Small Towns Edge Out Big Cities in Firearm Death Rates, Study Shows

Firearm death rates increased in 2011-2020 compared with 2001-2010, largely due to an increase in gun suicides in rural counties, according to a cross-sectional time-series study.

From 2011 to 2020, the most rural U.S. county type had a 37% (95% CI 22-55) higher overall gun death rate compared with the most urban county type, up from the 25% (95% CI 9-43) higher rate seen in 2001 to 2010, reported Paul Reeping, PhD, of the Mailman School of Public Health at Columbia University in New York City, and colleagues.

During the later decade, the most rural counties had a 76% higher gun suicide death rate (up from 54% in the earlier decade) and a 46% lower gun homicide rate (down from 50%) compared with the most urban counties, they noted in JAMA Surgery.

"Just in terms of a person's risk for firearm death, it is actually lower, at least on the population level, in urban areas," Reeping told MedPage Today. "So that goes against the sort of narrative that cities are these dangerous places."

"Perhaps we should be talking about rural areas more in terms of firearm deaths, and especially in terms of suicides, since that is definitely the main method for the firearm death in those areas," he added.

Reeping said he and his team weren't expecting firearm deaths to be statistically more likely in small towns. "We were expecting there to not really be a significant difference between the urban and rural total firearm death [rates]. So it was sort of a surprise, actually."

In 2004, a similar study showed that rates of firearm deaths from suicide and homicide were similar in urban and rural counties from 1989 to 1999, with the rate of rural gun suicide deaths increasing. Reeping said his team's study showed a shift in national trends.

"It's not the blue areas, the urban areas, that are struggling, or that have the highest burden of firearm deaths per capita," he noted. "It is the rural areas, and the conversation is flipped ... the general public thinks that that's the opposite."

Joseph Sakran, MD, MPH, MPA, of Johns Hopkins University School of Medicine in Baltimore, who was not involved in the study, told MedPage Today that "there's this focus that's been on not just the urban settings, but also on the mass shootings that are happening," which account for only a tiny percentage of gun deaths.

"The point of the article is yes, of course there's tragedy that's happening in urban cities, but actually there are these small towns ... that are actually also experiencing intentional firearm deaths, and it's important for us to have those conversations to recognize it," he added.

Sakran pointed out that for every death from a gun, there are far more nonfatal gun injuries, which is another important component of firearm violence to quantify. He also noted that attempts at suicide with a firearm result in death much more often than other methods. "That lethality component is important to consider," he said.

According to Reeping, physicians in rural areas should provide more counseling on firearms, especially in situations where a patient might be having suicidal thoughts. "People think that suicide is something that's often planned, but it's actually not -- it's normally an impulsive act," he said. "Just the seconds in between somebody saying, 'I'm going to commit suicide,' to 'oh, I have to get the key to unlock the safe' -- that's sometimes enough for the person to decide not to do it."

"Even slight things that are done to make a firearm less available for an individual can have pretty substantial life-saving effects for that person in the future," he added.

The findings of this study could inform policy that places a greater focus on suicide prevention, including mental health counseling, but also enacting waiting periods for buying a firearm, or better storage of firearms, Reeping said.

Sakran also pointed to red flag laws and the expansion of background checks. These policies, when used together, "help build this web that allows us to move away from simply trying to focus on changing human behavior, which alone we know in and of itself is not cost-effective, and really trying to develop a system that makes it less likely for people to be injured and killed," he said.

Sakran added that health inequities don't always break down in obvious ways, and the rural-urban disparity in gun deaths are an example. "Not everyone has necessarily the same access to a trauma center that's equipped with all the resources," he noted. "Who's affected most often? It's these rural small towns."

For this study, the researchers used cause-of-death data files for gun homicides and suicides at the county level from the National Center for Health Statistics' National Vital Statistics System from 2001-2020. Counties in which these deaths occurred were assigned to one of nine categories, from most urban to most rural, using the U.S. Department of Agriculture Economic Research Service classification system, which factors in population and proximity to metropolitan areas.

They adjusted for median age, median income, percentage of white decedents, percentage of decedents below the federal poverty level, percentage of female-led households, percentage of decedents who completed high school, a measure of state-level gun laws, and fixed effects per year.

Reeping noted that access to emergency services and hospitals in rural areas could have played a role in higher gun death rates, but this issue of access did not get worse over time, in accordance with the death rates.

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