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Objectives. To estimate US public opinion, overall and by gun ownership status, about the public places where legal gun owners should be allowed to carry firearms. Methods. We fielded an online survey among 3949 adults, including an oversample of gun owners and veterans, in April 2015. We used cross-tabulations with survey weights to generate nationally representative estimates. Results. Fewer than 1 in 3 US adults supported gun carrying in any of the specified venues. Support for carrying in public was consistently higher among gun owners than among non–gun owners. Overall, support for carrying in public was lowest for schools (19%; 95% confidence interval [CI] = 16.7, 21.1), bars (18%; 95% CI = 15.9, 20.6), and sports stadiums (17%; 95% CI = 15.0, 19.5). Conclusions. Most Americans, including most gun owners, support restricting public places legal gun owners can carry firearms. These views contrast sharply with the current trend in state legislatures of expanding where, how, and by whom guns can be carried in public. Recent state laws and proposed federal legislation that would force states to honor out-of-state concealed carry permits are out of step with American public opinion.

Declines in cooking skills in the United States may contribute to poor diet quality and high obesity rates. Little is known about how Americans learn to cook or their support for cooking education policies. The objective of this study was to examine how Americans learn to cook, attributions of responsibility for teaching children how to cook, and public support for policies to teach cooking skills. We used a concurrent, triangulation mixed-methods design that combined qualitative focus group data (from 7 focus groups in Baltimore, MD (N = 53)) with quantitative survey data from a nationally representative, web-based survey (N = 1112). We analyzed focus group data (using grounded theory) and survey data (using multivariable logistic regression). We find that relatively few Americans learn to cook from formal instruction in school or community cooking classes; rather, they primarily learn from their parents and/or by teaching themselves using cookbooks, recipe websites or by watching cooking shows on television. While almost all Americans hold parents and other family members responsible for teaching children how to cook, a broad majority of the public supports requiring cooking skills to be taught in schools either through existing health education (64%) or through dedicated home economics courses (67%). Slightly less than half of all Americans (45%) support increasing funding for cooking instruction for participants in the Supplemental Nutrition Assistance Program (SNAP). Broad public support for teaching cooking skills in schools suggests that schools are one promising avenue for policy action. However, school-based strategies should be complemented with alternatives that facilitate self-learning. More research is needed to identify effective means of teaching and disseminating the key cooking skills and knowledge that support healthy eating.

Every year, gun violence imposes an unacceptable toll on people in the United States. In 2014, the most recent year for which final data are available, 33 599 people died from gun violence; the majority of these deaths were suicides (> 21 000 deaths), and firearm homicides accounted for more than 11 000 deaths.(1) Unintentional shootings, in which children are often the shooter or victim,(2,3) comprised more than 500 deaths in 2013.(1) In addition to firearm fatalities, in 2013, more than 84 000 people in the United States suffered from nonfatal gunshot wounds, including both injuries resulting in hospitalization and injuries that were treated in emergency rooms but did not require admittance to the hospital.(1) (Am J Public Health. Published online ahead of print January 21, 2016: e1-e3. doi:10.2105/AJPH.2015.303041). Language: en

In 2 recent cases—with important implications for public health practitioners, courts, and researchers—the US Supreme Court changed the landscape for judging the constitutionality of firearm laws under the Constitution's Second Amendment. In District of Columbia v Heller (2008), the court determined for the first time that the Second Amendment grants individuals a personal right to possess handguns in their home. In McDonald v City of Chicago (2010), the court concluded that this right affects the powers of state and local governments. The court identified broad categories of gun laws—other than handgun bans—that remain presumptively valid but did not provide a standard to judge their constitutionality. We discuss ways that researchers can assist decision makers.

Threatened by possible government regulation and critical public opinion, industries often undertake self-regulatory actions, issue statements of concern for public welfare, and assert that self-regulation is sufficient to protect the public. The food industry has made highly visible pledges to curtail children's food marketing, sell fewer unhealthy products in schools, and label foods in responsible ways. Ceding regulation to industry carries opportunities but is highly risky. In some industries (e.g., tobacco), self-regulation has been an abject failure, but in others (e.g., forestry and marine fisheries), it has been more successful. We examined food industry self-regulation in the context of other self-regulatory successes and failures and defined 8 standards that should be met if self-regulation is to be effective.

This installment of Law and the Public’s Health considers the role of the judiciary in advancing public health goals. Typically, public health policy advocacy efforts aim to affect the regulation and legislation produced by the executive and legislative branches of federal, state, and local government bodies. But one branch of government—the judiciary—is less frequently considered as a venue, which is a missed opportunity for public health. The goal of this article is to demonstrate the need and identify the strategies for what we call “public health advocacy in the courts,” defined as actions by public health professionals that inform and affect how courts approach matters that affect the public’s health. We first review the court’s traditional roles in defining and deciding public health-related matters and consider judicial actions in the areas of constitutional and administrative law, civil litigation, and criminal law. Within criminal law, we highlight the recent expansion of problem-solving courts as a new opportunity for public health professionals to engage with the criminal justice community in advancing prevention strategies to address public health issues such as substance abuse and intimate partner violence (IPV). We then discuss specific strategies by which public health professionals can engage as advocates in the criminal and civil judicial processes. We conclude by presenting public health advocacy in the courts as a natural extension of existing public health advocacy, and offer strategies for overcoming the obstacles that public health professionals may encounter when they engage in these efforts. The courts, both state and federal, have a profound influence on public health policy and practice. This installment of Law and the Public’s Health examines the nature and power of the judiciary in the area of public health law and policy, discussing some of the landmark cases that together both define and test the limits of governmental powers and the rights of individuals and private interests.

Context: The law is a powerful public health tool with considerable potential to address the obesity issue. Scientific advances, gaps in the current regulatory environment, and new ways of conceptualizing rights and responsibilities offer a foundation for legal innovation. Methods: This article connects developments in public health and nutrition with legal advances to define promising avenues for preventing obesity through the application of the law. Findings: Two sets of approaches are defined: (1) direct application of the law to factors known to contribute to obesity and (2) original and innovative legal solutions that address the weak regulatory stance of government and the ineffectiveness of existing policies used to control obesity. Specific legal strategies are discussed for limiting children's food marketing, confronting the potential addictive properties of food, compelling industry speech, increasing government speech, regulating conduct, using tort litigation, applying nuisance law as a litigation strategy, and considering performance-based regulation as an alternative to typical regulatory actions. Finally, preemption is an overriding issue and can play both a facilitative and a hindering role in obesity policy. Conclusions: Legal solutions are immediately available to the government to address obesity and should be considered at the federal, state, and local levels. New and innovative legal solutions represent opportunities to take the law in creative directions and to link legal, nutrition, and public health communities in constructive ways.

Obesity is widely recognized as a preventable cause of death and disease. Reducing obesity among adults and children has become a national health goal in the United States. As one approach to the obesity epidemic, public health practitioners and others have asserted the need to provide consumers with information about the foods they eat. Some state and local governments across the United States have introduced menu labeling bills and regulations that require restaurants to post information, such as calorie content, for foods offered on their menus or menu boards. A major dilemma is whether state and local menu labeling laws are preempted by the federal Nutrition Labeling and Education Act (NLEA). While few courts have addressed this issue, ongoing litigation in New York City provides an early glimpse of judicial interpretation in this area. This article explores these preemption issues, arguing that appropriately written and implemented menu labeling laws should not be preempted by the NLEA. We offer guidance for states and localities that wish to develop and implement menu labeling laws.

In the United States, firearms are involved in tens of thousands of deaths and injuries each year. The magnitude of this problem prompted the National Academy of Sciences (NAS) to issue a report in 2004 detailing the strengths and limitations of existing research on the relationship between firearms and violence. In response, a multidisciplinary group of experts in the field of firearms and violence formed the National Research Collaborative on Firearm Violence. The Collaborative met for 2 days in June 2005 to (1) critically review the main findings of the NAS report and (2) define a research agenda that could fill research and data gaps and inform policy that reduces gun-related crime, deaths and injuries. This article summarizes the Collaborative's conclusions and identifies priorities for research and funding.

In early 2006, 2 separate but virtually identical bills were introduced in the Virginia and West Virginia legislatures that would have profoundly affected the relationship between a physician and his or her patients. Each bill would have prohibited a physician from asking a patient if he or she owned firearms for the purpose of counseling that patient about ways to reduce risks associated with firearms. Penalties for violation of the bills included revocation of a physician's license to practice. The Virginia bill was initially approved by its state House of Delegates by a vote of 88 to 11. It was ultimately defeated in a Virginia Senate committee. The West Virginia bill did not receive a vote during the 2006 legislative session. Although neither bill became law this year, this type of bill is likely to reappear in future legislative sessions. The Virginia and West Virginia bills were contrary to the best-practices recommendations of medical societies, including the American Academy of Pediatrics. Anticipatory guidance regarding firearms can indeed reduce risks to patients. Yet, the bills would have preferred the judgment of legislators over physicians regarding this aspect of the practice of medicine. In addition, the 2 bills raise legal issues regarding both medical malpractice and the First Amendment protection of the freedom of speech. The Virginia and West Virginia bills would have treated risks associated with firearms differently from other hazards and interfered with a physician's ability to protect his or her patients. The Virginia bill was defeated, in part, through the efforts of physicians to educate legislators. However, physicians must remain prepared to respond to similar state legislative initiatives in the future.

Objectives. Our goal was to determine whether school-level variability in implementation of immunization requirements is associated with the likelihood of a child having received an exemption to school immunization requirements. Methods. We surveyed 1000 school immunization personnel in Colorado, Massachusetts, Missouri, and Washington. We explored associations between school implementation of immunization requirements and the likelihood of a child having an exemption using logistic regression models. Results. School policies associated with an increased likelihood of children having exemptions included lack of provision of written instructions for completing the school immunization requirement before enrollment, administrative procedures making it easier to claim an exemption, and granting of philosophical exemptions. In the 2 states we surveyed where philosophical exemptions are not authorized (Massachusetts and Missouri), 17.0% and 18.1% of schools reported permitting philosophical exemptions. Conclusions. Inconsistencies in the interpretation and implementation of school immunization laws contribute to variability in rates of exemptions. School policies should be reviewed to ensure consistency with the intent of state laws.

Senate Bill 1435, the “Prison Rape Elimination Act of 2003,” was introduced into the Senate on July 21, 2003, and in less than a week passed both the Senate and House by unanimous consent. The Bill was presented to President Bush on September 2, 2003, and he signed it two days later on September 4, 2003. The stated purposes of the Act are far-reaching and ambitious:(1)establish a zero-tolerance standard for the incidence of prison rape in prisons in the United States;(2)make the prevention of prison rape a top priority in each prison system;(3)develop and implement national standards For the detection, prevention, reduction, and punishment of prison rape;(4)increase the available data and information on the incidence of prison rape, consequently improving the management and administration of correctional facilities;(5)standardize the definitions used for collecting data on the incidence of prison rape

The public health community has long recognized unintentional gun injuries as a public health issue. In 1998 in the United States, 866 people died from unintentional gunshot wounds, resulting in a crude death rate of 0.32 per 100,000. Unintentional gun deaths have been declining since at least 1920, yet the reasons for this downward trend are not understood. Possible explanations, such as changes in gun ownership and demography, changes in access to guns among population subgroups, safety practices, and artifactual influences are discussed. Intervention strategies for reducing the risk of unintentional gun injury are also discussed.

New policy options are emerging in the debate regarding the regulation of firearms in the United States. These options include the treatment of firearms as consumer products, the design of which can be regulated for safety; denial of gun ownership to those convicted of misdemeanors; and strategies to curtail the illegal sale of guns. The public's opinion of these innovative gun-policy options has not been thoroughly assessed.We conducted two telephone surveys of 1200 adults each in the United States in 1996 and 1997-1998. Cognitive interviews and pretests were used in the development of the survey instruments. Potential participants were then contacted by random-digit dialing of telephone numbers.A majority of the respondents favored safety standards for new handguns. These standards included childproofing (favored by 88 percent of respondents), personalization (devices that permit firing only by an authorized person; 71 percent), magazine safeties (devices that prevent firing after the magazine or clip is removed; 82 percent), and loaded-chamber indicators (devices that show whether the handgun is loaded; 73 percent). There was strong support for policies prohibiting persons convicted of specific misdemeanors from purchasing a firearm. Support for such prohibitions was strongest for crimes involving violence or the illegal use of a firearm (83 to 95 percent) or substance abuse (71 to 92 percent). There was also widespread support for policies designed to reduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers (90 percent), a limit of one handgun purchase per customer per month (81 percent), and mandatory registration of handguns (82 percent). Even among the subgroup of respondents who were gun owners, a majority were in favor of stricter gun regulations with regard to 20 of the 22 proposals covered in the poll.Strong public support, even among gun owners, for innovative strategies to regulate firearms suggests that these proposals warrant serious consideration by policy makers.

Through their products and behaviours, corporations greatly influence the health of populations.1 2 Some corporations, such as pharmaceutical manufacturers, develop vaccines and life-saving medications, which are essential for protecting the public's health. Other corporations manufacture products that confer benefits to society but are also associated with hundreds of thousands of injuries and deaths each year. For example, despite certain required safety features, motor vehicles are associated with approximately 34 000 US deaths each year and over 1.2 million deaths globally.3 4 Firearms are associated with approximately 30 000 US deaths annually and over 200 000 deaths worldwide.5 6 Participation by injury prevention professionals in the policy-making process is an important strategy to reduce injuries associated with some corporate behaviours. Too often, corporations pursue increased profits even though this might elevate the injury risks their products pose. This was highlighted last year during a congressional hearing about Toyota Motor Corporation's response to concerns about uncontrolled sudden acceleration.7 During its investigation, a US House of Representative's committee received over 70 000 pages of Toyota documents.8 One document, a now publicly available July 2009 presentation, given by Toyota's president and CEO of North American operations, noted a ‘win’ because Toyota saved over US$100 million by negotiating with federal regulators for an ‘equipment’, or limited, recall of certain Camry and Lexus ES models due to uncontrolled sudden acceleration.9 This 2007 ‘equipment’ recall meant that Toyota saved millions of dollars because it was not required to repair the affected cars. Instead, Toyota recalled 55 000 floor mats that could ‘potentially [get] stuck under the accelerator pedal …

An organized campaign by groups such as the National Rifle Association has sought to convince policymakers and others that the Second Amendment to the US Constitution grants an unfettered right to individuals to possess any firearm, free from federal or state regulation. Although advocates may debate the meaning that should be given to the Second Amendment, under the American legal system the meaning of any particular constitutional provision is determined by the controlling precedent of Supreme Court cases. Two cases, Presser v Illinois and United States v Miller, remain the Supreme Court's latest word on the meaning of the Second Amendment. In Presser, the Court held that the Second Amendment is applicable only to federal, not state, laws. In Miller and subsequent federal cases, any Second Amendment "right" to bear arms is closely linked to the preservation of state militias, upholding a variety of federal gun legislation. Unless the Supreme Court modifies or reverses its Presser and Miller decisions, health advocates should understand that the Second Amendment poses no obstacle to even broad gun control legislation.

Firearm-related injuries are a substantial public health problem. A wide array of policies designed to prevent these injuries have been discussed, but few are enacted into legislation. Even fewer have undergone scientific evaluation for their effectiveness. We offer a nosology for categorizing existing and future gun policies. A brief review of the effectiveness of existing gun policies is presented, and an argument is made for redirecting gun policy.

Recently, the U.S. Supreme Court reached one of its most controversial decisions in years, in Citizens United v. Federal Election Commission. Lainie Rutkow and colleagues write that, with this decision, the Court has effectively opened the financial floodgates to give corporations unprecedented influence over the election of the people who determine health policy.

Law is one of the most effective tools of injury prevention. Legislation, regulation, and litigation have all been used successfully to reduce the toll of injuries. The article examines the full range of the law as it has been used to prevent injuries associated with all-terrain vehicles. The rise in popularity of such vehicles, the realization of the injuries associated with their use, and the law's response to their hazards provide a valuable case study of how the various aspects of the law can be used as tools for injury prevention.

We test the hypothesis that there are host or environmental factors that significantly affect the likelihood of alcohol involvement in drownings. Our results are based on records of 234 drownings that meet predetermined eligibility criteria designed to exclude cases with postmortem blood alcohol concentrations (BACs) that do not reflect the BAC at the time of immersion. Cases are drawn from a total of 442 drownings occurring in Sacramento County, California, from 1974 to 1985. Overall, 41% of deaths were alcohol-associated; among these only one victim was under 15 years old. Among older persons, increasing age generally suggested a higher likelihood of alcohol involvement, and particularly of a BAC greater than 200 mg/dl. Other associated factors were male gender (OR = 2.5; 95% CI = 1.6, 3.8), activity (for land motor-vehicle occupants vs. all others, OR = 3.3; 95% CI = 2.6, 4.3), and time of year (January-June vs. July-December, OR = 2.1; 95% CI = 1.6, 2.8). A lower likelihood of alcohol involvement was seen for drownings in bathtubs (OR = .16; 95% CI = .04, .57) and swimming pools (OR = .47; 95% CI = .27, .82). Race was not a factor. Differing eligibility criteria have been used in studies of alcohol and drowning. After a critical review of the experimental literature, we propose that the following be adopted in future such studies: (i) death must occur within six hours of the onset of immersion, unless an antemortem sample is available and, unless evidence to the contrary exists, death can be assumed to have occurred within a few minutes of immersion; (ii) blood must be drawn for BAC determination within 24 hours of death.

Corporations, through their products and behaviors, exert a strong effect on the wellbeing of populations. Public health practitioners and academics have long recognized the harms associated with some corporations’ products. For example, firearms are associated with approximately 30,000 deaths in the United States each year1 and over 200,000 deaths globally. Motor vehicles are associated with about 40,000 deaths in the United States each year and over 1.2 million deaths globally. Tobacco products kill about 438,000 people each year in the United States5 and about 4.9 million people worldwide. In addition to producing unsafe or harmful products, some corporations behave in ways that negatively impact the public’s health, such as marketing alcohol to youth and other vulnerable populations. Given these observations, one can conclude that it is possible to quantify the public health impact of individual industries, such as firearms, motor vehicles, tobacco, and alcohol. Health professionals can then target these individual industries to prevent or lessen the harms they cause.

The Maryland Gun Violence Act, enacted into law in 1996, explicitly authorized courts to order batterers to surrender their firearms through civil protective orders. It also vested law enforcement with the explicit authority to remove guns when responding to a domestic violence complaint. In order to assess how these laws were implemented, we designed a case study and collected data from in-depth, key informant interviews, court observations, and relevant documents. We present findings from this study and recommend how to increase the likelihood that policies designed to separate batterers and guns are implemented in a way that will result in greater protections for victims of domestic violence.

Summary Compulsory vaccination has contributed to the success of immunisation programmes in the USA and Australia, yet the benefits from compulsory vaccination are not universally recognised. Some people—experts and the public alike—believe that the benefits of compulsory vaccination are outweighed by the associated ethical problems. A review of vaccination legislation in the UK, Australia, and the USA raises four main points. First, compulsory vaccination may be effective in preventing disease outbreaks, reaching and sustaining high immunisation coverage rates, and expediting the introduction of new vaccines. Second, to be effective, compulsory programmes must have a reliable supply of safe and effective vaccines and most people must be willing to be vaccinated. Third, allowance of exemptions to compulsory vaccination may limit public backlash. Finally, compulsory vaccination may increase the burden on governments to ensure the safety of vaccines. Nevertheless, although compulsory immunisation can be very effective, it might not be acceptable in some countries where high coverage has been achieved through other approaches or efforts, such as in Sweden, Norway, Denmark, the Netherlands, and the UK. These factors should be considered when compulsory vaccinations are being introduced or immunisation laws refined. Lessons learned from compulsory vaccination could be useful to other public-health programmes.

Native American populations have long experienced excess morbidity and mortality attributable to alcohol. Historically, alcohol was introduced to the Native American population by European settlers, and was used to help those settlers get land and goods from the Indian population. In modern times, alcohol beverage makers and distributors continue to supply and market their products to Native American populations in amounts and manners that contribute to continuing health and safety problems. When some other products have been over-supplied or over-promoted to the detriment of the public's health, litigation has been brought against the makers or dealers of those products, sometimes using the legal theory of public nuisance. This article explores the potential for litigation brought by Native Americans against alcoholic beverage makers and distributors.

In 2002, the Baltimore City Health Department, in collaboration with the Baltimore Police Department and the Johns Hopkins Center for Gun Policy and Research, launched the Youth Ammunition Initiative. The initiative addressed Baltimore’s problem of youth gun violence by targeting illegal firearm ammunition sales to the city’s young people. The initiative included undercover “sting” investigations of local businesses and issuance of health department violation and abatement notices. Intermediate results included the passage of 2 Baltimore city council ordinances regulating ammunition sales and reducing the number of outlets eligible to sell ammunition. Although it is too early to assess effects on violent crime, the intervention could theoretically reduce youth violence by interrupting one source of ammunition to youths. More important, the initiative can serve as a policy model for health commissioners seeking to become more active in gun violence prevention efforts.

Compulsory vaccination has contributed to the enormous success of US immunization programs. Movements to introduce broad “philosophical/personal beliefs” exemptions administered without adequate public health oversight threaten this success. Health professionals and child welfare advocates must address these developments in order to maintain the effectiveness of the nation’s mandatory school vaccination programs. We review recent events regarding mandatory immunization in Arkansas and discuss a proposed nonmedical exemption designed to allow constitutionally permissible, reasonable, health-oriented administrative control over exemptions. The proposal may be useful in political environments that preclude the use of only medical exemptions. Our observations may assist states whose current nonmedical exemption provisions are constitutionally suspect as well as states lacking legally appropriate administrative controls on existing, broad non-medical exemptions.

For at least the past three decades, injuries have been recognized as an important public health problem in the United States. In 2001, there were approximately 157,000 deaths due to injuries in the US. There were also almost 30 million non-fatal injury incidents.Injuries have been defined as: “…any unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen”. Within public health, the field of injury prevention and control is dedicated to reducing the burden of injuries on the lives of people around the world.Injury prevention seeks to reduce injuries by: 1) identifying risk factors, 2) designing interventions to address the risk factors, 3) implementing those interventions, 4) evaluating their effectiveness, and 5) replicating those that work. As with many other public health problems, interventions can target factors associated with the human or host, vehicle or vector, and the physical or social environment.

In his editorial “A New Traffic Safety Vision for the United States,”1 Evans argues that litigation has harmed the US motor vehicle safety effort and that interventions focused on changing the behavior of drivers, rather than the safe design of vehicles, are “overwhelmingly” more important. Although one might not realize it from Evans’s editorial, the reduction in the risk of fatal motor vehicle crash is one of the major success stories of public health and injury prevention. From 1966 to 2001, the fatality rate per million vehicle miles traveled has declined by more than 70%.2 This reduction has been achieved not by a single-minded focus on driver behavior but through a combination of improving vehicle, roadway, and driver safety. But it is perhaps not surprising that Evans, having previously been a research scientist at General Motors for more than 30 years, seeks to deflect attention away from vehicle-related factors and toward the role of the driver. This focus is contrary to well-accepted public health principles of injury prevention, established by Haddon and others, that reducing the likelihood of injury in the event of a crash is a crucial strategy.3,4 In the pages of the Journal, Evans has previously expressed his feelings toward lawyers and litigation in even more pejorative terms: “Only the most gullible can imagine that any net good emerges from the resulting system, which lavishly supports a pestilence of avaricious lawyers.”5(p785) Actually, it is well documented that litigation against motor vehicle and other product manufacturers has made important contributions to public health, providing necessary incentives to make products safer.6–8 Evans also argues it is simply a “trivial truism” when litigation demonstrates that, had a car manufacturer made its product safer, “the outcome of a crash would have been different.”1(p1385) We doubt that the families of people killed in vehicles without safety devices such as air bags—especially during the period when General Motors and other car manufacturers fought the imposition of the federal standard requiring them— would agree. And from a population perspective, air bags are estimated to have saved well over 2000 lives in the United States since 19879—an accomplishment that is hardly trivial. Evans is correct to note that there remain too many deaths on US roadways each year. We see no reason why vehicle safety cannot continue to be improved while seat belt use and other driver-oriented interventions are also encouraged.

Injuries and the law are connected in many important ways. The law can be a powerful tool for reducing the risk of injury (1). Laws can compel certain individual behaviors, such as seatbelt use, and prohibit other behaviors, such as speeding, to protect the safety of us all. Laws can also require product manufacturers to design and market their products in a manner that will reduce the likelihood of injury. Product safety rules are enacted at all levels of government—federal, state, and local. Sometimes these laws, called statutes, are enacted directly by a legislature. Often, however, the details of safe design are delegated to administrative agencies, such as the National Highway Traffic Safety Administration (NHTSA) or the Consumer Product Safety Commission, for promulgation and enforcement. These administrative rulings are referred to as “regulations.” There is a substantial body of literature that evaluates the effectiveness of a variety of product safety statutes and regulations, and often they have been proven effective in controlling the risk of injury (1, 2).

Injury prevention experts have suggested that gun manufacturers could reduce youth violence by changing the design of guns. Product safety features could make guns more difficult for children to fire unintentionally and more difficult to use if stolen or obtained illegally. This article gives a brief history of efforts to make safer, smarter guns and assesses the potential of the product safety approach for reducing youth gun violence. Among the article's key findings: Research from the injury prevention field suggests that changing product design may be more effective in preventing injuries than trying to change personal behaviors; Existing product safety technologies for guns could reduce unintentional gun injuries, especially to young children. In addition, emerging technologies will enable gun manufacturers to "personalize" guns, which could prevent unauthorized users of any age from firing the weapons. Personalization could decrease access to guns by adolescents; Gun manufacturers have been slow to incorporate safety features into their products; but legislative, regulatory, and litigation efforts are under way to mandate safer guns. The authors envision a future when the law requires product safety features--including personalization--on all new firearms. These product safety features have the potential to reduce both intentional and unintentional firearm injury and death.

There is an urban/rural variation to gun deaths, with the highest firearm death rates being found in core metropolitan counties. These geographic variations in the severity of a significant public health problem suggest that regulation designed to address that problem might best be applied at the local level. The history of public health recognizes the effectiveness of home rule, and courts have generally upheld local legislation designed to address local problems. Specifically, courts have upheld local laws designed to reduce gun-related injuries. But recently many states have preempted localities from enacting gun laws, consigning exclusive jurisdiction of this subject to the state legislatures. This is largely the product of lobbying by the National Rifle Association. Such preemption laws represent a step backward for public health.

With the current progress of state firearm injury surveillance systems reported in this issue of the Journal, questions about the logical progression of these efforts are being raised. This article reviews the current state of firearm injury data, discusses the importance of firearm injury surveillance, and offers suggestions for maximizing the potential of future efforts in this area.

Faced with the national epidemic of gun violence, legislators should be especially sensitive to their constituents' support for various policy options. This support is best evidenced by well-conducted public opinion polls. We review public opinion polls on gun policy since 1987. Although the public support for a number of promising interventions targeting the design and manufacture of firearms has not been meaningfully investigated, strong support is evidenced for most other gun-control options. The public also believes, contrary to Supreme Court rulings, that the Second Amendment to the Constitution protects a broad individual right to bear arms.

Beginning with the swine flu litigation of the early 1980s, epidemiological evidence has played an increasingly prominent role in helping the nation's courts deal with alleged causal connections between plaintiffs' diseases or other harm and exposure to specific noxious agents (such as asbestos, toxic waste, radiation, and pharmaceuticals). Judicial reliance on epidemiology has high-lighted the contrast between the nature of scientific proof and of legal proof. Epidemiologists need to recognize and understand the growing involvement of their profession in complex tort litigation.

We present an epidemiologic characterization of deaths from motor vehicle immersions, based on 77 deaths in 63 motor vehicle immersions in Sacramento County, CA, during 1974-85. All persons were autopsied; all but one of the deaths were due to drowning. Average annual mortality rates per million person years were 12 for males, four for females, 30 for Hispanics, six for White non-Hispanics, Blacks and Asians. Seventy-one percent of drivers and 60 percent of passengers had a blood alcohol concentration greater than or equal to 22 mmol/L. Most cases (57 percent) had an Injury Severity Score of 1 (minor injury) or 0 (no injury). Alcohol use was associated with higher Injury Severity Scores. Road curvature of 20 degrees or greater was far more common at crash sites than at matched control sites one mile away (OR = 6.57, 95% CI = 2.93, 14.71). Guard rail placement along highly curved sections of roadway may be an effective preventive measure.

The Model State Emergency Health Powers Act (MSEHPA), written by request of the Centers for Disease Control and Prevention, has galvanized the debate around the appropriate balance between public health and civil liberties ([1][1]). R. Bayer and J. Colgrove are widely known scholars who seek to offer a neutral commentary (“Public health vs. civil liberties,” Policy Forum, 13 Sept., p. [1811][2]). However, some of their points require clarification. Focusing on a vocal minority of critics, the authors imply that MSEHPA has not been well received. Yet, 36 states have introduced legislation based, at least in part, on some provisions of the Act, with 20 states (and the District of Columbia) passing bills. The Secretary for Health and Human Services recommends that states use MSEHPA as a checklist to ensure legal preparedness for bioterrorism. The authors suggest that the Act provided a range of “extraordinary measures” that “radically enhanced the power of the state.” Yet, MSEHPA is based largely on existing state laws. Its powers regarding persons (e.g., testing, treatment, and isolation) and property (e.g., nuisance abatements and “takings,” i.e., the acquisition of private property by the state for legitimate governmental purposes) are a traditional part of state public health law. Nothing within MSEHPA is “extraordinary” or a “grave threat.” MSEHPA safeguards personal liberty by providing clear standards governing state power rather than relying on officials' discretion; ensures procedural due process rather than arbitrary actions without hearings; respects cultural, religious, and ethnic differences instead of tolerating discrimination; and entitles individuals to adequate information, basic treatment, and humane conditions during an emergency. What is the appropriate balance between individual rights and public goods in response to bioterrorism? Critics contend that no conflict exists. Past experiences, however, show that fighting serious health threats sometimes interferes with individual interests ([2][3]). Law alone cannot ensure that power is appropriately exercised; preparedness and competencies of judges, health officials, and citizens are essential. The Act offers clear criteria, fair procedures, and robust entitlements that are conspicuously absent from existing, antiquated infectious disease statutes. 1. [↵][4]1. L. O. Gostin 2. et al. , JAMA 288, 622 (2002). [OpenUrl][5][CrossRef][6][PubMed][7][Web of Science][8] 2. [↵][9]1. L. O. Gostin , Public Health Law: Power, Duty, Restraint (Univ. of California Press and Milbank Memorial Fund, Berkeley and New York, 2000). # Response {#article-title-2} We agree with Gostin and colleagues that “fighting serious health threats sometimes interferes with individual interests.” Indeed, this conflict has been at the heart of American public health and is reflected in the views of groups concerned with privacy rights and civil liberties who objected to provisions of MSEHPA in both its original and revised forms. Our intent was not to judge the validity of the claims made by MSEHPA's supporters or critics about the extent to which the act would or would not violate individual rights or about the extent to which the proposed legislation entails an advance over the current legal regime in terms of the rights that would be accorded to individuals in the face of a public health emergency. Rather, it was to describe an enduring tension that lies at the heart of public health in the United States and the resulting challenges that face those who attempt to strike a balance between privacy rights and the common good when crafting policy and law. It is, however, worth noting that organizations such as the New York Civil Liberties Union that have a historic commitment to liberty and privacy remain unconvinced by the analysis of the current legal regime undertaken by Gostin and colleagues, and by the remedy they offer ([1][10]). 1. [↵][11]New York Civil Liberties Union, “Testimony of Robert Perry on Behalf of the New York Civil Liberties Union before the Assembly Standing Committee on Health and the Assembly Standing Committee on Codes Concerning the Model State Emergency Health Powers Act,” 14 March 2002. 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