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Suicide and Life-Threatening Behavior 3 l(3) Fall 2001 0 2001 T h e American Association of Suicidology 303 Suicide and Firearm Prevalence: Are Youth Disproportionately Affected? JOHANNA BIRCXMAYER, MPH, PHD, AND DAVID HEMENWAY, PHD T h e effect of firearm availability on suicide may differ among age groups. W e used regression analysis to examine the relationship between suicide rates and household firearm ownership for four age groups in the nine census regions from 1979 to 1994, adjusting for regional divorce rates, education, unemployment, and urbanicity. Results showed that firearm ownership levels are correlated with sui- cide rates among 15- to 24-year-olds and 65- to 84-year-olds, but not among 25- to 64-year-olds. The findings suggest that if the relationship is causal, a 10% fall in regional firearm ownership levels would lead to a 3.0% decrease in suicide rates. Every year since 1990 more than 30,000 Americans have committed suicide. Suicide is the eighth leading cause of death across all ages in the United States and the third lead- ing cause of death among adolescents and young adults. Firearms are the most common method used to commit suicide; in 1996, 60% of suicide victims used a firearm to kill themselves. A higher percentage of adolescents and young adults use firearms to commit suicide than middle-aged adults. In 1994,67% of 15- to 24-year-olds used firearms to commit suicide compared to 56% of 25- to 64-year- olds. Youthful impulsivity, coupled with ac- cess to an easy and lethal method of suicide, may make youth more susceptible to levels of firearm availability than other adults. Fire- arms are also commonly used by older Americans; 71% of suicides among 65- to JOHAWA BIRCKMAYEK is with the Associ- ation for the Study and Development of Commu- nity, Gaithersburg, MD. DAVID HEMENWAY is Professor of Public Health at Harvard University. Address correspondence to Johanna Birck- Inayer, 16810 Excalibur Way, Sandy Spring, MD 20860. E-mail: [email protected]. 84-year-olds were committed by a gun in 1994. Case control studies consistently find that firearm availability is significantly greater in homes of suicide completers than in matched control groups (Brent et al., 1991, 1993; Cummings, Koepsell, Grossman, Savarino, & Thompson, 1997; Kellerrnan et al., 1992). Cross-sectional studies of firearms and suicide find suicide rates are often (Kil- lias, 1993; Lester, 1989; Markush & Bartol- lucci, 1984), but not always (Lester, 1987), higher in geographic areas with greater fire- arm availability. A review of the literature on gun availability and suicide concludes “the preponderance of current evidence indicates that gun availability is a risk factor for youth suicide in the United States. The evidence that gun availability increases the suicide rates of adults is credible but is currently less compelling” (Miller & Hemenway, 1998, While several studies focus on particu- lar age groups, only two studies to date have compared the relationship across different age groups (Kellerman, et al., 1992; Sloan, Rivara, Reay, Ferris, & Kellerman, 1990). Both studies suggest that higher rates of fire- p. 73).

Suicide and Firearm Prevalence: Are Youth Disproportionately Affected?

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Page 1: Suicide and Firearm Prevalence: Are Youth Disproportionately Affected?

Suicide and Life-Threatening Behavior 3 l(3) Fall 2001 0 2001 T h e American Association of Suicidology

303

Suicide and Firearm Prevalence: Are Youth Disproportionately Affected? JOHANNA BIRCXMAYER, MPH, PHD, AND DAVID HEMENWAY, PHD

The effect of firearm availability on suicide may differ among age groups. W e used regression analysis to examine the relationship between suicide rates and household firearm ownership for four age groups in the nine census regions from 1979 to 1994, adjusting for regional divorce rates, education, unemployment, and urbanicity. Results showed that firearm ownership levels are correlated with sui- cide rates among 15- to 24-year-olds and 65- to 84-year-olds, but not among 25- to 64-year-olds. The findings suggest that if the relationship is causal, a 10% fall in regional firearm ownership levels would lead to a 3.0% decrease in suicide rates.

Every year since 1990 more than 30,000 Americans have committed suicide. Suicide is the eighth leading cause of death across all ages in the United States and the third lead- ing cause of death among adolescents and young adults. Firearms are the most common method used to commit suicide; in 1996, 60% of suicide victims used a firearm to kill themselves.

A higher percentage of adolescents and young adults use firearms to commit suicide than middle-aged adults. In 1994,67% of 15- to 24-year-olds used firearms to commit suicide compared to 56% of 25- to 64-year- olds. Youthful impulsivity, coupled with ac- cess to an easy and lethal method of suicide, may make youth more susceptible to levels of firearm availability than other adults. Fire- arms are also commonly used by older Americans; 71% of suicides among 65- to

JOHAWA BIRCKMAYEK is with the Associ- ation for the Study and Development of Commu- nity, Gaithersburg, MD. DAVID HEMENWAY is Professor of Public Health at Harvard University.

Address correspondence to Johanna Birck- Inayer, 16810 Excalibur Way, Sandy Spring, MD 20860. E-mail: [email protected].

84-year-olds were committed by a gun in 1994.

Case control studies consistently find that firearm availability is significantly greater in homes of suicide completers than in matched control groups (Brent et al., 1991, 1993; Cummings, Koepsell, Grossman, Savarino, & Thompson, 1997; Kellerrnan et al., 1992). Cross-sectional studies of firearms and suicide find suicide rates are often (Kil- lias, 1993; Lester, 1989; Markush & Bartol- lucci, 1984), but not always (Lester, 1987), higher in geographic areas with greater fire- arm availability. A review of the literature on gun availability and suicide concludes “the preponderance of current evidence indicates that gun availability is a risk factor for youth suicide in the United States. The evidence that gun availability increases the suicide rates of adults is credible but is currently less compelling” (Miller & Hemenway, 1998,

While several studies focus on particu- lar age groups, only two studies to date have compared the relationship across different age groups (Kellerman, et al., 1992; Sloan, Rivara, Reay, Ferris, & Kellerman, 1990). Both studies suggest that higher rates of fire-

p. 73).

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3 04 SUICIDE AND FIREARM PREVALENCE

arm availability may affect youth more strongly than older Americans.

This study explores the relationship between firearm availability and suicide by age group in the nine regions of the United States from 1979 to 1994. We hypothesize that higher levels of firearm ownership will be associated with higher levels of overall sui- cide, and that adolescents and young adults (1 5- to 24-year-olds) will be more strongly affected by this availability than older adults.

There is some debate as to whether and how much suicide victims substitute one method of suicide for another. Under the as- sumption that substitution of methods oc- curs, an increase in firearm availability may relate to a change in suicide methods, but not to an increase in overall suicides committed. To explore the issue of substitution of meth- ods, we looked at the association between firearm ownership and three outcomes-sui- cides by all means, suicides by firearms only, and suicides by means other than a firearm.

METHODS

We used pooled cross-sectional data from the nine geographic regions in the United States for 16 years, from 1979 to 1994, to examine the relationship between firearm availability and suicide for suicide victims aged 15 to 84. Data for the outcome variables-the suicide rate, the firearm sui- cide rate, and the nonfirearm suicide rate by age and year-come from the National Health Statistics Mortality File.’ Four age groups were created; 15- to 24-year-olds, 25- to 44-year-olds, 45- to 64-year-olds, and 65- to 84-year-olds. We aggregated suicides by year over the nine US. Census-defined geo- graphic regional divisions. Suicide rates were calculated using age-specific population esti- mates from the U.S. Census.

Suicides are estimated to be underre- ported in this dataset (Rosenburg et al.,

1. ICD9 codes 950.0 to 959.0 for all sui- cides and 955.0 to 955.9 for firearm suicides.

1988). However, most analysts agree that variations in reporting are sufficiently ran- dom to allow for epidemiological research (Pescosolido & Mendelsohn, 1986; Sains- bury &Jenkins, 1982).

Firearm availability is measured using regional estimates of household firearm owner- ship collected by the National Opinion Re- search Center (NORC) General Social Surveys for 1977, 1980, 1982, 1984, 1985, 1987, 1988, 1989, 1990, 1991, 1992, 1993, and 1994. Esti- mates of firearm ownership are interpolated for the 5 years when data are not available (1978, 1979, 1981, 1983, 1986). NORC samples ap- proximately 1,500 respondents nationally each year. Respondents are asked, “DO you happen to have in your home any guns or revolvers?” The standard deviation for national firearm ownership in these years is .13 and ranges from .04 to .10 for the nine regions.

Levels of household firearm ownership vary over the regional divisions, in 1994 the largest percentage of households owning guns was in the East South Central Region (60%) and the lowest percentage was in the New England Region (32%). The NORC survey indicates a slight decrease nationally in the percentage of households owing a gun, from 49% in 1979 to 42% in 1994 (Blendon, Young, & Hemenway, 1996).

We used linear regression to examine the relationship between firearms and sui- cide, running separate regression models for each age group. For any region, the firearm ownership level in one time period is not in- dependent of the firearm ownership in the previous period. We adjusted for the “clus- tering” of firearm ownership within regions by using a robust variance matrix calculation, relaxing the assumption of independence within the region. Our principal results-the relationship between firearm ownership lev- els and the rates of firearm suicide and sui- cide by all methods-were similar when Poisson regression was used rather than lin- ear regression. The results presented are those for the clustered linear regression.

There were three dependent variables in our models: (1) the log of the overall sui- cide rate per regiodyear, (2) the log of the

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BIRCKMAYER AND HEMENWAY 305

firearm suicide rate per regiodyear, and ( 3 ) the log of the nonfirearm suicide rate per re- gion/year for each age group. Log rates of the dependent variable allow the coefficient on each independent variable to be interpre- ted as the percent change in the rate of sui- cide resulting from a unit change in the inde- pendent variable.

In the regression equations, we con- trolled for four independent variables that are associated with suicide: divorce, educa- tion, unemployment, and urbanization. De- scriptions of the variables are found in Table 1. We use Stata Statistical Software, release 5.0, for all analysis.

From 1979 to 1994, overall suicide rates remained relatively constant at 15.6 per 100,000 population in 1979 and 15.0 per 100,000 in 1994 (Table 2). Aggregated across all age groups, the percentage of suicides

committed with a gun also remained fairly constant: 57% in 1979 and 60% in 1994. However, the percentage of suicides commit- ted with a gun increased among 15- to 24- year-olds and 45- to 84-year-olds, while de- creasing slightly among 2 5- to 44-year-olds (Table 3 ) .

We found a strong positive bivariate association between household firearm own- ership levels and the firearm suicide rate, and the overall suicide rate, across all age groups. There was also a strong bivariate negative as- sociation between household firearm owner- ship and the nonfirearm suicide rate (Table 4). When we control for divorce, education, unemployment, and urbanicity, the positive association between firearm levels and the suicide rate for all ages combined remains significant for all age suicide, for IS- to 24- year-olds and 65- to 84-year-olds ( p < .05), but not for 25- to 64-year-olds (Table 5). Higher levels of divorce and education are significantly associated (p < . O l ) with higher

TABLE 1 Control Viwiables: Mean, Standard Deviation, Definition and Sozwce

Mean (standard

Variable Name deviation) Definition Source

Suicide rate (all means) 16.3 (4.6) Suicides/100,000 popu- National Center for Health

Firearm suicide rate 10.2 (4.4) Firearm suicides/100,000 N C H S

Nonfirearm suicide rate 6.1 (1.8) Nonfirearm suicides/ N C H S

Firearm ownership .45 (. 13) % of household reporting National Opinion Reseach

Divorce" 5.0 (1. I ) Rate of divorce/annulnient Vital Statistics, N C H S

Education" 72.5 (6.4) % of over 25 population Statistical Abstracts of the

lation Statistics (NCHS)

population

100,000 population

owning a firearm

per 1,000 couples

with at least high school education

employed tistics

urban area United States

Council Social Survey

United States

Unemployinent 6.8 (1.7) % of civilian labor force un- US. Bureau of Labor Sta-

Urbanicity 72.9 (8.6) % of population living in Statistical Abstracts of the

"Divorce data were not available for all years in the West South Central Region; values for missing observations were interpolated from surrounding years. Education and urbanicity data were available for census years only and are interpolated for between years.

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3 06 SUICIDE AND FIREARM PREVALENCE

TABLE 2 Suicide Rates per 100,000 Population by Age Group for the Nine US. Census Divisionsfor Selected Years, 1979-1 994

Age 1979 1982 1986 1990 1994

15-24 12.6 12.4 13.6 14.0 14.3 25-44 16.2 16.1 15.9 15.6 15.9 45-64 17.0 17.2 17.5 15.8 14.4 65-84 19.1 18.9 22.5 21.2 18.0 TOTAL 16.2 16.1 17.4 16.6 15.7

TABLE 3 Percentage of Suicides Committed Using a Fiyeam, by Age Group for the Nine U.S. Census Divisionsfor Selected Years, 1979-1994

Age 1979 1982 1986 1990 1994

15-24 62 62 61 64 67 25-44 56 56 53 55 53 45-64 57 58 59 61 59 65-84 62 65 67 69 70 TOTAL 59 60 60 62 62

TABLE 4 Bivariate Association Bet-ween Fiream Ownership and the Overall Suicide Rate, Fiream Suicide Rate, and Nonfiream Suicide Rate, by Age Groups, for the Nine U.S. Census Divisions, 1979-1994

All Ages (15-84) 15-24 25-44 45-64 65-84

Overall suicide rate Pearson correlation

Firearm suicide rate Pearson correlation

Nonfirearm suicide rate Pearson correlation

.42 .41 .49 .57 .53

.60 .62 .75 .77 .70

-.39 -.36 -.41 -.46 - s o

suicide rates for all ages. We find no associa- tion between unemployment or urbanicity and overall suicide rates for any age group.

In the multivariate analyses, we found a statistically significant association ( p < .lo) between firearm ownership and firearm suicide rates for every age group except among 25-44 year-olds (Table 6) and no significant associa-

tion between firearm ownership and nonfire- arm suicide for any age group (Table 7).

DISCUSSION

This study revealed that levels of fire- arm ownership are highly correlated with

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BIRCKMAYEK AND HEMEWAY 3 07

TABLE 5 Factors Associated with the Log of the Overall Suicide Rate, by Age Group, for the Nine U.S. Cenms Divisions, 1979-1 994, Coeficients and Standard Errors

All Ages (15-84) 15-24 25-44 45-64 65-84

Firearm ownership .30(.12)* .35(.15)* .oo 1 (. 10) .25(. 19) .62(.22)* Divorce .15(.02)** .14(.02)** .15(.02)** .15(.03)** .17(.02)** Education .01(.003)** .02(.004)** .01(.003)** .O1 (.O04) .01(.003)** Unemployment -.002(.005) -.01(.01) -.005(.004) .01(.01) .003(.01)

Intercept .9 .3 1.3 1.3 .6 Urbanicity .001(.002) -.002(.003) -.001(.002) .002(.003) .01(.003)

R' .53 .82 .83 .75 .74

*p < .os **p < .01

TABLE 6 Factors Associated with the Log of the Fiream Suicide Rate, by Age Group for the Nine U S . Census Divisions, 1979-1994, Coefficients and Standard Errors

All Ages (1 5-84) 15-24 25-44 45-64 65-84

Firearm ownership .82(.31)* .84( .2 7)* .49(.22) .81(.3S)* 1.15(.50)* Divorce .25(.02)** .19(.02)** .24(.02)** .26(.03)** .28(.03)** Education .O1 (.OO4)** .02(.003)** .O 1 (.004) .Ol(.Ol) .02 (.004)** Unemployment -.003(.01) -.02(.01) -.01(.01) .002(.0 1) .o 1 (.02) Urbanicity -.005(.004) -.O 1 (.003) -.O 1 (.0O3) -.O 1 (.004) -.004(.0 1) Intercept .02 -.49 .67 .44 -.56 R2 .68 3 6 .89 .86 .8 1

*p < .o5 **p < .01

TABLE 7 Factors Associated with the Log of the Nonfiream Suicide Rate, by Age Group for the Nine U.S. Census Divisions, 1979-1994, Coefficients and Standard Errors

All Ages (1 5-84) 15-24 25-44 45-64 65-84

Firearm ownership -.08(.48) -. I6(.43) -.3 1 (.36) -.04(.59) .20(.64) Divorce -.004(.05) .02(.04) .04(.03) -.02(.06) -.07(.07) Education .02(.01)* .02(.01)** .02(.004)** .o 1 (.O 1)* .01(.01) Unemployment .003(.01) -.004(.02) .OOl(.Ol) .01(.02) .oo 1 (.02)

R .42 .57 .67 .52 .53

Urbanicity .01(.005)* .Ol(.Ol) .01(.003)* .02(.01)* .03(.01)** Intercept -.54 -.67 -.16 -.47 -.84

*p < .os **p < .01

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308 SUICIDE AND FIREARM PREVALENCE

levels of firearm suicide across regions, even after controlling for divorce, education, un- employment, and urbanicity. Our results sug- gest that if household firearm ownership lev- els fell 10% (e.g., from 42% to 32%), the firearm suicide rate would fall by 8.2%.

More important is the finding that lev- els of firearm ownership are highly correlated with overall suicide rates by all means. Our results suggest that if household firearm ownership levels fell lo%, the overall suicide rate would fall by 3.0%. These results are consistent with the hypothesis that availabil- ity of a lethal instrument is important for completed suicide.

W e hypothesized that firearm owner- ship levels would have a stronger relationship with youth suicide than with suicide among older adults. We find that hypothesis to be true comparing 15- to 24-year-olds with 25- to 64-years-olds, but for 65- to 84-year-olds the association between firearm ownership levels and suicide rates is as strong as for the younger age group. After controlling for four variables-divorce, education, unemploy- ment, and urbanicity-higher levels of firearm ownership were associated with higher levels of firearm suicide among 45- to 64-year-olds, but not with higher levels of overall suicide. Although we do not find a statistically significant association in the mul- tivariate analysis between firearm ownership and nonfirearm suicide among this age group, some substitution of methods may occur.

Similar to our analysis, two studies use NORC estimates of firearm ownership to ex- amine the relationship between firearm levels and suicide rates. Markush and Bartolucci (1 984) correlated suicide rates and firearm ownership in the same nine geographical re- gions from 1973 to 1977 and found firearm ownership significantly associated with total suicides. Kaplan and Geling (1998) corre- lated suicide rates and firearm ownership for the nine regions for 1989-1991 and found a strong positive association between firearm ownership and firearm suicide and a negative association between firearm ownership and nonfirearm suicide. They do not report the

association between firearms and overall sui- cide but their results suggest some substitu- tion of methods may occurs.

Ecological studies at the state and city level have used a variety of proxies for house- hold gun ownership (e.g., subscriptions to gun magazines, accidental death rates by fire- arms, percentage of homicides committed with a gun, percentage of robberies commit- ted with a gun) (Heck & Patterson, 1993; Lester, 1987, 1989). Some studies assess the relationship of the strictness of firearm con- trol laws (as a proxy for firearm availability) with suicide rates (Boor & Blair, 1990; Les- ter, 1988; Lester & Murrell, 1982, 1986; Medoff & Magaddino, 1983; Yang & Lester, 1991). Most studies, but not all, have found a significant relationship between firearm availability and suicide.

Similar to other studies, we found that higher levels of divorce are associated with higher levels of suicide (Leenaars, Yang, & Lester, 1993). Suicide victims tend to be bet- ter educated that those who do not commit suicide (Saucer, 1993), and regions with higher levels of education have higher levels of suicide. While some studies have found unemployment to be a predictor of suicide (Dooley, Fielding, & Levi, 1996; Leenaars, et al., 1993), we found no evidence to support this relationship in our analysis.

Our study has several limitations. First, as in any ecological study, we can only identify an association between firearm own- ership levels and suicide rates and cannot de- duce whether the relationship is causal. For example, from our data, we do not know if people who commit suicide live in gun-own- ing households. Second, since the NORC data come from a survey, with only 1,500 re- spondents nationally, there is an uncertainty associated with the yearly regional measures of gun ownership, which may bias the esti- mated relationship between firearm owner- ship and suicide. Third, regional grouping of firearm ownership undoubtedly masks con- siderable variation in the level of firearm availability at the state and community levels. Fourth, while our data covers 16 years, house- hold gun ownership levels change very

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BTRCKMAYKR AND HEMENWAY 3 09

slowly; variations in gun ownership are greater among regions than within a region over time. W e adjusted for the “clustering” of firearm ownership levels within a region over time. W e assessed the sensitivity of the analyses to influential observations and found no regions or years that systematically altered the coefficient estimates. Finally, while we controlled for four variables often associated with suicide, other factors undoubtedly influ- ence suicide rates.

We made several assumptions for our model. First, we assumed that yearly rates of suicide are independent of each other. W e tested this assumption using the Durbin- Watson statistic and found no indication of autocorrelation for any of the regional time series or for the average time series across re- gions. Second, our model assumes that levels of firearm ownership are not influenced by suicide rates; there is no suggestion in the lit- erature that people are more likely to obtain firearms because the regional suicide rate is high.

The strengths of our study are that we

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Manuscript Received: September 13, 1999 Revision Accepted: July 5, 2000