Gunsmoke Changing Public Attitudes toward Smoking and ... - NCBI

Editorials, Annotations, Comments

and/or spermicides as a dual-purpose method, and to use them consistently, the levels of both unintended pregnancy and sexually transmitted infection would decline.'4 Certainly, this hypothesis is testable through observational, and possibly experimental, designs oriented to young, sexually active persons. The wider availability of emergency contraception will have a positive public health impact in two ways: first, by reducing the burden of unintended pregnancies; second, to the extent it increases use of barrier methods, by decreasing the overall level of STD/HIV within the community. Emergency contraception is reproductive health in the medicine cabinet. D Willard Cates, Jr Elizabeth G. Raymond Family Health International Research Triangle Park, NC

References 1. Harlap S, Kost K, Forrest JD. Preventing Pregnanci; Protecting Health: A New Look

2.

3.

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5.

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at Birth Control Choices in the United States. New York, NY: The Alan Guttmacher Institute; 1991. Trussell J, Leveque JA, Koenig JD, et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health. 1995;85:494-503. Mosher WD, Bachrach CA. Understanding U.S. fertility: continuity and change in the national survey of family growth, 19881995. Fam Plann Perspect. 1996;28:-12. Brown SS, Eisenberg L, eds. The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, DC: National Academy Press; 1995. Harrison PF, Rosenfield A, eds. Contraceptive Research and Development: Looking to the Future. Washington, DC: National Academy Press; 1996. Trussell J, Stewart F, Guest F, Hatcher RA. Emergency contraceptive pills: a simple proposal to reduce unintended pregnancies. Fam Plann Perspect. 1992;24:269-273. Hatcher RA, Trussell J, Stewart F, Howells S, Russell CR, Kowal DA. Emergency Contraception: The Nation s Best Kept Secret. Atlanta, Ga: Bridging the Gap

Communications; 1995. 8. Trussell J, Koenig J, Ellertson C, Stewart F. Preventing unintended pregnancy: the cost-

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effectiveness of three methods of emergency contraception. Am J Public Health. 1997;87:932-937. Trussell J, Ellertson C, Stewart F. The effectiveness of the Yuzpe regimen of emergency contraception. Fam Plann Perspect. 1996;28:58-64,87. Robinson ET, Metcalf-Whittaker M, Rivera R. Introducing emergency contraceptive services: communication strategies and the role of women's health advocates. Int Fam Plann Perspect. 1996;22:71-80. Stein Z. Family planning, sexually transmitted diseases, and the prevention of AIDSdivided we fail? Am J Public Health. 1996;86:783-784. Feldblum PJ, Morrison CS, Roddy RE, Cates W Jr. The effectiveness of barrier methods of contraception in preventing the spread of HIV. AIDS. 1995;9(suppl A):S85S93. Hatcher RA, Stewart F, Trussell J, et al. Contraceptive Technology. 16th ed. New York, NY: Irvington Publishers; 1994. Cates W Jr. Contraception, unintended pregnancies, and sexually transmitted diseases: why isn't a simple solution possible? Am J Epidemiol. 1996; 143:311-318.

Comment: Gunsmoke Changing Public Attitudes toward Smoking and Firearms Forty years ago Hollywood glamorized cigarettes, and half of all Americans smoked. Then, in the early 1950s, a series of case-control studies were published that suggested a strong association between cigarette smoking and lung cancer. '4 Over the next 12 years, large cohort studies confirmed this finding.5-8 As the evidence for a link between cigarette smoking and lung cancer grew stronger, public attitudes about smoking began to change.9 Today, fewer Americans smoke, and the rate of death from smokingrelated diseases has declined.01'2 Progress did not come without a fight. Powerful economic and political interests were threatened by this research. Studies of the relationship between smoking and lung cancer were criticized by doctors as well as spokesmen for the tobacco industry. Efforts to fool the public continue to this day.9 In this issue of the Journal, epidemiologists Cummings and colleagues at the University of Washington report the results of another case-control study with important implications for public health. Although their methods are the same as those used to detect the association between cigarette smoking and lung cancer, the topic is different. The risk 910 American Journal of Public Health

factor of interest is ownership of a handgun. The disease is violent death.'3 The authors' finding-that ownership of a handgun is associated with a significantly increased risk of suicide and homicide-is consistent with the results of five previous case-control studies.'4-'8 Taken together, these studies support the notion that access to a firearm increases the likelihood that an assault or suicide attempt will end in death.'9'20 They also suggest that the risks associated with keeping a gun in the home outweigh the potential benefits. Information of this sort is vital to home owners who want to keep themselves and their families safe. Fear of crime is widespread. Many people believe that keeping a gun for protection is a reasonable precaution.2 V23 The firearms industry reinforces this view with advertisements that imply that a home is not "safe" unless it is protected by a handgun.24 Ironically, the evidence points to the contrary. 14-18,25,26 Almost half of all homes in America contain one or more firearms.21 People who own a gun for protection often keep the weapon loaded and readily available, so it can be reached in a moment of need.27 Unfortunately, the gun that is kept

unlocked and loaded can also be reached by a curious child, an angry spouse, or a distraught teen. The odds that a gun in the home will someday be involved in a suicide, a homicide, an assault, or an accidental shooting are substantially greater than the odds that it will ever be used to shoot an intruder.25'26'28 Critics point out that it is not necessary to fire a gun to use it for self-defense. Intruders can be frightened off by the threat or display of a firearm. Proponents of guns for self-defense argue that the prospect of encountering an armed home owner is enough to deter many would-be intruders.22 However, the presence of a gun in the home does not guarantee that it will be reached when needed or used effectively when reached. A study of 197 home invasion crimes in Atlanta revealed that a gun was used to repel the intruder in only 3 instances (1.5%). In 6 cases the intruder reached the home owner's gun first or seized it during a scuffle with the victim.29 Using pooled data from 9 years of the National Crime Editor's Note. See related article by Cummings et al. (p 974), editorial by Morgenstern (p 899), and commentary by Webster et al. (p 918) in this issue.

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Victimization Survey (1979 through 1987), Cook calculated that only 3.1 % of burglaries of occupied households were resisted with a gun.'9 Between 1987 and 1992, an average of 62 200 victims each year reported that they used a gun to defend themselves from violent crime.30 Another 20 300 each year used a gun to defend property. During this same interval, approximately 341 000 victims per year lost one or more firearms to burglary or theft. Almost 80% of the weapons were taken from the home of the victim. Gun industry claims about the value of handguns for home defense are reminiscent of the early days of tobacco advertising, when cigarette companies extolled the health benefits of smoking.9 When scientific research demonstrated that there were no health benefits, defenders of smoking claimed that the soothing effect of the product outweighed any potential for harm. Recently, sociologist James Wright advanced a similar argument for the merits of gun ownership: Many guns are also owned for selfdefense against crime, and some indeed are used for that purpose; whether they are actually any safer or not, many people certainly seem to feel safer when they have a gun.... The only sensible response to the argument that guns provide only an illusion of security is, So what?2I(p65)

Mounting evidence of the health consequences of smoking did not deter tobacco executives from declaring research findings inconclusive.9 Some in the industry found it useful to accuse public health researchers and advocates of extremism. Between 1974 and 1979, a spokesman for the Tobacco Institute traveled around the country making the following claim: [A] widespread antitobacco industry is out to harass sixty million Americans who smoke and to prohibit the manufacture and use of tobacco products.... Outrageous and medically unsubstantiated assertions made by well-financed and highly organized groups opposed to smoking are disputed by many men and

of science.3' Critics of firearm injury research are taking a similar line of attack. Consider the following quote from an article entitled "Guns and Public Health: Epidemic of Violence or Pandemic of Propaganda?": Based on studies, and propelled by women

leadership from the Centers for Disease Control and Prevention (CDC), the objective has broadened so that it now includes banning and confiscation of all

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handguns, restrictive licensing of owners of other firearms, and eventual elimination of firearms from American life, excepting (perhaps) only a small elite of extremely wealthy collectors, hunters or target shooters.32(P514)

Although there are many parallels between the early days of smoking research and the current state of research on firearms, there are also important differences. Smokers choose to start smoking, but they do not choose to contract lung cancer or heart disease. People who attempt suicide or homicide with a handgun do so to accomplish a goal. The decision to employ such a lethal method probably reflects both the strength of the individual's intent and the immediate accessibility of the weapon.'8" 9 Another difference resides in the nature of the evidence. A case-control study can detect a statistical association between a hypothesized risk factor and a health outcome, but it cannot prove causation. Although the epidemiological evidence of a causal relationship between smoking and lung cancer was overwhelming, the biological basis for the link remained obscure for many years.33 The biological basis for the link between firearms and violent death is as obvious as a gunshot wound to the head. The medical community's response to firearms has differed from its initial response to studies of tobacco use. In the early years of research on smoking and health, a number of prominent physicians and professional organizations derided or ignored study findings. Efforts to mobilize doctors to oppose smoking took years.9 In contrast, most of the nation's leading medical and public health organizations have already adopted position statements on firearm safety.34(PP35-37)41 Several are actively working to reduce the public health impact of gun injuries.42"5 To counter evidence of a link between smoking and lung cancer, the tobacco industry created a highly publicized program of industry-sponsored research.9 Opponents of public health research on firearms, on the other hand, are attempting to suppress further work in the field. The bulk of their attention has been focused on the Centers for Disease Control and Prevention (CDC).4647 During the last congressional session, lobbyists for the National Rifle Association urged Congress to terminate funding of the CDC's National Center for Injury Prevention and Control.48 Although this effort was ultimately unsuccessful, the House of Representatives voted to cut

$2.6 million from the Center's budget. This is precisely the amount of money the CDC spent on firearm injury research last year. Funding was restored in joint conference committee, but the money was earmarked for traumatic brain injury. The net effect was a sharp reduction in support for firearm injury research. To ensure that officials at the CDC got the message, the following language was added to the final appropriation: "[N]one of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control."49 Exactly what will and will not be permitted under the terms of this appropriation is unclear. Does it mean the CDC must stop reporting trends in firearmrelated mortality? Should the CDC curtail efforts to identify and evaluate promising strategies to prevent gunshot injuries? Would promotion of safe storage of guns and ammunition in the home constitute advocacy of gun control? Will anyone at the CDC risk his or her career to find out? This may not be the first time that a special interest group has been able to constrain the actions of a public health agency, but it is arguably the most egregious. If the CDC is effectively barred from funding gun safety research, private foundations and health care organizations must step in to fill the gap. One of the most important studies in the early days of tobacco research was conducted by the American Cancer Society, a private nonprofit organization.8 The study that appears in this issue of the Joumal was funded by the Group Health Foundation. 13 Lack of funding is not the only obstacle to firearm injury research.50 Lack of data is another concem. In contrast to the wealth of information about lung cancer, sources of data for research on firearm injuries are woefully inadequate.5' Just as public health researchers are learning to link public safety data sets to health records, some state legislatures are taking steps to close off this line of research. In Washington State, handgun registration files are no longer accessible to epidemiologists like Cummings and

colleagues.52 Those who want quick progress on firearm injuries are doomed to disappointment. Despite 4 decades of scientific discovery about the health consequences of smoking, the tobacco lobby is alive and well.53 Millions of Americans still smoke, and hundreds of thousands die each year from tobacco-related diseases.54 American Journal of Public Health 911

Editorials, Annotatons, Comments

It will not be any easier to reduce firearm violence in the United States.55 Violence, like cancer, is both multifactorial and difficult to treat.56 Some of its most powerful causes-poverty, ignorance, racism, drug and alcohol abusewill take a long time to change. Guns in themselves do not increase or decrease the general level of violence in a community. However, access to a gun appears to amplify the consequences of violence when it occurs.19'57 All of these factors must be addressed if we are going to make a lasting impact on violence in America. Nonetheless, there is cause for hope. Deaths and injuries from firearms can be prevented.58 Promising interventions have been identified.59 Those that are implemented must be rigorously evaluated.56'57 Today, Hollywood glamorizes gun violence, and nearly half of all American homes contain one or more firearms. Although the public remains sharply divided over the issue of gun control, attitudes about handguns are beginning to change. New research is challenging long-held assumptions. Perhaps, one day, fewer Americans will choose to keep or carry a handgun, and the rate of death from firearm-related injuries will decline. [l Arthur L KeUermann

School of Public Health and School of Medicine Emory University Atlanta, Ga

References 1. Schreck R, Baker LA, Ballard G, et al. Tobacco as an etiological factor of cancer. CancerRes. 1950;10:49-58. 2. Doll R, Bradford Hill A. A study of the aetiology of carcinoma of the lung. BMJ.

1952;4797:1271-1286.

3. Wynder EL, Graham EA. Tobacco smoking as a possible etiologic factor in bronchogenic carcinoma. JAMA. 1950;143: 329-336. 4. Levin M, Goldstein H, Gerhardt PR. Cancer and tobacco smoking: a preliminary report. JAMA. 1950;143:336-338. 5. Doll R, Bradford Hill A. The mortality of doctors in relation to their smoking habits. BMJ. 1954;4877: 1451-1455. 6. Doll R, Bradford Hill A. Lung cancer and other causes of death in relation to smoking. BMJ. 1956;5001:1071-1081. 7. Doll R, Bradford Hill A. Mortality in relation to smoking: ten years' observations of British Doctors. BMJ. 1964;1: 1399-1410. 8. Hammond BC, Horn D. Smoking death rates-report on forty-four months of follow-up of 187 783 men. JAMA. 1958;

166:1294-1308.

9. Kluger R. Ashes to Ashes: America's Hundired-Year Cigarette War, the Public Health, andl the Unabashed Triumph of

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Philip Morris. New York, NY: Alfred A. KnopfInc; 1996. 10. Goldman L, Cook EF. The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle. Ann Intern Med. 1984;101:825-836. 11. Travis WD, Lubin J, Ries L, Devesa S. United States lung carcinoma incidence trends: declining for most histological types among males, increasing among females. Cancer: 1996;77:2464-2470. 12. Garfinkel L, Mushinski M. Cancer incidence, mortality and survival: trends in four leading sites. Stat Bull Metropolitan Insurance Companies. 1994;75:19-27. 13. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The association between the purchase of a handgun and homicide or suicide. Am J Public Health. 1997;87:974-978. 14. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry. 1988;45:581-588. 15. Brent DA, PerperJA, Allman CJ, et al. The presence and accessibility of firearms in the homes of adolescent suicides: a casecontrol study. JAMA. 1991;266:29892995. 16. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent suicide: a community-based case-control study. Am J Dis Child. 1993; 147:1066-1071. 17. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med. 1992;327:467472. 18. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med.

1993;329:1084-1091. 19. Cook PJ. The technology of interpersonal violence. In: Tonry M, ed. Crime and Justice: A Review ofResearch. Chicago, Ill: University of Chicago Press; 1991;14:171. 20. Kellernann AL. Do guns matter? West J Med. 1994;161:614-615. 21. Wright J. Ten essential observations on guns in America. Society. March/April

1995;63-68. 22. Kleck G. Crime control through the private use of armed force. Soc Probl. 1988;35:122. 23. Quigly P. Armed and Female. New York, NY: E.P. Dutton; 1989. 24. Vernick JS, Teret SP,Webster DW. Regulating firearm advertisements that promise home protection: a public health intervention. JAMA. 1997;277:1391-1397. 25. Kellermann AL, Reay DT. Protection or peril? An analysis of firearm-related deaths in the home. NEnglJMed. 1986;314:15571560. 26. Lee RK, Waxweiler RJ, Dobbins JG, Paschetag T. Incidence rates of firearm injuries in Galveston, Texas, 1979-1981. Am JEpidemiol. 1991;134:511-521. 27. Weil DS, Hemenway D. Loaded guns in the home: analysis of a national random survey of gun owners. JAMA. 1992;267: 3033-3037. 28. Kellermann AL, Rivara FP, Lee RK, et al.

Injuries due to firearms in three cities. N Engl JMed. 1996;335:1438-1444. 29. Kellermann AL, Westphal L, Fischer L, Harvard B. Weapon involvement in home invasion crimes. JAMA. 1995;273:17591762. 30. Rand MR. Guns and Crime: Handgun Victimization, Firearm Self-Defense, and Firearm Theft. Crime data brief. Washington, DC: US Dept of Justice, Bureau of Justice Statistics; April 1994. NCJ-147003. 31. Dwyer WF. Quoted by: Kluger R. Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York, NY: Alfred A. Knopf Inc; 1996:468. 32. Kates D, Schaffer HE, Lattimer JK, Murry GB, Cassem EW. Guns and public health: epidemic of violence, or pandemic of propaganda? Tenn Law Rev. 1995;62:513596. 33. Denissenko MF, Pao A, Tang M, Pfeifer GP. Preferential formation of benzo[alpyrene adducts at lung cancer mutational hotspots in P53. Science. 1996;274:430432. 34. Firearms. Policy Summaries 1995. Dallas, Tex: American College of Emergency Physicians; 1995. 35. Firearn Safety. 1995-1996 Compendium of AAFP Positions on Selected Health Issues. Kansas City, Mo: American Academy of Family Physicians; 1996. 36. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Firearm injuries affecting the pediatric population (RE9234). Pediatrics. 1992;89: 788-790. 37. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Firearms and adolescents (RE9233). Pediatrics. 1992;89:784-787. 38. American College of Physicians. Preventing firearm violence: a public health imperative. Ann Intern Med. 1995; 122:31 1312. 39. The Violence Prevention Task Force of the Eastern Association for the Surgery of Trauma. Violence in America: a public health crisis-the role of firearms. J Trauma. 1995;38:163-168. 40. HandGun Regulation. Washington, DC: American Public Health Association; 1976. APHA public policy statement 7620. 41. Firearm safety and youth (adopted 1994) and handgun control (adopted 1982). In: American Psychological Association Violence-Related Policy Statements. Washington, DC: American Psychological Association; 1996. 42. HELP Network News. The HELP Network-Handgun Epidemic Lowering Plan. Chicago, Ill: Children's Memorial Medical Center; April 1, 1994. 43. Taliaferro B. First steps toward a violencefree society. Womens Health Forum. 1995; 4:3. 44. STOP: Steps to Prevent Firearm Injury. Washington, DC: American Academy of Pediatrics and Center to Prevent Handgun Violence; 1994. 45. PSR works for violence prevention. PSR Reports: Physicians for Social Responsibility. 1994;15:1. 46. Kassirer J. A partisan assault on scienceJune 1997, Vol. 87, No. 6


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the threat to the CDC. N Engl J Med. 1995;333:793-794. Herbert R. More N.R.A. mischief. New York Tines. July 5, 1996:A23. Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 1997. Conigressionial Record-House. July 11, 1996. H7280-H7287. Omnibus Consolidated Appropriations Bill. HR 3610, Pub L No. 104-208. Centers for Disease Control and Prevention-Disease Control, Research, and Training. Kellermann AL. Obstacles to firearm and

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violence research. Health Aff: Winter 1993: 142-153. Kellermann AL. Firearm-related violencewhat we don't know is killing us. Am J Public Health. 1994;84:541-542. Wash Rev Code 9.41.129. Davis RM. The ledger of tobacco control: is the cup half empty or half full? JAMA. 1996;275:1281-1284. Cigarette smoking attributable mortality and years of potential life lost-United States, 1990. MMWR Morb Mortal Wklv Rep. 1993;42:645-649. Davidson OG. Under Fire: The NRA and

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the Battle for Gun Control. New York, NY: Henry Holt & Co Inc; 1993. Reiss A, Roth J, eds. Understanding anid Preventing Violence. Washington, DC: National Academy Press; 1993. Roth JA. Firearms and Violence. National Institute of Justice Research in Brief. Washington, DC: US Dept of Justice; February 1994:1-7. NCJ 145533. Kellermann AL, Lee RK, Mercy JA, Banton JG. The epidemiologic basis for the prevention of firearm injuries. Aniiii Rev Public Health. 1991; 1 2:17-40. Webster DW, Chaulk CP, Teret SP, Wintemute GJ. Reducing firearm injuries. Issues Sci Technol. Spring 1991:73-79.

Comment: Ethical Dilemmas in Worldwide Polio Eradication Programs Taylor, Cutts, and Taylor assert that there are ethical dilemmas in the implementation of worldwide polio eradication programs.' They make the following statement: "We consider it shortsighted, and possibly unethical, for donors to use their considerable influence to promote polio eradication if this delays or diverts long-term investment by [the least developed] countries in sustainable health systems." The central themes of their discourse are as follows: (1) Polio eradication should not be (or is not) high on the list of priorities for developing countries, and it is placed higher than it should be because of excessive influence by industrialized countries that already have controlled or eliminated polio, and (2) polio eradication does not contribute to the development of health systems in the least developed countries. We appreciate that the authors have made known their concerns and welcome the opportunity to report that developing countries are capable of making their own rational health decisions, that eradication programs strengthen national health systems and initiatives, and that the current polio eradication efforts are operational in nearly all polio-endemic countries with unprecedented support by governments throughout the world. Based solely on current poliomyelitis morbidity, mortality, and disability rates, developing countries have other, more important health priorities. Nonetheless, global polio eradication is and should be a health priority for all countries, including developing countries. Worldwide eradication is now feasible, and substantial resources are available. Eradication activities can be and are used by many developing countries as a springboard to address other health priorities. June 1997, Vol. 87, No. 6

After global eradication has been achieved, all countries will benefit from ending polio vaccination. The resources saved, both human and financial, are available for reallocation to other health priorities. The fact that Taylor et al. point out that the cost savings of acute care and rehabilitation are heavily weighted toward industrialized countries,2 serves only to highlight the economic undervaluation of poliodisabled children in developing countries. In human terms, they suffer no less than those from industrialized countries. The Polio Eradication Initiative has received worldwide political support at the highest levels, first through a unanimous resolution of the World Health Assembly,3 and then in every World Health Organization region of the world through resolutions by member countries. Most recently, the World Health Organization's African Regional Committee4 and the heads of state attending the Organization of African Unity Summit5 endorsed the program. In Africa, polio eradication activities are guided by a committee whose members include some of the most respected leaders of the continent, including President Mandela of the Republic of South Africa, Archbishop Desmond Tutu (chairperson of the South African Truth Commission), Dr Salim Salim (secretary general of the Organization of African Unity), and others. In 1995, the Taylor Commission6 reported that (1) the Polio Eradication Initiative has contributed positively to the overall strengthening of health systems in the Americas; (2) the initiative contributed substantially to the beginning of a "culture of prevention" among politicians, health workers, and community members and stimulated greater cooperation with health workers on the part of govemment

personnel and volunteers; (3) experience in the Americas showed definitively the need for implementing polio eradication activities as part of systematic programs to build health infrastructure; and (4) in the Americas, the greatest positive impact was on social mobilization, along with improvements in intersectoral cooperation (cooperation among the health sector and the other sectors of govemment and society). Social mobilization and intersectoral cooperation are two of the three pillars of primary health care as originally conceived at the 1978 Alma Ata World Conference on Primary Health Care. The report cautions, however, that direct extrapolation of these findings can be made, for the most part, only to health systems at levels of development similar to that of Latin America. A recent supplement to the Journal of Infectious Diseases7 includes several contributions that address the impact of the Polio Eradication Initiative on the Expanded Programme on Immunization and health systems development in general.8-'2 Sections on Cambodia and Laos, rated as two of the least developed countries, are included in the supplement. Reported benefits of the Polio Eradication Initiative now being observed in polioendemic regions of the world include (1) enthusiasm and high-level political support for the Expanded Programme on Immunization; (2) increased national funding for Expanded Programme on Immunization and Polio Eradication Initiative activities and vaccines; (3) increased intemational partnership and donor support for the Expanded Programme on Immunization; (4) enhanced disease surEditor's Note. See related article by Taylor et al. (p 922) in this issue.

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