Abstract
This cohort study assesses the association of firearm suicide risk with sociodemographic characteristics among US adults.
Although firearms are a highly lethal means of attempting suicide1 and were used in 24 432 of 48 344 US suicide deaths (50.5%) in 2018, little is known about factors associated with firearm suicide risk. Much of the previous research describing firearm suicide compared suicide decedents using firearms with other methods.2 Without prospectively evaluating firearm suicide risk among living populations, however, these analyses did not yield firearm suicide rates and thus have limited utility for identifying high-risk groups. To increase our understanding of firearm suicide risk patterns, we compared firearm suicide risk across sociodemographic groups of US adults. Results might help inform tailoring firearm safety interventions to high-risk groups, such as the lethal means safety counseling widely available within Veterans Health Administration facilities.
Methods
This cohort study used data from respondents in the Mortality Disparities Across Communities3 study, which linked 2008 American Community Survey data to 2008-2015 National Death Index death records. Respondents were classified by age at survey, sex, race/ethnicity, marital status, educational level, employment, income, disability, military service, residence, and US citizenship. State-level data on household firearms were obtained from the 2004 Behavioral Risk Factor Surveillance System.4 International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes identified firearm suicide (X72-X74) and nonfirearm suicide (X60-X71, X75-X84, Y87.0, U03) deaths. For each characteristic, we assessed the number of respondents, follow-up years, and mortality rates per 100 000 person-years. Hazard ratios (HRs) adjusted for age, sex, and race/ethnicity. Separate analyses were also performed for men and women. The US Census Bureau’s Disclosure Review Board approved the study procedures including a waiver of informed consent under 45 CFR 46.116 and approved the data output.
Results
Firearm suicide rates were highest among individuals with military service (21.2 per 100 000 person-years; 95% CI, 19.4-23.1 per 100 000 person-years), disabled individuals (14.0 per 100 000 person-years; 95% CI, 12.7-15.3 per 100 000 person-years), and men (13.6 per 100 000 person-years; 95% CI, 13.0-14.3 per 100 000 person-years) (Table 1). Other high-risk groups included adults aged 65 years or older, rural residents, adults living in states with more than 50% firearm ownership, and separated or divorced persons. Compared with noncitizens, US citizens had a greater risk for firearm suicide (HR, 3.00; 95% CI, 2.50-4.39) and nonfirearm suicide (HR, 1.20; 95% CI, 0.97-1.48).
Table 1. Firearm and Nonfirearm Suicide Death Rates in a Cohort of US Adults, 2008-2015a.
| Group | Persons, No. | Person-years at risk, No. | Suicide deaths | |||
|---|---|---|---|---|---|---|
| Firearm | Nonfirearm | |||||
| Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95%CI)b | Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95%CI)b | |||
| Total | 3 447 000 | 24 940 000 | 7.7 (7.3-8.0) | NA | 6.6 (6.3-7.0) | NA |
| Age, y | ||||||
| 18-39 | 1 168 000 | 10 250 000 | 6.1 (5.6-6.6) | 1 [Reference] | 6.4 (5.9-6.9) | 1 [Reference] |
| 40-64 | 1 576 000 | 11 020 000 | 7.7 (7.2-8.3) | 1.18 (1.06-1.31) | 7.9 (7.4-8.4) | 1.20 (1.09-1.33) |
| >65 | 703 000 | 3 663 000 | 11.8 (10.7-13.0) | 1.89 (1.67-2.13) | 3.5 (3.0-4.2) | 0.56 (0.46-0.67) |
| Sex | ||||||
| Male | 1 650 000 | 12 130 000 | 13.6 (13.0-14.3) | 7.03 (6.16-8.03) | 9.2 (8.7-9.8) | 2.18 (1.97-2.42) |
| Female | 1 798 000 | 12 810 000 | 2.0 (1.8-2.3) | 1 [Reference] | 4.2 (3.8-4.5) | 1 [Reference] |
| Race/ethnicity | ||||||
| Non-Hispanic white | 2 584 000 | 17 000 000 | 9.9 (9.4-10.3) | 1 [Reference] | 7.3 (6.9-7.7) | 1 [Reference] |
| Non-Hispanic black | 309 500 | 2 887 000 | 3.7 (3.0-4.5) | 0.27 (0.22-0.34) | 3.3 (2.6-4.0) | 0.45 (0.36-0.55) |
| Hispanic | 347 000 | 3 421 000 | 2.6 (2.1-3.2) | 0.41 (0.34-0.50) | 4.2 (3.6-5.0) | 0.56 (0.47-0.66) |
| Other | 206 000 | 1 628 000 | 2.3 (1.6-3.1) | 0.25 (0.18-0.34) | 10.6 (9.1-12.4) | 1.44 (1.23-1.69) |
| Marital status | ||||||
| Married | 1 983 000 | 13 250 000 | 7.1 (6.7-7.6) | 1 [Reference] | 5.1 (4.7-5.5) | 1 [Reference] |
| Separated or divorced | 432 000 | 3 341 000 | 11.3 (10.2-12.5) | 1.91 (1.69-2.15) | 10.3 (9.2-11.4) | 2.17 (1.91-2.47) |
| Widowed | 252 000 | 1 366 000 | 6.7 (5.4-8.2) | 1.28 (1.02-1.61) | 3.4 (2.5-4.6) | 1.19 (0.87-1.63) |
| Never married | 780 000 | 6 983 000 | 7.1 (6.5-7.8) | 1.30 (1.14-1.47) | 8.4 (7.7-9.1) | 1.93 (1.69-2.20) |
| Educational level | ||||||
| Less than high school | 484 000 | 3 677 000 | 8.1 (7.3-9.1) | 1.91 (1.62-2.24) | 6.9 (6.1-7.8) | 1.64 (1.39-1.94) |
| High school or general equivalency diploma | 1 015 000 | 7 099 000 | 9.1 (8.4-9.9) | 1.74 (1.53-1.98) | 7.2 (6.6-7.8) | 1.44 (1.26-1.65) |
| Some college or associate degree | 1 045 000 | 7 744 000 | 7.8 (7.2-8.4) | 1.58 (1.38-1.80) | 6.7 (6.2-7.3) | 1.31 (1.15-1.50) |
| Bachelor’s degree or higher | 904 000 | 6 415 000 | 5.6 (5.1-6.2) | 1 [Reference] | 5.7 (5.1-6.3) | 1 [Reference] |
| Employment | ||||||
| Employed | 2 111 000 | 16 250 000 | 6.3 (5.9-6.7) | 1 [Reference] | 5.7 (5.3-6.0) | 1 [Reference] |
| Unemployed | 1 337 000 | 8 689 000 | 10.2 (9.5-10.9) | 1.89 (1.71-2.10) | 8.4 (7.8-9.1) | 2.18 (1.97-2.41) |
| Income, $ | ||||||
| Loss | 139 000 | 763 400 | 8.0 (6.1-10.3) | 1.69 (1.27-2.26) | 11.8 (9.4-14.5) | 2.51 (1.95-3.23) |
| 0-40 000 | 1 027 000 | 7 519 000 | 9.9 (9.2-10.6) | 2.35 (2.00-2.75) | 7.9 (7.2-8.5) | 1.90 (1.62-2.24) |
| 40 001-75 000 | 968 000 | 7 033 000 | 7.6 (7.0-8.3) | 1.58 (1.35-1.86) | 6.2 (5.6-6.8) | 1.28 (1.08-1.50) |
| 75 001-125 000 | 791 000 | 5 768 000 | 6.3 (5.7-7.0) | 1.24 (1.05-1.47) | 5.6 (5.0-6.5) | 1.05 (0.88-1.24) |
| >125 000 | 523 000 | 3 852 000 | 5.4 (4.7-6.1) | 1 [Reference] | 5.7 (5.0-6.5) | 1 [Reference] |
| Disability statusc | ||||||
| Disabled | 572 000 | 3 397 000 | 14.0 (12.7-15.3) | 1.90 (1.70-2.12) | 11.8 (10.7-13.0) | 2.48 (2.20-2.80) |
| Not disabled | 2 876 000 | 21 540 000 | 6.7 (6.3-7.0) | 1 [Reference] | 5.8 (5.5-6.1) | 1 [Reference] |
| Military service | ||||||
| Service | 397 000 | 2 424 000 | 21.2 (19.4-23.1) | 1.47 (1.31-1.65) | 8.4 (7.3-9.6) | 1.02 (0.87-1.19) |
| No service | 3 050 000 | 22 510 000 | 6.2 (5.9-6.5) | 1 [Reference] | 6.4 (6.1-6.8) | 1 [Reference] |
| Residence | ||||||
| Rural | 1 074 000 | 5 777 000 | 11.5 (10.6-12.4) | 1.43 (1.30-1.57) | 6.0 (5.4-6.7) | 0.80 (0.71-0.90) |
| Urban | 2 372 000 | 19 160 000 | 6.5 (6.2-6.9) | 1 [Reference] | 6.8 (6.5-7.2) | 1 [Reference] |
| US citizenship | ||||||
| Citizen | 3 237 000 | 22 760 000 | 8.2 (7.9-8.6) | 3.00 (2.05-4.39) | 6.8 (6.4-7.1) | 1.20 (0.97-1.48) |
| Noncitizen | 210 000 | 2 171 000 | 1.5 (1.0-2.1) | 1 [Reference] | 5.2 (4.3-6.3) | 1 [Reference] |
| State firearm ownership, %d | ||||||
| <20 | 989 000 | 7 871 000 | 4.6 (4.1-5.1) | 1 [Reference] | 6.9 (6.3-7.5) | 1 [Reference] |
| 20-35 | 1 042 000 | 7 948 000 | 9.3 (8.6-10.0) | 1.84 (1.62-2.09) | 6.7 (6.1-7.3) | 0.98 (0.86-1.10) |
| 36-50 | 1 241 000 | 7 973 000 | 8.5 (7.9-9.2) | 1.57 (1.38-1.79) | 6.6 (6.1-7.2) | 0.93 (0.82-1.05) |
| >50 | 161 000 | 1 035 000 | 11.5 (9.5-13.7) | 2.05 (1.66-2.53) | 4.2 (3.1-5.7) | 0.58 (0.43-0.79) |
Data are from the Mortality Disparities Across Communities study.3
Adjusted for age, sex, and race/ethnicity.
Self-reported serious difficulty in hearing, vision, concentrating, remembering or making decisions, walking or climbing stairs, dressing or bathing, or independent living.
Based on 2004 Behavioral Risk Factor Surveillance System.4
Among men, firearm suicide rates were highest for widowers (29.1 per 100 000 person-years; 95% CI, 22.9-36.5 per 100 000 person-years), adults aged 65 years or older (25.9 per 100 000 person-years; 95% CI, 23.4-28.5 per 100 000 person-years), and rural residents (25.7 per 100 000 person-years; 95% CI, 23.2-28.3 per 100 000 person-years) (Table 2). Male firearm suicide rates were 19.9 per 100 000 person-years) (95% CI, 16.2-24.1 per 100 000 person-years) in states with high firearm ownership and 7.9 per 100 000 person-years (95% CI, 7.1-8.9 per 100 000 person-years) in states with low firearm ownership. Rates of nonfirearm suicide were 6.0 per 100 000 person-years (95% CI, 4.1-8.6 per 100 000 person-years) in states with high firearm ownership and 9.8 per 100 000 person-years (95% CI, 8.9-10.9 per 100 000 person-years) in states with low firearm ownership. Firearm suicide rates among women were highest for those with a net income loss (5.5 per 100 000 person-years; 95% CI, 3.2-9.0 per 100 000 person-years), those with a disability (3.8 per 100 000 person-years; 95% CI, 3.0-4.8 per 100 000 person-years), and in states with greater than 50% firearm ownership (3.5 per 100 000 person-years; 95% CI, 2.1-5.5 per 100 000 person-years).
Table 2. Firearm and Nonfirearm Suicide Death Rates in a Cohort of Men and Women in the US, 2008-2015a.
| Group | Men | Women | ||||||
|---|---|---|---|---|---|---|---|---|
| Firearm suicide deaths | Nonfirearm suicide deaths | Firearm suicide deaths | Nonfirearm suicide deaths | |||||
| Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95% CI)b | Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95% CI)b | Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95% CI)b | Unadjusted rate, per 100 000 person-years (95% CI) | Adjusted hazard ratio (95% CI)b | |
| Total | 13.6 (13.0-14.3) | NA | 9.2 (8.7-9.8) | NA | 2.0 (1.8-2.3) | NA | 4.2 (3.8-4.5) | NA |
| Age, y | ||||||||
| 18-39 | 10.2 (9.4-11.1) | 1 [Reference] | 9.0 (8.2-9.9) | 1 [Reference] | 1.8 (1.4-2.2) | 1 [Reference] | 3.6 (3.1-4.2) | 1 [Reference] |
| 40-64 | 13.4 (12.5-14.4) | 1.18 (1.05-1.32) | 10.7 (9.8-11.6) | 1.13 (1.00-1.28) | 2.3 (1.9-2.8) | 1.18 (0.90-1.55) | 5.3 (4.7-5.9) | 1.39 (1.16-1.67) |
| ≥65 | 25.9 (23.4-28.5) | 2.13 (1.87-2.42) | 4.9 (3.9-6.2) | 0.51 (0.40-0.65) | 1.7 (1.2-2.3) | 0.80 (0.55-1.18) | 2.5 (1.9-3.3) | 0.65 (0.48-0.88) |
| Race/ethnicity | ||||||||
| Non-Hispanic white | 17.6 (16.7-18.5) | 1 [Reference] | 10.1 (9.4-10.8) | 1 [Reference] | 2.6 (2.3-2.9) | 1 [Reference] | 4.7 (4.2-5.2) | 1 [Reference] |
| Non-Hispanic black | 7.2 (5.8-8.8) | 0.44 (0.36-0.54) | 5.5 (4.3-6.9) | 0.54 (0.42-0.68) | 0.7 (0.3-1.2) | 0.26 (0.14-0.48) | 1.3 (0.8-2.1) | 0.28 (0.18-0.44) |
| Hispanic | 4.4 (3.5-5.5) | 0.28 (0.22-0.35) | 6.1 (5.0-7.3) | 0.59 (0.48-0.72) | 0.6 (0.3-1.2) | 0.25 (0.13-0.46) | 2.3 (1.6-3.1) | 0.49 (0.35-0.68) |
| Other | 3.6 (2.4-5.2) | 0.22 (0.15-0.32) | 13.9 (11.4-16.8) | 1.36 (1.11-1.66) | 1.1 (0.5-2.0) | 0.41 (0.21-0.80) | 7.7 (5.9-9.7) | 1.62 (1.24-2.10) |
| Marital status | ||||||||
| Married | 12.4 (11.6-13.3) | 1 [Reference] | 6.8 (6.2-7.5) | 1 [Reference] | 1.7 (1.4-2.1) | 1 [Reference] | 3.4 (3.0-3.9) | 1 [Reference] |
| Separated or divorced | 22.4 (20.0-25.1) | 1.92 (1.68-2.18) | 14.9 (12.9-17.0) | 2.16 (1.84-2.55) | 3.2 (2.5-4.1) | 1.96 (1.43-2.68) | 6.9 (5.8-8.2) | 2.17 (1.75-2.69) |
| Widowed | 29.1 (22.9-36.5) | 1.61 (1.26-2.05) | 4.6 (2.3-8.0) | 0.88 (0.48-1.60) | 1.5 (0.9-2.4) | 0.98 (0.55-1.76) | 3.2 (2.2-4.4) | 1.33 (0.91-1.95) |
| Never married | 11.4 (10.4-12.6) | 1.29 (1.12-1.48) | 11.7 (10.6-12.9) | 2.02 (1.73-2.36) | 2.0 (1.5-2.6) | 1.50 (1.06-2.10) | 4.4 (3.7-5.2) | 1.71 (1.34-2.20) |
| Educational level | ||||||||
| Less than high school | 13.9 (12.3-15.7) | 1.92 (1.62-2.27) | 10.0 (8.6-11.5) | 1.77 (1.45-2.16) | 1.9 (1.3-2.6) | 2.03 (1.26-3.26) | 3.6 (2.8-4.7) | 1.34 (0.98-1.83) |
| High school or general equivalency diploma | 16.2 (14.9-17.6) | 1.78 (1.55-2.05) | 10.4 (9.3-11.5) | 1.54 (1.30-1.81) | 2.2 (1.7-2.7) | 1.69 (1.17-2.44) | 4.1 (3.5-4.8) | 1.23 (0.97-1.57) |
| Some college or associate degree | 14.1 (12.9-15.4) | 1.57 (1.36-1.81) | 9.2 (8.3-10.3) | 1.30 (1.10-1.54) | 2.3 (1.9-2.8) | 1.71 (1.21-2.42) | 4.6 (4.0-5.3) | 1.32 (1.06-1.65) |
| Bachelor’s degree or higher | 10.0 (8.9-11.1) | 1 [Reference] | 7.6 (6.6-8.6) | 1 [Reference] | 1.5 (1.1-1.9) | 1 [Reference] | 3.9 (3.3-4.7) | 1 [Reference] |
| Employment | ||||||||
| Employed | 10.4 (9.7-11.1) | 1 [Reference] | 8.0 (7.4-8.6) | 1 [Reference] | 1.6 (1.3-1.9) | 1 [Reference] | 3.0 (2.6-3.4) | 1 [Reference] |
| Unemployed | 21.6 (20.0-23.2) | 1.86 (1.67-2.08) | 12.3 (11.1-13.5) | 2.01 (1.77-2.29) | 2.6 (2.2-3.1) | 1.96 (1.51-2.55) | 5.9 (5.2-6.6) | 2.54 (2.12-3.03) |
| Income, $ | ||||||||
| Loss | 9.5 (6.9-12.7) | 1.36 (0.99-1.89) | 17.3 (13.8-21.5) | 2.65 (2.01-3.50) | 5.5 (3.2-9.0) | 5.86 (3.06-11.23) | 2.6 (1.1-5.2) | 1.20 (0.56-2.57) |
| 0-40 000 | 19.9 (18.4-21.5) | 2.37 (2.00-2.80) | 10.4 (9.4-11.6) | 1.58 (1.30-1.92) | 2.2 (1.8-2.7) | 2.39 (1.50-3.81) | 5.9 (5.2-6.7) | 2.74 (2.04-3.68) |
| 40 001-75 000 | 13.2 (12.0-14.5) | 1.52 (1.28-1.81) | 8.8 (7.8-9.8) | 1.22 (1.01-1.48) | 2.2 (1.7-2.7) | 2.04 (1.28-3.27) | 3.6 (3.0-4.3) | 1.42 (1.04-1.94) |
| 75 001-125 000 | 10.8 (9.6-12.1) | 1.22 (1.02-1.47) | 7.9 (6.9-9.5) | 1.02 (0.83-1.25) | 1.6 (1.2-2.2) | 1.40 (0.85-2.31) | 3.2 (2.5-3.9) | 1.12 (0.80-1.56) |
| >125 000 | 9.2 (8.0-10.7) | 1 [Reference] | 8.1 (6.9-9.5) | 1 [Reference] | 1.2 (0.8-1.9) | 1 [Reference] | 3.1 (2.3-4.0) | 1 [Reference] |
| Disability statusc | ||||||||
| Disabled | 19.8 (18.2-21.5) | 1.82 (1.61-2.05) | 15.1 (13.2-17.1) | 2.10 (1.81-2.45) | 3.8 (3.0-4.8) | 2.63 (1.93-3.59) | 9.0 (7.7-10.5) | 3.40 (2.77-4.19) |
| Not disabled | 11.7 (11.0-12.4) | 1 [Reference] | 8.4 (7.8-8.9) | 1 [Reference] | 1.7 (1.5-2.0) | 1 [Reference] | 3.4 (3.0-3.7) | 1 [Reference] |
| Military service | ||||||||
| Service | 22.7 (20.7-24.7) | 1.40 (1.25-1.58) | 8.7 (7.5-10.0) | 1.04 (0.88-1.22) | 3.3 (1.2-7.2) | 1.65 (0.73-3.72) | 4.6 (2.0-9.0) | 1.13 (0.57-2.24) |
| No service | 11.6 (10.9-12.3) | 1 [Reference] | 9.4 (8.8-10.0) | 1 [Reference] | 2.0 (1.7-2.2) | 1 [Reference] | 4.2 (3.8-4.5) | 1 [Reference] |
| Residence | ||||||||
| Rural | 25.7 (23.2-28.3) | 1.40 (1.26-1.55) | 8.0 (7.0-9.1) | 0.77 (0.66-0.89) | 3.2 (2.6-3.9) | 1.58 (1.21-2.05) | 4.1 (3.4-4.9) | 0.87 (0.70-1.07) |
| Urban | 11.8 (11.2-12.5) | 1 [Reference] | 9.6 (9.0-10.3) | 1 [Reference] | 1.7 (1.4-1.9) | 1 [Reference] | 4.2 (3.8-4.6) | 1 [Reference] |
| US citizenship | ||||||||
| Citizen | 14.8 (14.1-15.6) | 3.49 (2.26-5.39) | 9.5 (8.9-10.1) | 1.26 (0.98-1.63) | 2.1 (1.9-2.4) | 1.50 (0.68-3.29) | 4.2 (3.9-4.6) | 1.08 (0.74-1.57) |
| Noncitizen | 2.1 (1.3-3.1) | 1 [Reference] | 6.8 (5.3-8.4) | 1 [Reference] | 0.8 (0.3-1.5) | 1 [Reference] | 3.5 (2.5-4.9) | 1 [Reference] |
| State firearm ownership, %d | ||||||||
| <20 | 7.9 (7.1-8.9) | 1 [Reference] | 9.8 (8.9-10.9) | 1 [Reference] | 1.4 (1.1-1.8) | 1 [Reference] | 4.2 (3.6-4.8) | 1 [Reference] |
| 20-35 | 16.6 (15.3-17.9) | 1.89 (1.65-2.17) | 9.3 (8.3-10.3) | 0.95 (0.82-1.10) | 2.3 (1.9-2.9) | 1.55 (1.12-2.16) | 4.2 (3.6-4.9) | 1.03 (0.82-1.27) |
| 36-50 | 15.5 (14.3-16.8) | 1.64 (1.42-1.88) | 9.0 (8.1-10.0) | 0.88 (0.76-1.03) | 2.0 (1.6-2.5) | 1.22 (0.87-1.72) | 4.3 (3.7-5.0) | 1.02 (0.83-1.27) |
| >50 | 19.9 (16.2-24.1) | 2.04 (1.62-2.56) | 6.0 (4.1-8.6) | 0.58 (0.40-0.84) | 3.5 (2.1-5.5) | 2.10 (1.24-3.57) | 2.5 (1.4-4.3) | 0.58 (0.34-1.02) |
Data are from the Mortality Disparities Across Communities study.3
Adjusted for age and race/ethnicity.
Self-reported serious difficulty in hearing, vision, concentrating, remembering or making decisions, walking or climbing stairs, dressing or bathing, or independent living.
Based on 2004 Behavioral Risk Factor Surveillance System.4
Discussion
Increased firearm suicide risk was observed among groups with high firearm ownership5 and groups with high overall suicide risk. The former included residents of states with high firearm ownership, rural residents, individuals with military service, men, non-Hispanic white adults, and US citizens. Adults who were older, unemployed, separated or divorced, and had a lower educational level or lower incomes have not previously been found to have elevated rates of firearm ownership but had increased firearm suicide risk in this study.
Despite evidence that firearm access is associated with increased suicide risk,6 firearm safety interventions are commonly criticized as leading to offsetting increases in suicide by other methods. However, greater differences in firearm suicide rates between states with high and low firearm ownership alongside more modest differences in nonfirearm suicide rates support a population-level counterfactual case against means substitution.
Limitations of the study include absence of data for several factors associated with suicide risk, such as psychiatric and medical disorders; uncertain validity of the self-reported disability measure; collection of crude state firearm ownership data in 2004 compared with 2008 to 2015; and a lack of data after 2015.
Wide distribution of firearm suicide risk across social, economic, and geographic characteristics underscores the need to develop a range of firearm safety messages for these different patient groups.
References
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