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Toxic Firearm Exposure: A Social Determinant of Health

Introduction

Suicide is the tenth leading cause of death in the United States and is currently on the rise while

many of the other leading causes of death are falling (Centers for Disease Control and Prevention [CDC],

2018). Therefore, suicide prevention has been deemed as a focus area for Healthy People 2020. The CDC

has identified that rural communities have the highest rates of death by suicide in the United States (CDC,

2017). There is a major need to look at this public health concern in rural communities with a Social

Determinants of Health (SDOH) approach and from a structural perspective to act on the characteristics

of populations that are disproportionally impacted when it comes to dying by suicide in the United States

because this is a health inequity.

As a disclaimer, the phrase “die by suicide” will be used in lieu of “commit suicide” due to the

semantic shift members of the professional and the suicide loss community are trying to promote in an

effort to decriminalize suicide.

Background

The health disparity that is addressed here is high firearm suicide rates in Western rural,

predominantly non-Hispanic White communities (i.e. mountainous states like Montana, Dakotas, Idaho,

Wyoming, Utah, and Alaska). Half of all suicides are completed with a firearm in the United States

(American Foundation for Suicide prevention [AFSP], 2018). Suicides in nonmetropolitan/rural counties

are consistently higher than the suicide rate in more metropolitan areas, with rates of suicide by firearms

being two times higher in these rural counties than more metropolitan counties (CDC, 2017). Suicide is

complex. Certain challenges that face rural communities include accessible physical and behavioral

healthcare, availability of timely and qualified mental health professionals, untreated mental illness,

isolation, a declining farming industry, lack of reliable transportation, and lack of health insurance (Rural

Health Information Hub, 2018). These negative structural and social factors when combined with

increased rates of firearm ownership and knowledge of how to use firearms in rural communities can be a

mechanism for high rates of firearm suicides.

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In rural America, nearly 6 in 10 individuals have a firearm in their household compared to almost

3 in 10 individuals who have a firearm in their household in urban America (PEW Research Center,

2017). Of note, firearms in the home increase the risk of someone dying by suicide in the home

(Kellermann et al., 1992). Therefore, as presence of firearms in the home increase in rural communities,

so do completed suicides. Also, an important note is that firearms have been shown to be the most lethal

mean in completion of suicides, therefore, firearm suicide prevention is highly important because it has

the largest impact on self-inflicted mortality (CDC, 2018). The Harvard T.H. Chan School of Public

Health (2018) further validates this claim through the Means Matter Campaign which aims to discuss that

how suicidal people attempt – the means that they employ – can truly impact if they live or die. There is

also strong evidence to suggest that when people do not have access to a chosen lethal mean, they rarely

find a different mean to attempt suicide (AFSP, 2018). Therefore, means reduction – especially with

firearms – is extremely important in public health initiatives for suicide prevention.

When looking at how to impact this area of public health, a challenge is that firearm ownership is

a highly contested subject in the United States. The Second Amendment of the United States Constitution,

its varying interpretations, and its highly funded and powerful pro-firearm advocates such as the National

Rifle Association (NRA) make firearm ownership a difficult topic to intervene at the federal policy level.

Furthermore, firearm ownership is deeply embedded in the farming and hunting culture in rural states.

However, as a social determinant of health, firearm exposure could be highly impacted by policy and the

environment which could result in better health outcomes for those disproportionally exposed (Magnan,

2017). Therefore, tackling firearm ownership from a state based policy and environment structural

approach could be the first step in effectively changing the built environment that impacts firearm

suicides and large amounts of people compared to an individual-focused intervention because this health

disparity stems from many highly connected social systems like politics, healthcare, and the economy

(Davis & Chapa, 2015).

There are many issues that feed into suicidal ideation and suicidal behavior – relationship issues,

isolation, unemployment, insecure housing, substance use, physical and mental health issues, financial
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insecurity, involvement in the criminal justice system, and specifically for this intervention – firearm

exposure (CDC, 2018). A SDOH approach allows us to impact these higher-level influencers as being

some of the root causes that lead to suicidal ideation, behaviors, attempts, and completions. There is a

plethora of interventions that could address these highly macro-level topics, but there seems to be a lack

of interventions that target the physical environment in relation to means reductions. Therefore, a

structural intervention posed with the task of altering firearm exposure within the built environment by

limiting the most lethal mean for suicide is the approach that is proposed. Rural communities are in need

of a health equity perspective to reducing firearm suicide deaths since they are in the presence of an

obstacle that is preventing a safe environment (Robert Wood Johnson Foundation, 2017). The

communities need focused and tailored approaches in reducing firearm exposure to prevent firearm

suicides so that they are not disproportionally suffering from highly lethal suicidal behavior, attempts, and

completions to their more urban counterparts.

The disadvantage of using a SDOH approach is that it can take the individual out of the issue.

Particularly with suicide, this issue is highly influenced by individual behavioral decisions and actions

when complex, personal, intersectional issues compound on each other. This intervention should be

implemented at this structural level in conjunction with individual level interventions such as increasing

counselling through behavioral telehealth avenues, education about positive mental health practices, and

self-care. It would also be beneficial to engage key stakeholders such as local police departments, firearm

owners, and firearm shops to better develop specific policy language, advertising, and a positive shift in

attitudes among the community members to save lives of their loved ones if they choose to own firearms.

There have been other places that have implemented different types of policies or initiatives that

would reduce suicide. Particularly, Australia enacted a tremendously effective firearm policy in 1996

titled the National Firearms Agreement. This program enforced stricter policies regarding firearm

ownership and safety, made it more difficult to obtain a firearm, encouraged buyback initiatives, and

implemented highly structured licensing (Rand Corporation, 2018). Multiple studies looking at the effect

of the National Firearms Agreement found significant reductions in firearm suicide rates and also non-
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firearm suicide rates. While this exact policy would have implementation challenges in this country, a

purchasing waiting period, required training, storage requirements, and a comprehensive buyback scheme

adapted for rural states in the United States is outlined below as a proposed health equity intervention.

Structural intervention

The proposed structural intervention is for local and state health departments to work with state

legislators to pass the Safe Firearm Purchasing and Ownership policy in states that have prevalent rural

areas and high firearm ownership such as Wyoming, Montana, Idaho, Utah, etc. By connecting public

health professionals at the community and state level with state legislators, this issue becomes more

systematized and puts public health agencies in conjunction with the public at the center of the

intervention (Koo, O’Carroll, Harris, & DeSalvo, 2016). The proposed policy would consist of three

prongs to reduce firearm exposure in order to achieve health equity by decreasing death by suicide.

The first prong would be to establish a delayed firearm purchasing agreement with gun shops.

Essentially, this would require individuals who want to purchase a firearm to file paper work, but they

would not be allowed to obtain the firearm until one month after purchase. This policy would prevent

individuals who undergoing episodes of mania or impulsivity to purchase a firearm and within the hour

use the most lethal method for suicide completion. In the meantime, before they could receive the firearm,

a required training that would teach about safe firearm handling processes and information about suicide

risk would need to be completed at a local police station before being able to own their weapon. Local

police are used throughout this intervention over county or state police because they are viewed more

favorably by rural communities (Holmes, Painter, & Smith, 2015).

The second part of the policy would be at the community level to increase firearm buyback

programs more frequently and more uniformly such as the first Saturday of the month at every police

department in the state. Individuals could turn in a firearm, no questions asked, in return for gift

certificates to local grocery stores or participating businesses in the amount of at least the firearm’s

market value. There could also be a component that would allow for a tax-deductible donation to a charity

of their choice in lieu of a gift certificate. This accounts for individuals who already own a firearm in the
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fight for suicide prevention. To develop this approach, positive messaging about buyback programs,

preferably with testimonials from those who participated, would be encouraged to show peer support.

Lastly, the third part of the policy would increase safety presence in the community by having

local police do required, random check-ins with all firearm owning households in their particular district

to ensure proper storage and assess if there is any risk of self-harm or violent behavior. This would allow

those living in the household to voice concerns about suicidal behavior of loved ones and for local police

to provide educational reminders on proper storage, gun locks, crisis intervention, and in extreme cases,

remove firearms from the premises for safety preservation. Messaging would need to be framed that this

is a way to positively interact with local authorities and as a way to create a safe household. Similar to

Nurse-Family Partnership, this prong of the intervention could have messaging framed that this is a

partnership for the well-being of the community especially if there is distrust with police.

This intervention is founded in a distributive justice theoretical framework. Since this

intervention is working in environmental justice to reduce exposure to a hazard, a distributive justice

framework often refers to focused efforts to reduce the disproportional exposure (Devia et al., 2017). In

this case, distributive justice refers to minimizing firearm exposure in states where ownership is more

common and can have significant negative health outcomes when combined with other social

determinants of health that plague rural communities.

Conclusion

The Safe Firearm Purchasing and Ownership Policy works in health equity by adding additional

resources such as increased police involvement and trainings to prevent against self-injury in an

environment that is disproportionally exposed to extremely lethal means. By changing exposure and the

environment that vulnerable individuals live in, this policy would be the first step in reducing access to

highly lethal means, while not stripping individuals of their firearm ownership rights.
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References

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Centers for Disease Control and Prevention. (2017, October 6). Suicide trends among and within

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