The purchase of a handgun is associated with substantial changes in the risk of violent death. Among people who purchased a handgun in California in 1991, suicide was the leading cause of death in the first year after the purchase; suicide specifically with a firearm ranked second, after heart disease. The rate of suicide by firearm among handgun purchasers during the first week in which they could have had possession of their handguns, at 644 per 100,000 person-years, was similar to rates of suicide by all methods combined among male veterans who had been hospitalized for affective disorders (695 per 100,000 persons per year) or schizophrenia (456 per 100,000 persons per year).16

The increased risk of death associated with the purchase of a handgun resulted specifically from an increased risk of violent death; there were fewer deaths than expected from other causes among both men and women who purchased handguns. This finding is most likely due to an affluent-gun-buyer effect. The prevalence of handgun ownership rises with socioeconomic status,3 and increasing socioeconomic status is associated with a lower risk of death from most causes.17 Persons who in any year spend as much as $600 to purchase handguns are even more likely than other handgun owners to be of higher socioeconomic status than the general population. The risk of suicide generally decreases as socioeconomic status increases, however,18-20 suggesting that adjustment for socioeconomic status might reveal the increase in the risk of suicide after a handgun purchase to be even larger than we report here.

Two distinct explanations may be proposed for the increased risk of suicide by firearm among recent purchasers of handguns. The near absence of suicides by firearm during the waiting period and the marked increase in the first month after the end of the waiting period suggest that some purchasers owned no other firearms and bought handguns with the intention of killing themselves. Most suicides by firearm occurred after a longer period of ownership, however. In these cases, preexisting access to a handgun may have added to other newly arising risk factors. This possibility would be consistent with the finding that fewer than 10 percent of persons who committed or attempted suicide with a firearm acquired the firearm for that purpose.21-23

Some suicides that occurred soon after purchase may have been planned by persons with terminal illnesses so as to avoid further suffering. Our data suggest that this circumstance was not common, however. If it were, some persons who initiated such plans would probably not have completed them, and an increase in early deaths from cancer and heart disease, which we did not observe, would have resulted. On the contrary, studies of survivors suggest that suicide by means of a firearm usually occurs impulsively; alcohol use and conflict with an intimate partner are often involved.21,23,24

Our finding that the risk of death from homicide was lower among male purchasers of handguns than among men in the general population appears to conflict with findings in previous studies.8,11 Differences in study populations may be responsible. The previous studies were based on current ownership of firearms, whereas we focused on the recent legal purchase of handguns. The presumably high socioeconomic status of our study population relative to that of the general population would lessen the risk of homicide25,26; the previous studies sought to minimize differences in socioeconomic status. The handgun purchasers in our cohort also passed a background check; none had a conviction for any felony or violent misdemeanor or were known to have been judged mentally ill or to be addicted to controlled substances. The absence of such potential risk factors for death by homicide means that our estimates may be subject to a “good boy” bias.27 Finally, in the previous studies, the risk of death by homicide for persons in households with firearms was compared with the risk for persons in households without firearms. We compared this risk among recent purchasers of handguns with that in a general population in which the prevalence of handgun ownership may have been 25 percent after adjustment for sex.2,3 If any access to handguns increases the risk of death by homicide,8,11 then our estimate of the relative risk of death by homicide among recent handgun purchasers is artifactually low.

The findings for women are striking and suggest an additional, sex-specific link between handgun purchase and violent death. Women are at greater risk for death by homicide committed by an intimate partner with a firearm than by a stranger with all methods combined.28 Homicide committed by an intimate partner accounts for the increased risk among women of death by homicide when there is a firearm in the home.9,11 It may be that many women purchase handguns for protection against violence from an intimate partner and that these handguns are used by the partners against them or are at any rate not protective. Women in abusive relationships are also at increased risk for suicide.9,21,29

How might suicide among purchasers of handguns be prevented? Focusing efforts on a population at high risk does not substantially reduce rates of suicide.30-32 As noted in one report, “there is no single, readily identifiable, high-risk population that constitutes a sizeable proportion of overall suicides and yet represents a small, easily targeted group.”30 In our study, handgun purchasers accounted for only 10.3 percent of those who committed suicide by firearm statewide in the year after their handgun purchases and accounted for a smaller proportion thereafter. A screening test for handgun purchasers with a sensitivity and specificity of 99 percent for identifying the 188 persons who committed suicide by means of a firearm within a year would have had a positive predictive value of only 7.2 percent, generating 12.8 false positive results for every true positive.

Reducing access to firearms within an entire population can prevent suicides by firearm.30-37 Rates of suicide by firearm correlate very closely, both geographically and temporally, with measures of the availability of firearms.33,38-40 In cross-sectional studies, stricter controls on access to firearms have been found to be associated with lower rates of suicide by firearm.33,40,41 In New York City, where handgun ownership has been strictly regulated since the early 20th century, rates of suicide by firearm are very low; rates of suicide by other methods vary directly with the availability of those methods.42

More direct evidence comes from time-series studies. A near-ban on the sale and possession of handguns in Washington, D.C., was associated with a rapid and specific 25 percent decrease in the rate of suicide by firearm.43 Substantial decreases in suicides by firearm were reported in Queensland34 and Tasmania,36 Australia, and in Ontario, Canada,35 after waiting periods of 21 to 28 days and other restrictions on access to firearms were adopted, although in Queensland there was an increase in suicide by other methods. Tasmania's 21-day waiting period resulted in a 51 percent decrease in the proportion of suicides involving firearms that were committed with recently acquired firearms.36

Our findings are subject to several limitations. Results may be different in states where demographic features of the population, the base-line prevalence of firearm ownership, or public policy differs from that in California. New York and New Jersey enforce long waiting periods for the purchase of a handgun, and the very high rates of suicide that we observed in the period immediately after purchase may not occur in those states. Conversely, rates of suicide by firearm soon after purchase may be still higher in the 23 states that, because they have no stronger state law, are subject to the Brady Handgun Violence Prevention Act, where waiting periods for most purchases of firearms from licensed dealers were replaced by the National Instant Check System in November 1998.44

Policy differences at the state level also affect eligibility to purchase firearms. Few states deny firearms to persons with previous convictions for violent misdemeanors. Since a history of violence or aggression is a risk factor for both suicide7,9,18,19,45 and homicide,9,11,46 the risk of violent death associated with recent purchase of a handgun may be higher in most states than we observed in California.

It should be emphasized that we did not compare the risk of death between people who owned firearms and people who did not. If firearm ownership is a risk factor for violent death,7-9,11 we have underestimated the risk of both suicide and homicide associated with the purchase of a handgun by a person who did not previously own a firearm.

We cannot determine the extent to which increases or decreases in the risk of violent death are attributable specifically to the purchase of a handgun, since we lack information about other risk factors. In addition to a history of violence, alcohol and drug abuse and psychiatric disorders are risk factors for both suicide and homicide.16,46-48 An increased risk of suicide by firearm might be due to an increased prevalence of these risk factors among handgun purchasers, and not due to the handgun purchase itself. On the other hand, such risk factors may be less common among persons who have recently passed a background check than they are in the general population; this difference might account for the lower risk of death by homicide among men who have recently purchased a handgun than among men in the general population.

We do not know whether the handguns purchased by persons in our study cohort were actually involved in the deaths we analyzed. However, the percentages of firearm-related suicides and homicides that involved handguns were much higher among handgun purchasers than in the state as a whole.

In 1997, suicide by firearm accounted for 54.2 percent of all deaths by firearm nationwide; firearms were used in 62.0 percent of suicides among men and 39.3 percent among women.49 Suicide by firearm may be most effectively prevented by reducing overall access to firearms. (Unfortunately, however, reduction in access to the means to commit suicide is not among the interventions included in the 1999 Surgeon General's Call to Action to Prevent Suicide. 50) Rates of death by both suicide and homicide among handgun purchasers might also be reduced by prohibiting those with risk factors such as a history of violence or alcohol and drug abuse from purchasing handguns.

A substantial percentage of persons who commit suicide seek medical attention shortly before death.30 Clinicians need to identify persons who are at acute risk for suicide and to intervene appropriately.30,51 A patient's declaration of intent to purchase a handgun may also be an indication to determine whether other risk factors for violent death are present.