Casino accessibility and suicide: A county‐level study of 50 US states, 2000 to 2016.

SUICIDE risk factors; SUICIDE; CROWDS; ECOLOGICAL research; RISK assessment; GAMBLING; LONGITUDINAL method; COMPULSIVE behavior

Background and Aims: Suicide is the tenth leading cause of death in the United States (US). Research over many decades identifies that its etiology is complex, with risk factors operating in multiple domains. One such risk factor is gambling. Over the past three decades, exposure to gambling has increased dramatically in the United States. The aim of this study was to measure the magnitude of the association between casino density and absolute risk of suicide in US counties. Design, Setting, Cases: This spatial panel analysis used data for 3131 counties from 50 US states from 2000 to 2016, for an overall sample of 53 227 county‐year units. Using Bayesian conditional autoregressive Poisson models, we measured incidence rate ratios and credible intervals for the association between the density per population of casinos and other gambling outlets and the incidence of suicide. Measurements: The outcome of interest was counts of suicides. The main exposures of interest were casinos and other gambling outlets. Findings A total of 527 401 suicides occurred during the study period. On average, there was a mean of 1.3 casinos (SD = 9.1) and 1.4 other gambling venues (SD = 5.9) in each county‐year. After controlling for confounding, the incidence rate ratio for casinos was 1.016, and the credible interval was between 1.010 and 1.023. Conclusions: The density of casinos and other gambling venues is positively associated with suicide mortality in the United States. [ABSTRACT FROM AUTHOR]

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