 1608
Source: 1993 National Mortality Followback Survey (NMFS). *Reference group. Reference group is non-drinkers, which includes lifetime abstainers and former
drinkers. `Depressive symptoms include: (1) seeming drowsy or sluggish, (2) seeming unresponsive or withdrawn, (3) seeming impatient or annoyed, (4)
expressing feelings of worthlessness, (5) crying for long periods for no apparent reason, (6) having trouble sleeping or sleeping more or less than us ual, (7) eating
more or less than usual, and (8) having trouble concentrating or difficulty making decisions.
Key points
N
Locked and/or unloaded firearm storage may be
effective in reducing impulsive suicidal acts.
N
This protective effect is strongest among the majority of
suicide victims who engage in impulsive suicidal
behaviour.
Protective effect of saf er firearm s torage 845
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Table 4 shows that relative to those who perished because
of other causes, decedents who committed suicide by firearm
were significantly more likely to be younger (50 years v 71
years), male (87% v 57%), and Hispanic (6% v 2%). They were
more likely to have resided in the south (49% v 34%) and less
likely to have resided in the north east (10% v 17%).
Decedents who committed suicide by firearm were more
likely to have: never engaged in religious activities (57% v
37%); exercised frequently (55% v 35%); consumed alcohol
(59% v 24%); experienced an employment change (17% v
2%); avoided or refused needed health care (23% v 14%);
exhibited fewer depressive symptoms (32% v 23%, no
symptoms), and visited a mental health professional in the
past year (14% v 5%). They were also more likely than others
to have stored a firearm in/around their residence (91% v
35%) and were less likely to keep it unloaded (62% v 81%).
Multivariate analysis of the study sample shows that
(table 5 (A)), risk of committing suicide varies by age and
gender, but is independent of level of education and race/
ethnicity. Other predictors of suicide by firearm include
decedents’ alcohol consumption, employment change, and
visit(s) to a mental health professional during the last year of
life. Among decedents with access to firearms (table 5 (B)),
similar associations were found between the risk of suicide by
firearm and alcohol consumption, employment change, and
visit(s) to mental health professionals. Analysis of the
original NMFS sample (analyses not shown) yield similar
effect sizes.
Table 6 shows the risk of suicide by firearm relative to
death from other causes among decedents in the study
sample, as well as among the two groups with relatively
lower and higher intention to die. The risk of suicide by
firearms is highest among those with the highest intention to
die (that is, subsample consisting entirely of suicide victims;
OR = 36.7, 95% CI = 14.2 to 95.0), medium among those with
relatively moderate intention to die (that is, study sample,
OR = 17.7, 95% CI = 10.2 to 30.9), and lowest among those
with the lowest intention to die (that is, subsample excluding
those with any of the three strongest correlates of suicide;
OR = 14.0, 95% CI = 5.7 to 34.3).
The protective effect of safer firearm storage is strongest
among those with lowest relative intention to die (locked:
OR = 0.18, 95% CI = 0.06 to 0.49; unloaded: OR = 0.22, 95%
CI = 0.08 to 0.57) and medium among those with relatively
moderate intention to die (locked: OR = 0.39, 95% CI = 0.24
to 0.66; unloaded: OR = 0.30, 95% CI = 0.18 to 0.49). Among
those with the strongest intention to die, there is no
association between safer firearm storage and risk of suicide
by firearm.
DISCUSSION
In line with previous research (for example, Krug et al,
53
Blakely et al,
77
Shenassa et al
78
), we found an increased risk of
suicide among males, more frequent drinkers, and persons
with recent employment changes. Also in accord with
previous works,
7 8 30–32 36–44
we found that household access
to firearms is associated with an increased risk of suicide by
firearm. Decedents with access to firearms at home were 18
times as likely to commit suicide by a firearm than to die
from other causes. This points to the importance of factors
that may protect against the risk of suicide among popula-
tions with access to firearms at home. In this first study to
analyse the protective effect of safer firearm storage practices
in a nationally representative sample, we found that firearm
owners who keep their firearms locked or unloaded were at
least 60% less likely to die from firearm related suicide than
those who store their firearms unlocked and/or loaded.
These findings must be considered in light of the study’s
limitations and strengths. One shortcoming of this study
regards the assumption that household firearm ownership is
a reliable proxy for firearm access. Evidence suggests that
considering firearm ownership alone is likely to miss some
decedents with ready access to firearms, but not necessarily
at home.
79
Thus, these analyses may have underestimated the
proportion of decedents with ready access to a firearm. This
underestimation was probably more prevalent among dece-
dents who did not die of a firearm related injury. This would
result in a degree of overestimation of our odds ratios, as it is
likely that some members of the comparison groups have had
easy access to firearms. However, it is highly unlikely that the
large effect size can be explained away by this potential
source of misclassification.
We partially addressed one important limitation of existing
literature on suicide and firearms by using proxies for
decedents’ intention to die. We examined three groups that,
on average, had relatively high, medium, and low intention
to die. As expected, access to firearms at home was most
lethal among decedents with highest intention to die, for
whom safer firearm storage practices were not protective. For
the group with the moderate intention to die, access to
firearms at home was moderately lethal, as was the protective
effect of keeping firearms locked or unloaded. The most
striking results regard the group with the lowest relative
intention to die. For this group, access to firearms at home is
associated with relatively low risk of suicide by firearms,
while the protective effect of storing firearms locked and/or
unloaded was greatest. Considering that all those with a
stated intention to die were excluded from the study, and
considering that this group excludes those with any of the
three strongest correlates of suicide, it appears that the
Table 6 Comparison of groups with relatively low, medium, and high intention to die
Level of intention to die
(A) Risk of suicide by firearm at
home relative to death from other causes
(B) Protective effect of safer firearm storage
on risk of suicide by firearm at home
Locked Unloaded
OR (95% CI) OR (95% CI) OR (95% CI)
Group with relatively low intention to die* 13.98 (5.70 to 34.33) 0.18 (0.06 to 0.49) 0.22 (0.08 to 0.57)
Study sample (medium intention to die) 17.72 (10.18 to 30.85) 0.39 (0.24 to 0.66) 0.30 (0.18 to 0.49)
Group with relatively high intention to die 36.74 (14.21 to 95.00) 0.87 (0.29 to 2.64) 0.63 (0.18 to 2.22)
Source: 1993 National Mortality Followback Survey (NMFS). *Model includes age; gender; race/ethnicity; education; region of residence; frequency of religious
activities, physical activities, and contact with family/friends; avoidance/refusal of health care; and depressive symptoms. Model includes age; gender; race/
ethnicity; education; region of residence; frequency of religious activities, physical activities, and contact with family/friends; alcohol consumption; employment
change; avoidance/refusal of health care; depressive symptoms; and visit(s) to a mental health professional.
Policy implications
Implementation of federally mandated safety standards can
help reduce the risk of impulsive firearm related suicides.
846 Shenassa, Rogers, Spalding, et al
www.jech.com
decedents in this group had a fairly low intention to die and
may have engaged in an impulsive act. This suggests that
safer firearm storage may be most effective in reducing
impulsive suicidal acts.
Our findings are most generalisable to populations with
low to moderate intention to die. However, even among those
who are highly motivated to die,
80 81
lack of access to firearms
can lower suicide mortality. Even if all of those who
committed suicide by firearm simply switched to the next
most lethal method, still a significant reduction in suicide
mortality would occur.
78
Our findings further support the utility of devices intended
to reduce unauthorised or impulsive use of firearms,
including various types of locks and personalisation tech-
nology,
82–87
and the need for a consumer product regula-
tion approach to reducing firearm related injuries and
fatalities.
82–86 88–92
The importance of this approach is even
more evident when considering the difficulty of changing
individuals’ firearm storage practices,
82–87 93
and the failure of
otherwise safety conscious people to store their firearms
safely.
94–97
Although firearm training has frequently been
proposed as a means of promoting safer firearm storage,
information on the effectiveness of these programmes is
sparse. At least two community based programmes appear to
have improved firearm storage practices by distributing gun
locks or safes to firearm owners.
98 99
In contradiction, a
nationally representative survey of firearm owners suggests
that receiving firearm training may actually predict unsafe
storage practices,
5
and at least one intervention in a
paediatric primary care setting did not promote safer firearm
storage.
100
Thus, as it is currently provided, the efficacy of
firearm training in regard to firearm storage practices is
questionable.
Internationally, the World Health Organisation has called
for greater emphasis on passive approaches to suicide
prevention.
101
Although our findings and recommendations
are most directly applicable in nations with higher levels of
per capita firearm ownership, such as Australia, Finland,
Germany, Guinea, New Zealand, Sweden, the United States,
and Russia,
1 101 102
they also underscore the importance of
policies that make unauthorised and impulsive use of
firearms less likely in countries with strict gun control
policies. In these countries, efforts to increase the safety of
firearm storage among those who keep firearms at home,
such as members of military, is still warranted.
103
In the US, legislation mandating minimum safety features
on new firearms can be an essential part of the solution, one
that is supported by the vast majority of American adults.
104
Currently, minimum safety criteria exist for handguns
imported into the US.
105
However, the net effect of these
criteria is modest given that they do not apply to firearms
manufactured within the US, and they are, alone, not enough
to ensure that safety features are consistently applied to new
handguns.
105
Clearly, implementing federally mandated
safety standards may be necessary to reduce the risk of
violent death associated with firearm ownership. And to
the extent that changes in the legal and social milieu are
lasting, they are likely to reduce the suicide risk of future
generations.
106 107
Authors’ affiliations
.....................
E D Shenassa, K L Spalding, Department of Community Health, Brown
Medical School, Providence, USA
E D Shenassa, M L Rogers, M B Roberts, Centers for Behavioral and
Preventive Medicine, Brown Medical School and the Miriam Hospital,
Providence, USA
Funding: none.
Conflicts of interest: none declared.
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