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Abstract
Objective Previous research has identified that transnational tobacco companies lack transparency and that they hide their harms to health and nature behind environmental, social and governance (ESG) reporting. Our objective was to find whether independent tobacco supply chain companies similarly lack transparency on tobacco-related activities while prominently displaying ESG.
Methods In this cross-sectional study, mentions of tobacco supply chain activities and ESG company official documentation and websites were explored for independent tobacco supply chain companies (n=80) with identified annual reports included in the Tobacco Supply Chain Database. Bivariable statistical analysis tested for differences in the visibility of tobacco supply chain contribution and ESG within official documents and websites. In depth exploration was undertaken for seven case study companies.
Results Independent tobacco supply chain companies were significantly less likely to mention their tobacco supply chain contribution than ESG (31% and 80%, respectively p<0.001) in annual reporting. Tobacco supply chain contribution was also less prominent than ESG on websites (29% and 79%, respectively, mentioned on the home page or a home page menu p<0.001). The companies were making median annual profits of over US$2 million (n=76), with a large variation of revenue from tobacco activity (5–100%) where it was reported (n=9).
Conclusions Independent tobacco supply chain companies undertake ESG activities that they prominently display in official reporting and on websites while often being less transparent about their tobacco supply chain contribution. Potential investors and customers may thus be misled about the companies’ true nature. More rigorous reporting requirements are needed.
- Tobacco industry
- Surveillance and monitoring
- Tobacco industry documents
- Environment
Data availability statement
Data are available in a public, open access repository. Data are available upon reasonable request. Updated data are available from the Tobacco Supply Chains Database at https://www.tobaccotactics.org/supply-chain/. The 2023 download analysed is available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The role of actors in the tobacco supply chain other than transnational tobacco companies has received little academic attention.
There is a research gap in the transparency of these independent companies on their links to the tobacco supply chain.
Research is required on these links to a deadly industry, especially when the independent companies are promoting environmental, social and governance (ESG) frameworks as a key element of their business practices.
WHAT THIS STUDY ADDS
This study found companies, independent of the transnational tobacco companies, contributed to all supply chain processes.
We identified a pattern of frequent ESG promotion alongside limited disclosure of involvement in the tobacco supply chain.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Stock exchanges should consider mandating ESG reporting requirements to include disclosing involvement in any stage of the tobacco supply chain.
Improving transparency within the tobacco supply chain could reduce the willingness of companies to supply the tobacco industry.
Introduction
Since the 1980s, the prevailing orthodoxy has been that companies exist to maximise their profits and shareholders value.1 Researchers focusing on the commercial determinants of health have shown this has led to escalating health and environmental deterioration.2 Transnational tobacco companies dominate the global cigarette market, accumulating vast profits.3
Their tobacco supply chain is multifaceted, involving processes, products and actors.4 Nine processes are identified within the Tobacco Supply Chain Database: growing tobacco leaf, primary processing of the leaf, secondary processing of tobacco products, logistics (moving tobacco), retail and marketing, research and development, accessorising tobacco (lighters, ashtrays), finance and business services and disposing of tobacco waste.5 6 The ‘big five’ transnational tobacco companies are Philip Morris International, British American Tobacco, Japan Tobacco International, Imperial Brands and China National Tobacco Corporation.7 In addition to the ‘big five’, two transnational tobacco leaf companies—Alliance One (Pyxus) and Universal Leaf—and their networks of subsidiaries,8 and many ‘independent companies’ profit from the tobacco supply chain. We define an independent supply chain company for this study as a business that, first, is not part of a transnational tobacco or tobacco leaf company (TTLC) and, second, its main business is not manufacturing tobacco products.
Independent companies have received much less attention than the TTLCs yet are involved in every stage of the tobacco supply chain. For tobacco leaf growing, independent companies supply agrochemicals and machinery.4 In the primary and secondary processing phases, these companies provide drying, cutting, weighing and inspecting machinery and equipment as well as chemicals, including flavours.6 For cigarette sticks, independent companies supply paper, filters, adhesives, inks, dyes and packaging. Logistics firms store and transport tobacco leaf and processed products.4 Other independent companies provide marketing expertise and financial institutions offer finance.6
Although little is known about the activities of independent companies, more is known about the ‘big five’, who have demonstrated a lack of transparency:9 10 they concealed their knowledge of the health impacts of tobacco for decades,11 they manipulate research,12 13 fund front groups14 15 and lobby governments.16 17 With the tobacco industry denormalised and viewed negatively,18 independent companies may conceal their association with tobacco, raising transparency concerns.
There is a proliferation of corporate social responsibility (CSR) activities and environment, social and governance (ESG) frameworks reporting across industries. ESG is a combination of three non-financial categories relating to a company’s impact on society for which many businesses make commitments and report their progress.19 Although some stock exchanges require ESG reporting, non-mandated listed companies and indeed private companies also choose to report.20 However, reporting does not guarantee reliability and quality. Arvidsson and Dumay argue that ESG reporting ‘rests on the assumption that the quantity of disclosure also captures the quality or transparency of disclosure’.21(p.1093) The ‘big five’ have used ESG/CSR to draw attention away from the more well-known negative aspects of tobacco, a process termed ‘greenwashing’.22–24
The practices deployed along the tobacco supply chain—by TTLCs and independent companies—damage the environment through pollution, deforestation, contamination of water and reduction of biodiversity.25 In addition to the health damage of tobacco use, there are health and social impacts for workers in tobacco production including green tobacco sickness, long-term debt and child labour.26 If a company highlights its work in ESG on its website or its annual reports, but ignores or downplays its involvement in the tobacco supply chain, it raises questions about its transparency and the validity of those ESG claims.
The objectives of this study are, first, to understand how transparent independent tobacco supply chain companies with annual reports are about their involvement in the tobacco supply chain and, second, to analyse the relative prominence of their ESG claims.
Methods and data sources
We conducted an observational study encompassing cross-sectional statistical analysis and case studies.
We identified independent companies listed in the Tobacco Supply Chain Database (TSCD) developed by the Tobacco Control Research Group at the University of Bath.5 As of 18 December 2023, the TSCD included 754 companies that were not a subsidiary of a transnational tobacco or leaf company. Our criteria for inclusion of an independent company in this analysis were: currently active within the tobacco supply chain; available annual report in English or Spanish from 2020 onwards; and a functioning website. From the TSCD, 80 of the 754 companies met the inclusion criteria. Of these, 71 were listed on stock exchanges while 19 were unlisted private companies.
The spectrum of companies’ engagement in the tobacco supply chain was assessed via the TSCD’s supply chain products and processes classification.5 6 We developed a data collation scheme (table 1 and figure 1) to collect the data from the official documents (chiefly annual reports) and websites of the companies. We collected data on financial performance, volumes, transparency of involvement in the tobacco supply chain and relative prominence of their ESG claims. The company data was downloaded from the TSCD in December 2023, and the company website and official report availability were assessed in autumn 2023. Annual reports offer a manicured image, with a breakdown of business performance, targets and aspirations, with investors and the wider market in mind (Stanton and Stanton, 2008). There has been a growing trend to publish ESG performance in annual reports (sometimes then described as an ‘integrated report’) or alternatively, via a standalone ESG report.21 27 Websites were chosen as the outward-facing medium of a company, designed to present an image to customers and the public.
Search tree for identifying prominence on the website.
Scheme for data collation for each independent company by source
We used Microsoft Excel to analyse the data. We calculated the median company financial size and health (table 1). Companies often did not provide data on all financial measures. To maximise sample size we used all cases with available data when each median was calculated.
We tested for differences between mentions of the companies’ relationship to the tobacco supply chain and mentions of ESG using χ2 tests (see table 1) (n=80). For official documents, mentions or absence of mentions of tobacco supply chain activity (annual report or ESG report) were compared with mentions or absence of mentions of ESG (annual report or ESG report). For websites, we compared whether tobacco and ESG were highly visible (homepage or homepage menus) to whether there was poor or no visibility (identified on a secondary page, via an inurl search or not found) (see figure 1).
Seven of the 80 companies were selected as case studies. The seven case studies were selected on the basis that they represented a variety of arenas of the tobacco supply chain and global contexts, and demonstrated important themes (lacking transparency, using obscure language) that arose within the prior data analysis in relation to transparency and ESG prominence. The case studies were investigated in more depth than the rest of the sample, using additional data from the TSCD, further analysis of their websites and published reports, including available annual reports from the previous 5 years and supplementary internet searches.
Results
Company contribution to the tobacco supply chain
The 80 companies collectively contributed to all eight supply chain processes from farming to manufacturing to finance and business services with contribution to secondary processing, primary processing and logistics most common (online supplemental table S1). The companies supplied nine different types of supply chain products with machinery and packaging being the most common. Multiple companies performed more than one role, therefore the companies collectively are categorised as being involved in 179 different functions.
Supplemental material
Links to the tobacco supply chain: annual report/ESG report
Our assessment of companies’ transparency about their tobacco supply chain links via annual reports revealed that 69% (n=55) of the 80 companies did not mention their role in the tobacco supply chain (table 2). Only eight companies mentioned that they supplied one or more of the ‘big five’ in their annual reports (online supplemental table S2).
Comparison of mentions of tobacco supply chain-related activity and ESG
Annual reports revealed the 80 companies made an average annual revenue of US$12.2 billion and an average annual profit of US$2.1 billion from all their activities (revenue range US$40 660 to 101.6 billion, profit range US$−1668 to 27.5 billion) (online supplemental table S3). Only 11% (n=9) of companies in the study clearly identified the contribution of involvement in the tobacco supply chains to companies’ revenue or profit. Among these, a median of 43% of their annual revenue was attributable to involvement in the tobacco supply chain (range 5–100%).
Links to the tobacco supply chain: website
Our assessment of transparency of independent companies’ involvement in the tobacco supply chain via their website showed that 18% (n=14 of the 80 companies analysed) had no reference to tobacco-related activities on their websites (online supplemental table S4). Only 11 companies mention tobacco-related activities on their homepage, 12 on a homepage menu and seven on a secondary page. Of those with mentions, most required ‘inurl’ searches to find tobacco links (45% of total, n=36).
ESG: annual report/ESG report
Our assessment of independent companies’ ESG reporting via their official annual reports or dedicated ESG reports showed only 16 companies (20%) made no reference to ESG (online supplemental table S2). Nearly two-thirds (64% (n=51)) had either a section in their annual report dedicated to ESG or a supplementary ESG-focused report available through their website. 13 companies had some reference to ESG in their annual reports.
ESG: website
Our assessment of ESG reporting on websites found that 73 companies (91%) mentioned ESG on their website (online supplemental table S4).
Comparison of tobacco supply chain and ESG reporting
Overall, 23 (29%) companies mentioned the tobacco supply chain in both their annual report and their website, rising to 61 (76%) for the same criteria for ESG (online supplemental table S5). Only four companies (5%) did not mention ESG in either their website or official reporting whereas 12 (15%) made no mention of their links to the tobacco supply chain on their website or annual report.
When comparing mentions to no mentions in the official documents, ESG was more visible than tobacco (p<0.001) (table 2). Of those with any reference to ESG in an annual or ESG report, 64% (n=42) had no reference to their involvement in the tobacco supply chain in these reports (online supplemental table S5). ESG was included within an average of 11 pages per annual report (range 1–46 pages) (online supplemental table S2). In contrast, the average for the 31% of companies in the study that mentioned tobacco in their annual report was two pages of tobacco supply chain-related content (range 1–8 pages).
Mentions of ESG were higher on the most visible elements (homepage or homepage menus) than on the less visible elements (mention on any other part of the website or not visible) when compared with tobacco (p<0.001) (table 2). Comparing website mentions (online supplemental table S4), companies mentioned tobacco and ESG at the same frequency on their homepage (n=9) and secondary page (n=7). However, 68% (n=54) had a link to an ESG-related page on their homepage menu compared with only 16% (n=13) for tobacco supply chain-related activity. Double the number of companies (n=14) had no reference to tobacco-related activity compared with ESG on their website.
Seven case studies
The case study companies have a variety of positions, financial performances and transparency within the tobacco supply chain (table 3). A narrative description deepening our understanding of stances on transparency in the tobacco supply chain and ESG is presented (box 1).
Summary of case study companies
Case study narrative description
Case study 1: Eastman was chosen as an example of a company displaying its environment, social and governance (ESG) credentials more prominently than its role in the tobacco industry. This US-based company references its ESG achievements on its website homepage (ie, its appearance on Fortune’s Change the World list and 3BL’s Top 100 Corporate Citizens) and provides two links to its sustainability report.45 Its role in the tobacco supply chain is more obscured and only available either through searching or through an exploration of its production on a subsidiary page. It is involved in the tobacco supply chain through the manufacture of acetate tow, which is used in cigarette filters. In 2022, acetate tow accounted for 64% of its US$1022 million fibres segment sales or 6.18% of total sales.46 In its 2020 annual report it claimed it is one of the world’s two largest suppliers of acetate tow, including to large multinational cigarette companies.47 Eastman also has a 45% stake in acetate tow manufacturer Eastman Shuangwei Fibers company limited, a joint venture with China National Tobacco Corporation, the world’s largest tobacco company.48
Case study 2: Tunas Alfin, was chosen as an example of a company making no mention of its work in the tobacco supply chain on its website while its annual report details substantial and growing sales from the tobacco supply chain.49 The 2022 annual report of this Indonesian-based packaging company attributed 22.61% of total revenue as accruing from the tobacco supply chain and they saw a 137.37% increase in sales of cigarette packaging products.50
Case study 3: Henkel was chosen as an example of a company that lacks transparency on the true scale of its involvement in the tobacco industry. Its Swiss factory was described in 2017 by a member of staff as the ‘most advanced tobacco adhesives production facility in the world’ supplying ‘adhesives to about 450 cigarette and cigarillo manufacturing locations in more than 80 countries’.51 However, there is no reference to its role in the tobacco industry on its website other than the Chinese section of its subsidiary adhesives website, where it highlights the role of one of its products in cigarette production.52 The only mention of anything related to the tobacco industry or supply chain in its annual reports and sustainability reports 2019–2023, are seminars offered to Henkel employees to help give up smoking.53
Case study 4: Amcor was chosen as an example of a company using obscure language to describe tobacco supply chain involvement. This Swiss-based company labels its tobacco or cigarette-focused products as ‘specialty packaging’ or ‘specialty cartons’ on its website and in its annual reports. While it names its other market segments, ‘beverages’, ‘food’, ‘health’, ‘pet’, etc, on its homepage dropdown menu, its tobacco segment is listed as ‘speciality cartons’.54 Its ‘speciality cartons’ page reveals the tobacco industry is the main target of these products.55 There is no reference to ‘tobacco’ or ‘cigarettes’ in its annual report.56 Online supplemental table S6 in the supplemental file details the instances of obscure language uncovered.
Case studies 5–7: These case studies were chosen as operating within financial services, providing loans and other support to the tobacco industry. The scale of transactions (see below), implies a sizeable role in the tobacco business. However, there is little evidence of this on the websites or annual reports analysed for this study.
In 2022, US-based Goldman Sachs advised tobacco company Swedish Match on its takeover by Philip Morris International, potentially earning the investment and wealth management firm US$50 million.57 Despite this, there is no reference to this deal on its website or its 2022 annual report.58 It also manages investment funds that invest in tobacco companies.59
The Sumitomo Mitsui Banking Corporation (part of the Sumitomo Mitsui Finance Group (SMFG)) is a multinational banking financial services institution based in Japan. In 2020, SMFG introduced ESG policies around tobacco, noting that smoking can cause ‘lung cancer and respiratory dysfunction’ and that ‘it is important to consider human rights to eliminate illegal labor and child labor’.60 (p40) Despite this, it provided a JPY 100 billion loan (US$936 million) to Japan Tobacco International (JTI) in 2020.61 This deal with JTI does not appear on the English version of its website or annual reports.62
Eastern and Southern African Trade and Development Bank based in Burundi, provides credit for the transnational leaf-growing company Pyxus International totalling US$185 million across its African subsidiaries in 2022.63 There is no mention of any involvement in the tobacco industry on either its website or in its annual reports from 2019 to 2023.64
Discussion
This study has contributed two principal new findings to the hitherto under-researched role of independent companies supporting the tobacco industry. First, many independent companies are not transparent about their involvement in the tobacco supply chain. Second, the prominence of ESG reporting when considered alongside the lack of transparency around involvement in tobacco calls into question the authenticity and transparency of this ESG reporting.
The analysis of company annual reports and websites indicated a reluctance to reveal involvement in the tobacco industry. Only one-third of companies in the study mentioned an aspect of their role in tobacco supply chains in their annual reports, while the majority kept references on their website away from principal pages. The case studies further highlighted this trend, with companies appearing to obfuscate involvement in tobacco with opaque language and financial companies not publicising money given to the tobacco industry.
Most of the companies in the study mentioned ESG in their annual reports or had a supplementary ESG report yet the majority of these documents had no reference to their involvement in the tobacco supply chain. The high levels of ESG reporting can in part be attributed to the introduction of mandatory reporting requirements by financial exchanges in recent years.20 However, whether mandated or voluntary, given the tobacco industry’s well-documented negative public health and environmental impacts, investors and customers would presumably want to weigh these companies’ ESG claims against their contributions if they continue to engage in a supply chain of a harmful product.
In addition to the health and environmental aspects of tobacco leaf growing and use, some tobacco supply chain products produced by independent companies have further health and environmental implications. Cigarette filters are increasingly criticised for their damage to the environment with microplastics and heavy metals released into ecosystems.28 Furthermore, filters make smoking easier while misleading cigarette smokers into believing the filter renders the cigarette less harmful.29 The recent WHO Framework Convention on Tobacco Control (FCTC) 10th session of the Conference of the Parties decision on Article 18 further emphasised the damage caused by filters and called on parties to use litigation ‘to hold the tobacco industry accountable for the damage it causes to the environment’.30 This decision does not, to date, explicitly extend to the manufacturers supplying these products to the tobacco industry but this could be considered in future decisions.
Limitations
The Tobacco Supply Chain Database, while comprehensive, is not an exhaustive list of all the companies involved in supplying the tobacco industry. The database was primarily compiled from a 2020 English language tobacco industry journal digest of supply chain companies updated with internet-based searches.6 31 Although Arabic and Spanish speakers were also involved in original TSCD data collation and online translation tools were used, there may be under-representation of companies without an English language online presence. There are similar limitations around the selectivity of annual reports only published in English or Spanish for this study.
Identified annual reports as a selection criterion limited the sample to only 80 companies, and could reduce the generalisability of the findings to companies that do not publish annual reports. Similarly, it likely reduced the number of private (often smaller) companies from the study, as they are less likely to produce annual reports. While this does narrow the scope of the findings, annual reports were a crucial data source for this research design. It is important for further studies incorporating a different design to expand and capture information for more than the 19 private companies included in this study. Nevertheless, the most prominent companies are more likely to be captured in our dataset and potentially have more incentives to leave the tobacco supply chain due to shareholder pressure.
Unless selected as a case study, only the most recent annual reports were searched for this study. It could be that the 2021 or 2020 annual reports revealed different results. Similarly, company websites are often changing and if they were searched during a different time frame, the results may have been different. However, it is hoped that enough websites and annual reports were searched to reduce this variability. Furthermore, the research could be repeated in the future to reveal any changes.
There is a mixture of mandatory and voluntary ESG reporting requirements for companies publicly listed on stock exchanges.32 Further research is needed to understand the extent to which the ESG reporting identified was simply a fulfilment of stock exchange requirements and the extent to which this supports or produces ‘greenwashing’. On the other hand, more research is needed to understand the impact of the growing number of opaque private companies33 on the environment and health. Additional work could compare the ESG reporting of publicly listed and privately owned companies. Furthermore, the issue of transparency would benefit from expanding the focus of the research into first whether independent tobacco supply chain companies are involved with tobacco associations or lobbying organisations. Such organisations are key to the undermining of health via ultra-processed food, for example.34 Second the study could be repeated to understand the role of transparency and CSR in suppliers to other industries including a spectrum of controversial and non-controversial industrial sectors.
Implications
One implication of the study is that stock exchanges should mandate reporting requirements for involvement in any stage of the tobacco supply chain for companies who wish to be listed on their exchanges. To achieve this, organisations such as the UN Sustainable Stock Exchange Initiative35 and the International Sustainability Standards Board by the International Financial Reporting Standards (IFRS) Foundation36 should include involvement in the tobacco supply chain as a reporting requirement in their guidance. This would contribute to answering the call for more comprehensive and transparent ESG reporting.21 37
Many companies in this study have a large portfolio of business interests and the average earnings per company were in the billions of dollars. While their involvement in the tobacco industry may only be a small percentage of their revenue, this can still represent a large sum of money in absolute terms and substantial environmental and/or social impacts. Therefore, any revenue from the tobacco supply chain should be included in mandatory reporting requirements. To not do so undermines the veracity of ESG reporting and indices.
ESG funds screen for certain activities, such as tobacco, oil or arms, and either exclude them or require them to constitute below a specified percentage of their revenue to qualify.38 39 Like transnational and other tobacco companies, independent companies that contribute to the tobacco supply chain should be screened and excluded where appropriate. Mandatory reporting of tobacco supply chain involvement would assist with this and increase trust in ESG reporting.
While untangling the links between companies and the supply chains they contribute to is complex, there are options available to improve transparency. In several industries, blockchain technology is being discussed to increase the transparency of supply chains.40 41 While this would not resolve the issue of transparency on a company’s website, Liu et al, argue it could be used in ESG reporting in annual reports: if publicly available, it would make it easier for researchers to find information about upstream and downstream companies in the tobacco supply chain.42 This could be used by advocates to highlight a company’s involvement in the manufacture of tobacco products. However, if this were to be an industry-led initiative, it could be open to the same concerns around transparency and malfeasance, which have plagued the track and trace system around cigarettes.43
Conclusion
The findings in this study show that the majority of companies examined are open to legitimate criticism of obfuscation or downplaying their involvement in the tobacco industry. While companies appear keen to promote their work in ESG, tobacco-related activities are more hidden from the public and potential investors. The negative environmental and social impact of the tobacco supply chain means there is an inherent inconsistency created by the different levels of visibility.
Due to the WHO FCTC denormalisation strategy and the general negative image of the tobacco industry in many parts of the world, if transparency is encouraged or enforced, it could dissuade companies from contributing to the tobacco supply chain. Continued research in this area could foster increased transparency and highlight business practices at odds with the stated values of a company, while encouraging governments and intergovernmental organisations to introduce policies to improve transparency regarding entities contributing to the tobacco supply chain and to ensure adequate ESG standards. This can expand the strategy of denormalisation of the tobacco industry,18 reducing potential suppliers or collaborators for the ‘big five’.
This study opens a new avenue of research into the involvement of independent companies in the tobacco supply chain. The findings highlight a lack of transparency around this involvement that, once revealed, undermine claims made in ESG reporting. More transparency—through enhanced and mandated reporting—is required to substantiate ESG claims, and to potentially reduce the number of companies willing to supply transnational tobacco companies.
Data availability statement
Data are available in a public, open access repository. Data are available upon reasonable request. Updated data are available from the Tobacco Supply Chains Database at https://www.tobaccotactics.org/supply-chain/. The 2023 download analysed is available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors are grateful to HA for assisting with data acquisition and CJ for assisting with review.
References
Footnotes
X @AllenGallagher_
Contributors MB was in charge of the overall direction. RH conceived of the presented idea and designed the data collection tool. JM designed the database software. FDS, under the supervision of RH, collated much of the dataset, downloaded the data for analysis and conducted the majority of the analysis and drafting. All authors helped shape the research, made substantial contributions to the interpretation, reviewed the work critically for important intellectual content and gave final approval of the version to be published. RH is the guarantor.
Funding The work was supported by Bloomberg Philanthropies as part of the Bloomberg Initiative to Reduce Tobacco Use (www.bloomberg.org). This funder had no role in the design, preparation, or decision to publish this manuscript and the opinions expressed are those of the authors alone.
Competing interests No, there are no competing interests.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.