Curbing gun violence: lessons from public health successes.

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 guns' (homicides, suicides, and unintentional fatalities)—85 deaths per day plus many hundreds of nonfatal injuries. Gun homicide alone causes 11000 deaths each year,' 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 NewtoviTi 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 ov^mership 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 healdi successes in changing the prevalence, social norms, and cultures of harmful behaviors.^'* 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%.' This remarkable success was achieved by multicomponent approaches across a range of public health domains.•̂ •'* 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.^ 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."' Strategic use of media, education, celebrities, peers, teachers, and physicians served to shift sociocultural norms toward cigarettes as symbols of "weakness, irrationality, and addiction. "•' 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 stricdy 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.' Efforts to prevent unintentional poisonings'* 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.' The public health strategy to reduce motor vehicle deaths offers further instructive analogies.^ Culminating years of effort, systematic safety standards' were implemented for