• Gun Violence, Prevention of (Position Paper)

    INTRODUCTION

    Gun violence, which includes homicide, violent crime, attempted suicide, suicide, and unintentional death and injury, exacts a substantial toll on U.S. society. According to the Centers for Disease Control and Prevention, 48,830 firearm deaths (including suicides) occurred in the United States in 2021.1   The families of the tens of thousands of people who are killed or injured by gun violence each year must also cope with the consequences of this violence. However, there is a gap in knowledge regarding the true number of people and communities impacted by gun violence in the United States. Although some limited data on unintentional and intentional nonfatal firearm injuries are collected, it is difficult for researchers and the public to access accurate, specific data on these injuries.2,3

    In terms of the financial toll of gun violence, it is generally held that related expenses – including medical charges, loss of income, daily care/support and criminal justice expenditures – cost the U.S. economy approximately $557 billion annually, although estimates vary.4,5 Analysis of data from a 10-year period found an average increase of $2,495 per person per month in health care services costs within 12 months after a nonfatal firearm injury.6 Both inpatient and outpatient spending increased, including costs associated with emergency department visits, office visits, procedures, mental health visits and transportation services. Researchers also found increases in pain diagnoses, psychiatric disorders, substance use disorders and use of prescription pain medications and psychiatric medications among people who survived a firearm injury.

    The American Academy of Family Physicians acknowledges that gun violence is a public health epidemic that needs to be addressed with research and evidence-based strategies that reduce morbidity and mortality. Gun violence is also a political issue, as demonstrated by variations in firearm-related policies from state to state. Political and ideological differences have made gun control a highly controversial topic, impacting efforts to provide federal funding for relevant research and data collection. Debates are ongoing regarding the right of federal and state governments to regulate firearms versus a person’s right to own and bear firearms and how to proceed as a nation.7,8 It is notable that the impact of firearms on public health remains greater in the United States than in other high-income countries with a population over 10 million. For example, the rate of firearm homicides per 100,000 people is 4.52 in the United States, compared with 0.62 in Canada, 0.24 in France, 0.21 in Italy and 0.01 in the United Kingdom.9

    The National Academy of Sciences published a report on research priorities related to reducing firearm-related violence that states, “The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.”10 The CDC and World Health Organization have set forth a public health approach based on the following four steps:11

    1. Define and monitor the problem through systematic data collection at the federal, state and local levels. Researchers studying gun violence and prevention should make their data publicly available and easily accessible.
    2. Identify risk factors and protective factors by conducting research to uncover why gun violence occurs and who it impacts.
    3. Develop and test prevention strategies by designing, implementing and evaluating interventions.
    4. Ensure widespread adoption of effective strategies by increasing the scale of effective, promising interventions and evaluating how cost-effective and impactful they are.

    The AAFP encourages use of this public health approach and supports research to identify policies and interventions that effectively reduce firearm-related morbidity and mortality, while also respecting the constitutional right to bear arms.12 Family physicians care for people who experience gun violence and their families. They witness the substantial impact this violence has on the health of patients, families and communities and play an important role in helping to improve the safety and well-being of these groups.

    CALL TO ACTION

    As part of the Group of Six coalition, the AAFP  has joined the American Academy of Pediatrics, American College of Physicians, American College of Obstetricians and Gynecologists, American Osteopathic Association, and American Psychiatric Association to urge the president and Congress to take action to address the public health epidemic of gun violence:13,14 These six organizations encourage lawmakers to support the well-being of American families by working together to fund public health research focused on preventing firearm-related morbidity and mortality and enact evidence-based policies that address key drivers of gun violence.

    The AAFP and its partner organizations call on the federal government to do the following:15

    • Label violence caused by gun use as a national public health epidemic
    • Fund appropriate research as part of the federal budget
    • Establish constitutionally appropriate restrictions on the manufacture and sale for civilian use of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.

    This call to action from physician groups emphasizes the need to treat gun violence as a public health epidemic. However, a lack of sufficient, consistent federal funding and a lack of legislative support across partisan lines impede the United States from making significant advancements in establishing constitutionally appropriate restrictions and conducting research. The gap in data-backed knowledge continues to negatively impact the well-being of people in the United States.

    By taking the following steps, family physicians can further address gun violence in their practices and communities.

    Physician/Practice Level

    • Know the rates of gun violence in your area and the social determinants of health in your patient population so you can understand how gun violence impacts your patients.16-18
    • As part of routine preventive care and anticipatory guidance, ask patients and their families if they have guns in the home or other access to guns. If so, discuss safe storage of firearms and ammunition. Encourage participation in gun safety classes.19-22
    • As part of routine preventive care, screen for the following higher-risk situations for gun- related injury: depression or anxiety with suicidality, intimate partner violence and alcohol or drug use disorders. For patients who have a positive screen, discuss strategies for limiting or removing gun access as part of their management plan.22-25

    Community/Leadership Level

    • Know the rates of gun violence and social determinants of health in your area to better understand the impact on your community16,17,26
    • Participate in programs that address gun violence in your community.17,27

    Educational/Advocacy Level

    • Communicate with your local, state and federal officials about gun violence as a public health concern, making the comparison of successful strategies for motor vehicle safety. These conversations should specifically address the following:

    o     Funding for research to identify effective measures to increase  gun safety 28

    o     Gun safety legislation (e.g., red flag laws, safe storage, stricter licensing requirements)

    o     Strict enforcement of current gun laws

    o     Constitutionallyappropriate restrictions on the manufacture and sale for civilian use of large-capacity magazines and firearms

    o   Appropriate funding for mental health and social services17

    o   Advocacy for public and private funding for the development of a national resource to accurately capture all intentional and unintentional nonfatal firearm-related injuries

    GUN VIOLENCE: A PUBLIC HEALTH EPIDEMIC

    Gun violence is a public health epidemic and should be treated accordingly. While mass shootings are horrific and capture the media’s attention, they are only part of the gun violence picture. For example, more than half of all suicides in the United States involve a firearm.29 U.S. women and children are at particular risk for firearm-related death. Firearms are used in nearly two-thirds of intimate partner homicides, 80% of which are committed against women.30 In 2020, firearms became the leading cause of death among children and adolescents in the United States, with a firearm-related mortality rate of six out of 100,000 people.31 This is 9.5 times the rate in Canada (0.6 per 100,000) the peer country with the second-highest rate of firearm-related mortality in children and adolescents.31

    Public health professionals are trained to create and test interventions to reduce death and injury. However, in 1996, Congress passed the Dickey Amendment, which prohibited the allocation of federal funding to advocate for or promote gun control.32 This essentially ended all federally funded research on gun violence or gun control measures. In 2018, the Secretary of Health and Human Services clarified that the federal government can study the causes of gun violence as long as it does not promote gun control. In 2019, Congress passed a funding bill that appropriated funding to the CDC and the National Institutes of Health to study gun violence.33 Information about funded research on firearms-related violence and injury prevention can be found on the CDC and NIH websites.34,35

    Appropriate research funding is the first step to understanding gun violence and is essential to the development of programs focused on preventing firearm-related deaths. The National Violent Death Reporting System is a federal reporting system that collects data on suicides and homicides by any means in all 50 states, the District of Columbia and Puerto Rico. It collects vital information on unintentional firearm deaths and legal intervention deaths, which are “deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions.”36 Historically, such deaths have been miscounted in police data and death records. 37 Unfortunately, the United States does not have a system in place to track nonfatal firearm injuries at any level, leaving out data that are key to understanding and mitigating gun violence.

    A 2017 study found that gun violence was “the least researched cause of death and the second-least funded cause of death after falls."38 Almost all other leading causes of death in the United States, whether accident or disease, receive substantially more funding for research than gun violence.38 For example, collection of data on the public health issue of motor vehicle accidents has been extensively funded. This research led to multiple evidence-based interventions that effectively addressed high morbidity and mortality associated with motor vehicles, including implementation of vehicle safety measures, stricter enforcement of traffic laws and public awareness campaigns. As a result, U.S. motor vehicle deaths declined significantly over the past decade despite the presence of more motorists on the road. However, taking a similar approach to gun violence research is often considered a political stance rather than an evidence-based, data-driven way to prevent morbidity and mortality.

    The National Highway Traffic Safety Administration is committed to the continued improvement of the safety of motor vehicles and motorists. It operates with a budget of more than $1 billion annually, with special funding requests allocated specifically for research, development and technology.39,40  The AAFP supports the creation and development of a similar transparent, nonpartisan organization that would pursue funding for gun violence research and promote vital firearm safety measures. A national bureau for gun safety would bring together a wide range of experts in fields including medicine, public health, law enforcement, communications and engineering with a shared goal of decreasing firearm injury and death in the United States.

    Because family physicians provide whole-person health care, they see the effects of gun violence on their patients and in their communities. Using a public health perspective, family physicians can employ evidence-based strategies to treat their patients and guide their communities on this important issue. With that in mind, the AAFP is committed to the following actions:

    • Continue to oppose legislation that would prohibit the CDC and other agencies from conducting and distributing research on gun violence as a public health problem
    • Advocate for systems that support accurate reporting of surveillance data
    • Encourage the evaluation and implementation of evidence-based research and approaches that addresses gun violence to improve the health and lives of all patients

    Suicide

    Suicide and suicide attempts are significant public health issues as they can have lasting negative impacts on people, families and communities. There is no single cause or indicator for suicide. Rather, a variety of risk and protective factors influence a person’s risk for suicide, making it a complex issue to address. Among people with and without mental health conditions, many factors contribute to suicide risk, including relationships, job situation/status, substance use, physical health, housing stress, financial situation and other socioeconomic factors.

    People of all genders, sexes, ethnicities and ages can be at risk for suicide, but some populations have disproportionately high rates of suicide. Among racial and ethnic groups, age-adjusted suicide rates are highest among American Indian/Alaska Native people, followed by non-Hispanic white people.41 Men, veterans, people who live in rural areas and workers in certain industries and occupations (e.g., construction and mining) also have a disproportionately higher risk for suicide.42,43 Additionally, young people who identify as lesbian, gay, bisexual, questioning or another non-heterosexual identity are more likely to have suicidal thoughts and exhibit suicidal behavior compared with young people who identify as heterosexual.44

    Access to lethal means greatly increases the risk that a suicide attempt will result in death. Firearms are the most lethal method of suicide, with approximately 90% of suicidal acts with a firearm resulting in death.45 After steadily increasing over the last few decades, the number of firearm suicides reached an all-time high of 26,328 in 2021, accounting for 54% of all firearm-related deaths in the United States.1,29 The rate of firearm suicides increased by 8% from 2020 to 2021, and provisional data indicate the rate continued to increase in 2022.46

    Opportunities for Prevention

    Currently, no single feasible solution to address the firearm suicide epidemic has been identified. Expanding access to behavioral health services is often suggested as a potential solution since increased access to mental health services is associated with a decrease in overall rates of suicide.47 Evidence has shown that the majority of patients with mental health issues access the health care system through their primary care physician, so routine clinical screening for suicide risk is vital to a family physician’s contribution to reducing firearm suicide.48

    The U.S. Preventive Services Task Force recommends screening all adults for depression, including pregnant and postpartum people and older adults.49 In October 2022, the USPSTF adopted recommendations for screening adolescents ages 12 to 18 for major depressive disorder.50 Because family physicians are able to develop trusted relationships with patients, they are also well positioned to screen for other suicide risk factors, such as firearm access and firearm storage practices. Family physicians should be well informed and take a harm reduction approach to conversations about firearm safety and safe storage practices.22 These conversations should be respectful and individualized for each patient’s needs.

    While expanding access to behavioral health treatment can have a modest impact on the firearm suicide epidemic, current evidence suggests that improving firearm safety and implementing evidence-based limitations on access to firearms could provide superior protective effects against firearm suicide. There is evidence that waiting periods, minimum age of purchase laws and safe storage laws can reduce firearm suicides.51 Mandatory background checks, gun lock requirements and restrictions on open carrying of handguns are also associated with a reduction in suicide by firearm.52 Open-carry regulations decrease exposure to firearms, and safely securing guns creates a barrier to immediate access. Background checks and waiting periods limit access by creating a second barrier at the point of purchase. Research has shown that these mechanisms for reducing the availability of firearms not only decrease suicide by firearm but also decrease overall rates of suicide by any method.

    Intimate Partner Violence

    Every minute, nearly 20 people in the United States are physically abused by an intimate partner.53 Nearly 25 million U.S. adults have experienced nonfatal firearm abuse by an intimate partner (i.e., have been threatened by an intimate partner who possesses or has easy access to a firearm or have had an intimate partner threaten them with a firearm or use a firearm on them).54 When intimate partner violence, or IPV, involves a gun, the risk of death increases by five times.55

    Forty percent of female victims of firearm homicide are killed by a current or former intimate partner.30 Although IPV has traditionally been viewed as an act of gender-based violence against cisgender women, it is also important to recognize and acknowledge that it disproportionately impacts people of color, people in the LGBTQ+ community, pregnant and postpartum people, and people with disabilities.30

    People who live in households with guns are more than twice as likely to die by homicide than people who live in households with no guns.56,57 There is a sevenfold increased risk of firearm homicide when the perpetrator is the intimate partner or spouse of the victim.56 If the gun owner has a history of domestic violence, the risk of homicide is 20 times higher.57

    Opportunities for Prevention

    A proven strategy to reduce gun violence and IPV is to reduce the availability of guns to people who have a history of IPV and/or a restraining order.58,59.

    Restricting firearm purchases for people convicted of domestic violence-related crimes or under a domestic violence-related restraining order is an effective way to prevent IPV-related homicide.30,61 States with systems to screen for domestic violence restraining orders prior to firearm purchases have an 8% to 19% reduction in all intimate partner homicides and a 9% to 25% reduction in the rate of intimate partner homicide with a firearm.62

    The AAFP supports efforts to reduce instances of IPV and the implementation of related policies.63 Risk factors that contribute to violence, including IPV-related homicide, include social determinants of health and historical disinvestment in social and mental health services. The AAFP supports the USPSTF recommendation that all women of childbearing age should be screened for IPV and women who screen positive for IPV should be referred to intervention services.64 Family physicians can refer patients who have a positive assessment for IPV to organizations that have resources for crisis intervention and counseling and help people find safe housing, medical care and legal advocacy.65 Domestic violence fatality review teams, which review deaths associated with domestic violence and develop prevention strategies, are another emerging opportunity to reduce IPV. Currently, such teams operate in 45 states.66

    Homicide and Violent Crime with a Firearm

    The U.S. gun homicide rate is 26 times the rate in other high-income nations.67 In 2021, there were nearly 21,000 firearm homicides in the United States, accounting for 81% of all homicides and 43% of all deaths due to firearms.68,69 The U.S. homicide rate increased by nearly 35% from 2019 to 2020 and increased by approximately 8% from 2020 to 2021.70

    Gun violence is the leading cause of death for teens and young adults in the United States.69 As previously stated, 40% of female victims of firearm homicide are killed by a current or former intimate partner.30 The majority of victims of firearm homicide that is not related to IPV are men.69,71 Rates of firearm homicide continue to increase for both men and women in the United States,70 but disparities exist between racial and ethnic groups. People of color are more likely to die by homicide than white people, with non-Hispanic Black people continuing to experience the highest firearm homicide rates.71 Black people are disproportionately impacted by gun violence. They are nearly 14 times as likely to die by homicide with a firearm than their white counterparts, with Black males ages 15 to 34 accounting for 36% of all firearm homicides in 2021.69

    Opportunities for Prevention

    A lack of research has resulted in a scarcity of evidence regarding prevention of homicide and violent crime. A program implemented in Baltimore, Maryland, used a system of “hot-spotting,” that placed detectives in areas at high risk for gun violence.72 Between 2007 and 2012, areas of “hot spotting” experienced a 12 to13% reduction in homicides and an 18 to20% reduction in shootings. Data from several states with gun removal programs have shown that reducing access to illegal guns can also reduce homicide and violent crime rates.73 Evidence also suggests that enacting gun policies has some positive impact on reducing rates of gun violence in the United States.51,74For example, background checks may contribute to decreased rates of both homicide and overall violent crime, and limited  evidence suggests a decrease in violent crime with mental health background checks.51 However, many of these statistics are reported voluntarily by states and may vary depending on which conditions prohibit gun ownership. Further research and investigation into the outcomes of gun safety policies are still needed.51,75

    It is important to note that there is evidence that certain policies may increase violent crime. Moderate evidence has shown that policies such as “stand your ground” laws increase rates of homicide, and some evidence that states with concealed carry laws and “right-to-carry” laws see increased rates of violent crime.51,75,76

    Policing

    Negative interactions with law enforcement impact people and their communities and have resounding ramifications across many sectors, including health care. Ninety-five percent of civilian deaths caused by police involve use of a firearm, and Black people are three times more likely to be shot and killed by police compared with white people.77

    The AAFP’s mission is to improve the health of patients, families and communities. Its policy on policing standards urges police and law enforcement agencies to develop, implement and practice policies and procedures that will reduce the risk of harm to the public they serve.78 Particular attention should be paid to the impact policing standards have on people of color and other historically marginalized populations.

    Mass Shootings

    Since there is no standard definition of “mass shooting,” data on the subject are inconsistent. After the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, Congress defined “mass killing” as “3 or more killings in a single incident.”79 However, this definition does not include information about the weapon(s) used, the number of perpetrators or the location of the shooting. Currently, most research databases (e.g., the Gun Violence Archive) and gun safety advocacy groups such as Everytown for Gun Safety define a mass shooting as “any incident in which four or more people are shot and wounded or killed, excluding the shooter.”80  By this definition, there were 686 mass shooting incidents in 2021 and 636 in 2022. Developing standard definitions through consensus among researchers will be crucial for quality, consistent research regarding gun violence.

    Mass shootings account for only a small portion of gun violence deaths but garner media attention due to the public and horrific nature of the incidents. Though data are limited, certain trends have been identified. A report on U.S. mass shootings from 1996 to 2019 analyzed 172 perpetrators and found that 97.7% were male and 52.3% were white.81 Most people who perpetrated mass shootings had a prior criminal record (64.5%).81 From 2015 to 2022, at least 46% of mass shootings were related to domestic violence, with the perpetrator shooting an intimate partner or family member.80 Additionally, over 25% of mass shootings in this time period were carried out by a person who was legally banned from possessing a firearm. In over 30% of mass shootings, the shooter exhibited at least one warning sign before the event.

    Assault rifles (i.e., semi-automatic firearms that fire a round every time the trigger is pulled) and high-capacity magazines, or HCMs, that allow the firing of a higher number of bullets before reloading the weapon both contribute to greater mortality from mass shootings. Mass shootings with an assault rifle had twice the number of fatalities and 22 times more people wounded compared with shootings that did not involve an assault rifle.80 Use of an HCM resulted in 2.5 times as many people killed and nearly 10 times the number of people wounded compared to shootings that did not involve an HCM.

    Opportunities for Prevention

    There is an increasing, albeit small, body of research of evidence-based strategies to reduce mass shootings. Two studies found an association between state-level bans on HCMs and lower rates of mass shooting incidents, so banning HCMs at the state level is a potential step to reduce rates of mass shootings and deaths.82-84 However, more high-quality research is needed to characterize the efficacy of these bans.

    Banning assault weapons is another opportunity for prevention. The 1994 federal assault weapons ban, which included 18 types of assault weapons, weapons with military-style features and weapons with HCMs (10 or more bullets), lapsed in 2004. During the 10-year period when the ban was in place, “gun massacre” (shooting with six or more deaths) deaths declined compared to the previous decade. In the 10 years after the assault weapons ban lapsed, there were more than three times the number of gun massacre deaths, and the number of gun massacre incidents during the ban nearly tripled as well.85 During the federal ban period, mass shooting fatalities were 70% less likely to occur, and there were nine fewer mass shooting deaths per 10,000 firearm homicides.86

    Unintentional Death and Injury by Firearm

    Unintentional deaths and injuries by firearms are largely preventable. In 2021, 549 people died from unintentional firearm incidents.87 Of those, 168 (30.6%) were children and adolescents (19 years and younger). Most of those deaths were among two age groups: 15 to19 years of age (61 deaths) and 0 to4 years of age (54 deaths).

    In addition to being victims of unintentional firearm injury, children are also at risk of accidentally perpetrating shootings when they gain access to a loaded, unsecured firearm. A 2021 national survey found that guns are stored unlocked in 36.1% of households with children that contain firearms, and in 15% of these homes, guns are stored loaded and unlocked.88

    Between 2015 and 2022, there were over 2,800 incidents in which a child unintentionally shot themself or others.89 In 2022, 353 unintentional shootings by children occurred, leading to 156 deaths and 212 injuries. Children ages five and younger were the most likely to unintentionally shoot themselves, and children ages 14 to 17 were the most likely to unintentionally shoot others. Over 90% of the people wounded or killed in unintentional shootings by children are also younger than 18 years of age. These shootings are more likely to occur at times when children are home, such as weekends or summer holidays, and most often occur in or around a home.

    Opportunities for Prevention

    Firearms should be stored unloaded, locked and separate from ammunition to reduce risk. Safe storage of firearms decreases immediate access to guns, especially for children who are at increased risk of unintentional firearm injury.51 Research suggests clinical interventions and public health campaigns focused on safe storage are effective at preventing unintentional deaths and injuries by firearm.90 Despite fears that may prevent clinicians from asking about firearms, a 2016 survey found that 66% of patients felt it was at least sometimes appropriate for clinicians to discuss firearms in the office.91 Physician counseling about safe storage of firearms can improve patients’ storage practices, especially when a free safe storage device is provided.90,92 Online resources are available to help clinicians learn how to counsel patients about safe storage effectively.93

    Child access prevention, or CAP, laws (also called safe storage laws) are an effective policy approach to reduce the rate of unintentional firearm injury and death, especially among children. CAP laws are designed to protect children by legally prosecuting adults who intentionally or carelessly create situations in which children have unsupervised access to guns.90 Though the details of CAP laws vary, the strongest CAP laws prosecute people for storing a gun in an unsafe manner that would allow a child to access it, while the weakest CAP laws only hold people accountable if a firearm is accessed by a minor who uses it to cause injury or death.94

    Evidence has shown that CAP laws decrease unintentional firearm injury and death among children.51,95 Rates of unintentional shootings by children are 78% lower in states that require safe storage of a gun when it is not in the owner’s possession compared to rates in states without such laws.89 Evidence also suggests that classifying violations of a CAP law as felonies may further reduce unintentional deaths and injuries by firearm among children51 CAP laws may decrease unintentional firearm injuries and death among adults, but further research is needed to examine the effects of these laws on adult populations.

    ADDITIONAL POLICIES AND ACTIONS TO ADDRESS GUN VIOLENCE

    Prevention strategies employed in other public health interventions also have potential as approaches to address gun violence.  Two of the most effective tactics employed to reduce tobacco use in the United States are price increases and taxation, which have proven to deter initiation of tobacco use and encourage cessation of tobacco use.96 Applying these economic tactics to the purchase of firearms could potentially reduce gun ownership, and as a result, decrease gun violence.

    Other potential actions to address gun violence include background checks for firearm and ammunition purchases and identification requirements for firearms, all of which have been shown to reduce firearm deaths.97 Reinstating the 1994 federal assault weapons ban could decrease access to semi-automatic weapons. Requiring microstamping-microscopic, laser-generated engravings on guns and ballistic materials-can also provide information to help law enforcement identify and dismantle firearm trafficking networks, which can reduce future gun violence.98 Microstamping also contributes to a higher solve rate for homicides and other violent crimes.

    In the aftermath of multiple mass shootings, including those that occurred in May 2022 in Uvalde, Texas, and Buffalo, New York, the Bipartisan Safer Communities Act was signed into law on June 25, 2022. It includes many provisions for which the AAFP has long advocated. In an effort to address links between mass shootings and mental/behavioral health, the BSCA provides $11 billion in funding for the U.S. mental health system to expand access to community mental health providers, support people in crisis and reduce suicides, a leading cause of gun death. The law expands access to mental health services provided through telehealth for Medicaid and Children's Health Insurance Program beneficiaries. In addition, it promotes behavioral health integration into the pediatric primary care setting, further integrates school-based health services with primary care and invests in mental health training for primary care clinicians who treat children and youth.

    In addition to investments in mental/behavioral health services, the BSCA addresses school safety and includes a series of safeguards to limit access to firearms. Among its many provisions, it provides federal funding to build out red flag laws, requires stringent background checks for gun sales to people under the age of 21, protects victims of domestic violence and increases restrictions to prevent illegal firearm purchases.

    CALL FOR RESEARCH

    The AAFP calls for increased research funding on gun violence through the CDC and other relevant government research entities. Such funding could begin to address  key areas of gun violence prevention by answering the following questions:

    • What specific gun safety counseling given by physicians reduces the likelihood of gun violence?
    • Does gun safety training reduce gun violence?
    • What policies and interventions (including legal remedies and prevention strategies) reduce gun violence?
    • What are the most effective ways to secure public venues to minimize the risk of mass shootings and casualties if mass shootings occur?
    • What are the key drivers for gun violence in communities?

    AAFP EFFORTS TO PROMOTE FIREARM SAFETY AND DISCOURAGE VIOLENCE

    Family physicians frequently find themselves on the front lines on public health issues, including gun violence. They have an opportunity to address these issues and guide conversations about  them in both the exam room and their communities. Family physicians can be instrumental in the gun violence debate by supporting policies that promote firearm safety and discourage violence. To help equip family physicians as they serve the needs of their patients, the AAFP has undertaken advocacy efforts focused on gun violence prevention, developed policies related to violence, and drafted position papers that outline the multifaceted issues, challenges and opportunities surrounding violence and its health consequences (Table 1).

    The AAFP recognizes gun violence as a public health epidemic that has an impact on immediate and long-term health outcomes. It also acknowledges that violence occurs in the context of a broad range of human relationships and complex interactions. These encompass social, cultural and economic risk factors that include, but are not limited to, the influence of the media, substance abuse, interpersonal violence, fragmentation of family life and the increased availability of weapons. Moreover, the AAFP recognizes that violence disproportionately affects certain populations, including women, people of color, people in the LGBTQ+ community, birthing and postpartum people, and people with disabilities. The AAFP supports efforts to reduce harm and improve quality of life for all people.

     

    Table 1. AAFP Position Papers, Policies and Advocacy Related to Violence

    Position Papers

    Violence

    Mental and Behavioral Health Care Services by Family Physicians

    Policies

    Prevention of Gun Violence

    Violence as a Public Health Concern

    School Safety and Student Mental Health

    Advocacy

    LGBTQ+ Advocacy

    Historic Gun Safety Law Shows AAFP’s Mental Health Advocacy” (AAFP News, June 30, 2022)

    AAFP Joins Renewed Demand for Critical Gun Reforms” (AAFP News, September 16, 2019)

    AAFP Applauds Background Check Bill That Wins Swift Passage” (AAFP News, March 1, 2019)

    Organizations Call for $50 Million to Study Gun Violence” (AAFP News, February 26, 2019)

    2022 Joint Letter to Congress in Support of FY 2023 Funding for the CDC and NIH for Gun Violence Prevention Research

    2022 Joint Letter to Congress in Support of FY 2023 Funding for the CDC Community Violence Intervention Initiative

    2021 Joint Letters to the House and Senate Pressing Support for Gun Violence Research

    CONCLUSION

    Gun violence is a public health epidemic in the United States. Using comprehensive, interdisciplinary approaches and working in collaboration with other public health professionals, family physicians can play a vital role in reducing gun violence. As clinicians, family physicians can help prevent gun violence in their practice and within their community by screening for and treating depression, screening for IPV, referring patients to appropriate services, and talking with patients about the safe storage and handling of guns. Outside of the exam room, family physicians can help prevent suicide and intentional injuries and deaths by advocating for gun violence research funding and gun control legislation at the community, state and federal levels. In particular, it is essential for Congress to allocate research funding to support better understanding of gun violence and the development of evidence-based strategies to prevent it.

    References

    1. Centers for Disease Control and Prevention, National Center for Health Statistics. All injuries. September 13, 2023. Accessed September 25, 2023. https://www.cdc.gov/nchs/fastats/injury.htm
    2. Educational Fund to Stop Gun Violence. Nonfatal gun violence. July 2020. Accessed September 25, 2023. http://efsgv.org/learn/type-of-gun-violence/nontatal firearm-violence/
    3. Smart R, Peterson S, Schell TL, et al. Firearm injury hospitalizations in America. RAND Corporation. April 27, 2021. Accessed September 25, 2023. https://www.rand.org/research/gun-policy/firearm-injury.html
    4. Everytown for Gun Safety. The economic cost of gun violence. July 19, 2022. Accessed September 25, 2023. https://everytownresearch.org/report/the-economic-cost-of-gun-violence/
    5. Song Z. The business case for reducing firearm injuries. JAMA. 2022;328(12):1185-1186.
    6. Song Z, Zubizarreta JR, Giuriato M, et al. Changes in health care spending, use, and clinical outcomes after nonfatal firearm injuries among survivors and family members: a cohort study. Ann Intern Med. 2022;175(6):795-803. 
    7. Gale. Gun control. 2022. Accessed September 25, 2023. https://www.gale.com/open-access/gun-control
    8. RAND Corporation. Gun policy in America: an overview. January 10, 2023. Accessed September 25, 2023. https://www.rand.org/research/gun-policy/key-findings/gun-policy-in-america.html
    9. Leach-Kemon K, Sirull R. On gun violence, the United States is an outlier. May 31, 2022. Accessed September 25, 2023. https://www.healthdata.org/news-events/insights-blog/acting-data/gun-violence-united-states-outlier
    10. Institute of Medicine, National Research Council. Priorities for research to reduce the threat of firearm-related violence. June 2013. Accessed March 8, 2024. https://nap.nationalacademies.org/resource/18319/FirearmViolence_RB.pdf
    11. Educational Fund to Stop Gun Violence. The public health approach to gun violence prevention. November 2020. Accessed March 8, 2024. https://efsgv.org/wp-content/uploads/PublicHealthApproachToGVP-EFSGV.pdf
    12. Joint letter to Congress in support of FY 2023 funding for the CDC and NIH for gun violence prevention research [letter]. April 28, 2022. Accessed September 25, 2023. https://www.aafp.org/content/dam/AAFP/documents/advocacy/prevention/safety/LT-Congress-GunResearch-042822.pdf
    13. American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, American Psychiatric Association. Investment in violence intervention is a positive first step to address gun violence. April 21, 2021. Accessed September 25, 2023. https://www.groupof6.org/dam/AAFP/documents/advocacy/prevention/safety/ST-G6-GunViolence-042121.pdf
    14. Letter from the Group of Six to Congressional leadership on firearm violence research [letter]. October 16, 2019. Accessed September 25, 2023. https://www.aafp.org/content/dam/AAFP/documents/advocacy/prevention/safety/LT-G6-Congress-FirearmViolenceResearch-101619.pdf
    15. American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Psychiatric Association. America’s frontline physicians call on government to act on the public health epidemic of gun violence. February 16, 2018. Accessed September 25, 2023. https://www.aafp.org/news/media-center/more-statements/americas-frontline-physicians-call-on-government-to-act-on-gun-violence.html
    16. Gun Violence Archive. Accessed September 25, 2023. https://www.gunviolencearchive.org/charts-and-maps
    17. Centers for Disease Control and Prevention. Vital Signs: Firearm deaths grow, disparities widen. Comprehensive strategies can prevent violence and help reduce racial and ethnic disparities. June 6, 2022. Accessed September 25, 2023. https://www.cdc.gov/vitalsigns/firearm-deaths/index.html
    18. American Academy of Family Physicians. The EveryONE Project Toolkit. Accessed September 25, 2023. https://www.aafp.org/family-physician/patient-care/the-everyone-project/toolkit.html
    19. Hoops K, McCourt A, Crifasi CK. The 5 A's of firearm safety counseling: validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial. Prev Med Rep. 2022;27:101811. 
    20. National Center for Injury Prevention and Control, Division of Violence Prevention. Resources. May 4, 2022. Accessed September 25, 2023. https://www.cdc.gov/violenceprevention/firearms/resources.html
    21. Abdallah HO, Kaufman EJ. Before the bullets fly: the physician's role in preventing firearm injury. Yale J Biol Med. 2021;94(1):147-152. 
    22. Pallin R, Barnhorst A. Clinical strategies for reducing firearm suicide. Inj Epidemiol. 2021;8(1):57.
    23. U.S. Preventive Services Task Force. A & B recommendations. Accessed September 25, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
    24. Sexton SM, Lin KW, Weiss BD, et al. Preventing gun violence: the role of family physicians. Am Fam Physician. 2018;98(9):560-568.
    25. Jena AB, Prasad V. Primary care physicians' role in counseling about gun safety. Am Fam Physician. 2014;90(9):619-620.
    26. County Health Rankings & Roadmaps. Accessed September 25, 2023. https://www.countyhealthrankings.org/
    27. National Center for Injury Prevention and Control, Division of Violence Prevention. Resources for action. October 27, 2022. Accessed September 25, 2023. https://www.cdc.gov/violenceprevention/communicationresources/pub/resource-for-action.html
    28. National Center for Injury Prevention and Control, Division of Violence Prevention. Firearm violence prevention. June 14, 2023. Accessed September 25, 2023. https://www.cdc.gov/violenceprevention/firearms/firearm-suicide-trends.html
    29. Centers for Disease Control and Prevention, National Center for Health Statistics. Suicide and self-harm injury. September 19, 2023. Accessed September 25, 2023. https://www.cdc.gov/nchs/fastats/suicide.htm
    30. Everytown for Gun Safety. Guns and violence against women: America’s uniquely lethal intimate partner violence problem. Updated April 10, 2023. Accessed September 25, 2023. https://everytownresearch.org/report/guns-and-violence-against-women-americas-uniquely-lethal-intimate-partner-violence-problem/
    31. McGough M, Amin K, Panchal N, et al. Child and teen firearm mortality in the U.S. and peer countries. July 18, 2023. Accessed September 25, 2023. https://www.kff.org/mental-health/issue-brief/child-and-teen-firearm-mortality-in-the-u-s-and-peer-countries/
    32. Rostron A. The Dickey Amendment on federal funding for research on gun violence: a legal dissection. Am J Public Health. 2018;108(7):865-867.
    33. Roubein R. Now the government is financing gun violence research, but it’s years behind. Washington Post. May 26, 2022. Accessed September 25, 2023. https://www.washingtonpost.com/politics/2022/05/26/now-government-is-funding-gun-violence-research-it-years-behind/
    34. National Center for Injury Prevention and Control, Division of Violence Prevention. Funded research. July 12, 2023. Accessed September 25, 2023. https://www.cdc.gov/violenceprevention/firearms/funded-research.html
    35. National Institutes of Health, Office of Behavioral and Social Sciences Research. Violence research initiatives. Accessed September 25, 2023. https://obssr.od.nih.gov/about/violence-research-initiatives
    36. Wilson RF, Liu G, Lyons BH, et al. Surveillance for violent deaths - National Violent Death Reporting System, 42 states, the District of Columbia, and Puerto Rico, 2019. MMWR Surveill Summ. 2022;71(6):1-40.
    37. Barber C, Cook PJ, Parker ST. The emerging infrastructure of US firearms injury data. Prev Med. 2022;165(Pt A):107129.
    38. Stark DE, Shah NH. Funding and publication of research on gun violence and other leading causes of death. JAMA. 2017;317(1):84-85.
    39. U.S. Department of Transportation, National Highway Traffic Safety Administration. Budget estimates. Fiscal year 2023. Accessed September 25, 2023. https://www.transportation.gov/sites/dot.gov/files/2022-03/NHTSA_Budget_Estimates_FY23.pdf
    40. U.S. Department of Transportation, National Highway Traffic Safety Administration. Budget estimates. Fiscal year 2024. Accessed September 25, 2023. https://www.transportation.gov/sites/dot.gov/files/2023-03/NHTSA_FY_2024_President_Budget.pdf
    41. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide data and statistics. August 10, 2023. Accessed September 25, 2023. https://www.cdc.gov/suicide/suicide-data-statistics.html
    42. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Suicide prevention resource for action. October 26, 2022. Accessed September 25, 2023. https://www.cdc.gov/suicide/resources/prevention.html
    43. Peterson C, Sussell A, Li J, et al. Suicide rates by industry and occupation - National Violent Death Reporting System, 32 states, 2016. MMWR Morb Mortal Wkly Rep. 2020;69(3):57-62.
    44. Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention. Youth Risk Behavior Survey data summary & trends report: 2011-2021. Accessed September 25, 2023. https://www.cdc.gov/healthyyouth/data/yrbs/pdf/yrbs_data-summary-trends_report2023_508.pdf
    45. Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United States, 2007 to 2014: a nationwide population-based study. Ann Intern Med. 2019;171(12):885-895.
    46. National Center for Injury Prevention and Control, Division of Violence Prevention. Firearm suicide trends. October 19, 2023. Accessed September 25, 2023. https://www.cdc.gov/violenceprevention/firearms/firearm-suicide-trends.html
    47. RAND Corporation. The relationship between mental health care access and suicide. March 2, 2018. Accessed September 25, 2023. https://www.rand.org/research/gun-policy/analysis/essays/mental-health-access-and-suicide.html
    48. Goldstein EV, Prater LC, Wickizer TM. Behavioral health care and firearm suicide: do states with greater treatment capacity have lower suicide rates?. Health Aff (Millwood). 2019;38(10):1711-1718.
    49. U.S. Preventive Services Task Force. Depression and suicide risk in adults: screening. Final recommendation statement. June 20, 2023. Accessed September 25, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults
    50. U.S. Preventive Services Task Force. Depression and suicide risk in children and adolescents: screening. Final recommendation statement. October 11, 2022. Accessed September 25, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents
    51. Smart R, Morral AR, Ramchand R, et al. The Science of Gun Policy: A Critical Synthesis of Research Evidence on the Effects of Gun Policies in the United States. 3rd ed. RAND Corporation; 2023.
    52. Anestis MD, Anestis JC. Suicide rates and state laws regulating access and exposure to handguns. Am J Public Health. 2015;105(10):2049-2058.
    53. National Coalition Against Domestic Violence. Statistics. Accessed September 25, 2023. https://ncadv.org/STATISTICS
    54. Adhia A, Lyons VH, Moe CA, et al. Nonfatal use of firearms in intimate partner violence: results of a national survey. Prev Med. 2021;147:106500.
    55. Giffords Law Center to Prevent Gun Violence. Domestic violence & firearms. Accessed March 8, 2024. https://giffords.org/lawcenter/gun-laws/policy-areas/who-can-have-a-gun/domestic-violence-firearms/
    56. Studdert DM, Zhang Y, Holsinger EE, et al. Homicide deaths among adult cohabitants of handgun owners in California, 2004 to 2016 : a cohort study. Ann Intern Med. 2022;175(6):804-811.
    57. Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home [published correction appears in N Engl J Med. 1998 Sep 24;339(13):928-9]. N Engl J Med. 1993;329(15):1084-1091.
    58. Zeoli AM, McCourt A, Buggs S, et al. Analysis of the strength of legal firearms restrictions for perpetrators of domestic violence and their associations with intimate partner homicide. Am J Epidemiol. 2018;187(11):2365-2371.
    59. Díez C, Kurland RP, Rothman EF, et al. State intimate partner violence-related firearm laws and intimate partner homicide rates in the United States, 1991 to 2015. Ann Intern Med. 2017;167(8):536-543.
    60. Congressional Research Service. Firearms eligibility: domestic violence and dating partners. September 9, 2022. Accessed September 25, 2023. https://crsreports.congress.gov/product/pdf/IF/IF12210
    61. Educational Fund to Stop Gun Violence. Domestic violence and firearms. July 2020. Accessed September 25, 2023. https://efsgv.org/learn/type-of-gun-violence/domestic-violence-and-firearms/
    62. Zeoli AM, Malinski R, Turchan B. Risks and targeted interventions: firearms in intimate partner violence. Epidemiol Rev. 2016;38(1):125-139.
    63. American Academy of Family Physicians. Intimate partner violence. 2019. Accessed January 12, 2024. https://www.aafp.org/about/policies/all/intimate-partner-violence.html
    64. American Academy of Family Physicians. Clinical preventive service recommendation: intimate partner violence and abuse of vulnerable adults. Accessed September 25, 2023. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/domestic-violence.html
    65. Petrosky E, Blair JM, Betz CJ, et al. Racial and ethnic differences in homicides of adult women and the role of intimate partner violence - United States, 2003-2014. MMWR Morb Mortal Wkly Rep. 2017;66(28):741-746.
    66. National Domestic Violence Fatality Review Initiative. Frequently asked questions. Accessed January 12, 2024. https://ndvfri.org/about/faqs/
    67. Everytown for Gun Safety. The US gun homicide rate is 26 times that of other high-income countries. November 1, 2022. Accessed September 25, 2023. https://everytownresearch.org/graph/the-u-s-gun-homicide-rate-is-26-times-that-of-other-high-income-countries
    68. Centers for Disease Control and Prevention, National Center for Health Statistics. Assault or homicide. September 14, 2023. Accessed September 25, 2023. https://www.cdc.gov/nchs/fastats/homicide.htm
    69. Davis A, Kim R, Crifasi CK. A year in review: 2021 gun deaths in the U.S. Johns Hopkins Center for Gun Violence Solutions, Johns Hopkins Bloomberg School of Public Health; 2023. Accessed September 25, 2023. https://publichealth.jhu.edu/sites/default/files/2023-06/2023-june-cgvs-u-s-gun-violence-in-2021.pdf
    70. Simon TR, Kegler SR, Zwald ML, et al. Notes from the field: increases in firearm homicide and suicide rates - United States, 2020-2021. MMWR Morb Mortal Wkly Rep. 2022;71(40):1286-1287. 
    71. QuickStats: age-adjusted rates* of firearm-related homicide,† by race,§ hispanic origin, and sex - National Vital Statistics System, United States, 2021. MMWR Morb Mortal Wkly Rep. 2023;72(26):737.
    72. Samuels A. Hot spot policing focusing on guns is most effective strategy for reducing gun violence in Baltimore, study finds. HUB. January 11, 2018. Accessed January 12, 2024. https://hub.jhu.edu/2018/01/11/how-to-reduce-gun-violence-in-baltimore-city/
    73. Everytown for Gun Safety. At the forefront of gun safety: removing illegal guns [policy paper]. November 16, 2022. Accessed September 25, 2023. https://everytownresearch.org/report/at-the-forefront-of-gun-safety-removing-illegal-guns/
    74. Everytown for Gun Safety. Gun safety policies save lives. updated January 12, 2023. Accessed September 25, 2023. https://everytownresearch.org/rankings/
    75. RAND Corporation. What science tells us about the effects of gun policies. January 10, 2023. Accessed September 25, 2023. https://www.rand.org/research/gun-policy/key-findings/what-science-tells-us-about-the-effects-of-gun-policies.html
    76. Donohue JJ, Cai SV, Bondy MV, et al. Why does right-to-carry cause violent crime to increase? NBER Working Paper No. 30190. Revised June 2023. Accessed September 25, 2023. https://www.nber.org/system/files/working_papers/w30190/w30190.pdf
    77. Everytown for Gun Safety. Gun violence and the police. Updated May 24, 2023. Accessed September 25, 2023. https://everytownresearch.org/report/gun-violence-and-the-police/
    78. American Academy of Family Physicians. Policing standards. January 2022. Accessed January 12, 2024. https://www.aafp.org/about/policies/all/policing-standards.html
    79. Congressional Research Service. Mass murder with firearms: incidents and victims, 1999-2013. July 30, 2015. Accessed September 25, 2023. https://crsreports.congress.gov/product/pdf/R/R44126/5
    80. Everytown for Gun Safety. Mass shootings in the United States. Updated March 2023. Accessed September 25, 2023. https://everytownresearch.org/mass-shootings-in-america/
    81. National Institute of Justice. Public mass shootings: database amasses details of a half century of U.S. mass shootings with firearms, generating psychosocial histories. February 3, 2022. Accessed September 25, 2023. https://nij.ojp.gov/topics/articles/public-mass-shootings-database-amasses-details-half-century-us-mass-shootings
    82. RAND Corporation. Effects of assault weapon and high-capacity magazine bans on mass shootings. January 10, 2023. Accessed September 25, 2023. https://www.rand.org/research/gun-policy/analysis/ban-assault-weapons/mass-shootings.html
    83. Klarevas L, Conner A, Hemenway D. The Effect of Large-Capacity Magazine Bans on High-Fatality Mass Shootings, 1990-2017. Am J Public Health. 2019;109(12):1754-1761.
    84. Webster DW, McCourt AD, Crifasi CK. Evidence concerning the regulation of firearms design, sale, and carrying on fatal mass shooting in the United States. Criminology and Public Policy. 2020;19(1):171-212.
    85. Ingraham C. It’s time to bring back the assault weapons ban, gun violence experts say. Washington Post. February 15, 2018. Accessed January 12, 2024. https://www.washingtonpost.com/news/wonk/wp/2018/02/15/its-time-to-bring-back-the-assault-weapons-ban-gun-violence-experts-say/
    86. DiMaggio C, Avraham J, Berry C, et al. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019;86(1):11-19.
    87. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WISQARS fatal and nonfatal injury reports. Unintentional firearm deaths and rates per 100,000. Data years: 2021, United States, all ages, both sexes, all races, all ethnicities. Accessed September 25, 2023. https://wisqars.cdc.gov/reports/?o=MORT&y1=2021&y2=2021&t=0&d=&i=1&m=20890&g=00&me=0&s=0&r=0&ry=0&e=0&yp=65&a=ALL&g1=0&g2=199&a1=0&a2=199&r1=INTENT&r2=NONE&r3=NONE&r4=NONE
    88. Miller M, Azrael D. Firearm storage in US households with children: findings from the 2021 National Firearm Survey. JAMA Netw Open. 2022;5(2):e2148823. 
    89. Everytown for Gun Safety. Preventable tragedies: unintentional shootings by children. Updated April 26, 2023. Accessed September 25, 2023. https://everytownresearch.org/report/notanaccident/
    90. RAND Corporation. The science of gun policy: a critical synthesis of research evidence on the effects of gun policies in the United States. 2018. Accessed January 12, 2024. https://www.rand.org/pubs/research_reports/RR2088.html
    91. Betz ME, Azrael D, Barber C, et al. Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey. Ann Intern Med. 2016;165(8):543-550.
    92. Rowhani-Rahbar A, Simonetti JA, Rivara FP. Effectiveness of interventions to promote safe firearm storage. Epidemiol Rev. 2016;38(1):111-124.
    93. BulletPoints. The Basics. Accessed September 25, 2023. https://www.bulletpointsproject.org/the-basics/
    94. Giffords Law Center to Prevent Gun Violence. Child access prevention & safe storage. Accessed September 25, 2023. https://giffords.org/lawcenter/gun-laws/policy-areas/child-consumer-safety/child-access-prevention-and-safe-storage/
    95. Azad HA, Monuteaux MC, Rees CA, et al. Child access prevention firearm laws and firearm fatalities among children aged 0 to 14 years, 1991-2016. JAMA Pediatr. 2020;174(5):463-469.
    96. University of Bath. Price and tax, tobacco tactics. Updated May 17, 2022. Accessed September 25, 2023. https://tobaccotactics.org/article/price-and-tax/
    97. Kalesan B, Mobily ME, Keiser O, et al. Firearm legislation and firearm mortality in the USA: a cross-sectional, state-level study. Lancet. 2016;387(10030):1847-1855. 
    98. Educational Fund to Stop Gun Violence. Microstamping: a technology to help solve gun crimes, identify gun trafficking networks and reduce gun violence. 2021. Accessed September 25, 2023. https://efsgv.org/wp-content/uploads/EFSGV_Microstamping-Report-2021.pdf

    (2018 COD) (September 2024 COD)