The societal level explores how policy, social and cultural norms, and other larger societal factors influence health. Interventions for firearm suicide prevention at this level include implementing policies that reduce access to firearms by high-risk people and ultimately shift cultural norms related to guns and suicide.
Extreme risk laws are an evidence-based, bipartisan-supported state policy that establishes a new kind of protection order that temporarily prohibits the purchase and possession of a firearm and/or requires the removal of firearms from persons demonstrating behavioral risk factors for harming themselves or others. Law enforcement and, in some states, family or household members, among others, may request that a court issue an order.
As of February 2020, eighteen states and the District of Columbia have an extreme risk law. Click on a state to learn more about the state laws.
Analyses of Connecticut and Indiana’s risk-warrant laws shows that extreme risk laws are an effective tool for suicide prevention. Researchers found that risk-warrants reached individuals who were at a dangerously elevated risk of suicide and prevented additional suicide deaths by intervening in suicidal crises. These findings show the effectiveness of preemptive firearms removal laws in suicide prevention.
In the first 14 years of Connecticut’s law (1999-2013):
In the first 7 years of Indiana’s law (2006-2013):
These findings show how preemptive firearm removal laws can be an effective suicide prevention measure.
Voluntary self-prohibition policies allow individuals to place themselves on a do-not buy list that would place their name into the National Instant Criminal Background Check System, prohibiting them from purchasing firearms. One study surveying individuals at both inpatient and outpatient psychiatric clinics found that 46% of participants would put their name on a list. Notably, individuals with access to a firearm were less likely to sign up for a Do-Not-Sell list. As of September 2019, Washington is the only state with such a policy; however, several states have considered or introduced some version of this legislation.
Any policy that generally reduces access to firearms by individuals who may be at risk of suicide are critical. Such policies may include, but are not limited to, universal background checks with permit-to-purchase, child access prevention laws, mandatory waiting periods, and policies to support interventions at other levels of the model (such as a policy that provides funding to train healthcare providers on lethal means safety counseling or a policy that provides funding for law enforcement agencies to implement extreme risk laws).
Permit-to-purchase laws, also called purchaser licensing laws, are a state policy that require individuals to obtain a permit or license before purchasing a firearm. These laws vary from state to state, but may require an in-person application, safety training, finger prints, and additional wait time. Research has found that these laws are not only effective at reducing homicide, but also at reducing suicides. Connecticut’s handgun purchaser licensing law was associated with a 15% reduction in the state’s firearm suicide rate, while Missouri’s repeal of its handgun purchaser licensing law was associated with a 16% increase in the state’s firearm suicide rate.
Child Access Prevention (CAP) laws are state policies that encourage safer storage of firearms by holding gun owners criminally liable if a child accesses an unsecured firearm. CAP laws reduce suicides because they may encourage gun owners to adopt safer storage practices and may increase awareness and ultimately change social norms around firearm access and safer storage. An analysis of eighteen state CAP laws from 1976 to 2001 found these laws were associated with an 8% decrease in suicide rates among 14 to 17 year olds.
Mandatory waiting periods are a type of state policy that requires firearm purchasers to wait between three and fourteen days, depending on the state, after passing a background check before they may take home their newly purchased firearms. Suicidal thoughts can be transient or short-lived. As such, putting time and space between a person and a firearm through mandatory waiting periods means a suicidal crisis may pass or suicidal thoughts may subside before the person has access to a firearm. An analysis found waiting periods have been associated with a 7-11% reduction in firearm suicides.
Extreme Risk Laws
The Educational Fund to Stop Gun Violence, Giffords, and the Alliance for Gun Responsibility’s state legislative toolkit is designed to help enact and implement Extreme Risk Laws across the country.
Johns Hopkins Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health’s white paper, “The Impact of Handgun Purchaser Licensing Laws on Gun Violence”
The American Health Podcast’s episode, “Permit to Purchase: Proven to Save Lives”
Extreme Risk Laws
The Bloomberg American Health Initiative’s “Implement ERPO” project
A central resource for those implementing extreme risk laws across the country.
Gun Protection Order
A campaign to raise awareness of Washington’s Extreme Risk Protection Orders.
One Thing To Do
Everytown for Gun Safety’s campaign to create awareness around extreme risk laws.
Speak for Safety
A campaign to raise awareness of California’s Gun Violence Restraining Order.
Speak for Safety Illinois
A campaign to raise awareness of Illinois’s Firearm Restraining Order.
Extreme Risk Laws
Bonnie RJ & Swanson JW. (2018). Extreme risk protection orders – Effective tools for keeping guns out of dangerous hands. Developments in Mental Health Law.
Frattaroli S, McGinty EE, Barnhorst A, & Greenberg S. (2015). Gun violence restraining orders: Alternative or adjunct to mental health-based restrictions on firearms? Behavioral Sciences and the Law.
Frizzell W & Chien J. (2019). Extreme risk protection orders to reduce firearm violence. Psychiatric Services.
Horwitz J, Grilley A, & Kennedy O. (2015). Beyond the academic journal: Unfreezing misconceptions about mental illness and gun violence through knowledge translation to decision makers. Behavioral Sciences and the Law.
Kivisto AJ & Phalen PL. (2018). Effects of risk-based firearm seizure laws in Connecticut and Indiana on suicide rates, 1981–2015. Psychiatric Services.
McGinty EE, Frattaroli S, Appelbaum PS, Bonnie RJ, Grilley A, Horwitz J, Swanson JW, & Webster DW. (2014). Using research evidence to reframe the policy debate around mental illness and guns: Process and recommendations. American Journal of Public Health.
Parker GF. (2015). Circumstances and outcomes of a firearm seizure law: Marion County, Indiana, 2006–2013. Behavioral Sciences and the Law.
Roskam K & Chaplin V. (2017). The gun violence restraining order: An opportunity for common ground in the gun violence debate. Developments in Mental Health Law.
Sklar T. (2019). Elderly gun ownership and the wave of state red flag laws: An unintended consequence that could help many. Elder Law Journal.
Swanson JW, Easter MM, Alanis-Hirsch K, Belden CM, Norko MA, Robertson AG, Frisman LK, Lin H, Swartz MS, & Parker GF. (2019). Criminal justice and suicide outcomes with Indiana’s risk-based gun seizure law. Journal of the American Academy of Psychiatry and the Law.
Swanson JW, Norko MA, Lin HJ, Alanis-Hirsch K, Frisman LK, Baranoski MV, Easter MM, Robertson AG, Swartz MS, & Bonnie RJ. (2017). Implementation and effectiveness of Connecticut’s risk-based gun removal law: Does it prevent suicides? Law and Contemporary Problems.
Vernick JS, Alcorn T, & Horwitz J. (2017). Background checks for all gun buyers and gun violence restraining orders: State efforts to keep guns from high-risk persons. Journal of Law, Medicine & Ethics.
Vars FE, McCullumsmith CB, Shelton RC, & Cropsey KL. (2017). Willingness of mentally ill individuals to sign up for a novel proposal to prevent firearm suicide. Suicide & Life-Threatening Behavior.
Crifasi et al. (2015). Effects of changes in permit-to-purchase handgun laws in Connecticut and Missouri on suicide rates. Preventive Medicine.
Rodríguez AA & Hempstead K. (2011). Gun control and suicide: The impact of state firearm regulations in the United States, 1995-2004. Health Policy.
Child Access Prevention Laws:
DeSimone J, Markowitz S, & Xu J. (2013). Child access prevention laws and nonfatal gun injuries. Southern Economic Journal.
Gius, M. (2015). The impact of minimum age and child access prevention laws on firearm-related youth suicides and unintentional deaths. The Social Science Journal.
Hamilton EC, Miller CC, Cox CS, Lally KP, & Austin MT. (2018). Variability of child access prevention laws and pediatric firearm injuries. Journal of Trauma and Acute Care Surgery.
Prickett KC, Martin-Storey A, & Crosnoe R. (2014). State firearm laws, firearm ownership, and safety practices among families of preschool-aged children. American Journal of Public Health.
Webster DW & Starnes M. (2000). Reexamining the association between child access prevention gun laws and unintentional shooting deaths of children. Pediatrics.
Webster DW, Vernick JS, Zeoli AM, & Manganello JA. (2004). Association between youth-focused firearm laws and youth suicides. Journal of American Medical Association.
Mandatory Waiting Periods:
Anestis MD, Selby EA, & Butterworth SE. (2017). Rising longitudinal trajectories in suicide rates: The role of firearm suicide rates and firearm legislation. Preventive Medicine.
Luca M, Malhotra D, & Poliquin C. (2017). Handgun waiting periods reduce gun deaths. Proceedings of the National Academy of Sciences of the United States of America.
Anestis MD, Houtsma C, Daruwala SE, Butterworth SE. (2019). Firearm legislation and statewide suicide rates: The moderating role of household firearm ownership levels. Behavioral Sciences & the Law.
Ghiani M, Hawkins SS, & Baum CF. (2019). Associations between gun laws and suicides. American Journal of Epidemiology.
Kalesan B, Mobily ME, Keiser O, Fagan JA, & Galea S. (2016). Firearm legislation and firearm mortality in the USA: A cross-sectional, state-level study. Lancet.
Kaufman EJ, Morrison CN, Branas, CC, & Wiebe DJ. (2018). State firearm laws and interstate firearm deaths from homicide and suicide in the United Utates: A cross-sectional analysis of data by county. Journal of American Medical Association Internal Medicine.
Kposowa A, Hamilton D, & Wang K. (2016). Impact of firearm availability and gun regulation on state suicide rates. Suicide & Life-Threatening Behavior.
Santaella-Tenorio J, Cerdá M, Villaveces A, & Galea S. (2016). What do we know about the association between firearm legislation and firearm-related injuries? Epidemiologic Reviews.
Steinbrook R. (2018). Interstate association of state firearm laws with suicide and homicide. Journal of American Medical Association Internal Medicine.
Extreme Risk Laws
The Extreme Risk Protection Order policy was developed by the Consortium for Risk Based Firearm Policy, first outlined in the Consortium for Risk-Based Firearms Policy’s 2013 report, Guns, public health, and mental illness: An evidence-based approach for state policy.
Bryan Barks’ 2017 first-person essay entitled, I want a gun policy to defend myself – from suicide, advocates for a voluntary self-prohibition policy and discusses how such a policy would help to keep her safe.
The Giffords Law Center’s summary of Child Access Prevention laws across the country.
The Giffords Law Center’s summary of Waiting Period laws across the country.
The Giffords Law Center’s summary of Licensing laws across the country.