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Abstract
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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.
Language: en |