America’s top doctor issued a first-of-its-kind advisory on Tuesday declaring gun violence a national public health crisis and recommending it be treated as such.

The 40-page publication from U.S. Surgeon General Vivek Murthy outlines the scope of firearm violence, its impact on victims and communities and a slew of policy suggestions for lawmakers, community leaders and health systems.

A public health approach, Murthy said in the report, can guide the nation’s strategy and actions “as it has done in the past with successful efforts to address tobacco-related disease and motor vehicle crashes.”

“It is up to us to take on this generational challenge with the urgency and clarity the moment demands,” he added. “The safety and well‑being of our children and future generations are at stake.”

The advisory notes that firearm-related injury has been the leading cause of death for U.S. children and adolescents since 2020 — when it surpassed car accidents — and that ever-common instances of gun violence are taking not only a physical but also a mental toll on survivors, families and community members at large.

A recent national survey found that 54% of U.S. adults or their family members have experienced a firearm-related incident. And, linking gun violence to mental health, the advisory also notes that nearly 6 in 10 U.S. adults say they worry either sometimes, almost every day or daily about a loved one becoming a victim.

Some of the advisory’s recommendations — which, despite being strongly worded, are not enforceable — include increasing federal funding for gun violence prevention research, more community investment in educational programs and mental health resources and nationwide policy changes like an assault weapons ban and universal background checks.

Murthy, who has served as President Biden’s surgeon general since 2021, has issued advisories over the years warning about the risks of loneliness, health misinformation and social media on youth mental health.

But this is the first time the Office of the Surgeon General has ever published a warning focused on gun violence, a political minefield in the U.S.

The National Rife Association has long opposed the framing of gun violence as a public health issue and successfully lobbied for legislation that effectively froze federal funding into gun violence research over the last three decades. NRA opposition to Murthy, over his support for a federal assault weapons ban, also nearly cost him the nominationwhen then-President Barack Obama first picked him for the job in 2014.

The advisory comes after a second consecutive weekend of mass shootings across the U.S., two days before the first presidential debate between Biden and former President Donald Trump and a week after the Supreme Court upheld a federal ban on guns for domestic abusers, its first major gun ruling in two years.

The advisory lays out the problem …

The document begins by painting a grim picture of gun violence in the U.S.

Among the stark statistics: 48,204 people died from firearm-related injuries (including suicides, homicides and unintentional deaths) in 2022, after that number reached a near three-decade high the previous year.

The rate of firearm-related suicide grew by 20% between 2012 and 2022, with the highest increases among young people between 10 and 34 years old.

The advisory also notes the disproportionate impacts of gun violence across demographic groups.

Black Americans had the highest age-adjusted firearm homicide rates across all ages (27 per 100,000 in 2022). The firearm suicide rate was highest among white individuals older than 45 (14.8 per 100,000 in 2022) and American Indian and Alaska Natives under 45 years old (12.3 per 100,000).

Gun violence also disproportionately impacts veterans, male children and men — though firearms are used in about 50% of intimate partner violence-related homicides, of which more victims are female.

Mass shootings only represent about 1% of all firearm-related deaths in the U.S., but their number is increasing: The country experienced more than 600 mass shooting incidents each year between 2020 and 2023, according to the Gun Violence Archive. The organization defines a mass shooting as any incident in which four or more people are shot, not including the perpetrator.

The advisory also depicts the problem as uniquely American.

It points to 2015 data from the Centers for Disease Control and Prevention and World Health Organization that found the overall firearm-related death rate was 11.4 times higher in the U.S. compared to 28 other high-income nations.

It goes on to detail the collective toll that the exposure to gun violence takes, even on those who do not experience bodily harm themselves.

“There is increasing evidence that exposure to firearm violence can contribute to elevated stress levels and mental health challenges and threaten the sense of well‑being for entire communities,” it reads.

Examples include healthcare and community workers suffering secondary traumatic stress, adults avoiding certain places or events out of fear of a possible mass shooting, children experiencing long-term mental and behavioral problems, and a studied increase in psychiatric disorders among family members of victims.

… And prescribes recommendations

Murthy then discusses some of the factors that contribute to the problem, namely socioeconomic, geographic and racial inequities and the lethality and availability of guns, before recommending a “public health approach” to fixing it.

“A public health approach is designed to prevent and reduce harm by changing the conditions and circumstances that contribute to risk of firearm violence as measured by deaths, injuries, as well as the reverberating mental health and emotional impacts detailed in this Advisory,” it reads.

The advisory recommends more investment in firearm prevention research, which receives less federal funding than causes of death with relatively comparable mortality, like sepsis and drowning.

In the meantime, it says, communities can invest in interventions and educational programs to try to support populations with increased risk of gun violence involvement, including by organizing them into workplace safety trainings. It similarly recommends communities do more to increase access to quality mental health care, substance-use treatment and trauma-informed resources.

And, addressing public health leaders and policymakers, it suggests a number of prevention strategies that can “build distance in terms of time and space between firearms and people who are at risk of harming themselves or others.”

Those include requiring safe and secure firearm storage (including child access prevention laws), implementing universal background checks, banning assault weapons and large-capacity magazines for civilian use and regulating the safety of firearms like any other consumer products.

While some individual states have passed such laws, including requiring universal background checks, secure storage and red flag laws, Congress would need to act to make those recommendations a reality nationwide.

And even though a majority of Americans are in favor of stricter gun laws, as several 2023 surveys found, a deeply divided Congress has struggled to pass them. It passed its first major gun law legislation in 30 years in 2022, which Biden signed one month after the Uvalde school shooting. It extended background checks on prospective gun buyers between 18 and 21 years old and further incentivizes states to pass red flag laws, among other provisions.

Murthy’s advisory cites two examples of successful public health approaches in the past: tobacco use and motor vehicle safety.

They have contributed to a more than 70% decline in the prevalence of cigarette smoking among U.S. adults since the 1960s, and a more than 93% decrease in the mileage death rate over the past century, according to the report.

“Taking such an approach to firearm violence prevention has the potential to curb the alarming trends of firearm‑related injury and death in America and the resulting health impacts,” he adds.

How much power does an advisory have?

Calls to address gun violence as a public health issue rather than a political problem are not entirely new, and this advisory amplifies them even louder.

Tuesday’s publication was released alongside statements of support from 10 different medical, public health and children’s groups, applauding the advisory for raising awareness and calling for policymakers to act.

“Firearm violence is indeed a public health crisis, and the data now show it touches the majority of U.S. adults,” said the American Medical Association. “We applaud the Office of the Surgeon General for issuing this Advisory and for outlining an evidence‑based public health approach to addressing firearm violence.”

Opposition came from the NRA, which released a statement slamming the advisory as “an extension of the Biden Administration’s war on law-abiding gun owners” and blaming “a crime problem caused by criminals,” in a familiar refrain for the gun lobby.

Whether Tuesday’s publication will lead to legislation or policy changes at the state and federal level is unclear.

The advisory explains that is just that: “A public statement that calls the American people’s attention to an urgent public health issue.”

“Advisories are reserved for significant public health challenges that require the nation’s immediate awareness and action,” the introduction reads.

Advisories tend to be shorter and more urgent than the office’s full reports. Its landmark 1964 report on smoking and health for example, is credited with saving an estimated 8 million lives in half a century.

Dr. Deborah Prothrow-Stith, a physician who has spent decades defining youth violence as a public issue, used the analogy of cigarette smoking to explain prevention strategies in a 2023 interview with NPR.

She remembered how ubiquitous smoking was when she was younger, and that it took roughly half a century after the first report on its health effects for the public understanding to follow — and hopes something similar will happen with guns.

“It is time again to treat this epidemic, reduce our rates and stay with it,” she said. “We’ve done it before. We can do it again.”