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Abstract
Introduction Indonesia has a high smoking prevalence that has not diminished significantly since 1990. Considering this, we aim to summarise the existing national tobacco-related policy mix and explore markers of policy incoherence in tobacco control between 2014 and 2020.
Methods We conducted (1) a review and synthesis of Indonesian tobacco-related legislation and regulations; (2) a systematic search and synthesis of related literature and news reporting; and (3) interviews with tobacco control activists and academics to understand political will towards tobacco control regulations and the tobacco industry.
Results Indonesia’s existing tobacco-related policy mix lies across the president’s office, six national ministries and one independent agency. However, current responsibility lies primarily with four government ministries: Ministries of Health, Finance, Communication and Information, and Trade and Industry, with the Ministry of Finance most active. Evidence demonstrates that official interministerial collaboration was lacking from 2014 to 2020 and suggests that institutional will to introduce more effective tobacco control varies considerably between different arms of government.
Discussion Political will differs according to ministerial mandates and priorities, fostering a fragmented policy approach and undermining the development of a coherent response. Without political will from the president or national parliament to create an overarching framework for tobacco control, either via ratification of the Framework Convention on Tobacco Control or another mechanism, there remains no formal impetus for intragovernmental cooperation. Nonetheless, this analysis reveals some government progress and ‘pressure points’ that advocates can focus on to promote tobacco control policies within the current policy mix.
- public policy
- low/middle income country
- taxation
- advocacy
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. The regulatory review uses publicly available data. Relevant interview data are included in the article, but full interviews and the identities of interviewees are not available due to ethical and privacy concerns.
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Introduction
Indonesia has a high prevalence of tobacco use compounded by an ongoing failure to substantially decrease smoking rates.1 While estimates vary, the most recent Ministry of Health national survey reported that 62.9% of adult men and 4.8% of women are smokers,2 among the highest male rates in the world.3 4 There are also concerns about youth uptake, with rates increasing from 7.2% in 2013 to 9.1% in 2018 among those aged 10–18 years old.5 Despite the morbidity and mortality associated with smoking,6 rates of tobacco consumption in Indonesia suggest that national policies to curb smoking and protect the public from tobacco-related harms lag behind other countries, both regionally and globally.
The WHO Framework Convention on Tobacco Control (FCTC) emphasises multisectoral tobacco control efforts, identifying policy interventions which can act, in concert, to reduce tobacco supply and demand.7 While FCTC ratification is not essential for government progress on tobacco control, it nonetheless offers a structured approach for developing evidence-based policy interventions. To promote multisectoral cooperation, Article 5 of the FCTC requires signatories to develop a government focal point for tobacco control that oversees a coherent policy approach to regulation.8
Indonesia has neither ratified the FCTC nor does it have a national framework for tobacco control. While there has been progress on tobacco control, existing tobacco-related policies comprise a complex arrangement of strategies overseen by various institutions within the government that can be characterised as a ‘policy mix’.9 Responsibility for tobacco control initiatives is divided among various national ministries, with some realms, such as the implementation of smoke-free areas, left primarily to subnational governments. Some government institutions, broadly speaking, support stricter tobacco control measures, while others are inconsistent in their approach or even closely aligned with the tobacco industry. Moreover, the attitudes of key individual decision-makers, such as the president and ministers, strongly influence policy priorities.
These dynamics characterise the ‘realities of political opportunities and constraints’, determining the likelihood of particular policy.10 In this paper we focus on the question of coherence within Indonesia’s policy mix. Policy coherence—the ‘synergistic and systematic’ processes that contribute to an overall policy objective, across and within governmental jurisdictions—is crucial for effective, multisectoral tobacco control policies.8 11 12 Coherence is best enabled when political will across relevant institutions aligns, manifesting through cooperative actions towards shared goals.
This paper assesses Indonesia’s recent progress towards a more coherent regulatory framework for tobacco control, examining existing regulations and political will among key national institutions. We focus on the period 2014–2020, as this captures developments under the current political administration of President Joko Widodo, elected in 2014. To identify key barriers to coherence, we aim to (1) establish the policy mix by summarising national policy instruments and key executive institutions involved in creating tobacco regulation; and (2) examine political will among key national ministries. A nuanced analysis of the policy mix that considers how existing government structures, divisions of responsibility and ministerial priorities shape tobacco policy helps identify avenues for improvement.13 This evidence base provides a critical tool for campaigns that advocate for a national tobacco control framework and interventions across different government institutions.
Methods
Design and data sources
Our approach involves qualitative analyses of two data sets. The first is a systematic review of Indonesian legislation and regulations, and relevant published literature, focusing on the period 2014–2020. We conducted an internet search for legal instruments using the website Tobacco Control Laws, a project of the International Legal Consortium of the Campaign for Tobacco-Free Kids.14 Noting that the website omitted more general laws that could influence tobacco regulations, particularly from a rural or industry perspective, we identified further laws through a keyword search via the Indonesian government regulations database, the Network for Documentation and Legal Information. We also searched the keywords ‘farmers’ and ‘tobacco’ on the Ministry of Agriculture and ‘tobacco’ and ‘cigarettes’ on the Ministry of Trade and Industry websites. Supplementary information, including media reporting and relevant reports in English and Indonesian, was also collected via internet searches (using Google and Google Scholar), incorporating keywords from the title of each policy identified.
Second, we conducted semistructured, face-to-face interviews (n=13) with key informants from March to August 2019. Participants included advocates from non-governmental organisations (n=7), academics (n=4) and civil servants (n=2). The questions were adapted to each interviewee to ensure relevance. We asked participants open-ended questions about (1) their assessment of existing regulations, (2) their observations about implementing tobacco control policy, (3) their opinions about what factors influenced tobacco policy outcomes, and (4) which government institutions they believed support tobacco control initiatives and which do not.
Analyses
We identified laws for specific articles that are used, or could potentially be used, to regulate the promotion, production, sale, restriction, taxation and excise, and advertising of tobacco products. We identified specific articles within legislation that mentioned tobacco (tembakau) and/or cigarettes (rokok) through a keyword search. In addition, we reviewed other policy documents with relevance to tobacco issues in Indonesia, including those related to farmer protection and industry. Supplementary materials gathered through internet searches were reviewed and analysed to identify additional commentary, specifically critiques that emerged in relation to improving tobacco control in Indonesia.
After a close reading of interview transcripts, we sorted data according to associated government institution, then extracted instances where interviewees offered an opinion on government policy and institutional support for tobacco control. Relevant data were thematically coded based on (1) aspect of tobacco policy (key nodes: government coordination, taxation/excise, advertising, smoke-free areas, agriculture/farming regulation, industry regulation) and (2) nature of support for tobacco control (key nodes: positive, negative, neutral). This coding helped to develop a narrative of the contemporary context and conditions surrounding tobaccopolicy.
Results
Creation of policy
There are eight governmental jurisdictions under which laws and regulations are in effect, with varying realms of administrative authority (see table 1). Policy creation occurs in both legislative and executive realms, where legislative bodies create laws and executive bodies (president, cabinet and ministers) issue regulations to enact these laws.
Legislative and regulatory framework in Indonesia42
The highest legal authority for policy creation is the national legislature, with these laws ultimately guiding the enactment of policies by lower levels. While ministers are able to advocate for increased funding towards priority issues through the annual national development planning consultations (known as Musrembangnas) and the parliamentary budget committee (known as Banggar), the national parliament must still approve the annual ministerial budgets.15
Existing policy mix
We identified 15 existing national laws (see online supplemental material 1) relevant to tobacco policy. Five of these laws have accompanying implementation regulations impacting the tobacco industry and/or tobacco control: the laws on (1) industry, (2) national long-term planning and development, (3) protection and empowerment of farmers, (4) excise, and (5) health. As of October 2020, these laws have 16 associated regulations, including 3 presidential decrees, 1 government (cabinet) regulation, 11 ministerial regulations and 1 independent agency regulation (see table 2). In addition to the president and cabinet, six national ministries and one independent agency have issued regulations: (1) Ministry of Agriculture, (2) Ministry of Finance, (3) Ministry of Health, (4) Ministry of Internal Affairs, (5) Food and Drug Supervisory Agency, (6) Ministry of Education and Culture, and (7) Ministry of Trade and Industry. (The Ministry of Trade and the Ministry of Industry were previously separate entities but were united under the 2014–2019 government administration.) A more detailed summary of the policy implications of these regulations is available in online supplemental material 2.
Supplemental material
Key regulations related to tobacco by executive government agency
Of the three presidential decrees, only one explicitly addresses tobacco control. The 2020 decree on the National Medium-Term Development Plan permits the Ministry of Finance to increase targeted contributions from tobacco excise in its annual budget. It does not, however, make clear whether increased contributions should derive from higher taxes and/or excise, or from increases in cigarette sales. The decree also allows for simplified cigarette excise structures, but regulations to simplify these structures already existed under a 2017 Ministry of Finance regulation. Moreover, the decree specifies that tobacco tax and excise increases must be gradual to mitigate negative impacts on farmers and industry workers. This decree also provides the Ministry for Development and Planning with a mandate for coordinating policy strategy to reducing smoking rates among those aged 10–18 years old. However, being empowered to coordinate strategy still relies on political will from relevant ministries and the decree includes no sanctions against ministries that fail to cooperate. While serving to highlight certain policy areas, this decree did little to progress concrete policy change or coordination among ministries.
The majority of Indonesia’s tobacco control policy instruments (nine regulations) derive from the 2009 Law on Health. Other tobacco control regulations were issued under the 2009 Law on Excise, which guides the tax and excise policy for the Ministry of Finance, and the 2014 Law on Industry, which informs oversight of the cigarette industry. Conspicuously absent in the policy mix is the Ministry of Communication and Information, responsible for overseeing tobacco advertising and portrayals in media. This ministry has issued none of its own regulations, instead deferring to policies for tobacco in advertising and media included in the 2012 Government Regulation, developed by the cabinet.
An investigation of current policy instruments captures existing regulations, but there is also policy-related activity that does not result in regulation. For example, the Ministry of Trade and Industry promulgated tobacco-related policies that were not implemented owing to judicial intervention. In 2014, the ministry created a national ‘tobacco industry roadmap’, which aimed to boost the industry and set increasing cigarette production targets over a 5-year timeframe.16 This policy was overturned by the Supreme Court, who deemed it to breach existing laws on health, human rights, excise and the protection of children. The trade-focused arm of the Ministry of Trade and Industry also attempted to regulate the import of tobacco leaves in 2017 (draft Ministry of Trade Regulation No 84/2017), but the regulation stalled, primarily due to internal dissent from the industry-focused side of the ministry.17 Although this ministry was unable to enact this regulation, the Ministry of Agriculture took its own steps to address the issue with Regulation No 23/2019 on the Technical Recommendations for the Import of Tobacco. This requires tobacco importers to gain permission from the Ministry of Agriculture to import tobacco, as well as compelling them to locally source at least two-thirds of their raw tobacco unless they can demonstrate that local production is insufficient to meet demand. The underlying aim of the policy was to protect markets for local tobacco farmers and safeguard the profitability of growing tobacco.
Other ministries involved in public debates on tobacco policy lack authority to enforce relevant regulations themselves. For example, the Ministry for Development and Planning highlighted a national decline in the smoking rate among those below age 18 and the implementation of smoke-free areas as key indicators in its 2019 work plan for ‘strengthening the movement for healthy living and preventing disease’.18 This plan was supported by Presidential Regulation No 72/2018. In 2020, this ministry underscored its interest in tobacco control as a development issue, but also recognised the need to balance the health risks of smoking with impacts on industry jobs.19 However, the ministry has no authority to issue regulations in this realm, relying on support from the Ministries of Finance, Trade and Industry, and Internal Affairs, as well as subnational actors.
Similarly, the Ministry of Women’s Empowerment and Child Protection has issued a 24-point plan for ‘child friendly cities’ (kota layak anak), which includes restricting advertising billboards, distribution of free samples, sponsorship of sports and music events, and the creation of merchandise for children.20 This ministry also launched a ‘Smoke Free Family’ (keluarga bebas rokok) movement in 2020.21 However, while it has the capacity to promote these initiatives, the ministry relies on local governments to create regulations and monitor enforcement.
Evidence of political will
Political will is a fundamental driver of policy coherence. The key ministries involved in tobacco regulation each has its own institutional priorities. Lacking presidential leadership that compels them to cooperate, or a parliament willing to pass legislation creating a national tobacco control framework, policy coherence hinges on the willingness of decision-makers within ministries to collaborate. Media reporting and official statements from 2014 to 2020 provide some insight into actions by ministries related to tobacco control (table 3). The data reveal that the Ministry of Finance has been most active in creating policy, particularly post-2019. The Ministry of Health implemented internal policies to guard against conflict of interest with the tobacco industry, as well as lobbying the Ministry of Communication and Information to better enforce regulations on online advertising and portrayals of smoking.
Tobacco-related actions among key ministries (2014–2020)
Key informant interviews
Key informant interviews generated insights that were used to further assess political will for tobacco control among government institutions. Here, our results focus on critiques pertaining to the four ministries with the most significant roles in tobacco regulation: Ministries of Health, Finance, Communication and Information, and Trade and Industry (table 4).
Support for tobacco control initiatives among key ministries: key indicative quotations (translated from Indonesian)
Comparing the actions highlighted by our desk review with the interview results, the question of political will among key ministries becomes more complex. While the Ministry of Trade and Industry apparently lacks the political will to contribute to stronger national tobacco control policies, many tobacco control activists and academics were also disappointed with the Ministry of Health’s progress in this sphere. These interviews also highlighted industry influence in policy discussions, particularly within the Ministry of Finance. Furthermore, the Ministry of Communication and Information’s lack of commitment to enforcing advertising regulations on an ongoing basis was evident.
Discussion
Our analysis of Indonesia’s tobacco-related policy mix reveals no cooperative policies issued between 2014 and 2020. This is partially explained by collaborations undertaken prior to this timeframe, such as the cabinet-issued wide-ranging Government Regulation No 109/2012 concerning materials that contain addictive substances, which was attached to the 2009 Law on Health, and the joint regulation between the Ministries of Health and Interior on guidelines related to the implementation of smoke-free areas. The Ministries of Health, Internal Affairs, Education and Culture, and the Food and Drug Supervisory Agency have all enacted individual regulations pertaining to this 2009 law. No cabinet or interministerial joint regulations were issued after 2012.
In terms of individualised portfolio responses, the Ministry of Health issued three relevant regulations between 2014 and 2020, two of which pertained directly to a tobacco control agenda—taking steps to manage conflict of interests with the tobacco industry within the Ministry of Health itself (notably, no other ministries have such regulations) and imposing stricter regulations for health warnings on tobacco packaging. However, interview data suggest that activists felt that the Ministry of Health was not prioritising tobacco control. Thus, while the Ministry of Health made some gains, tobacco control advocates were disappointed with the institution’s political will in this realm.
The Ministry of Finance’s core responsibility is to manage budgeting and ensure there are adequate funds to meet government expenditure. Responsibility for taxation and excise, a linchpin of tobacco control policy, lies with this ministry. Effective tobacco tax policy can decrease smoking rates, as well as discourage youth uptake.22 23 The tobacco industry is considered a vital contributor to Indonesia’s budget, with the ministry declaring that it contributed 153 trillion rupiah (approximately US$10.9 billion) in 2018.24 The ministry has identified this as a key consideration for tobacco tax policy.24 It has been reticent to increase tobacco taxes in the past. This was acutely evident in 2018, when concerns about voter backlash during an election year were suspected to have influenced the cancelling of planned excise hikes in 2019.25 26
Since the end of 2019 there has been a discernible shift, with the passing of regulations to increase base cigarette prices and tobacco excise. The year 2020 saw the average excise tariff increased by 23% and the minimum retail price increased by an average of 35%. It also updated the existing banderole price regulations set in 2018, through which the Indonesian government prevented cigarette companies from decreasing their prices in order to minimise the impact of percentage-based tax increases.27 While excise costs are born by the manufacturer and may or not be passed on to consumers via price increases, minimum price increases affect consumers. Increasing excise is a positive step towards curbing smoking rates but, even with these increases, cigarette excise in Indonesia falls well below the WHO recommendation that excise and taxes account for a minimum of 70% of cigarette retail price.28
The Ministry of Finance’s realm of responsibility means that it must balance the financial impacts of tobacco control policy against other benefits. The Minister of Finance herself identified five considerations when determining tobacco tax policy, namely (1) the need to decrease consumption; (2) the impact on workers in the tobacco sector; (3) the impact on tobacco farmers; (4) the need to ensure that higher prices do not incentivise illegal trade in cigarettes; and (5) the need to support the government budget, setting a goal of obtaining 173.78 billion rupiah (approximately US$ 12.34 billion) from cigarette tax and excise.29 Key informants point to a close relationship between industry and some individuals within the ministry, complicating advocacy efforts. The ministry has experienced pushback from the tobacco industry in its bid to simplify the complex tiered excise structure for cigarette manufacturers, where distinct types of cigarettes are subject to varying tax and excise rates depending on the type of cigarette, method of production (hand-rolled or machine-rolled), and whether it was manufactured locally or imported. Industry stakeholders claim that a simplified structure would severely disadvantage small-scale producers who produce hand-rolled clove cigarettes.30 However, the Minister appears sympathetic towards tobacco control and price regulation, with further excise increases announced in November 2020 for 2021, while asserting the need to balance this with protecting jobs and government revenue.
The third key ministry involved in tobacco control policy, particularly in implementing regulations around advertising and media portrayals, is the Ministry of Communication and Information, which has not issued any of its own policies since 2012. Key informant interviews and media coverage portray a ministry that is inconsistent in enforcing advertising regulations, tending to be reactive rather than proactive on the issue. For example, in June 2019, the Minister for Health was forced to write to the Minister for Communication and Information stating its concern that Government Regulation No 109/2012 was not being enforced with respect to online media advertising and portrayals of cigarettes.31 To its credit, the Ministry of Communication and Information responded by committing resources to block online advertising, social media posts and other content that portrayed cigarettes in breach of this law. But the lax enforcement of this regulation prior to this letter and the fact that the Health Minister felt compelled to publicly intervene indicate that enforcement of cigarette advertising restrictions was not a priority. Some key informants interviewed highlighted that the Minister of Health’s letter was made public on social media, sparking public attention that prompted a swift response, expressing doubt that the Ministry of Communication and Industry would have responded so quickly if not for the public attention.
The policy mix also features two ministries—Trade and Industry and Agriculture—that have enacted regulations that support the tobacco industry. The Ministry of Trade and Industry has garnered a reputation for industry support, especially following the ‘tobacco industry roadmap’ regulation it attempted to enact.32 Tobacco control advocates shared that they do not believe it worth engaging with this ministry as the institutional focus seems fundamentally at odds with the goals of tobacco control. The Ministry of Agriculture has also favoured the industry in terms of providing protection for tobacco farmers through regulations that safeguard domestic tobacco markets. Its reticence in establishing agricultural schemes that would support tobacco farmers to shift to alternate crops and decentre tobacco production reflects a reluctance to participate in broader tobacco control efforts.
In considering the policy mix, it is also important to note that tobacco regulation is not a solely national government concern. The Ministries of Health and Internal Affairs issued a joint regulation in 2011 providing guidelines relating to the implementation of smoke-free areas. The roll-out of this regulation, which is ongoing, tasks each provincial and local government with creating their own by-laws for the designation of smoke-free areas and local restrictions on tobacco advertising. Some provincial governments, using their own authority, have issued additional constraints on tobacco advertising, although regulations vary between provinces.33 34 This adds further complexity to Indonesia’s policy mix, as different provincial and local governments enact varying regulations.
Indonesia’s lack of a multisectoral national policy for tobacco control has been cited as a key factor in ‘stalling’ the progress of tobacco control efforts, due to the ‘unclear authority and responsibilities of each [government] stakeholder’.35 Our evidence supports the assertion that, although there has been progress in tobacco control policy since 2014, this progress has been delineated along ministerial lines. The adoption of FCTC protocols is a potential step towards bridging the lack of cohesion among different institutions that play a role in regulating various aspects of tobacco control.36 However, Indonesia’s current president, Joko Widodo, has expressed no desire to ratify the FCTC or create a comparable national framework. Within parliament, there is vocal support for policies protecting the livelihoods of farmers, cigarette factory workers and, by extension, the tobacco industry. There are numerous examples of media statements by national parliamentarians supporting the tobacco industry.37–39 The problem of industry interference in public health policymaking has been recognised publicly. For example, independent transparency watchdog, Indonesia Corruption Watch, called on politicians to declare funding or links to the tobacco industry ahead of the 2019 elections.40 However, no politicians heeded the call and publicly acknowledged links to industry.
Limitations
This study has limitations. We focus on issues identified between 2014 and 2020, but several relevant laws and regulations were created prior to this timeframe. The study is also limited to policies at the national level, and the extended role of provincial and local governments has not been elucidated. Other advocates and academics not interviewed in the convenience sample for this study might have reported different issues. Future research could expand on this study to investigate the experiences of those within government involved in creating national tobacco policy.
Conclusion
Indonesia’s tobacco policy mix is characterised by a vast diversity of regulations, distributed across nine different government institutions. The lack of an overarching framework—guided either by the FCTC or a national initiative—further entrenches this siloed approach to tobacco regulation. Despite this, there have been positive steps and tobacco control policy has progressed in Indonesia since 2014, particularly in the realm of tax and excise. A recent high-level policy meeting in March 2021 initiated by the Ministry of Health and including representatives from the Ministries of Home Affairs, Development and Planning, and Finance showed promising signs of collaborative efforts among some ministries.41
While ratifying the FCTC is by no means a panacea, a nationally coordinated framework for tobacco control, established by the president and supported by parliament, would be an important next step in streamlining policy responses and ensuring coherence across institutions. In assessing the support of various stakeholder ministries towards tobacco control, we find that competing institutional logics lead to diverging interests regarding tobacco control, manifesting in the current policy mix and level of coherence in regulations. A centrally coordinated tobacco control response could enhance existing progress by providing a stronger impetus for ministries to confer and cooperate on joint policy development and implementation.
This paper highlights the need for continued pressure on the office of the president and the national parliament to adopt a national framework and advance strategies to eliminate tobacco industry influence in the policy process.
What this paper adds
What is already known on this subject
Smoking rates in Indonesia are high and have not significantly decreased in the past two decades, unlike most other countries in the world.
The Indonesian government has not signed the Framework Convention on Tobacco Control and lacks an overarching national framework for implementing more effective tobacco control policies.
What this paper adds
This study charts the national legislative framework for tobacco control in Indonesia, outlining 14 key national laws that could be applied to a broad tobacco regulatory framework; however, of these 14 laws, only 5 have associated regulations that have been applied specifically to the purpose of tobacco control.
We identify the Indonesian Ministries of Health, Finance, Industry and Trade, and Communication and Information as playing the most substantive role in tobacco-related policy, with the Ministries of Health and Finance currently most active.
Identifying these key institutions, their current regulatory roles and attitudes towards tobacco control allows advocates to tailor targeted lobbying efforts towards these actors.
Interviews with tobacco control activists and academics reveal that the political will of these ministries to better regulate the tobacco industry varies significantly, and also highlight that developments from 2014 to 2020 have been disappointing.
Indonesian national tobacco policy is characterised by policy incoherence, underpinned by both a lack of political will among key ministries and a lack of impetus to collaborate in creating and implementing regulations.
Despite this, Indonesia has made positive steps towards tobacco control, including recent tobacco excise hikes in 2020 and 2021; however, overcoming enduring incoherence will require a concerted effort from the central government, under a supportive president, who can compel ministries to work together under a national framework.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information. The regulatory review uses publicly available data. Relevant interview data are included in the article, but full interviews and the identities of interviewees are not available due to ethical and privacy concerns.
Ethics statements
Patient consent for publication
Ethics approval
Interviews were conducted per University of Sydney Human Research Ethics Guidelines, with project approval number 2018/192.
Acknowledgments
The authors would like to acknowledge the research assistance provided by Owen James and Achmad Zulfikar.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @liskramer
Contributors EK contributed to project conceptualisation, literature review, data collection, data analysis, and writing and review of drafts. AA and VWR contributed to project conceptualisation, data analysis and review of drafts.
Funding Funding for this project was received from the Australian Department of Education, Skills and Employment via the Endeavour Leadership Scheme and The University of Sydney-Harvard University Mobility Grant.
Competing interests None declared.
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.