KNOX AND CAINE RESPOND

We agree with Sorenson and Miller that firearms control in the United States has significant potential public health implications—for self-inflicted injury and suicide, homicide, and accidental injury. We also recognize the substantial social, cultural, and political implications of any public health–oriented discussion about firearms, a discussion that is likely to continue for many years into the future.1

While there is some indication that restriction of firearms in the homes of adolescents with previous histories of self-harm may be effective in reducing the risk of suicide,2 the focus of our article was to move priority-setting discussions beyond consideration of death rates (which are highest among older White men) and beyond common areas of public attention (most often involving school-aged children) to a broader view of the burdens of death and loss associated with suicide. Middle-aged men have not been the focus of suicide prevention efforts in the United States, despite the disproportionately high public health burden caused by suicide in this group. Feasible and effective approaches to suicide prevention such as those implemented and sustained through the US Air Force’s Suicide Prevention Program3 demonstrate the greatest promise for reducing the years of potential life lost and associated economic losses owing to suicide among men in the middle years of life.

Whether or not control of firearms or other means serves as an effective suicide prevention method remains an empirical question that requires careful examination. Rich et al.4 found that in San Diego, Calif, and Toronto, Ontario, gun control legislation resulted in a decrease in suicide by firearms among males. In both locations, there was a concomitant increase in the number of males who leaped to their deaths, so that the overall suicide rate for males did not change during the years after gun control legislation. In the United Kingdom, a change from coal-derived cooking gas containing carbon monoxide to gas from the North Sea was associated with an immediate decline in deaths from suicide. This reduction eventually faded as other means were used.5 Changes in the packaging of paracetamol (acetaminophen) and aspirin have been associated with fewer related deaths and liver transplants; it remains unclear whether there has been a decrease in overall deaths or deaths from poisoning.6

At the same time, the work of our colleagues and other researchers7^,8 and ample clinical experience underscores the fact that family members and physicians too often have failed to ask potentially suicidal individuals whether or not they own or have access to guns. The education of physicians and health care workers is minimal in this respect. We surely would recommend the development of coalitions to enhance such training—coalitions including medical educators and gun safety–promoting organizations such as the National Rifle Association, whose courses for youths have taught the careful use of guns for many generations.