Comparison of Rates of Firearm and Nonfirearm Homicide and Suicide in Black and White Non-Hispanic Men, by U.S. State

Corinne A. Riddell; Sam Harper; Magdalena Cerdá; Jay S. Kaufman

doi:10.7326/M17-2976

Original Research |15 May 2018

Comparison of Rates of Firearm and Nonfirearm Homicide and Suicide in Black and White Non-Hispanic Men, by U.S. State Free

Corinne A. Riddell, PhD; Sam Harper, PhD; Magdalena Cerdá, PhD; Jay S. Kaufman, PhD

Article, Author, and Disclosure Information

This article was published at Annals.org on 24 April 2018.

McGill University, Montreal, Quebec, Canada (C.A.R., S.H., J.S.K.)
University of California, Davis, Davis, California (M.C.)
Financial Support: Dr. Riddell is a postdoctoral researcher at McGill University and received salary support from the Department of Epidemiology, Biostatistics, and Occupational Health. Dr. Harper is supported by a Chercheur Boursier Junior 2 from the Fonds de la Recherche en Santé du Québec. Dr. Cerdá is a CAMPOS Faculty Scholar, ADVANCE Program at the University of California, Davis, and supported by the National Institutes of Health (grant 1R21 DA041154-01).
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2976.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Not available. Statistical code: Available at GitHub (https://github.com/corinne-riddell/InjuryDisparity/tree/master/Code. Data set: Available at GitHub (https://github.com/corinne-riddell/InjuryDisparity/tree/master/Data).
Requests for Single Reprints: Corinne A. Riddell, PhD, Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West, Room 27, Montreal, Quebec H3A 1A2, Canada; e-mail, corinne.riddell@mail.mcgill.ca.
Current Author Addresses: Drs. Riddell, Harper, and Kaufman: Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West, Room 27, Montreal, Quebec H3A 1A2, Canada.
Dr. Cerdá: Violence Prevention Research Program, Department of Emergency Medicine, University of California, Davis, 2315 Stockton Boulevard, Sacramento, CA 95817.
Author Contributions: Conception and design: C.A. Riddell, S. Harper, M. Cerdá, J.S. Kaufman.
Analysis and interpretation of the data: C.A. Riddell, S. Harper, M. Cerdá, J.S. Kaufman.
Drafting of the article: C.A. Riddell.
Critical revision for important intellectual content: C.A. Riddell, S. Harper, M. Cerdá, J.S. Kaufman.
Final approval of the article: C.A. Riddell, S. Harper, M. Cerdá, J.S. Kaufman.
Statistical expertise: C.A. Riddell, S. Harper, J.S. Kaufman.
Obtaining of funding: J.S. Kaufman.
Administrative, technical, or logistic support: J.S. Kaufman.
Collection and assembly of data: C.A. Riddell.

Abstract

Background:

The extent to which differences in homicide and suicide rates in black versus white men vary by U.S. state is unknown.

Objective:

To compare the rates of firearm and nonfirearm homicide and suicide in black and white non-Hispanic men by U.S. state and to examine whether these deaths are associated with state prevalence of gun ownership.

Design:

Surveillance study.

Setting:

50 states and the District of Columbia, 2008 to 2016. Cause-of-death data were abstracted by using the Centers for Disease Control and Prevention's WONDER (Wide-ranging Online Data for Epidemiologic Research) database.

Participants:

Non-Hispanic black and non-Hispanic white males, all ages.

Measurements:

Absolute rates of and rate differences in firearm and nonfirearm homicide and suicide in black and white men.

Results:

During the 9-year study period, 84 113 homicides and 251 772 suicides occurred. Black–white differences in rates of firearm homicide and suicide varied widely across states. Relative to white men, black men had between 9 and 57 additional firearm homicides per 100 000 per year, with black men in Missouri, Michigan, Illinois, Indiana, and Pennsylvania having more than 40 additional firearm homicides per 100 000 per year. White men had between 2 fewer and 16 more firearm suicides per 100 000 per year, with the largest inequalities observed in southern and western states and the smallest in the District of Columbia and densely populated northeastern states.

Limitations:

Some homicides and suicides may have been misclassified as deaths due to unintentional injury. Survey data on state household gun ownership were collected in 2004 and may have shifted during the past decade.

Conclusion:

The large state-to-state variation in firearm homicide and suicide rates, as well as the racial inequalities in these numbers, highlights states where policies may be most beneficial in reducing homicide and suicide deaths and the racial disparities in their rates.

Primary Funding Source:

McGill University and the National Institutes of Health.

In 2016, non-Hispanic black men were nearly 10.4 times more likely than non-Hispanic white men to die by homicide in the United States, whereas white men were 2.5 times more likely than black men to die by suicide (1). More than 80% of homicides and 60% of suicides involved firearms. The relative racial inequalities in violent deaths are especially marked for firearm homicide. Black men are 14 times more likely than white men to die by firearm homicide (1).

Racial disparities in violent deaths are well-established in the United States overall, but whether these inequalities vary by state—and if so, by how much—is unknown. Large variation in racial disparities would suggest the presence of explanatory factors that differ across states. These factors might reflect differences in race-specific levels of exposure to socioeconomic characteristics, neighborhood residential conditions, medical care, or policy environments that are known to affect violence (2). Measuring state-to-state variation in racial disparities in homicide and suicide rates, which are masked when looking only at the population average, may help identify areas where subpopulations may have an excess burden of injury and where efforts might be directed to reduce inequalities.

Across the United States, states with the highest levels of household gun ownership also have the highest rates of firearm suicide and homicide (3). Ecological studies comparing U.S. states have estimated that gun ownership rates are positively associated with rates of firearm homicide and suicide (4–8), and case–control studies have found positive associations between the presence of a gun in the home and a person's risk for homicide occurring at home (9), as well as his or her overall risk for suicide (10). Two components of the causal pathway to homicide or suicide are motivation and opportunity (11). Gun availability or ownership increases opportunity, and motivation conceivably might vary by racial group. For example, participation in illegal activity is linked to increased homicide risk (12), whereas social support and cultural cohesion are linked to decreased suicide risk (13). Thus, the relationship between gun availability and homicide or suicide may differ according to race. This information is currently unknown but could inform whether policies aimed at reducing gun prevalence might have different effects among blacks versus whites.

In this study, we aimed to compare the rates of firearm and nonfirearm homicide and suicide among black and white non-Hispanic men by U.S. state and to examine the association between state gun ownership prevalence and firearm homicide and suicide rates.

Methods

We used the WONDER (Wide-ranging Online Data for Epidemiologic Research) database of the Centers for Disease Control and Prevention to abstract age-adjusted rates of homicide and suicide (1). Data were abstracted for all states and the District of Columbia between 2008 and 2016 for non-Hispanic white and black males of any age. Codes from the International Classification of Diseases, 10th Revision, were used to identify firearm homicides (X93, X94, and X95), nonfirearm homicides (X85 to X92, X96 to X99, and Y01 to Y05), firearm suicides (X72, X73, and X74), and nonfirearm suicides (X60 to X71 and X75 to X84). Rates were suppressed by the data provider for any state that had fewer than 20 deaths for the race group between 2008 and 2016. Suppressed data were set to missing in our statistical analysis. These data originated from death certificates provided by states to the National Vital Statistics System and overseen by the Centers for Disease Control and Prevention's National Center for Health Statistics. Race and Hispanic ethnicity were recorded by medical examiners. Throughout this article, we refer to the study population as men because the vast majority of deaths occurred after childhood.

We computed the average annual fatality rate according to race, intent, and firearm involvement by dividing the number of fatalities by the total population estimate (that is, the sum of population estimates from 2008 to 2016), and we calculated the absolute inequality (rate difference) in estimates between black and white men. For homicide, we subtracted the fatality rate of white men from that of black men. For suicide, these rates were reversed, such that the estimated rate differences are mostly positive and interpreted as the number of additional deaths of black (white) men due to homicide (suicide) associated with the heightened fatality rate of black (white) men. When either of the race-specific rates was suppressed, a rate difference was not calculated for the state. To reflect varying population sizes among states and by race, we represent the area of each data marker to be proportional to the race-specific average annualized population size.

To examine the relationships among household gun ownership, firearm homicide, and firearm suicide by race and state, we used the last available state-level estimates of household firearm ownership from the National Behavioral Risk Factor Surveillance System (BRFSS) from 2004. The BRFSS is an annual telephone survey of the noninstitutionalized adult population that asks respondents about their health-related risk behaviors, chronic health conditions, and use of preventive services. In 2001, 2002, and 2004, the BRFSS asked, “Are any firearms kept in or around your home?” More than 293 000 people responded to this question; estimates of household gun ownership prevalence (percentage) by state were computed previously and ranged from 10.2% in Hawaii to 65.5% in Wyoming (14). Given that respondents may have underreported gun ownership and that state gun prevalence may have shifted since 2004, we grouped states into 4 broad categories of gun prevalence—10.2% to 19.9%, 20.0% to 34.9%, 35.0% to 44.9%, and 45.0% to 65.5%—to provide a reasonable approximation of current levels of ownership.

We then visually assessed the relationships among state gun prevalence, firearm homicide, and firearm suicide by plotting the rate of firearm homicide as a function of firearm suicide. We color-coded the points by category of gun prevalence, separately for black and white men. This descriptive exercise illustrates whether states with relatively high rates of firearm homicide also have relatively high rates of firearm suicide, and whether this pattern exists for both black and white men and is associated with state gun ownership. A strong association would suggest that firearm homicide and suicide share risk factors and may be amenable to similar prevention strategies. A weak association would indicate less overlap in risk factors and therefore a need for distinct preventive approaches.

Data management and visualization were performed in R, version 3.3.2 (The R Foundation) (15). Because this study used publicly accessible data, an institutional ethical review was not required (16). A replication data set including the raw data and statistical code to reproduce this work is publicly available on GitHub (https://github.com/corinne-riddell/InjuryDisparity/).

Role of the Funding Source

This research was not formally supported by a research grant, although one of the authors (M.C.) was supported by the National Institutes of Health (grant 1R21 DA041154-01).

Results

Our analysis included 84 113 homicides and 251 772 suicides from 2008 to 2016. Homicide deaths were suppressed by the National Center for Health Statistics for black men in 16 states and for white men in 8 states. Suicide deaths were suppressed in 14 states for black men; no suicides were suppressed for white men.

Comparison of Firearm Homicide Rates

Figure 1 displays the homicide rates among black versus white men, according to state and firearm use. The Supplement contains tables providing the exact estimates of the rates shown in the figures. Across the entire United States, black men had 27 more homicides per 100 000 per year than white men. The black–white difference in firearm homicide rates varied strikingly by state, from 9 to 57 per 100 000 per year, and was driven by marked variation in firearm homicides of black men across states. States with the smallest firearm homicide rates among blacks had fewer than 15 deaths per 100 000 per year during the study period, compared with more than 40 deaths per 100 000 per year in states with the highest rates. Firearm homicide rates for white men showed relatively little variation across states: between 1 and 5 deaths per 100 000 per year. The states with the highest rates of firearm homicide for black men (namely Missouri, Michigan, Illinois, and Indiana) also had the largest differences in rates between blacks and whites, signaling states that had the highest risk for blacks but a relatively low risk for whites. The District of Columbia also had a relatively high risk for black but not white men.

Figure 1.

Comparison of firearm and nonfirearm homicide rates between black and white non-Hispanic men by U.S. state, 2008 to 2016.

The homicide rate for non-Hispanic white men (open circles) is compared with the rate for non-Hispanic black men (solid circles) for each state. The area of the circle is proportional to its race-specific population size, as defined in the key. For each state, the difference between rates is shown to the right of the circles and quantifies the excess number of homicides in black men per 100 000 per year. The average firearm and nonfirearm homicide rates for the entire United States are shown at the top of each graph, followed by the states organized according to the size of the black–white difference. States that are missing circles for black or white men had 19 or fewer firearm or nonfirearm homicides within the affected racial group during the study period, and data were not available for analysis.

Comparison of Firearm Homicide Rates in Black Men Among States With the Largest Black Populations

Another way to make comparisons is to consider the states that are home to the most black residents to determine whether these states also varied in their rates of firearm homicide compared with spatially contiguous states. Nearly 40% of the U.S. black population lives in Georgia, New York, Florida, Texas, and California, and make up between 6% and 30% of each state's population. Among these states, Texas exhibited the smallest black–white difference in firearm homicide (15 additional deaths in black men per 100 000 per year), which also was substantially lower than the differences estimated for neighboring states, including Louisiana (+39), Oklahoma (+30), and Arkansas (+29). Georgia (+18) and Florida (+23) had differences similar to those of nearby South Carolina (+21) and North Carolina (+18) and had lower rates than Alabama (+29) and Tennessee (+30). New York's difference (+18) was similar to that of Massachusetts (+16) and Connecticut (+21) but substantially lower than the rates of neighboring New Jersey (+31) and Pennsylvania (+42). California exhibited the largest black–white difference (+30) in firearm homicide among the 5 states with the largest black populations. California's black–white difference was larger than that estimated for contiguous states, including Nevada (+20) and Oregon (+12), although these states had relatively small black populations.

Comparison of Nonfirearm Homicide Rates

Nonfirearm homicides occur much less frequently among both black and white men. On average, 3 more nonfirearm homicides per 100 000 per year occurred among black than white men. Black men had rates that varied between 2 and 8 per 100 000 per year by state, whereas rates in white men were less than 1 per 100 000 per year. On average, firearm homicide rates were 9-fold higher than nonfirearm rates among black men. The states with the largest differences between firearm and nonfirearm homicide rates were Missouri, Indiana, Illinois, and Louisiana, each of which had firearm homicide rates more than 12 times higher than their nonfirearm homicide rates.

Comparison of Firearm Suicide Rates

In contrast to homicide, suicide rates were higher among white than black men, independent of firearms involvement, with the exception of firearm suicide in the District of Columbia (Figure 2). Across the United States, white men had 9 more firearm suicides per 100 000 per year than black men. The white–black difference in firearm suicides varied from −2 per 100 000 per year in the District of Columbia to 16 per 100 000 per year in Missouri, although differences could not be estimated for 12 states with fewer than 20 firearm suicides among blacks. The annual rate of firearm suicide varied more markedly for white than black men: from 2 per 100 000 per year in the District of Columbia to 29 per 100 000 per year in Wyoming for white men, compared with a range of 2 per 100 000 per year in Massachusetts to 13 per 100 000 per year in Alaska among black men.

Figure 2.

Comparison of firearm and nonfirearm suicide rates between black and white non-Hispanic men by U.S. state, 2008 to 2016.

The suicide rate for non-Hispanic white men (open circles) is compared with the rate for non-Hispanic black men (solid circles) for each state. The area of the circle is proportional to its race-specific population size, as defined in the key. For each state, the difference between rates is listed to the right of the circles and quantifies the excess number of suicides in white men per 100 000 per year. The average firearm and nonfirearm suicide rates for the entire United States are shown at the top of each graph, followed by the states organized according to the size of the white–black difference. States that are missing circles for black or white men had 19 or fewer firearm or nonfirearm suicides within the affected racial group during the study period, and data were not available for analysis.

Six of the 10 states with the largest white–black differences in firearm suicide—Mississippi, Arkansas, Alabama, Texas, South Carolina, and Louisiana—are located in the South, whereas the other 4—Nevada, Arizona, New Mexico, and Colorado—are in the West (range, 12.9 to 15.7 per 100 000 per year). Along with the District of Columbia, the northeastern states of Massachusetts, New Jersey, Connecticut, and New York had the smallest white–black differences (≤4 per 100 000 per year) in firearm suicide rates.

Comparison of Nonfirearm Suicide Rates

The rates of nonfirearm suicides among whites and blacks, as well as the difference between rates, varied substantially less than the rates of suicides involving firearms. In the United States overall, the nonfirearm suicide mortality rate was 10.6 per 100 000 per year in white men compared with 4.4 per 100 000 per year among black men. Of all the states, Hawaii had the highest rate of nonfirearm suicides for white men—19 per 100 000 per year—whereas Nebraska had the lowest rate—8 per 100 000 per year. For black men, the highest estimated rate was 8 per 100 000 per year in Colorado; the lowest was 3 per 100 000 per year in Mississippi.

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among White Men

Firearm homicide and suicide were strongly associated for white men (Figure 3). In terms of the relationship among firearm homicide, suicide, and state gun prevalence, the 5 states with lower rates of both firearm homicide and suicide in white men (namely Massachusetts, New Jersey, Rhode Island, New York, and Connecticut) also were in the lowest category of reported state gun prevalence. Furthermore, many states with the highest firearm homicide and suicide rates belonged to the highest category of gun prevalence, whereas most states located in the middle of the graph were in the middle categories of gun prevalence. Of note, several states in the highest gun prevalence category had relatively low rates of firearm homicide, including Iowa, Nebraska, the Dakotas, Idaho, Montana, and Wyoming.

Figure 3.

Relationship between the annual rates of firearm homicide and suicide among white men, by state, and reported household firearm ownership, 2008 to 2016.

Each state's homicide and suicide mortality rates among non-Hispanic white men are plotted. The area of the circle is proportional to the white male population size, and the shading represents state gun ownership prevalence. The District of Columbia and Hawaii had suppressed estimates for firearm homicide or suicide in white men; therefore, the estimates are not plotted.

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among Black Men

Among black men, firearm homicide and suicide were modestly associated (Figure 4). States with the lowest reported prevalence of guns had the lowest rates of firearm suicide and below-average rates of firearm homicide. Missouri and several rust belt states (Illinois, Indiana, Michigan, and Pennsylvania) reported the most firearm homicides among black men but medium levels of gun ownership. Among the southern states, those with high levels of gun ownership, such as Louisiana, reported higher homicide rates among black men than states with medium levels, such as Texas.

Figure 4.

Relationship between the annual rates of firearm homicide and suicide among black men, by state, and reported household firearm ownership, 2008 to 2016.

Each state's homicide and suicide mortality rates among non-Hispanic black men are plotted. The area of the circle is proportional to the black male population size, and the shading represents state gun ownership prevalence. Hawaii, Idaho, Iowa, Maine, Montana, North Dakota, New Hampshire, South Dakota, Rhode Island, Utah, Vermont, and Wyoming had suppressed estimates for firearm homicide or suicide in black men; therefore, the estimates are not plotted.

Discussion

Firearm homicide rates among black men varied substantially across states. For white men, rates were consistently lower and less variable, leading to large racial inequalities in firearm homicide, especially in Missouri, Michigan, Illinois, Indiana, and Pennsylvania. Nonfirearm homicides occurred much less frequently than firearm homicides and exhibited little variation across states. However, these homicides still occurred more frequently among black than white men. White men were at higher risk than black men for firearm suicide, most notably in Mississippi, Nevada, Arkansas, New Mexico, and Alabama. Northeastern states with reliable data (New York, Connecticut, New Jersey, and Massachusetts) and the District of Columbia showed the smallest differences in firearm suicide rates. These states also had the lowest suicide risk for both black and white men, implying that they offer the lowest race-specific risks and are the closest to achieving racial equality in firearm suicide. In terms of nonfirearm suicide, white men had higher rates than black men, although these rates varied less than those of firearm suicide.

For white men, firearm homicide and suicide shared a strong positive association. This suggests that the characteristics that generate variation across states in firearm homicide and suicide are similar for white men. States with the lowest gun ownership rates had the lowest rates of firearm homicide and suicide among white men, and several states with the highest gun ownership rates had the highest rates of firearm homicide and relatively high rates of firearm suicide.

The relationship between firearm homicide and suicide was modest for black men. In contrast to white men, this moderate relationship suggests that the risk factors for firearm homicide and suicide for black men are more dissimilar, and the substantial variation in firearm homicide among black men suggests the presence of additional explanatory factors for firearm homicide compared with firearm suicide. Although state gun ownership was positively associated with both outcomes for white men, some states with medium levels of gun ownership had the highest homicide rates among black men, whereas others had relatively low rates, implying the presence of important unexamined factors in determining homicide risk for black men.

The spatial distribution of homicides is known to vary, with suicides occurring at the highest rates in the most rural settings and homicides occurring at the highest rates in the most urban settings (17). Particularly with respect to homicide, this urban–rural divide probably reflects predictors present in metropolitan environments, such as higher levels of income inequality, female-headed households, and crowding (18). Higher suicide rates in rural areas have been attributed to social and geographic isolation, access to lethal mechanisms, and stresses associated with agricultural work (19).

Although ample research has been done on homicide and suicide risk factors, the mechanisms that have led to varying racial inequalities across states are less clear. Structural disadvantage (namely concentrated poverty, joblessness, and family disruption) (20), racial residential segregation (21–24), and participation in drug markets (25, 26) have all been implicated in the higher risk for homicide among black men relative to white men. Thus, these risk factors may occur more frequently among black men residing in states with the largest disparities in firearm homicide.

Firearm policy also has been implicated in differences in the overall rates of homicide and suicide across the United States. A cross-sectional ecological study found that states with more restrictive firearm laws had 6.6 fewer firearm deaths per 100 000 per year than states with the least restrictive environments (27). Analyses comparing states that revised their firearm policies with a synthetic control estimated that changes to permit-to-purchase laws are linked to decreases in firearm (but not nonfirearm) homicide and suicide rates (28, 29). Thus, differences in state policy environments probably have contributed to the levels of homicide and suicide estimated in this study, although whether policies are linked to racial inequalities is less clear.

State gun prevalence was strongly tied to firearm suicide for both black and white men, and firearms are the most lethal means of attempted suicide (30, 31). In addition, states with the lowest risk for firearm suicide also had the most restrictive gun laws (32).

Alcohol is another important risk factor for suicide, in terms of both history of alcoholism and overuse at the time of suicide (33, 34). Alcohol was found in the system of 25% of white and 15% of black men who died by suicide in 2005 to 2006, with 16% of the white men being described as alcohol dependent at the time of suicide, compared with 7% of the black men (35). Given that white men have higher rates of alcohol abuse than black men (35), alcohol use might be implicated in both the direction of the white–black inequality and its variation across states.

Although we could not estimate state-level disparities in age-specific mortality rates, national figures indicate very different trends for black and white men (36). Suicidal risk increases for white men as they age and exceeds 30 firearm suicides per 100 000 per year for men aged 75 years or older. For black men, the peak rate of 10 firearm suicides per 100 000 per year occurs at ages 25 to 29 years (36). The estimated white–black differences in suicide mortality and their variation by state therefore may reflect differences across states in the risks for younger black and older white men to commit suicide by firearm.

We searched MEDLINE for literature on racial disparities in homicide or suicide using the search strategy

“Homicide”[MeSH] OR “Suicide”[MeSH]) AND (health disparit [Text Word] OR health inequal [Text Word] OR health inequit [Text Word] OR social disparit [Text Word] OR social inequit [Text Word] OR social inequal [Text Word])

from database conception to 19 January 2018 with no language restriction. We identified 102 articles, none of which estimated inequalities in homicide or suicide mortality by U.S. state. One report did classify states according to their rates of overall homicide mortality (37). This report estimated that overall rates of homicide mortality ranged from 1.1 to 12.8 deaths per 100 000 in 2009, with southern states generally having the highest rates (37). Given the large differences in homicide mortality by race, our analysis adds to these findings by emphasizing racial disparities and demonstrating their considerable variation across states.

This study was subject to several limitations. Some homicide and suicide deaths are difficult to classify. Homicides may be classified as suicides, or vice versa, and either may be misclassified as an unintentional injury. Misclassification of drug poisoning deaths is particularly important during the current opioid epidemic, which has led to a sharp increase in fatal overdoses (38). The most recent data on state gun ownership was collected in 2004, 4 to 12 years before the mortality data used in this study. Given that more than 80% of firearm suicide attempts are fatal (30, 31) and approximately 20% of firearm homicide attempts result in death (39), studying only fatal outcomes misses the morbidity of nonfatal assaults and suicide attempts. We were limited to contrasting age-standardized mortality rates but would rather have contrasted age-specific rates, had there been more deaths. We did not examine homicide or suicide in women, because their risks are much lower than men's, and data for black women were suppressed for more than half the states. We did not examine homicide or suicide in Hispanic persons, because they are subject to higher rates of misclassification on death certificates than blacks and whites (40), and extracting Hispanic persons from the black–white grouping would have cut the data too sparsely. Finally, these results are purely descriptive and make no claims regarding causal mechanisms.

This work elicits questions for future investigation. In particular, we would like to better understand the wide variation in black homicide rates, especially across southern and rust belt states with similar levels of gun ownership. Multilevel models that account for state-, county-, and individual-level characteristics also might shed light on the reasons for the variation in homicide and suicide rates across states.

Firearms feature differently in the deaths of black and white men in the United States. The large variation in homicide and suicide rates and their racial differences across states highlight areas where policies may help reduce the rates of homicide and suicide, as well as their racial disparities.

References

Centers for Disease Control and Prevention. About underlying cause of death, 1999-2016. December 2017. Accessed at http://wonder.cdc.gov/ucd-icd10.html on 17 January 2018.
Williams
DR
,
Jackson
PB
.
Social sources of racial disparities in health.
Health Aff (Millwood)
2005
24
325
34
PubMed
CrossRef
PubMed
Miller
M
,
Azreal
D
,
Hemenway
D
.
Firearms and violent death in the United States. In: Webster DW, Vernick JS, eds. Reducing Gun Violence in America: Informing Policy with Evidence and Analysis.
Baltimore
Johns Hopkins Univ Pr
2013
14
5
Miller
M
,
Azrael
D
,
Hemenway
D
.
Rates of household firearm ownership and homicide across US regions and states, 1988-1997.
Am J Public Health
2002
92
1988
93
PubMed
CrossRef
PubMed
Miller
M
,
Hemenway
D
,
Azrael
D
.
State-level homicide victimization rates in the US in relation to survey measures of household firearm ownership, 2001-2003.
Soc Sci Med
2007
64
656
64
PubMed
CrossRef
PubMed
Siegel
M
,
Ross
CS
,
King
C
3rd
.
The relationship between gun ownership and firearm homicide rates in the United States, 1981-2010.
Am J Public Health
2013
103
2098
105
PubMed
CrossRef
PubMed
Miller
M
,
Barber
C
,
White
RA
,
Azrael
D
.
Firearms and suicide in the United States: is risk independent of underlying suicidal behavior?
Am J Epidemiol
2013
178
946
55
PubMed
CrossRef
PubMed
Miller
M
,
Lippmann
SJ
,
Azrael
D
,
Hemenway
D
.
Household firearm ownership and rates of suicide across the 50 United States.
J Trauma
2007
62
1029
34
PubMed
CrossRef
PubMed
Kellermann
AL
,
Rivara
FP
,
Rushforth
NB
,
Banton
JG
,
Reay
DT
,
Francisco
JT
.
et al
Gun ownership as a risk factor for homicide in the home.
N Engl J Med
1993
329
1084
91
PubMed
CrossRef
PubMed
Kellermann
AL
,
Rivara
FP
,
Somes
G
,
Reay
DT
,
Francisco
J
,
Banton
JG
.
et al
Suicide in the home in relation to gun ownership.
N Engl J Med
1992
327
467
72
PubMed
CrossRef
PubMed
Kubrin
CE
,
Wadsworth
T
.
Explaining suicide among blacks and whites: how socioeconomic factors and gun availability affect race-specific suicide rates.
Soc Sci Q
2009
90
1203
27
CrossRef
Loeber
R
,
Farrington
DP
.
Young Homicide Offenders and Victims.
New York
Springer
2011
1
17
Gibbs
JT
.
African-American suicide: a cultural paradox.
Suicide and Life-Threatening Behavior
1997
27
68
79
PubMed
Monuteaux
MC
,
Lee
LK
,
Hemenway
D
,
Mannix
R
,
Fleegler
EW
.
Firearm ownership and violent crime in the U.S.: an ecologic study.
Am J Prev Med
2015
49
207
14
PubMed
CrossRef
PubMed
R Core Team. R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2014. Accessed at www.R-project.org on 17 January 2018.
Canadian Institutes of Health Research; National Sciences and Engineering Research Council of Canada; Social Sciences and Humanities Research Council of Canada
Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.
Ottawa
Interagency Secretariat on Research Ethics
December 2014
Branas
CC
,
Nance
ML
,
Elliott
MR
,
Richmond
TS
,
Schwab
CW
.
Urban-rural shifts in intentional firearm death: different causes, same results.
Am J Public Health
2004
94
1750
5
PubMed
CrossRef
PubMed
Cubbin
C
,
Pickle
LW
,
Fingerhut
L
.
Social context and geographic patterns of homicide among US black and white males.
Am J Public Health
2000
90
579
87
PubMed
CrossRef
PubMed
Hirsch
JK
.
A review of the literature on rural suicide: risk and protective factors, incidence, and prevention.
Crisis
2006
27
189
99
PubMed
CrossRef
PubMed
Wilson
WJ
.
The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy
Chicago
Univ Chicago Pr
1987
Massey
D
.
Problem of the Century
New York
Russell Sage
2001
314
44
Ousey
GC
,
Kubrin
CE
.
Exploring the connection between immigration and violent crime rates in US cities, 1980–2000.
Soc Probl
2009
56
447
73
CrossRef
Shihadeh
ES
,
Flynn
N
.
Segregation and crime: the effect of black social isolation on the rates of black urban violence.
Soc Forces
1996
74
1325
52
CrossRef
Peterson
RD
,
Krivo
LJ
.
Racial segregation and black urban homicide.
Soc Forces
1993
71
1001
26
CrossRef
Blumstein
A
.
Youth violence, guns, and the illicit-drug industry.
J Crim Law Criminol
1995
86
10
36
CrossRef
Fryer
RG
,
Heaton
PS
,
Levitt
SD
,
Murphy
KM
.
Measuring crack cocaine and its impact.
Econ Inq
2013
51
1651
81
CrossRef
Fleegler
EW
,
Lee
LK
,
Monuteaux
MC
,
Hemenway
D
,
Mannix
R
.
Firearm legislation and firearm-related fatalities in the United States.
JAMA Intern Med
2013
173
732
40
PubMed
CrossRef
PubMed
Crifasi
CK
,
Meyers
JS
,
Vernick
JS
,
Webster
DW
.
Effects of changes in permit-to-purchase handgun laws in Connecticut and Missouri on suicide rates.
Prev Med
2015
79
43
9
PubMed
CrossRef
PubMed
Rudolph
KE
,
Stuart
EA
,
Vernick
JS
,
Webster
DW
.
Association between Connecticut's permit-to-purchase handgun law and homicides.
Am J Public Health
2015
105
e49
54
PubMed
CrossRef
PubMed
Spicer
RS
,
Miller
TR
.
Suicide acts in 8 states: incidence and case fatality rates by demographics and method.
Am J Public Health
2000
90
1885
91
PubMed
CrossRef
PubMed
Miller
M
,
Azrael
D
,
Hemenway
D
.
The epidemiology of case fatality rates for suicide in the northeast.
Ann Emerg Med
2004
43
723
30
PubMed
CrossRef
PubMed
Siegel
M
,
Pahn
M
,
Xuan
Z
,
Ross
CS
,
Galea
S
,
Kalesan
B
.
et al
Firearm-related laws in all 50 US states, 1991-2016.
Am J Public Health
2017
107
1122
9
PubMed
CrossRef
PubMed
Moscicki
EK
.
Identification of suicide risk factors using epidemiologic studies.
Psychiatr Clin North Am
1997
20
499
517
PubMed
CrossRef
PubMed
Mościcki
EK
.
Epidemiology of completed and attempted suicide: toward a framework for prevention.
Clin Neurosci Res
2001
1
310
23
CrossRef
Centers for Disease Control and Prevention (CDC)
Alcohol and suicide among racial/ethnic populations—17 states, 2005-2006.
MMWR Morb Mortal Wkly Rep
2009
58
637
41
PubMed
PubMed
Wintemute
GJ
.
The epidemiology of firearm violence in the twenty-first century United States.
Annu Rev Public Health
2015
36
5
19
PubMed
CrossRef
PubMed
Logan
JE
,
Hall
J
,
McDaniel
D
,
Stevens
MR
.
Centers for Disease Control and Prevention (CDC)
Homicides—United States, 2007 and 2009.
MMWR Suppl
2013
62
164
70
PubMed
PubMed
Rossen LM, Bastian B, Warner M, Khan D, Chong Y. Drug poisoning mortality: United States, 1999–2016. National Center for Health Statistics. 2017. Accessed at www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality on 15 January 2018.
Cook
PJ
,
Rivera-Aguirre
AE
,
Cerdá
M
,
Wintemute
G
.
Constant lethality of gunshot injuries from firearm assault: United States, 2003-2012.
Am J Public Health
2017
107
1324
8
PubMed
CrossRef
PubMed
Arias
E
,
Schauman
WS
,
Eschbach
K
,
Sorlie
PD
,
Backlund
E
.
The validity of race and Hispanic origin reporting on death certificates in the United States
Vital Health Stat 2
2008
1
23
PubMed

This article was published at Annals.org on 24 April 2018.

Figure 1.

Comparison of firearm and nonfirearm homicide rates between black and white non-Hispanic men by U.S. state, 2008 to 2016.

Figure 2.

Comparison of firearm and nonfirearm suicide rates between black and white non-Hispanic men by U.S. state, 2008 to 2016.

Figure 3.

Relationship between the annual rates of firearm homicide and suicide among white men, by state, and reported household firearm ownership, 2008 to 2016.

Figure 4.

Relationship between the annual rates of firearm homicide and suicide among black men, by state, and reported household firearm ownership, 2008 to 2016.

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

This feature is available only to Registered Users

Subscribe/Learn More

PDF

Not Available

2018 American College of Physicians

Original Research |15 May 2018

Comparison of Rates of Firearm and Nonfirearm Homicide and Suicide in Black and White Non-Hispanic Men, by U.S. State Free

Abstract

Methods

Role of the Funding Source

Results

Comparison of Firearm Homicide Rates

Figure 1.

Comparison of Firearm Homicide Rates in Black Men Among States With the Largest Black Populations

Comparison of Nonfirearm Homicide Rates

Comparison of Firearm Suicide Rates

Figure 2.

Comparison of Nonfirearm Suicide Rates

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among White Men

Figure 3.

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among Black Men

Figure 4.

Discussion

References

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Clinical Slide Sets

This feature is available only to Registered Users

0 Comments

Related Articles

Journal Club

Related Point of Care

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

Original Research |15 May 2018

Comparison of Rates of Firearm and Nonfirearm Homicide and Suicide in Black and White Non-Hispanic Men, by U.S. State Free

Abstract

Methods

Role of the Funding Source

Results

Comparison of Firearm Homicide Rates

Figure 1.

Comparison of Firearm Homicide Rates in Black Men Among States With the Largest Black Populations

Comparison of Nonfirearm Homicide Rates

Comparison of Firearm Suicide Rates

Figure 2.

Comparison of Nonfirearm Suicide Rates

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among White Men

Figure 3.

Relationship of Firearm Homicide and Suicide to State Household Gun Ownership Among Black Men

Figure 4.

Discussion

References

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Clinical Slide Sets

This feature is available only to Registered Users

0 Comments

Related Articles

Journal Club

Related Point of Care

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

You need a subscription to this content to use this feature.