John Yule, 53, manages Wildlife Sport Outfitters, a hunting and fishing supplies store on the edge of Manchester, N.H., and is “deeply involved in the Second Amendment community.”
But six years ago, while listening to a public radio story, Yule heard about a way he could tackle a familiar problem — the high rates of suicide in rural areas like some nearby in his state — through the New Hampshire Firearms Safety Coalition.
He decided to get involved.
Now he’s part of a team of people on the front lines — gun dealers like himself who, in many cases, claim a rural customer base — trying a simple but radical approach to curb rates of suicide, the nation’s 10th-leading cause of death.
Their methods involve noticing certain “tells” that indicate a customer is shopping for a firearm with suicide in mind. Their goal is to keep guns, the most common method of suicide, out of the hands of those they deem at risk.
“We’re not trying to step on anyone’s toes or deny them any rights. [But] you can guide them, or suggest to them or talk them into a different approach,” Yule said. He has these conversations only with people he believes are moving toward this tragic end.
A study, published Thursday in the American Journal of Public Health, underscores the need for such efforts.
Across the country, suicide rates are higher in rural areas than in urban centers. In 2015, rural communities saw 19 people per 100,000 kill themselves, compared with 11 per 100,000 in urban areas, according to the federal Centers for Disease Control and Prevention’s injury statistics database.
Researchers from Johns Hopkins Bloomberg School of Public Health in Baltimore used the state medical examiner’s data tracking all suicide-related deaths to tease out the role firearms play in this disparity. They analyzed a sample of about 6,200 Maryland residents, age 15 and older, and found that when gun-related suicides were excluded, there was no significant difference in rates between rural and urban areas.
“This does point to the important role that guns play in the rural suicide rate,” said Paul Nestadt, a postdoctoral student at Hopkins and the study’s lead author. “It also suggests where we might focus public health.”
Researchers — both involved with the study and unaffiliated — said these findings have national significance, even though Maryland has a lower suicide rate than other states and access to mental health care is better in rural Maryland than in other states’ rural areas.
More analysis is needed, but many said the study provides more evidence that preventing rural suicides means tackling the problem of suicide-by-firearm.
Gun ownership is more common in rural parts of the country, which may explain why researchers detected the striking rural-vs.-urban difference in suicide rates. But that speaks to another challenge. Limiting firearm-related suicide means limiting access to firearms — which can generate a lot of pushback.
“We’re up against something really difficult in the United States, because the key to success is proper storage, or removal of firearms from homes where somebody has a mental illness or is imminently suicidal,” said Jameson Hirsch, an associate professor of clinical psychology at East Tennessee State University, who researches suicide prevention but was not involved with this study. “[But] it’s such a tough sell. … You want to respect people’s rights.”
Still, suicide attempts that involve a firearm are the most likely to end in death.
“In rural areas, we need to be aware of the outsize role that gun safety and availability play,” Nestadt said. “If we fail to recognize the role of guns in suicides, we are missing an opportunity to prevent death.”
From a legislative or regulatory standpoint, though, it’s tough to effect real change, noted Alan Morgan, executive director of the National Rural Health Association. Proposals for any government action related to firearms are politically loaded, he added.
That difficulty makes room for initiatives like the one in New Hampshire, which has inspired similar efforts in Colorado and Maryland.
Gun shops, after all, have particular sway in these areas: A 2016 report from the Violence Prevention Center noted that firearm retailers are most common per capita in highly rural states, such as Wyoming, the Dakotas and Iowa. Beyond just training staff to be watchful, many gun shops keep educational materials in their stores. At Yule’s, there are suicide prevention advice cards, and pamphlets that recommend gun owners store firearms off-site when someone at home is at risk.
Those sound like small steps — and detractors argue that if guns became more difficult to obtain, people who want to commit suicide would use other means. But research shows that making it harder for a suicidal person to lay hands on a weapon — even by telling the customer to go home and come back later, or by refusing the transaction — can make all the difference.
With more barriers, a person’s impulse to kill oneself can pass, or they may use other means, such as pills, that have lower fatality rates. And, research shows, if an attempt is foiled, that person is ultimately less likely to die by self-harm.
That’s the logic behind New Hampshire’s effort. But it will take years before the project or its emulators can show a quantitative impact, said Elaine Frank, who co-chairs the New Hampshire initiative.
Plus, it gets at only part of the problem — stopping possibly at-risk people in the gun shop is “low-hanging fruit,” she said. Data is hard to come by, but it appears that most people who use guns for suicide have had them for more than a week. That, she said, means more public education is needed to teach people how to recognize mental illness and even temporarily remove firearms when appropriate.
Those kinds of efforts are particularly important, suggest the Hopkins paper’s authors. But, Nestadt emphasized, in isolation they won’t be enough. Some other potential approaches: improving access to mental health care, destigmatizing depression, limiting access to other methods of self-harm and encouraging doctors to broach suicide prevention with their patients.
“We’re talking about everything you can do on every side. No one thing is going to fix everything,” he said. “Anything we can do to chip away at this national problem, the better.”