• Tobacco: Preventing and Treating Nicotine Dependence and Tobacco Use (Position Paper)


    Since the Surgeon General’s Advisory Committee on Smoking and Health report in 1964, more than 20 million deaths have occurred prematurely in the United States due to cigarette smoking.1 While efforts in the U.S. have led to a decline in cigarette smoking among adults from 42% in 19651 to 14% by 2017,2 more than 34 million adults still currently smoke.2 It is estimated that 47.4 million adults (19.3%) in the U.S. use any form of tobacco product.2

    The leading cause of death and preventable disease in the U.S. is cigarette smoking and secondhand smoke exposure,1,3 accounting for an average of more than 480,000 deaths each year.2 If cigarette use continues at the current rate, 5.6 million children younger than 18 years who are alive today will die prematurely as a result of smoking.1,3

    Cigarette smoking has been causally linked to diseases of nearly all organs of the body, including an increased risk of heart disease, stroke, chronic obstructive pulmonary disease (COPD), and lung cancer.1 It causes about 90% of all lung cancer deaths.1,4 Other common diseases correlated to smoking include diabetes mellitus and rheumatoid arthritis.1,4 It also causes complications in pregnancy, harms the fetus and leads to diminished overall health status.1 People who smoke are estimated to lose more than 10 years of life expectancy, and half of all of those who smoke who do not quit by middle age die of a tobacco-related cause.1

    Inhaling secondhand smoke is also detrimental to health. It consists of a mixture of gases and fine particles that includes smoke from a burning tobacco product, as well as exhaled smoke.5 It contains thousands of chemicals, hundreds which are toxic, and 70 which can cause cancer.4

    Some cancers, along with respiratory and cardiovascular diseases may be a result of secondhand smoke, and it can also cause serious adverse effects during pregnancy and in infants and children.4 Several risks associated with secondhand smoke exposure during pregnancy affect unborn babies and infants, including premature delivery, low-birth weight, stillbirth, sudden infant death syndrome (SIDS), lower respiratory infection, asthma, and middle ear infection.4

    Nicotine is a highly-addictive, naturally-occurring chemical found in tobacco.1 Cigarette companies intentionally modify tobacco products to “create and sustain addiction.”6 Nicotine affects multiple biological pathways important for fetal development, which can increase the risk for both short- and long-term disease, impact neurological development in utero, and lead to preterm birth.1

    While cigarette smoking is the predominant form of tobacco use in the U.S., other tobacco products are often used by and marketed to certain racial, ethnic, and lower socioeconomic populations, as well as children and young adults.7 These include bidis, smoking tobacco with a hookah (i.e., waterpipe), snus, dissolvables, cigars, cigarillos, electronic nicotine delivery systems (ENDS), and electronic cigarettes (also called e-cigarettes).7

    E-cigarettes and ENDS are battery-operated devices that contain nicotine-filled cartridges. The resulting vapor is inhaled as a mist that contains flavorings and various levels of nicotine and other toxic substances.8 Manufacturers and marketers tout e-cigarettes as cheaper and safer alternatives to traditional cigarettes.9 These claims are being made despite a number of studies that show several harmful effects likely caused by increases in blood nicotine level,10 multiple physical symptoms,11 and negative effects on indoor air.12 A significant concern is the increased focus by manufacturers, marketers, and retailers of e-cigarette use as a smoking cessation tool.9 The American Academy of Family Physicians (AAFP) does not endorse ENDS as a cessation device in any population due to insufficient evidence of its efficacy.13 The AAFP does support the 7 U.S. Federal Drug Administration (FDA) -approved cessation options, acknowledging that pharmacotherapy and counseling substantially improve cessation outcomes.14

    Call to Action

    The AAFP urges all state, federal, and private sector institutions involved in tobacco prevention and cessation activities to increase and coordinate their efforts. Bold new initiatives are necessary to decrease the harm caused by tobacco and nicotine use. The AAFP supports the American Academy of Pediatrics, American Cancer Society, Cancer Action Network, American Heart Association, American Lung Association, Americans for Nonsmokers’ Rights, Campaign for Tobacco-Free Kids, and Legacy® to call for action by all levels of government to achieve the following three bold goals:

    • Reduce smoking rates to less than 10% by 2024;
    • Protect all Americans from secondhand smoke by 2019; and
    • Eliminate the death and disease caused by tobacco use.15

    There are opportunities for family physicians to become active in advocating for tobacco and nicotine control measures at the community, state, and national levels. Family physicians are trusted members of their communities and can serve as effective agents in facilitating and advocating for policy change, especially at the local level. To reach these bold goals, the AAFP calls for advocacy in the areas below.

    Community and State Advocate for:

    • Evidence-based tobacco control policy changes, including increased tobacco excise taxes
    • Comprehensive, evidence-based tobacco control programs using tax revenue
    • Tobacco-free pharmacies and health care facilities, and elimination of all forms of tobacco sales in pharmacies
    • Comprehensive, clean indoor air polices

    National Advocate for:

    • Insurance coverage with no co-payments or cost sharing, including Medicaid coverage, for evidence-based cessation counseling, prescriptions, and over-the-counter tobacco cessation medications
    • Enhanced access to tobacco cessation services for all patients, regardless of health insurance
    • Aggressive regulation of all products containing nicotine by the U.S. Food and Drug Administration’s (FDA’s) Center for Tobacco Products (CTP)
    • Research on e-cigarettes to assess their safety, quality, and efficacy as a potential cessation device
    • Restriction of access and marketing of e-cigarettes to children and youth

    Through these and other actions, the AAFP, its constituent chapters, and its individual members can work in partnership to help eliminate the epidemic of tobacco-related death and disease.

    Family Physician's Role

    Family physicians can make a significant impact on the tobacco-use behavior of Americans. Approximately 70% of individuals who use tobacco products see a physician each year.16 Recent evidence reinforces the positive impact that primary care physicians can have by encouraging smoking cessation with their patients.17

    Patients want to quit smoking. Nearly 70% of adults who smoke do want to quit, and more than half tried quitting in the past year. However, fewer than one-third try to quit using evidence-based cessation methods.18 Quitting smoking can be difficult without assistance. One study found that only 3-5% of adults who attempted to quit without cessation assistance maintained their smoking abstinence for 6-12 months.19

    While most individuals try to quit on their own without participating in smoking cessation programs,18 research shows that evidence-based cessation programs can double successful quitting rates.16 If physicians would advise 90% of people who smoke to quit and offer them medication or other assistance, 42,000 lives could be saved each year.20

    There are many opportunities for family physicians to address tobacco use and nicotine dependence in the practice setting. The following actions may help physicians take advantage of those opportunities:

    • Counsel all patients on the harms of nicotine and tobacco products.
    • Promote medical education sessions for all care team staff focused on effective cessation tools and ways to overcome barriers.
    • Implement or enhance office-based prevention programs and policies, including those that target high-risk populations.
    • Engage the health care team to provide tobacco cessation counseling and medical treatments.
    • Provide a clearly-defined process for practices and clinicians to assess patient interest in quitting, encourage quitting for those not currently interested, encourage counseling and use of cessation medications, and provide follow up.
    • Include a systematic way to provide patients with more information and support for quitting, using appropriate members of the medical team besides physicians, when possible.
    • List tobacco use as a cause of death when appropriate.
    • Use tobacco-use status as a vital sign.
    • Create a flow sheet in the patient’s record so the clinician can see a summary of past smoking discussions and quit attempts.16,21

    The AAFP encourages its members to use a variety of counseling techniques to address tobacco and nicotine dependence, such as motivational interviewing, brief interventions, and group visits. Members should recognize and address barriers to successful intervention and treatment. Barriers exist at the patient and physician level, as well as at a systemic level.

    Patient and physician level barriers include:

    • Lack of motivation to quit22
    • Non-adherence to medications and counseling23
    • Use of non-evidence-based treatments18
    • Limited time with patients24

    Systemic level barriers include:

    • Inconsistent follow up to ensure patient adherence to cessation plans, and that appropriate referrals occurred25
    • Reimbursement and payment for cessation counseling and treatments26
    • Inconsistent follow up with patients to remind them to utilize services20

    Tobacco Cessation Tools for the Family Physician

    Ask and Act

    The U.S. Public Health Service (USPHS) encourages the five A’s (Ask, Advise, Assess, Assist, and Arrange) as a brief intervention for patients who smoke.16 The AAFP encourages its members and their practice teams to ASK all patients about tobacco use, and then to ACT to help them quit. The AAFP’s tobacco cessation program, “Ask and Act,” is an evidenced-based strategy based on USPHS recommendations. This easy-to-remember approach provides the opportunity for every member of a practice team to intervene at every visit. The implementation of team-based care offers significant opportunity to improve the rate of interventions for nicotine and tobacco dependence. For more information about tobacco cessation tools and interventions, visit www.askandact.org.

    Electronic Health Records

    Electronic health records (EHRs) allow for integration of evidence-based recommendations into the practice workflow. The AAFP encourages:

    • The use of EHRs that include a template that prompts clinicians or their practice teams to collect information about tobacco and nicotine use, secondhand smoke exposure, current cessation interest, and past quit attempts.
    • The use of EHRs that include clinical-decision support that assist clinicians and/or staff in screening for use, encouraging quitting, connecting patients and families to appropriate cessation resources, and advising them about the benefits of smoke-free environments.

    The AAFP encourages all members to track and assess tobacco and nicotine use at every visit or opportunity. Tobacco assessments can be beneficial in meeting requirements of a variety of quality reporting programs.

    Payment and Covered Benefits

    Repeated clinical tobacco-cessation counseling is one of the three most important and cost-effective preventive services that can be provided in a medical practice.23 The AAFP strongly advocates for health plan coverage and appropriate payment for evidence-based physician services for screening and treatment of tobacco use consistent with the U.S. Preventive Services Task Force (USPSTF) recommendations.27

    The AAFP recommends that all people who use tobacco in the U.S. be aware of the existence of and have access to all evidenced-based, FDA-approved therapies and counseling.28 The Centers for Medicare & Medicaid Services (CMS) pays for physician services related to smoking cessation counseling provided to Medicare beneficiaries.29 The Patient Protection and Affordable Care Act (PPACA) requires insurance plans to cover many clinical preventive services, including tobacco-use screening and counseling.30 A coding reference is available online at www.askandact.org.

    High-risk Populations

    The AAFP recommends universal screening for tobacco and nicotine use, especially in high-risk populations. Higher rates of tobacco and nicotine use in these populations places them at an increased risk of harmful health effects. Despite the overall decline, certain populations maintain high rates of tobacco use. Populations more likely to use tobacco include:

    • Racial and ethnic minorities;31
    • Lesbian, gay, bisexual, and transgender individuals;32
    • Individuals with lower education levels32 and lower socioeconomic status;32,33
    • Individuals living in rural areas;34
    • Individuals with mental illness;35
    • Individuals with substance abuse disorders.36

    Individuals with mental illness smoke at rates that are twice as high as the general population.35 Nearly half the cigarettes in the U.S. are smoked by individuals with mental illness.37 Smoking prevalence is even higher for individuals diagnosed with schizophrenia, bipolar disorder, depression, post-traumatic stress disorder (PTSD), and alcohol/illicit drug use disorder.37 Smoking prevalence also increases as the number of mental disorders increase, with 61% smoking rates for individuals diagnosed with three or more mental disorders.37

    Other populations with increased health threats from tobacco use include women who are pregnant; patients with human immunodeficiency virus (HIV); and individuals with comorbid conditions such as diabetes, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and asthma.

    Tobacco Use in Adolescents

    In 2017, approximately 3.6 million middle and high school students were current tobacco users.38 Among high school students, 7.6% reported smoking in the past 30 days, with one in five reporting using some form of tobacco.39 In addition to the well-known, long-term health effects of smoking, children may experience immediate effects on the brain, as well as the respiratory, cardiovascular, gastrointestinal, immune, and metabolic systems.40

    While cigarette smoking by high school students has been on the decline, the FDA reported a 77% increase in ENDS use in 2018 among youth within a 12-month timeframe.41 The Surgeon General’s Advisory on E-cigarette Use Among Youth report, released in 2018, classified ENDS use among youth as an epidemic. The surgeon general called for immediate action to mitigate the rapid increase of ENDS among youth, subsequently leading to nicotine addiction. Nicotine exposure in adolescence can impact brain development, and subsequently learning, memory, and attention. Evidence also suggests ENDS use during adolescence may lead to traditional cigarette smoking later in life.42

    There is clear evidence that there is a causal relationship between tobacco advertising and the influence, initiation, and progression of tobacco use among youth.7 Tobacco companies extensively market to youth, adolescents, and young adults.7 In a 1984 R.J. Reynolds report, the company expressed how essential those smokers are when they stated, “Younger adult smokers are the only source of replacement smokers...If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle.”43 Youth, adolescents, and young adults are increasingly using ENDS. ENDS products are being directly marketed to youth by tobacco companies, emphasizing youth-friendly flavors and glamorizing use.7

    The tobacco industry has worked hard and spent aggressively to keep those customers. In 2016, cigarette and smokeless tobacco companies spent $9.5 billion on advertising and promotional expenses in the U.S., the majority which was spent on cigarette marketing.44,45

    Tobacco prevention programs are increasingly important to curb youth tobacco initiation. Nearly all adults who smoke every day initiated smoking at 26 years or younger, with the majority (88%) beginning by 18 years.1

    Tar Wars

    The AAFP’s tobacco prevention program, Tar Wars, helps keep youth from using tobacco and nicotine products. The AAFP encourages its members to talk to children and adolescents about the risks of using tobacco and nicotine products, and to participate in community awareness and prevention activities. The AAFP’s Tar Wars program was developed by a family physician and health educator in 1988. It teaches children about the effects of tobacco use, cost of using tobacco products, and advertising techniques used by the tobacco industry to market their products to children.

    Research and Development

    The budgets in the public and private sectors for development of new technologies and approaches to screening and treatment of tobacco use are not commensurate with the size and scope of the tobacco and nicotine use epidemic. The AAFP encourages increased funding for the pursuit of innovative approaches to identifying those at risk for tobacco and nicotine use and helping people quit. This includes providing medications, counseling, policy change, and improvements in primary care clinic systems.

    Medical Education

    The AAFP strongly advocates for in-depth, effective education in the prevention and cessation of tobacco use in medical schools and residency programs. The AAFP also encourages family physicians to participate in continuing medical education (CME) activities and programs related to prevention and cessation of tobacco use, and strongly encourages organizations involved in the creation of CME to integrate tobacco and nicotine use screening, prevention, and treatment into their curricula. Organizations involved in the ongoing credentialing of primary care physicians, such as the American Board of Family Medicine (ABFM), should include questions about tobacco dependence treatment in examinations and test-preparation materials.

    Taxation and Subsidies

    The AAFP believes that increasing taxes on tobacco products provides a major disincentive to potential buyers. The AAFP encourages the development of health education and other tobacco control programs funded by the taxes collected on tobacco products. The AAFP supports its constituent chapters to ensure that funds from the Master Settlement Agreement (MSA) or excise taxes on tobacco products be used for tobacco prevention, cessation, education, and other elements of comprehensive tobacco control.

    Secondhand Smoke

    The AAFP strongly supports prohibiting the use of all tobacco and nicotine products that emit a vapor or any form of inhalable substance in all public places. Eliminating any tobacco or nicotine product smoke or inhalable vapor in indoor spaces must be eliminated to fully protect those who do not use those products. Separating people who smoke or use any device containing nicotine that emits a vapor from those who do not within the same air space, cleaning the air, opening windows, or ventilating buildings does not effectively eliminate secondhand smoke exposure. Family physicians should advise their patients, especially those with children and those with cardiovascular diseases or other chronic conditions, to avoid establishments that permit smoking and to request that family members not smoke in their home or vehicle. To reduce children’s exposure to secondhand smoke, family physicians should encourage cessation for all household members that use tobacco, and to create a smoke-free home. The AAFP urges all employers to provide smoke-free work environments and incentives for employees who participate in cessation programs. Family physicians and AAFP constituent chapters are encouraged to work with local governments and agencies to advocate for comprehensive clean indoor air ordinances and regulations.

    Framework Convention on Tobacco Control Health Treaty

    The AAFP fully supports the World Health Organization’s (WHO’s) Framework Convention on Tobacco Control (FCTC) and urges its full ratification by the U.S. The FCTC is the world’s first global public health treaty that requires nations to adopt a comprehensive range of measures designed to reduce the devastating health and economic impact of tobacco use. The FCTC calls for provisions that include price and tax measures to reduce the demand for tobacco products.46

    The FCTC non-price measures to reduce the demand for tobacco products address the:

    • Protection from exposure to tobacco smoke
    • Regulation of the contents of tobacco products
    • Regulation of tobacco product disclosures
    • Packaging and labeling of tobacco products
    • Education, communication, training, and public awareness
    • Tobacco advertising, promotion, and sponsorship
    • Demand reduction measures concerning tobacco dependence and cessation47

    The FCTC core supply reduction provisions address the:

    • Illicit trade in tobacco products
    • Sales to and by minors
    • Provision of support for economically viable alternative activities to tobacco farming and production47

    The U.S. signed the treaty in 2004, but it has yet to be sent to the Senate for ratification.47 The AAFP supports the FCTC and urges the Senate to ratify the treaty.

    Electronic Nicotine Delivery Systems (ENDS)

    Electronic nicotine delivery systems (ENDS), also called electronic cigarettes, e-cigarettes, vaping devices, or vape pens, are battery-powered devices used to smoke or “vape” a flavored solution which usually contains nicotine.8 The AAFP recognizes the alarmingly increased use of ENDS, especially among youth and young adults,48 as well as its use by those attempting to quit smoking tobacco.49

    The AAFP calls for further research to assess ENDS’ safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of ENDS to children and youth cease immediately. The AAFP encourages members to screen for ENDS use starting with school-age children, to discuss the potential harms of ENDS, and to recommend cessation interventions with e-cigarette users. The AAFP encourages members to inform patients who use ENDS, especially children, that the majority of these products contain nicotine and are addictive.

    Tobacco Advertising and Labeling

    The AAFP opposes all forms of advertisement of tobacco products, including any form of ENDS, and direct or indirect marketing of tobacco products to children. The AAFP will endeavor to place advertising material and develop relationships with publications that do not accept tobacco advertising. If unavoidable, the adjoining pages will not promote tobacco or alcohol. The AAFP urges removal of corporate tax deductions for the advertising of tobacco products. The AAFP supports state and community efforts to reduce or eliminate point-of-sale advertising.

    The AAFP strongly supports prominently displayed labeling warning potential users of health hazards of all tobacco products, including any form of ENDS. The AAFP supports “plain pack” tobacco product packaging, removing logos and colors associated with individual brands, and implementing depictions of tobacco-related disease on packaging.

    Distribution and Sales

    The AAFP supports legislation raising the minimal legal sales age of tobacco products to 21 years of age and requiring active enforcement of minimal legal sale age verification at time of sale. The AAFP supports requiring all tobacco products be placed behind sales counters in retail stores. The AAFP supports legislation to ban the sale of tobacco products via the internet and from vending machines and ban the promotional distribution of free tobacco products. The AAFP supports tobacco retailer licensing programs and zoning requirements reducing the density, type, and location of tobacco retailers.

    Sales of Tobacco Products by Facilities that Provide Health Care Services 

    The AAFP supports a ban on the sale of tobacco products in facilities that provide clinical patient care services, pharmacies, and retail outlets housing health clinics.

    Food and Drug Administration (FDA) Regulation of Tobacco Products

    The AAFP calls for robust and comprehensive regulation of all tobacco and nicotine products by the FDA. The AAFP recommends the FDA regulate all tobacco products at least as stringently as cigarettes, including the manufacture, sale, labeling, distribution, and marketing of tobacco and nicotine products.

    The AAFP calls for the ban of all flavored tobacco and nicotine products, including menthol and an immediate reduction in the nicotine content of combustible tobacco products to non-addictive levels. The FDA’s decisions regarding all tobacco and nicotine products should be subject to stringent enforcement of pre-market review regulations with no exceptions. Tobacco product use is attributed to the leading cause of death in the U.S., and the AAFP believes the tobacco industry should be stringently and comprehensively regulated to protect the health of the public.

    Health Care Facilities

    The AAFP recommends tobacco- and ENDs-free policies on all hospital and health care facility premises, including not allowing designated smoking areas.

    Smoking in Movies

    The AAFP supports efforts to reduce the impact of smoking in movies on youth tobacco initiation, and calls on the film industry to adopt the following voluntary steps:

    • Require movies containing scenes depicting smoking to have an R-rating. The only exceptions should  be when the presentation of tobacco clearly and unambiguously reflect the dangers and consequences of tobacco use or is necessary to represent the smoking of a real historical figure.
    • Require producers to certify on screen that no one on the production received anything of value in consideration for using or displaying tobacco.
    • Require strong anti-smoking ads before any movie with tobacco use, regardless of rating.
    • Stop identifying tobacco brands.
    • End public subsidies for films containing tobacco imagery.

    Organizational Commitments and Acknowledgments

    The AAFP acknowledges that some religious practices involve the ceremonial use of tobacco. Tobacco use in this position paper exclusively refers to the commercial use of tobacco products. The AAFP has no direct association with organizations involved in the manufacture of tobacco products and urges its members to avoid such association.

    The AAFP supports this policy by prohibiting the use of tobacco products in all AAFP buildings, at all meetings sponsored by the AAFP, and by physicians and staff while representing the AAFP. The AAFP encourages constituent chapters to prohibit the use of tobacco products in their offices and at constituent chapter-sponsored meetings. Finally, the AAFP encourages the use of smoke-free meeting and conference space whenever possible.

    The AAFP acknowledges that due to the 21 U.S.C. § 387g(d)(3) provision of the Tobacco Control Act, the FDA is prohibited to require the reduction of nicotine yields of a tobacco product to zero.

    For the purpose of these policies, “tobacco” and “tobacco product(s)” include any product containing tobacco and/or nicotine (including electronic nicotine delivery systems [ENDS]). “Tobacco” and “tobacco product(s)” does not include drugs, devices, or combination products, like nicotine replacement therapy or cessation treatment, authorized for sale by the FDA.

    Clinical Recommendations

    The AAFP has the following Clinical Preventive Service Recommendations regarding tobacco use:

    Tobacco Use, Screening Adults
    The AAFP recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco. (2015)
    Grade Definition (www.uspreventiveservicestaskforce.org)
    Clinical Considerations (www.uspreventiveservicestaskforce.org)

    Tobacco Use, Pregnant Women
    The AAFP recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. (2015)
    Grade Definition (www.uspreventiveservicestaskforce.org)
    Clinical Considerations (www.uspreventiveservicestaskforce.org)

    Tobacco Pharmacotherapy, Pregnant Women
    The AAFP concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. (2015)
    Grade Definition (www.uspreventiveservicestaskforce.org)
    Clinical Considerations (www.uspreventiveservicestaskforce.org)

    Tobacco Use, Adults
    The AAFP concludes that the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) for tobacco cessation in adults, including pregnant women. The AAFP recommends that clinicians direct patients who smoke tobacco to use other cessation interventions with established effectiveness and safety. (2015)
    Grade Definition (www.uspreventiveservicestaskforce.org)
    Clinical Considerations (www.uspreventiveservicestaskforce.org)

    Tobacco Use, Counseling, Children and Adolescents
    The AAFP recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (2013)
    Grade Definition (www.uspreventiveservicestaskforce.org)
    Clinical Considerations (www.uspreventiveservicestaskforce.org)

    These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of Americans. To be effective, the recommendations must be implemented.



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    (2009 COD) (2019 COD)