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| Coalition to Stop Gun Violence (Photo credit: Wikipedia) |
JAMA. 2013;309(6):551-552. doi:10.1001/jama.2013.38.
The
tragic slaughter of innocents in Newtown, Connecticut, has horrified
and refocused the nation on the burden of gun violence. Each year in the
United States, more than 30 000 individuals are killed by guns1
(homicides, suicides, and unintentional fatalities)—85 deaths per day
plus many hundreds of nonfatal injuries. Gun homicide alone causes
11 000 deaths each year,1
more than all US troops killed throughout the last decade in Iraq and
Afghanistan. Remarkably, the 26 deaths in Newtown represent fewer gun
homicides than the daily US average.
The
Newtown shooting has rekindled a national discussion about gun policy.
Most proposals focus on gun ownership such as a ban on rapidly firing
assault weapons, piercing bullets, and high-capacity ammunition clips;
waiting periods for firearm purchases; and universal background checks
for all gun sales and transfers. This focus on gun ownership has been
controversial due to Second Amendment interpretations and regional,
partisan, and personal preferences. Although such commonsense
regulations on ownership warrant implementation, a broader public health
perspective is imperative. Gun violence arises from sociocultural,
educational, behavioral, and product safety issues that transcend gun
ownership alone. Addressing this crisis will require a comprehensive,
multidimensional strategy. Toward that end, much can be learned from
prior public health successes in changing the prevalence, social norms,
and cultures of harmful behaviors.2- 6
These major achievements—in the realms of tobacco, unintentional
poisoning, and motor vehicle safety—provide a set of evidence-based,
successful tactics for immediate application to gun violence (Table).
Between 1966 and 2010, the prevalence of cigarette smoking among US adults was reduced by more than half from 43% to 19%.7 This remarkable success was achieved by multicomponent approaches across a range of public health domains.2,4
For example, taxation produced better representation of long-term
societal costs in the purchase price of tobacco products and, crucially,
secured funding for prevention efforts. Existing federal and local
taxes on firearms and ammunition are neither comprehensive nor
representative of the true external costs of gun ownership.8
A new, substantial national tax on all firearms and ammunition would
provide stable revenue to meaningfully target gun violence prevention.
This revenue should fund a national endowment to benefit those harmed by
gun violence and their families; a sustained public awareness campaign
to increase gun safety, reduce gun violence, and assist in recognition
of at-risk individuals; and stronger enforcement of existing gun laws.
Such efforts would not necessarily be intended to reduce ownership, a
key regulatory and political distinction.
A
multicomponent initiative to modify sociocultural norms also played a
critical role in reducing tobacco use. Through much of the 20th century,
cinema, television, and advertisements glorified cigarettes as “symbols
of modernity, autonomy, power, and sexuality.”3
Strategic use of media, education, celebrities, peers, teachers, and
physicians served to shift sociocultural norms toward cigarettes as
symbols of “weakness, irrationality, and addiction.”3
An analogous campaign could equate gun violence with weakness,
irrationality, and cowardice. In today's society, US adults and
especially youth view a staggering amount of graphic violence in
television shows, commercials, movies, and video games, much of it
idolized and glorified. A generation ago, many popular movie heroes
smoked. Today, many movie heroes shoot at other people. To protect
children, current policies strictly restrict obscenities and sexual
imagery, yet remain permissive of gun violence. In a recent poll, 4 of 5
US adults agreed that decreasing depictions of gun violence in
television shows, movies, and video games would be “somewhat” or “very
effective” at preventing mass shootings; notably, this conviction spans
partisan lines.9
Efforts to prevent unintentional poisonings5- 6
afford additional off-the-shelf approaches for immediate application to
gun violence. These approaches include safety measures to limit access
to appropriate users, product changes to reduce toxicity potential,
routine education and counseling by physicians, and national networks
for education and prevention (Table).
Together, the Poison Prevention Packaging Act of 1970 and related
public health measures produced a remarkable 75% reduction in childhood
deaths from poisonings over a 20-year period.5
The public health strategy to reduce motor vehicle deaths offers further instructive analogies.3 Culminating years of effort, systematic safety standards3
were implemented for the driver (eg, education and licensing, speed
limits, seat belts and child seats, drunk-driving legislation), the
product (safety glass, collapsible steering columns, padded interiors,
shoulder seat belts, air bags), and the environment (crash cushions,
divided highways) (Table). Together, these sensible, comprehensive policies reduced death rates per mile of driving by more than 90%.3
Policy aimed exclusively at the individual perpetrator of gun violence
would be no more effective than a motor vehicle injury prevention
strategy focused only on the individual driver in a motor vehicle crash.
The
lessons from other public health successes do not mean that guns should
be equated with cigarettes. Tobacco at any dose harms when used as
intended, whereas guns can be used safely. The primary priority should
be reducing gun violence. This distinction between ownership and
violence is important for the design, focus, and implementation of these
strategies. Safety standards for gun ownership still represent one key
facet of a comprehensive approach—just as automobiles and medications
are widely used but are subject to sensible safety policies. A
coordinated, multidimensional public health strategy informed by other
public health successes will reduce the risk of future tragedies like
the Newtown shooting and the broader scourge of gun violence.
AUTHOR INFORMATION
Published Online: January 7, 2013. doi:10.1001/jama.2013.38
Conflict of Interest Disclosures:
The authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Dr Hemenway reported receiving
funding from the Joyce Foundation to conduct and disseminate research on
firearms. Drs Mozaffarian and Ludwig did not report any disclosures.
Funding/Support:
Dr Ludwig is supported in part by an endowment from Boston Children's
Hospital and career award K24DK082730 from the National Institute of
Diabetes and Digestive and Kidney Diseases.
Role of Sponsors: The funders had no role in the preparation, review, or approval of the manuscript.
Disclaimer:
The content of this Viewpoint is solely the responsibility of the
authors and does not necessarily represent the official views of the
National Institute of Diabetes and Digestive and Kidney Diseases or the
Joyce Foundation.
Additional Contributions:
We thank Frederick Lovejoy, MD (Boston Children's Hospital, Boston,
Massachusetts), for providing advice and encouragement. He received no
compensation for this contribution.
REFERENCES
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Mozaffarian D, Afshin A, Benowitz NL,
et al. Population approaches to improve diet, physical activity, and smoking habits. Circulation. 2012;126(12):1514-1563
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Hemenway D. The public health approach to motor vehicles, tobacco, and alcohol, with applications to firearms policy. J Public Health Policy. 2001;22(4):381-402
PubMed | Link to Article
PubMed | Link to Article
Institute of Medicine Committee on Reducing Tobacco Use. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: National Academies Press; 2007
Walton WW. An evaluation of the Poison Prevention Packaging Act. Pediatrics. 1982;69(3):363-370
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Lovejoy FH Jr, Robertson WO, Woolf AD. Poison centers, poison prevention, and the pediatrician. Pediatrics. 1994;94(2 pt 1):220-224
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Centers
for Disease Control and Prevention (CDC). Vital signs: current
cigarette smoking among adults aged ≥18 years—United States, 2005-2010. MMWR Morb Mortal Wkly Rep. 2011;60(35):1207-1212
PubMed
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Gallop Politics. To stop shootings, Americans focus on police, mental health. http://www.gallup.com/poll/159422/stop-shootings-americans-focus-police-mental-health.aspx. Accessed December 23, 2012
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