Abstract
IMPORTANCE: Firearm suicides constitute a crisis in the US, accounting for more than half (55.4%) of all suicide deaths in 2023. Extreme Risk Protection Orders (ERPOs; ie, red flag laws) authorize temporary firearm removal from individuals deemed at high risk of harming themselves or others. While ERPOs are designed to reduce firearm-related suicides, whether they result in a net reduction in suicide deaths or shift firearm suicides to suicides by other methods remains an important but unresolved issue in determining their effectiveness. OBJECTIVE: To determine the association of ERPOs with firearm suicides and nonfirearm suicides in states with sufficient postpolicy data and no confounding firearm legislation that may bias findings on ERPO outcomes. DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, 2-way difference-in-differences event study analyses were conducted using county-level data from 2012 to 2022. All states that passed ERPO laws alone, with no other new firearm laws, from 2018 to 2020, and had at least 1 year post-ERPO laws during which no new firearm laws were passed were investigated. All states that had no existing ERPO laws and passed no new firearm legislation from 2016 to 2022 were used for comparison. The model accounted for staggered treatment timing, treatment heterogeneity, and key methodological assumptions. Data were analyzed between February 6 and October 9, 2025. EXPOSURE: State-level ERPO law passage. MAIN OUTCOMES AND MEASURES: County-level annual firearm suicides and nonfirearm suicides per 100 000 population, derived from Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. RESULTS: This study examined county-level data from 4 states passing ERPO laws alone (Massachusetts, New Jersey, New Mexico, and Rhode Island) compared with 8 that did not (Alabama, Alaska, Michigan, Minnesota, Nebraska, North Carolina, Pennsylvania, and South Carolina). ERPO passage was associated with a mean reduction of 3.79 firearm suicides per 100 000 population after 1 year (95% CI, -6.74 to -0.83; P = .01), equivalent to an estimated 675 suicides. With regard to nonfirearm suicides, no association was found in the year ERPO laws were passed (0.41; 95% CI, -1.21 to 1.94; P = .60) or in the next year (-2.45; 95% CI, -6.84 to 1.93; P = .27). CONCLUSIONS AND RELEVANCE: In this cohort study, ERPO laws in Massachusetts, New Jersey, New Mexico, and Rhode Island were associated with substantial reductions in firearm suicides, with no evidence of substitution with nonfirearm methods. These findings support ERPOs as targeted public health interventions to reduce firearm suicides without increasing suicides by other methods.