Suicide is the second leading cause of death among youth and young adults in the United States.1 Approximately 50% of all suicides in this group involve the use of firearms.1 During the most recent decade for which official data are available, the rate of suicide by firearms among individuals aged 14 to 24 years steadily increased from 4.3 per 100 000 in 2009 to 6.6 per 100 000 in 2018.1 In this issue of JAMA Network Open, Bhatt and colleagues2 present findings from their study examining the association of changes in firearm suicide rates among youth (aged 14-18 years) and young adults (aged 19-24 years) with changes in 2 specific firearm policies in Missouri, ie, repealing the handgun permit-to-purchase (PTP) law in 2007 and lowering the legal age for obtaining a concealed carry permit in 2011 (from age 23 years to 21 years) and 2014 (from age 21 years to 19 years). Using the synthetic control method, they reported that repealing the PTP law was associated with a 5.2% decrease in firearm suicide rates among youth and a 21.8% increase in that outcome among young adults. Lowering the legal age for obtaining a concealed carry permit in 2011 was found to be associated with a 5.0% and 13.5% decrease in firearm suicide rates among youth and young adults, respectively. In contrast, the change in 2014 was associated with a 32.0% and 7.2% increase in firearm suicide rates among youth and young adults, respectively.
These findings highlight the importance of considering the mechanisms by which firearm policies are intended to exert an effect on firearm injury and violence. A robust body of evidence indicates that reduced access to lethal means saves lives. The central question is whether the changes in policies examined by Bhatt and colleagues2 can meaningfully increase exposure and access to firearms among youth and young adults. Many youth and young people already have access to both handguns and long guns in their home without having to purchase a firearm.3 Among homes with children, 34% contain at least 1 firearm; of those households, only 29% store all firearms unloaded and locked.4 Importantly, 41% of adolescents living in homes with a firearm report that they can easily access it.5
In the presence of PTP laws, it is conceivable that the additional time required to obtain a firearm could restrict access to firearms during times of suicidal crisis among young adults who do not already own a firearm. Prior studies examining the repeal of the PTP law in Missouri have found it associated with increases in firearm suicide rates, including an investigation6 with a longer follow-up time that reported a 23.5% increase during the decade after that policy change. Notably, 1 of those studies7 specifically conducted a subgroup analysis among individuals aged 20 to 29 years and did not find the association to be more pronounced in that group than what was observed among the full population of Missouri. It is not clear why repealing the PTP law would affect firearm suicide rates among youth aged 14 to 18 years. Licensing requires robust vetting procedures and increases the real cost of purchasing firearms with additional time commitments and fees6; therefore, one may postulate that repealing the PTP law could increase the availability of household firearms and in turn elevate firearm suicide rates among youth. However, Bhatt and colleagues2 report that repealing the PTP law was associated with a decrease in firearm suicide rates among youth. This finding should be interpreted with caution, especially considering the lack of traditional measures of uncertainty when using the synthetic control approach. If not explained entirely by chance, one would want to understand why the consequences of repealing the PTP law might be qualitatively in different directions for individuals aged 14 to 18 years compared with those aged 19 to 24 years. This repeal does not seem to coincide with additional safety measures at home for families with youth, questioning the mechanism behind these seemingly opposing associations.
The mechanism, if any, by which age restrictions for obtaining a concealed carry permit could plausibly affect firearm suicide rates among youth and young adults is less clear. The discrepant findings in the study by Bhatt and colleagues2 associated with changes in the law in 2011 and 2014 and firearm suicide rates can call the presence of a genuine and compelling mechanism of action into question. The interpretation of these results becomes even more challenging once the findings for the association between these laws and nonfirearm suicides are considered for the possibility of lethal means substitution. For example, the 2014 change was associated with a 29.7% increase in nonfirearm suicide among youth but a 19.2% decrease in that outcome among young adults.2 It is possible that there are behavioral and situational differences in firearm familiarity, access, carrying, and use that may help to explain some of the disparate associations among the 2 age groups observed in this study; however, whether such factors can partially explain the findings remains an area for future research. In addition, visual inspection of some of the synthetic control plots suggests some separations in the rates of outcomes between Missouri and synthetic Missouri prior to these laws, despite efforts to analytically minimize root mean squared prediction error. These patterns could be due to chance or indicate unmeasured or partially measured confounding. As the authors appropriately mention, certain potential determinants of firearm suicide (eg, mental health, substance use, and their pertinent state-level policies) should be considered in such analyses.
Changes in firearm policies do not occur in a vacuum. Repealing the PTP law and reducing the minimum age to obtain a concealed carry permit can each theoretically increase access to firearms and in turn elevate the risk of firearm suicide among certain subgroups of youth and young adults. If so, they may collectively or synergistically compound that risk through interacting with each other or with other existing policies. Future studies could consider design configurations that allow for the examination of such influences while also accounting for any lead and lag periods in relation to the implementation date of the policy.
Each firearm suicide by a young person causes unspeakable pain for their loved ones and leads to immeasurable costs for society. The study by Bhatt and colleagues2 adds to the existing body of knowledge on the association between firearm policies and firearm suicide among youth and young adults, specifically in the setting of Missouri, which has been the subject of a number of firearm policy evaluations. Continued efforts for interrogating the mechanism by which certain changes in firearm laws may plausibly affect the risk of youth suicide and identifying strategies that enhance the implementation of effective policies for prevention are much needed. In the meantime, the totality of evidence indicates that realizing success in preventing firearm suicide at the population level, especially among youth, would require meaningful reductions in easy access to firearms of all types at home.
Published: November 4, 2020. doi:10.1001/jamanetworkopen.2020.24920
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Rowhani-Rahbar A et al. JAMA Network Open.
Corresponding Author: Ali Rowhani-Rahbar, MD, MPH, PhD, Box 351619, Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA 98195 (email@example.com).
Conflict of Interest Disclosures: None reported.