Gun Sellers Must Provide Information About Suicide Risk to Buyers at the Point of Sale
In Maryland Shall Issue, Inc. v. Anne Arundel County Maryland, 91 F.4th 238 (4th Cir. 2024), the Fourth Circuit Court of Appeals reviewed the U.S. District Court for the District of Maryland’s decision, finding constitutional an Anne Arundel County ordinance requiring gun and ammunition sellers to distribute educational material identifying gun ownership as a risk factor for suicide.
Facts of the Case
In 2018, a gunman opened fire and killed five individuals in a mass shooting at the Capital Gazette in Annapolis, Maryland. In an effort to address gun violence, Anne Arundel County (hereafter, the county) created a task force to examine how public health infrastructure might be used to minimize gun violence. The task force found that, between 2013 and 2017, 67 percent of deaths in the county caused by firearms were suicides and that the most common method of suicide was by self-inflicted gunshot wound. The county subsequently passed an ordinance in 2022 requiring the distribution of an educational pamphlet, coauthored by the National Shooting Sports Foundation and the American Foundation for Suicide Prevention, to educate “firearms retailers, shooting range operators and customers” (Anne Arundel County Maryland, p 243) on risk factors for suicide, including access to firearms. This pamphlet was to be posted in the store and provided after purchase, along with a separate flyer on conflict resolution.
Soon after the ordinance went into effect, the plaintiffs, four firearms retailers and a gun owners’ rights corporation, Maryland Shall Issue, Inc., filed suit against the county, seeking declaratory and injunctive relief and compensatory damages for what they argued was a violation of their First Amendment right not to speak against their own interests. The district court granted summary judgment to the county and, in the course of its ruling, excluded the plaintiffs’ expert witness report. The plaintiffs then appealed to the Fourth Circuit Court of Appeals.
The plaintiffs argued that the lower court inappropriately applied the standard for commercial speech established under Zauderer v. Office of Disciplinary Counsel of the Supreme Court of Ohio, 471 U.S. 626 (1985), which requires compelled commercial speech to be both “factual and uncontroversial.” They contested the application of Zauderer on two fronts, arguing that the pamphlet did not, in fact, qualify as commercial speech and that the content was not “factual and uncontroversial.” They argued that the lower court should have looked instead to National Institute of Family and Life Advocates v. Becerra, 585 U.S. 755 (2018) for guidance in its interpretation of the constitutionality of the county’s ordinance.
Ruling and Reasoning
In a unanimous decision authored by Judge Neimeyer, the Fourth Circuit Court of Appeals held that the pamphlet both qualifies as commercial speech and meets the standards established under Zauderer. It does not violate firearm retailers’ First Amendment right not to speak.
The opinion begins by affirming the lower court’s interpretation of the pamphlet. The plaintiffs asserted that the pamphlet’s content conveyed a causal relationship between gun ownership and suicide. Therefore, the plaintiffs argued, the pamphlet propagated an ideological view contrary to their interests that had the effect of “discouraging or demonizing the exercise of Second Amendment rights” (Anne Arundel County Maryland, p 245). The court rejected the plaintiffs’ causal interpretation of the pamphlet’s content and upheld the lower court’s decision to grant the defendant’s motion to exclude the plaintiffs’ expert’s report and testimony. The court found that “any reasonable reader” would interpret the pamphlet as simply seeking to address a public health concern by offering gun owners information on firearm safety.
In addition, the court rejected the plaintiffs’ argument that the pamphlet does not constitute commercial speech, finding that the pamphlet is clearly linked to the sale of a product and, much like warning labels on cigarettes or labeling on food products, “assists consumers and furthers the societal interest” (Central Hudson Gas and Electric Corporation v. Public Service Commission of New York, 447 U.S. 557 (1980), p 561). The court also dismissed the plaintiffs’ contention that the pamphlet was factually inaccurate and controversial, as this argument was based on an interpretation of the pamphlet (that guns have a causal relationship to suicide) that the court had already rejected. Consistent with an expert opinion submitted in support of the county, the court found that access to firearms as a risk factor for suicide was both factual and uncontroversial.
In light of these findings, the court held that the pamphlet qualifies as commercial speech, that the content of the pamphlet was “factual and uncontroversial” and that the pamphlet’s distribution was reasonably related to the county’s interest in reducing gun violence, including by suicide. Although not central to the plaintiffs’ argument against the constitutionality of the county’s ordinance, the Fourth Circuit also found that distribution of the pamphlet was not “unduly burdensome” to firearm retailers and therefore satisfied an additional criterion of constitutional compelled commercial speech established under Zauderer.
Ultimately, the Fourth Circuit ruled that the county’s ordinance was constitutional, adding further that the ordinance does not “discourage gun ownership or undermine Second Amendment rights” (Anne Arundel County Maryland, p 252) but rather welcomes gun dealers to participate in public health efforts to reduce gun violence.
Discussion
This case raises an important question: does the assertion that firearm ownership is a risk factor for suicide mean that firearm ownership causes suicide? The American Psychiatric Association (APA) defines suicide risk factors as “characteristics that make it more likely that an individual will consider, attempt or die by suicide” (APA. Suicide prevention [Internet]; 2023. Available from: https://www.psychiatry.org/patients-families/suicide-prevention. Accessed August 22, 2025). It is a definition asserting likelihood rather than causality. This distinction is key to the district court’s decision to exclude the plaintiffs’ expert witness report and testimony as well as the Fourth Circuit’s decision to uphold it.
Public health researchers seek to improve societal health by identifying risk factors that, when subject to public health intervention, can positively affect health outcomes. The county’s pamphlet, for example, outlined a number of risk factors for suicide, including firearm ownership, and provided resources for and educational materials on mitigating risk, including information on safe gun storage. The pamphlet is an example of a public health intervention that seeks to address risk factors for a specific health concern (in this case, suicide) to decrease the likelihood of a negative health outcome.
Risk factors, however, are not in and of themselves causal factors. The discrepancy between how risk factors are defined and the plaintiffs’ expert’s testimony (which asserted a causal interpretation of the pamphlet content) was sufficient for the court to find the expert’s opinion inadmissible. Because his testimony was excluded, the court did not need to directly address the key substance of the plaintiffs’ expert’s opinion that there is no “convincing” evidence to support the assertion that gun ownership increases the likelihood of a person committing suicide. And yet data to the contrary are robust.
An amicus brief submitted in support of the county summarizes current research on the relationship between suicide and firearm ownership (Brief for Matthew Miller and Deborah Azrael as Amicus Curiae Supporting Defendant-Appellee, Maryland Shall Issue, Inc v. Anne Arundel County, Maryland, No. 23-1351 (4th Cir. 2023)). It directly addresses the essence of the plaintiffs’ argument that risk lies with the gun owner, not the gun. Drs. Miller and Azrael present several key research findings to argue otherwise.
According to the Miller and Azrael report, a gun in the home carries an increased risk of suicide for all members of the household, not just the owner. The risk of an adolescent dying by suicide in a home with a gun, for example, is three times greater than that in a home without one. The likelihood that an as-yet-unidentified variable (an “antecedent factor” or unidentified confounder) better accounts for the magnitude of this increased risk is low. Several studies cited by Miller and Azrael provide additional supporting evidence. Suicide rates by methods other than firearms are more consistent across states, but firearm suicide rates are higher in places where there are more guns. The higher rate of suicide seen in firearm owners compared with nonowners is propelled by ownership of the firearm; the most robust data available do not support a finding of an elevated rate of suicide by other means in firearm owners. Furthermore, individuals owning guns are no more likely than nongunowners to have other risk factors for suicide.
In this case, the educational materials on suicide prevention produced by the county and distributed at the point of firearm sale included information on gun ownership as a risk factor for suicide. The research supports this information as both factual and uncontroversial. The Fourth Circuit agreed, allowing Anne Arundel County’s modest intervention to reduce firearm suicide to stand. The U.S. Supreme Court has subsequently declined to hear the case.
- © 2026 American Academy of Psychiatry and the Law
