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Overall, deaths caused by guns rose to a three-decade high in 2021, driven by increases in homicides and suicides, the advisory says. In 2022, more than half of all gun deaths were from suicide, while 40% of firearms deaths were homicides.

Murthy, who has long sounded the alarm about the danger of firearms, said the impetus for Tuesday’s advisory stems from the increase in gun violence, especially mass shootings since 2020, which he said exact a profound toll on the nation’s well-being.

“I want people to understand the full impact of firearm violence in our country, and I want them to see it as a public health issue,� Murthy said in an interview. “I know it’s been polarizing, and I know it’s been politicized, but if we can see it as a public health issue, we can come together and implement a public health solution.�

As of 2020, firearm-related injuries had become the leading cause of death for children and adolescents ages 1 to 19 in the United States. Gun-related deaths for youths exceed those from vehicular accidents, cancer and heart disease.

“This isn’t just a law and order policing problem. We need a more public health approach to reducing and preventing gun violence,� said Alexander McCourt, who researches gun laws at the Johns Hopkins Center for Gun Violence Solutions.

Gun violence deaths are a uniquely American phenomenon — and an issue that medical groups and public health advocates have sought to address, often with limited success. In 2015, data from the federal Centers for Disease Control and Prevention and the World Health Organization showed that the United States had a firearm-related death rate 11.4 times higher than 28 other high-income nations. The disparity is even greater for the young: U.S. children up to age 14 accounted for 90% of all firearm-related injuries in that age group across the 29 countries in the study.

“We’re clearly the outlier and not in a good way,� Murthy said. “There are parents who are worried about dropping their kids off at school because of school shootings.�

The report argues for measures that put more space between firearms and people at risk of hurting themselves or those around them, including laws meant to prevent children from accessing guns, mandatory universal background checks for firearm transactions — including those given as gifts — and a ban on civilian use of assault weapons.

“We did a study a couple of years ago showing that states that had banned large capacity magazines had fewer mass shootings,� said David Hemenway, professor of health policy at the Harvard T.H. Chan School of Public Health and director of the Harvard Injury Control Research Center, which conducts firearms research. “And when they had the mass shootings, fewer people were killed.�

Despite the number of gun-related deaths in the United States, legislative efforts often impede implementation of stricter gun restrictions, the surgeon general’s advisory says, perpetuating loose regulations that contribute to the prevalence of mass shootings. Some research shows mass shootings are more likely to happen in states with looser gun laws, according to an analysis by the Harvard T.H. Chan School of Public Health.

“Even though we see a lot of effort at the state level, it doesn’t always translate because some states have strict laws bordering states with more relaxed laws so the laws may get diluted and aren’t as effective,� McCourt said.

Despite growing public sentiment favoring stronger firearm laws, gun groups, including the National Rifle Association, have long opposed stricter gun measures. In 2021, the NRA launched a $2 million campaign opposing President Biden’s efforts to bolster gun-control measures. The surgeon general’s advisory also met with criticism from the NRA.

“This is an extension of the Biden Administration’s war on law-abiding gun owners. America has a crime problem caused by criminals,� Randy Kozuch, executive director of the NRA Institute for Legislative Action, said in a statement. “The reluctance to prosecute and punish criminals on the part of President Biden and many of his allies is the primary cause of that. That’s a simple fact.�

The advisory on firearm violence arrives a week after the surgeon general issued a pronouncement on another major issue: social media. Murthy urged that warning labels akin to those on packs of cigarettes be applied to social media.

Jonathan M. Metzl, who has been researching gun violence for two decades, said that while he appreciates the advisory on firearm violence, framing it as a purely public health issue does not address deeper forces at play involving race and democracy.

“They said they’re going to use the same playbook as cigarettes, seat belts and other public health interventions. … It’s a mistake to think that people will think of guns the same way,� said Metzl, who directs the department of medicine, health and society at Vanderbilt University.

“For a long time, the NRA tapped into history that framed gun ownership as a privilege of Whiteness, and that wasn’t the case for cigarettes, and that wasn’t the case for cars,� Metzl said. “White gun owners are often coded as patriots, and Black gun owners code as threats or criminals.�

Tuesday’s report on gun violence highlights the effect of mass shooting deaths, which account for about 1% of all gun-related deaths, but the frequency of mass shooting incidents is increasing. Mass homicide events, which the advisory defines as four or more victims in addition to the perpetrator, affect a higher proportion of women, White people and children compared with other homicides.

The surgeon general’s advisory says high-schoolers exposed to campus shootings are 20% more likely to steer clear of school because of safety concerns compared with peers not exposed to shootings.

“I remember meeting with a group of high school students telling me that when they go for walks in their neighborhood, they hear gunshots all the time, and it makes them worry about walking in their own neighborhoods,� Murthy said.

Health insurance claims from 2007 to 2021 revealed that youths from birth to 19 who were injured by a gun experienced a 117% increase in pain disorders and a 68% increase in psychiatric disorders compared with youths not injured by gun violence.

The scourge of gun violence is not shared equally. The report cites a nationwide study conducted in 2019 at Northwestern University, which found that firearm homicides and poverty are intertwined, with rates of gun deaths 27% higher among residents living in poverty.

Murthy said he worries that the public does not appreciate the psychological trauma inflicted by pervasive gun violence.

There are “people who witness these events, or family members who suffer the loss of a loved one,� Murthy said. “All of them experience negative mental health outcomes.�

Black people in America face the highest risk of gun-related deaths at a rate of 27 per 100,000 compared with 6.2 for all other racial and ethnic groups combined. White people ages 45 and older have the highest rates of gun suicide at 14.8 per 100,000, while for those under age 45, American Indians or Alaska Natives have the highest rates of gun suicide at 12.3 per 100,000. Veterans also have significantly increased rates of suicide by gun.

The report calls for a public health approach to reducing firearm violence. The advisory advocates for increased funding of gun violence research to inform prevention strategies, which include community violence interventions. These interventions involve “credible messengers and practitioners� who prevent violent conflict by disseminating resources within communities, including health-care and employment services, according to the surgeon general’s advisory.

“If you think about health care being a touchpoint for many families … in the name of health and keeping folks safe, I think [doctors] have a major responsibility� for gun violence prevention, said Chethan Sathya, a pediatric trauma surgeon and director of Northwell Health’s Center for Gun Violence Prevention.

The advisory similarly advocates for increasing access to mental health services that help people cope with the trauma inflicted by firearm violence.

“We’ve taken on difficult public health challenges that were complicated … and by taking a thoughtful scientific public health approach, we were able to make real progress,� Murthy said.