proposals for future bpm research directions

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Exploring Explorative BPM - Setting the Ground for Future Research

University of Liechtenstein, 9490, Vaduz, Liechtenstein

Vienna University of Economics and Business, 1020, Vienna, Austria

University of Bayreuth, 95444, Bayreuth, Germany

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Business Process Management: 17th International Conference, BPM 2019, Vienna, Austria, September 1–6, 2019, Proceedings

Recent claims in the literature highlight that BPM should become more explorative and opportunity-driven. The underlying argument is that BPM has been mainly concerned with exploitation activities – i.e., analysis and improvement of existing business processes – but it has neglected the role of innovation. In this conceptual article, we aim to establish a systematic understanding of what explorative BPM is and how it can be brought about. We pursue three goals. First, we derive an overarching definition of explorative BPM. Second, we propose the “triple diamond model” as a means to integrate explorative BPM activities in business process work. Third, we point to future research opportunities in the context of explorative BPM.

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University of Copenhagen, Copenhagen, Denmark

Eindhoven University of Technology, Eindhoven, The Netherlands

University of Bayreuth, Bayreuth, Germany

Vienna University of Economics and Business, Vienna, Austria

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• Published: 1 September 2019

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• Explorative BPM
• Process innovation
• Opportunity identification

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Business Process Management Journal

ISSN : 1463-7154

Article publication date: 25 March 2024

Issue publication date: 17 April 2024

The aim of this paper is to identify the main challenges and limitations of current business process management (BPM) development directions noticed by researchers, as well as to define the areas of the main BPM paradigm shifts necessary for the BPM of tomorrow to meet the challenges posed by Industry 4.0 and the emerging Industry 5.0. This is extremely important from the perspective of eliminating the existing broadening gap between the considerations of academic researchers and the needs of business itself.

Design/methodology/approach

A systematic literature review was conducted on the basis of the resources of two digital databases: Web of Science (WoS) and SCOPUS. Based on the PRISMA protocol, the authors selected 29 papers published in the last decade that diagnosed the challenges and limitations of modern BPM and contained recommendations for its future development. The content of the articles was analyzed within four BPM core areas.

The authors of the selected articles most commonly point to the areas of organization (21 articles) and methods and information technology (IT) (22 articles) in the context of the challenges and limitations of current BPM and the directions of recommended future BPM development. This points to the prevalence among researchers of the perspective of Industry 4.0 – or focus on technological solutions and raising process efficiency, with the full exclusion or only the partial signalization of the influence of implementing new technologies on the stakeholders and in particular – employees, their roles and competencies – the key aspects of Industry 5.0.

Research limitations/implications

The proposal of BPM future development directions requires the extension of the BPM paradigm, taking into account its holistic nature, especially unpredictable, knowledge-intensive business processes requiring dynamic management, the need to integrate BPM with knowledge management (KM) and the requirements of Industry 5.0 in terms of organizational culture. The limitation is that the study is based on only two databases: WoS and SCOPUS and that the search has been narrowed down to publications in English only.

Practical implications

The proposal of BPM future development directions also requires the extension of the BPM paradigm, taking into account the specific challenges and limitations that managers encounter on a daily basis. The presented summaries of the challenges and limitations resulting from the literature review are accompanied by recommendations that are primarily dedicated to practitioners.

Social implications

The article indicates the area people and culture as one of the four core areas of BPM. It emphasizes the necessity to account to a greater degree for the influence of people, their knowledge, experience and engagement, as well as formal and informal communication, without which it is impossible to use the creativity, innovativeness and dynamism of the individual and the communities to create value in the course of business process execution.

Originality/value

To the authors' knowledge, this is the first systematic review of the literature on the limitations of modern BPM and its future in the context of Industry 4.0 and Industry 5.0.

• Business process management (BPM)
• Future of BPM
• Industry 4.0
• Industry 5.0
• Systematic literature review

Szelągowski, M. and Berniak-Woźny, J. (2024), "BPM challenges, limitations and future development directions – a systematic literature review", Business Process Management Journal , Vol. 30 No. 2, pp. 505-557. https://doi.org/10.1108/BPMJ-06-2023-0419

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Source: Business Process Management Journal , Volume 30, Number 2, 2023, pp. 505-557(53)

Publisher: Emerald Group Publishing Limited

DOI: https://doi.org/10.1108/BPMJ-06-2023-0419

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Keywords: Business process management (BPM) ; Future of BPM ; Industry 4.0 ; Industry 5.0 ; Systematic literature review

Document Type: Research Article

Publication date: November 21, 2023

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Ideas for writing the “future research directions” section (pt.I)

Kayla Greenstien

In research, it’s important to build upon previous work. This is why researchers often discuss future research directions at the end of a paper, providing a clear roadmap for the field’s next steps.

Here is a list of areas to consider that I generated using chat-gpt, then reviewed. It is surprisingly comprehensive and useful in my opinion.

Part II covers other general tips for writing a discussion section.

While these points can help with brainstorming, the best way to gain a deeper understanding of how researchers write on future research directions is by widely reading high-quality papers from different.

• Addressing Limitations : Start by acknowledging the limitations highlighted in your study. Explain how future research can overcome these limitations to build on the current findings.
• Longitudinal Studies: If your study had a cross-sectional design, suggest the need for longitudinal studies. Long-term observations can reveal trends and changes over time, providing a more comprehensive understanding of the phenomenon.
• Diverse Samples : Emphasize the importance of using diverse and representative samples in future research. This ensures that findings are more generalizable and applicable to a broader population.
• Experimental Designs: If your study was observational, propose the incorporation of experimental designs to establish causal relationships between variables. Controlled experiments can provide stronger evidence of cause and effect.
• Multi-Level Analysis: Consider examining the phenomenon at different levels, such as individual, group, organizational, or societal levels. This approach can unveil complex interactions and shed light on various influencing factors.
• Cultural Context : Highlight the need for cross-cultural research to explore how the phenomenon varies across different cultural contexts. This approach can help identify cultural-specific factors that influence the phenomenon.
• New Variables or Measures : Suggest exploring new variables or measures that weren’t considered in your study but might contribute to a more nuanced understanding of the topic.
• Comparative Studies : Propose conducting comparative studies that compare the phenomenon across different groups, conditions, or time periods. Comparative analyses can uncover patterns and differences.
• Mixed-Methods Approach : Consider integrating qualitative and quantitative methods to provide a more holistic understanding of the phenomenon. Qualitative insights can complement quantitative findings.
• Application in Real-World Settings : Discuss how future research can focus on implementing the findings in real-world settings, translating theoretical insights into practical applications.
• Intervention Studies: If relevant, suggest the need for intervention studies to test the effectiveness of strategies or interventions derived from your research. This can bridge the gap between theory and practice.
• Ethical Considerations: Address any ethical concerns related to future research directions. Ensure that proposed studies adhere to ethical standards and prioritize participant well-being.
• Replication and Extension: Emphasize the importance of replication studies to validate your findings. Additionally, suggest extending your study to explore related aspects that were beyond the scope of your research.
• Interdisciplinary Collaboration: Encourage interdisciplinary collaboration with experts from related fields to bring diverse perspectives and methods into your research area.
• Theoretical Advancements: Discuss how future research can contribute to the development of existing theories or the formulation of new theoretical frameworks that better explain the phenomenon
• Practical Implications : Explore how the findings of future research can be applied in practical contexts, such as policy-making, intervention development, or organizational strategies.

You most definitely do not need to cover all of these points. It is best to choose two or three of the most relevant to your discussion based on the study’s limitations. Ensure you make a meaningful tie back to concrete aspects of the current study rather than tagging on general future research suggestions that lack specificity. The above points should be elaborated on with clear details.

See Part II for more tips.

Written by Kayla Greenstien

University of Sydney psychology PhD student studying psychedelics, ethics and complex trauma.

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BPM in the Digital Age

The following are some of the central references in connection with our study.

BPTrends Article

Business Process Management in the Digital Age

Delphi Study

Dalkey, N., & Helmer, O. (1963). An Experimental Application of the DELPHI Method to the Use of Experts. Management Science , 9 (3), 458–467.

Keeney, S., McKenna, H.(2006). Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J ournal of Advanced Nursing, 53(2) ,205-212.

Okoli, C., & Pawlowski, S. D. (2004). The Delphi method as a research tool: An example, design considerations and applications. Information & Management , 42 (1), 15–29.

Paré, G., Cameron, A.-F., Poba-Nzaou, P., & Templier, M. (2013). A systematic assessment of rigor in information systems ranking-type Delphi studies. Information & Management , 50 (5), 207–217.

Schmiedel, T., vom Brocke, J., & Recker, J. (2013). Which cultural values matter to business process management? Business Process Management Journal , 19 (2), 292–317.

Skinner, R., Nelson, R. R., & Chin, W. W. (2015). The Delphi Method Research Strategy in Srudies of Information Systems. Communications of the Association for Information Systems , 37 .

BPM Capability Development

de Bruin, T., & Rosemann, M. (2007). Using the Delphi Technique to Identify BPM Capability Areas. ACIS 2007 Proceedings. 42.

Forstner, E., Kamprath, N., & Röglinger, M. (2014). Capability development with process maturity models - Decision framework and economic analysis. Journal of Decision Systems , 23 (2), 127–150.

Lehnert, M., Linhart, A., & Röglinger, M. (2016). Value-based process project portfolio management: Integrated planning of BPM capability development and process improvement. Business Research , 9 (2), 377–419.

Pöppelbuß, J., Plattfaut, R., & Niehaves, B. (2015). How Do We Progress? An Exploration of Alternate Explanations for BPM Capability Development. Communications of the Association for Information Systems , 36 (1).

Rosemann, M., & vom Brocke, J. (2015). The Six Core Elements of Business Process Management. In J. vom Brocke & M. Rosemann (Eds.), Handbook on Business Process Management 1 (pp. 107–122). Berlin, Heidelberg: Springer Berlin Heidelberg.

van Looy, A., Backer, M. D., & Poels, G. (2014). A conceptual framework and classification of capability areas for business process maturity. Enterprise Information Systems , 8 (2), 188–224.

vom Brocke, J., & Rosemann, M. (Eds.). (2015). Handbook on Business Process Management 1 . Berlin, Heidelberg: Springer Berlin Heidelberg.

Future of BPM

Recker, J. (2014). Suggestions for the next wave of BPM research: strengthening the theoretical core and exploring the protective belt. Journal of Information Technology Theory and Application , 15 (2), 5–20.

Recker, J., & Mendling, J. (2016). The State of the Art of Business Process Management Research as Published in the BPM Conference. Business & Information Systems Engineering , 58 (1), 55–72.

Rosemann, M. (2014). Proposals for Future BPM Research Directions. In W. van der Aalst, J. Mylopoulos, M. Rosemann, M. J. Shaw, C. Szyperski, C. Ouyang, & J.-Y. Jung (Eds.), Lecture Notes in Business Information Processing. Asia Pacific Business Process Management (pp. 1–15). Cham: Springer International Publishing.

van der Aalst, W. M. P. (2013). Business Process Management: A Comprehensive Survey. ISRN Software Engineering , 2013 (1), 1–37.

vom Brocke, J., Schmiedel, T., Recker, J., Trkman, P., Mertens, W., & Viaene, S. (2014). Ten principles of good business process management. Business Process Management Journal , 20 (4), 530–548.

Digitalization and Future of Work

Bughin, J., Lund, S., & Remes, J. (2016). Rethinking work in the digital age. Retrieved from http://www.mckinsey.com/business-functions/organization/our-insights/rethinking-work-in-the-digital-age

Brynjolfsson, E., & McAfee, A. (2016). The second machine age: Work, progress, and prosperity in a time of brilliant technologies (6. Auflage). New York, London: W.W. Norton & Company.

Davenport, T. H., & Kirby, J. (2016). Only humans need apply: Winners and losers in the age of smart machines (First edition). New York, NY: Harper Business.

Denner, S., Püschel, L., & Röglinger, M. (2017). How to Exploit the Digitalization Potential of Business Processes. Business & Information Systems Engineering

Gartner. (2017). Gartner IT Glossary. Retrieved from http://www.gartner.com/it-glossary/digitalization/

Gartner. (2016). Gartner Hype Cycle for Emerging Digital Technologies. Retrieved from www.gartner.com/newsroom/id/3412017

Gimpel, H., & Röglinger, M. (2015). Digital Transformation: Changes and Chances - Insights based on an Empirical Study.

Kerpedzhiev, G., Lehnert, M., & Röglinger, M. (2016). The Future of Business Process Management in the Future of Work. Proceedings of the 24th European Conference on Information Systems (ECIS) , 81.

Malone, T. W. (2007). The future of work: How the new order of business will shape your organization, your management style, and your life ([reprint]). Boston, Mass.: Harvard Business School Press. Retrieved from http://www.gbv.de/dms/faz-rez/FD1200410042486663.pdf

McAfee, A. P. (2010). Enterprise 2.0: New collaborative tools for your organization's toughest challenges (reprint). Boston, Mass.: Harvard Business Press.

Zarkadakis, G., Jesuthasan, R., & Malcolm, T. (2016). The 3 Ways Work Can be Automated. Harvard Business Review . Retrieved from https://hbr.org/2016/10/the-3-ways-work-can-be-automated

Asia Pacific Business Process Management

Second Asia Pacific Conference, AP-BPM 2014, Brisbane, QLD, Australia, July 3-4, 2014, Proceedings

• Conference proceedings
• © 2014
• Chun Ouyang 0 ,
• Jae-Yoon Jung 1

Queensland University of Technology, Brisbane, Australia

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Kyung Hee University, Yongin, Republic of Korea

Part of the book series: Lecture Notes in Business Information Processing (LNBIP, volume 181)

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• AP-BPM: Asia-Pacific Conference on Business Process Management

Conference proceedings info: AP-BPM 2014.

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Table of contents (10 papers)

Front matter, keynote paper, proposals for future bpm research directions.

• Michael Rosemann

Process Mining

A universal significant reference model set for process mining evaluation framework.

• Qinlong Guo, Lijie Wen, Jianmin Wang, Zizhe Ding, Cheng Lv

A Systematic Methodology for Outpatient Process Analysis Based on Process Mining

• Minsu Cho, Minseok Song, Sooyoung Yoo

Measuring Patient Flow Variations: A Cross-Organisational Process Mining Approach

• Suriadi Suriadi, Ronny S. Mans, Moe T. Wynn, Andrew Partington, Jonathan Karnon

Process Modeling and Repositories

A study on geospatial constrained process modeling using uml activity diagrams.

• Guobin Zhu, Xinwei Zhu

Generating Synthetic Process Model Collections with Properties of Labeled Real-Life Models

• Zhiqiang Yan, Remco Dijkman, Paul Grefen

Process Model Comparison

A method of process similarity measure based on task clustering abstraction.

• Jian Chen, Yongjian Yan, Xingmei Liu, Yang Yu

Efficient Syntactic Process Difference Detection Using Flexible Feature Matching

• Keqiang Liu, Zhiqiang Yan, Yuquan Wang, Lijie Wen, Jianmin Wang

Process Analysis

A model-checking based approach to robustness analysis of procedures under human-made faults.

• Naoyuki Nagatou, Takuo Watanabe

Incorporating the Effects of Organizational Structure into Business Process Simulation

• Jinyoun Lee, Sung-Nyun Hearn, Jinwoo Kim, Injun Choi

Back Matter

Other volumes.

• business process management
• process analysis
• process mining
• process modeling
• process repositories

About this book

This book constitutes the proceedings of the Second Asia Pacific Conference on Business Process Management held in Brisbane, QLD, Australia, in July 2014.

In all, 33 contributions from 12 countries were submitted. After each submission was reviewed by at least three Program Committee members, nine full papers were accepted for publication in this volume. These nine papers cover various topics that can be categorized under four main research focuses in BPM: process mining, process modeling and repositories, process model comparison, and process analysis.

Editors and Affiliations

Chun Ouyang

Jae-Yoon Jung

Bibliographic Information

Book Title : Asia Pacific Business Process Management

Book Subtitle : Second Asia Pacific Conference, AP-BPM 2014, Brisbane, QLD, Australia, July 3-4, 2014, Proceedings

Editors : Chun Ouyang, Jae-Yoon Jung

Series Title : Lecture Notes in Business Information Processing

DOI : https://doi.org/10.1007/978-3-319-08222-6

Publisher : Springer Cham

eBook Packages : Computer Science , Computer Science (R0)

Copyright Information : Springer International Publishing Switzerland 2014

Softcover ISBN : 978-3-319-08221-9 Published: 05 August 2014

eBook ISBN : 978-3-319-08222-6 Published: 28 June 2014

Series ISSN : 1865-1348

Series E-ISSN : 1865-1356

Edition Number : 1

Number of Pages : XVI, 143

Number of Illustrations : 58 b/w illustrations

Topics : Computer Appl. in Administrative Data Processing , IT in Business , Information Systems Applications (incl. Internet) , Data Mining and Knowledge Discovery

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A call for 'Holistic' Business Process Management

• W. Bandara , Amy Van Looy , +1 author Lara Meyers
• Published in Problems@BPM 2021
• Business, Computer Science

4 Citations

The biggest business process management problems of our time, process innovation capabilities in less-structured business processes, bpm challenges, limitations and future development directions – a systematic literature review, how to make it stick institutionalising process improvement initiatives, 16 references, enterprise business process management in the public sector: the case of the department of human services (dhs) australia, proposals for future bpm research directions, from strategy to process improvement portfolios and value realization - a digital approach to the discipline of business process management, capabilities for managing business processes: a measurement instrument, a literature review on business process management, business process reengineering, and business process innovation, re-designing process architectures towards a framework of design dimensions, a quantitative and qualitative study of the link between business process management and digital innovation, a critical analysis of j.c. smuts’ theory of holism, process portfolio management for enhanced digital readiness: insights from a large australian bank.

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• Tobacco endgame goals and measures in Europe: current status and future directions
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• http://orcid.org/0000-0002-8814-1021 Hanna Ollila 1 ,
• http://orcid.org/0000-0001-9601-7330 Otto Ruokolainen 1 ,
• http://orcid.org/0000-0002-6614-4782 Tiina Laatikainen 1 , 2 ,
• http://orcid.org/0000-0003-3339-8441 Helena Koprivnikar 3
• and JATC-2 WP9 co-authors
• 1 Department of Public Health , Finnish Institute for Health and Welfare , Helsinki , Finland
• 2 Institute of Public Health and Clinical Nutrition , University of Eastern Finland , Kuopio , Finland
• 3 National Institute of Public Health of the Republic of Slovenia , Ljubljana , Slovenia
• Correspondence to Hanna Ollila, Department of Public Health, Finnish Institute for Health and Welfare, Helsinki 00271, Finland; hanna.ollila{at}thl.fi

The European Union (EU) aims for a tobacco use prevalence of less than 5% by 2040 with its Tobacco-Free Generation goal, aligning with the tobacco endgame approach. In the Joint Action on Tobacco Control 2 (JATC-2) -project, we examined adopted and planned endgame goals and measures as well as preparedness to counter tobacco industry interference in the process. We surveyed key informants in 24 out of 50 countries in the WHO European Region (19 of the 27 EU Member States, MS). Altogether, eight countries (7 EU MS) had official governmental endgame goals, and an additional six EU MS had similar proposals from government, civil society or research entities. Movement towards tobacco endgame was most evident in retail-oriented and consumer-oriented policies. These include restricting the sales of tobacco and related products and raising the age limit above 18 years. Product standards were used especially to regulate flavours but no measures to substantially reduce addictiveness were reported. Market-oriented measures that tap into industry profits were predominantly missing, and countries often lacked concrete tools to prevent industry interference. Respondents’ concerns around tobacco endgame were related to high smoking prevalence in some population groups, non-combustible and new nicotine products, cross-border marketing, political will, challenges with the existing regulations and industry interference. Results indicate both momentum and challenges in adopting and disseminating measures that facilitate achieving tobacco endgame goals. The EU goal can be used to advocate for national endgame goals and measures, and for the strengthened implementation of the WHO Framework Convention on Tobacco Control.

• Public policy
• Tobacco industry

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/tc-2024-058606

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WHAT IS ALREADY KNOWN ON THIS TOPIC

In the tobacco endgame approach, the focus is shifted from controlling the tobacco epidemic to ending it by reducing use to a minimal level in the population with structural, political and social changes. In the European Union, this is supported by the recently launched Tobacco-Free Generation goal.

Tobacco endgame is well aligned with the WHO Framework Convention on Tobacco Control, which encourages parties to implement measures beyond the convention to better protect human health and obliges them to adopt effective measures to prevent and reduce nicotine addiction besides tobacco consumption.

WHAT THIS STUDY ADDS

While several European countries already have governmental tobacco endgame goals or proposals towards these, there is substantial variation in their definitions, timelines and coverage of tobacco and nicotine products.

Adopted and planned tobacco endgame measures centre around product-oriented, retail-oriented and consumer-oriented policies, such as product standards to reduce appeal, restricting sales and increasing the age limit above 18 years.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Knowledge sharing facilitates the dissemination of tobacco endgame approach.

More focus is needed on measures that can be expected to have a substantial impact on product availability, appeal and addictiveness.

Concrete tools to prevent and counter tobacco industry interference are needed, as it is seen as a clear challenge in tobacco endgame.

Introduction

In the WHO European Region, encompassing 53 countries including 27 European Union (EU) Member States, 25% of adults use tobacco. 1 This prevalence ranks second highest among the WHO regions, with a relatively slow decline compared with other regions. In 2021, as part of Europe’s Beating Cancer Plan, the EU announced a ‘Tobacco-Free Generation’ goal for the region. 2 While the concept of tobacco-free generation originates in a proposal to limit tobacco sales by year born, 3 the EU goal is defined as less than 5% of the population using tobacco by 2040. The EU goal aligns with the tobacco endgame approach, where the focus shifts from controlling the tobacco epidemic to ending it by reducing use to a minimal level in the population with structural, political and social changes. 4 The EU goal is well justified under the WHO Framework Convention on Tobacco Control (WHO FCTC), which encourages parties to implement measures beyond the convention to better protect human health (Article 2.1) and obliges them to adopt effective measures and cooperate in developing appropriate policies to prevent and reduce tobacco consumption, nicotine addiction and exposure to tobacco smoke (Article 5.2b). 5 Several European countries have already set their national tobacco endgame goals prior to the EU goal. 6 We examine the current status of adopted and planned national goals and measures in the WHO European region, and how these reflect the EU goal among the Member States. We also examine how experts perceive the likelihood of adopting or achieving the endgame goal in their own country, and countries’ preparedness to counter tobacco industry interference in the process.

In the Joint Action on Tobacco Control 2 (JATC-2) project, 7 Work Package 9 (WP9) is tasked to identify national tobacco endgame strategies and forward-looking tobacco control policies, to explore and exchange best practices in the development, implementation and evaluation of these strategies and policies, and to facilitate their development in the European region. The WP9 involves 21 partner organisations from 15 European countries (Belgium, Cyprus, Denmark, Finland, France, Greece, Hungary, Ireland, Italy, Lithuania, Norway, Portugal, Serbia, Slovenia and Spain), with the Netherlands collaborating. As part of this work, we surveyed key tobacco control informants in the WHO European region between 15 September 2022 and 13 January 2023.

Participants

Key informants consisted primarily of national WHO FCTC focal points, who are nominated by their country to participate in the official treaty reporting. Contacting them was made possible through assistance from the WHO FCTC Knowledge Hub on Surveillance and Convention Secretariat. In the absence of a functional contact with the focal point (eg, due to personnel changes), other national tobacco control experts were identified with assistance from JATC-2 partners and the WHO European Office for the Prevention and Control of Noncommunicable Diseases. We excluded Switzerland and Monaco due to lack of contacts, and the Russian Federation due to the suspension of research collaboration because of the war in Ukraine. From each country, one coordinated response was requested if the respondent engaged other stakeholders. The questionnaire gathered information and expert opinions on national-level policies and was, therefore, not subjected to an ethics approval. Respondents gave an informed consent on their participation.

Responses were received from 24 of 50 countries (19 of 27 EU Member states), with response rates of 48% across the region and 70% within the EU. The respondents were from Austria, Azerbaijan, Belgium, Cyprus, Czechia, Denmark, Estonia, Germany, Finland, France, Hungary, Ireland, Italy, Lithuania, Luxembourg, the Netherlands, North Macedonia, Norway, Portugal, Serbia, Slovenia, Spain, Sweden and Uzbekistan. The majority of the respondents were officials from health ministries/departments/directorates in the government. One respondent was from the interior ministry, two from national authorities specialised in addictions or substance use and one from a public health institute. Respondents were contacted back in March 2023 for potential updates, which were received from Uzbekistan. The JATC-2 partners could further update the information on new national policies up to May 2024. Partner updates were provided by Belgium, Finland, France, Ireland, the Netherlands, Norway, Slovenia and Spain.

Questionnaire

The questionnaire assessed the existence of national tobacco endgame goals, their definition, the selected time frame, tobacco or nicotine products covered by the goals and the perceived likelihood of adopting/achieving these goals (from 0=very unlikely to 10=very likely). The reason for the selected response was asked. Furthermore, we inquired about adopted or planned endgame measures and measures to prevent industry interference ( table 1 ). The endgame measures for the questionnaire were identified from earlier reviews. 4 8 In WP9, harm reduction measures are outside the scope of work and were, therefore, not included in the questionnaire. The measures on tobacco industry interference were derived from screening the recommendations of the WHO FCTC Article 5.3 guidelines. Some additional measures of interest to WP9 partners were also added (marked with * in table 1 ). The questionnaire and more details of its development are available in the WP9 indicator compendium at www.jaotc.eu . 9

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Measures included in the JATC-2 WP9 questionnaire

We describe adopted goals and measures based on respondent-provided details supplemented with publicly available information on the goals and measures (from, eg, governmental and EU websites). For plans or proposals, we disclose country names only if the information is publicly available to prevent industry interference. We present quotes from the experts’ open-ended responses. This article does not seek to present an exhaustive list of endgame goals and measures in Europe but provides examples and experiences, which can help draw an overview of their status and future directions.

Tobacco endgame goals

Official goals adopted or acknowledged by governments.

Altogether eight countries reported official tobacco endgame goals ( table 2 ). These were divided into general population goals without subgroup targets and goals including certain generations or subgroups. Most of the countries are aiming for less than 5% prevalence of use, but three countries aim at no use at all in certain subgroups addressing children or pregnant women. Three countries define their prevalence goals specifically as daily use. All countries except Norway have set a target year between 2025 and 2040. The official definitions focus on smoking or tobacco use, except for three countries that also mention nicotine products or tobacco-related products. Some countries extend the scope of endgame compared with the main definition: Belgium and the Netherlands reported including all tobacco and non-pharmaceutical nicotine products, while France and Norway also reported including heated tobacco products (HTPs) under their smoking targets. Finland and Norway have integrated the endgame goal into the objective of the tobacco control law.

Official tobacco endgame goals among the countries responding to the JATC-2 WP9 questionnaire

Proposals from governmental bodies or other relevant organisations or entities (eg, NGOs, political parties, public health organisations)

Altogether seven countries reported endgame proposals from their countries. In Denmark, the former government introduced a Nicotine-Free Generation goal where no one born since 2010 should start smoking or using nicotine products, 10 but this proposal has not progressed. A strategy for tobacco-free Germany by the German Cancer Research Center, supported by several NGOs and research entities, aims for <5% adult and <2% adolescent prevalence in tobacco and non-pharmaceutical nicotine use by 2040. 11 Additionally, the German government’s strategy for the Sustainable Development Goals contains a goal close to the common endgame prevalence level, namely, of 7% smoking prevalence among youth by 2030. 12 In Italy, scientific societies and independent scientists have allied to advocate for the development of a national tobacco endgame strategy. 13 In Spain, a new comprehensive plan for the prevention and control of tobacco for years 2024–2027 includes a goal to achieve <5% prevalence of daily use among 14–18-year olds. 14 Previously, public health organisations and civil society associations published an endgame declaration calling for a goal of <5% smoking prevalence by 2030 and 2% by 2040 in Spain. 15 Two other countries reported that an endgame proposal exists but is not yet publicly available. One was part of national health strategy discussions, where a goal in line with the EU goal has been proposed. From the second, no details were provided.

Perceived challenges and opportunities in tobacco endgame

Among the respondents from eight countries with official endgame goals, six provided a score for the likelihood of achieving their goal. On a scale of 0–10, the responses were either 6 (three countries) or 7 (three countries), reflecting moderately positive expectations. Concerns were expressed in relation to non-combustible and new nicotine products, differences between population groups, industry interference, cross-border marketing and sales, sustaining the political will and challenges in estimating the impact of the measures ( table 3 ).

Respondents’ reflections on the perceived likelihood of achieving their official governmental tobacco endgame goals (six countries, panel A), and on the perceived likelihood of adopting such goals in their country (12 countries, panel B).

Among 12 of the 16 countries without an endgame goal who provided a score, the expectations of adopting such a goal in their own country varied greatly: from very negative 0–2 (five countries) and somewhat unsure 5 (three countries) to rather positive 7–8 (two countries). Two countries perceived the adoption very likely, scoring 10. Concerns among these countries related to lack of political will, industry interference and problems in current tobacco control processes, shifting the focus to the COVID-19 pandemic, and the current high use of tobacco and related products ( table 3 ). Some countries reported a preference for general addiction or non-communicable disease (NCD) prevention strategies over tobacco control strategies. Having previously established governmental prevalence reduction goals in a cross-cutting way was seen as a strength for moving towards an endgame approach.

Tobacco endgame measures

Independently of whether a national tobacco endgame goal exists, a few measures that can contribute to such a goal were already implemented to some extent. These are presented in table 4 according to the taxonomy set in table 1 and summarised below.

Adopted and planned tobacco endgame measures and forward-looking tobacco control measures among the countries responding to the JATC-2 WP9 questionnaire

Product-oriented measures

The EU Tobacco Products Directive (TPD) and the delegated directive 2022/2100 prohibit characterising flavours in cigarettes, roll-your-own and HTPs, but some countries go beyond this to reduce product appeal with different product standards. Five countries had fully prohibited menthol as an additive that facilitates inhalation in combustibles, and seven countries had prohibited all or most flavours in e-cigarette liquids ( table 4 ). These measures were also planned in some countries, and Finland was processing regulation on nicotine pouch flavours. Plain packaging had been extended from tobacco products to e-cigarette packaging in three countries and was also considered for nicotine pouch packaging in two. Some countries had standardised or were standardising the appearance of individual cigarettes, nicotine e-liquids, e-cigarette refill containers and/or nicotine pouches. Health warnings on individual cigarette sticks were considered in Norway, which had also prohibited imports and sales of waterpipe tobacco, therefore partially addressing a ban on combustibles.

The TPD allows Member States to prohibit a certain category of tobacco or related products if the Commission approves it after considering whether national provisions are justified, necessary and proportionate, and whether they constitute a disguised barrier to trade. Belgium has received approval to prohibit disposable e-cigarettes, and two other countries also have proposals to introduce such a ban. Two countries reported an authorisation scheme for novel tobacco products, where the government authorises or rejects market entry applications. Non-pharmaceutical nicotine products (other than e-cigarettes) are not under TPD and countries regulate their market entry independently. An authorisation scheme for novel nicotine products was reported by two countries. Two countries have prohibited nicotine pouches. One country reported considering a ban on products that do not fall into existing product categories or are placed on the market after a certain date, but no specification was available.

Retail-oriented measures

Some countries reported prohibiting or restricting tobacco or related product sales in retail types or locations related to minors, and Cyprus was planning to restrict points of sales near schools ( table 4 ). Broader restrictions were still rare. New stepwise sales reductions were adopted in two countries, and a substantial reduction in retailers was set to the strategy in Norway but without concrete proposals. Two countries limited tobacco sales to specialist shops, and one country was considering including also e-cigarette sales to these. Hungary has set numerical limits to the density of the specialist tobacco shops. Finland introduced high annual supervisory fees to retail license holders and has had a proposal to prohibit the granting of a retail license to temporary and mobile sales places. France supported the transition of tobacco retailers into other local shops and no longer selling tobacco.

Consumer-oriented, market-oriented and other innovative measures

Most of the proposed endgame measures in these categories were not in place or planned. Plans focused on consumer-oriented measures, mainly age limits of 20 or 21 years, where altogether six countries have had proposals to raise the age of sale above 18. Of these, Ireland already approved in May 2024 a proposal for legislation that will increase the age of sale of tobacco to 21, aiming to be the first EU country to do so. 16 In Norway, a tobacco-free and nicotine-free generation to those born in 2010 is envisaged in a national strategy, but decisions and details on its implementation are awaited. In Denmark, the new prevention agreement proposes prohibiting the import, purchase and possession of nicotine products that are illegal to market in the country. Sweden is utilising excise duty for curtailing industry to set its own retail prices. Five countries have a regulated market model where the state has a monopoly on tobacco sales.

Preparedness to counter tobacco industry interference

While many respondents referred to implementing Article 5.3 of the WHO FCTC, concrete tools to prevent industry interference were often missing. However, some examples of adopted measures were shared. These addressed legislative measures, lobbying registers, a code of conduct/procedure, public disclosure of necessary correspondences, disclosure of lobbying expenses, plans to better regulate production and industry reporting obligations, and ethical guidelines preventing state investments in the tobacco industry ( table 5 ). As for planned measures, three countries were developing guidelines on contact between the industry and governmental organisations, one country was planning to develop a transparency register of contacts between the tobacco industry and government, and another country for the disclosure of the records from necessary interactions.

Regulations and measures to prevent tobacco industry interference among the countries responding to the JATC-2 WP9 questionnaire

Our results indicate both momentum and challenges in adopting and disseminating measures that facilitate achieving the EU Tobacco-Free Generation goal of less than 5% tobacco use by 2040. Almost half of the 27 EU Member States either have already adopted a national tobacco endgame goal or have a proposal for such a goal from the government, civil society or research entities. Outside the EU in the WHO European Region, Norway reported an official tobacco endgame goal. While most of the countries with an official goal aim for a similar <5% prevalence level as the EU goal, the definitions of goals and their specifications in the government documents vary considerably. For some countries, this can also pose challenges in measuring the progress. In Ireland and Sweden, the target year of 2025 is approaching soon, calling for the first comprehensive evaluations of national tobacco endgame strategies in the region. Including tobacco endgame as an objective of tobacco control legislation—like in Finland and Norway—may provide sustainability behind changing governmental programmes or strategies and political will.

In the EU, the Member States have benefitted from common minimum product standards set in the TPD. While several countries already go beyond the TPD to address attractiveness and appeal, no measures that would substantially reduce addictiveness were adopted or planned. To meet the <5% prevalence level by 2040, the TPD should be developed from this perspective in a forward-looking way. The EU has invested substantial effort and resources into the advisory mechanism for the prohibition of characterising flavours. 17 Yet a simplified, effective approach would be to follow the WHO FCTC Article 9 and 10 guidelines to prohibit the use of all ingredients that make tobacco products attractive, including flavouring agents. Furthermore, the EU-level nicotine limits for cigarettes could be lowered to make them less or non-addictive, leading to their gradual phase-out from the market. Based on the evidence, reducing nicotine content in cigarettes to very low levels could improve public health and have benefits across different population groups by decreasing the uptake of regular smoking, decreasing the amount smoked and increasing smoking cessation. 18 Introducing very low nicotine cigarettes on the EU level could be a balanced and justified measure considering the increased product supply caused by the continuous entrance of novel tobacco or nicotine products to the market. These novel products were mainly seen as challenges in tobacco endgame by the respondents, and several countries are already covering nicotine products such as e-cigarettes and nicotine pouches in their endgame goals or measures. This can be seen as a forward-looking approach to respond to tobacco industry strategies, which aim to increase product portfolio and profit, attract new customers and delay and distract from effective control policies. 19 Clear separation between measures to only reduce harm and measures to end the tobacco epidemic may help regulators and policymakers to understand and identify measures that are feasible and likely to produce substantial impact in their local context.

The reported retail-oriented and consumer-oriented measures tended to focus on reducing the sales points by limiting sales to certain retailers and raising the age limit of sales above 18 years. For example, substantial stepwise reductions in retail outlets are beginning to be implemented in the Netherlands and in Belgium. Yet, most countries in the region would still need to introduce retail licensing to effectively control and reduce retail density. 20 In Finland, the licensing with high annual costs has gradually reduced the number of tobacco retailers to approximately a half. However, the number remains high and unequally distributed to more socioeconomically disadvantaged areas—reminding of the continued need to consider the impact of tobacco endgame measures in different population groups. 21 In Hungary, the introduction of state-owned specialist tobacco shops has decreased the density of tobacco shops by 85%, concurring with declining adolescent smoking. 22 The age limits that were under consideration focused on 20 or 21 years. In the European context, where no country yet has implemented an age limit above 18 years for tobacco, this measure could have a substantial impact considering most of the initiation occurs by the age of 20. 23 24 In Europe, Norway was first to publish in March 2023 a goal that children born since 2010 do not use tobacco and nicotine products, but its practical implementation is undecided. 25 The United Kingdom has then moved ahead by announcing in October 2023 that it will become an offence to sell tobacco products to anyone born on or after 1 January 2009. 26 Based on the evidence, the retail- and consumer-oriented measures, especially if combined, can be expected to have a notable impact on tobacco use prevalence and lead to health gains over time. 23 27

The EU goal can be used to support the development of similar national goals. Additionally, it can be used to bring the need for better implementation of the WHO FCTC to the political agenda, connected to the national work for NCD prevention and sustainable development goals. This can be beneficial especially in countries where adopting an endgame goal is not yet seen as feasible in the current tobacco control context. The implementation of the WHO FCTC as well as the capacity for tobacco control needs to be strengthened in Europe. 28 As part of this, countries should look into measures that tap into tobacco industry profits, which are mostly not even planned in the region. Together with the lack of concrete tools to prevent and counter industry interference, this enables the industry to mobilise resources for lobbying and distracting policymaking away from timely and effective measures. Industry interference was identified as a challenge both in adopting and achieving tobacco endgame goals. Better protection is needed even on the EU level, as shown in the recent European Ombudsman investigations. 29 Besides national actions, the EU-level investment and support for the enforcement of tobacco control, together with the regular revision of key directives and recommendations, are essential for achieving the EU goal. An interesting comparison can be found in food safety where the EU audits the application and effectiveness of the laws and controls and provides training to the responsible authorities. 30

Finally, the EU goal can be used to raise awareness of the tobacco endgame approach, leveraging support from civil society and the public. For instance, a study from Ireland showed low awareness but broad support for the local tobacco endgame goal. 31 In the Netherlands, key factors in accelerating tobacco control have been the genesis of a ‘Smoke-free Generation’ movement in the wider society, initiated by the three main national charities, combined with stricter adherence to Article 5.3 of the WHO FCTC and a comprehensive marketing ban. 32 In 2022, several European civil society associations launched a joint European Citizen’s Initiative calling for a broad range of measures including tobacco-free environments and ending the sale of tobacco and nicotine products to citizens born since 2010, but it did not reach enough signatories. 33 To facilitate the dissemination of measures that are likely to have a substantial impact within a reasonable timeframe, knowledge sharing between countries with different tobacco control contexts and approaches is needed. Multinational collaborations such as the JATC-2 can serve as platforms to share best practices and act as vehicles to overcome the barriers of lack of knowledge or political will. A great global opportunity for information exchange presents in the 11th session of the Conference of the Parties of the WHO FCTC in 2025, where an expert group established by the COP10 will present its report on Article 2.1 and forward-looking tobacco control measures. 34 The possibility of shifting the focus from controlling to ending the tobacco epidemic is an important message to convey to policymakers.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study gathered only information on national-level policies and expert opinions related to these and was therefore not subject to ethics approval. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors want to thank all the respondents of the questionnaire. The authors are grateful for the support and contributions from all JATC-2 WP9 partners in the development of the questionnaire and provision of feedback to the analysis and reporting of the results as part of the project reporting and deliverable drafting. Further, the authors are grateful for the support from the WHO FCTC Knowledge Hub on Surveillance, the Secretariat of the WHO FCTC and the WHO NCD Office in identifying the contacts for the questionnaire.

• World Health Organization
• European Commission
• McDaniel PA ,
• Ruokolainen O ,
• Laatikainen T , et al
• Straarup MS ,
• O’Donovan F ,
• Lambrou A , et al
• Puljević C ,
• Morphett K ,
• Hefler M , et al
• JATC-2 WP9 partners
• Sundshedsministeriet
• The German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) 2021
• Die Bundesregierung
• TOBACCO ENDGAME
• Ministerio de Sanidad
• Cuadrado García de U ,
• Fernández Megina R , et al
• Government of Ireland, Department of Health
• Chaiton M ,
• Kuipers MAG ,
• Nuyts PAW ,
• Willemsen MC , et al
• Pätsi S-M ,
• Ollila H , et al
• Brys Z , et al
• Reitsma MB ,
• Mullany EC , et al
• Government of Norway
• Department of Health and Social Care
• van der Deen FS ,
• Cleghorn CL , et al
• González-Marrón A ,
• Koprivnikar H ,
• Tisza J , et al
• European Union
• Cosgrave EJ ,
• Murphy E , et al
• Willemsen MC ,
• ↵ Call to achieve a tobacco-free environment and the first European tobacco-free generation by 2030 . 2022 . Available : https://citizens-initiative.europa.eu/initiatives/details/2022/000005_en [Accessed 22 Apr 2024 ].
• Algemene Cel Drugsbereid
• Ministry of Social Affairs and Health, Finland
• Tobacco Act
• Ministère de la Santé et de la Prévention
• Ministry of Health, Welfare and Sport
• Lov om vern mot tobakksskader (Tobakksskadeloven) - Lovdata . Available : https://lovdata.no/dokument/NL/lov/1973-03-09-14?q=1973-03-09-14 [Accessed 17 Oct 2023 ].
• Republica Slovenija
• Regeringskansliet
• Government proposal to Parliament for an Act amending the Tobacco Act. 2024/0210/FI (Finland) . TRIS - Eur Comm 2024 . Available : https://technical-regulation-information-system.ec.europa.eu/en/notification/25788
• The Danish Ministry of the Interior and Health
• National Addictions Authority Cyprus

Collaborators Co-authors of the Work Package 9 of the Joint Action on Tobacco Control 2 (JATC-2) -project: Adrián González-Marrón (Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain), Alessandra Lugo (Department of Medical Epidemiology; Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy), Angeliki Lambrou (Directorate of Epidemiology and Prevention of Non-Communicable Diseases and Injuries, National Public Health Organization (NPHO), Athens, Greece), Anna Mar Lopez Luque (Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, (CIBERES), Madrid, Spain; Programa de Prevenció i Control del Càncer, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain), Armando Peruga (Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, (CIBERES), Madrid, Spain; Centro de Epidemiología y Políticas de Salud, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile), Biljana Kilibarda,(Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”, Belgrade, Serbia), Cristina Lidón-Moyan (Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain), Daniela Alejandra Blanco-Escauriaza (Group of Evaluation of Health Determinants and Health Policies, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain), Dolors Carnicer-Pont (Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, (CIBERES), Madrid, Spain; Programa de Prevenció i Control del Càncer, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain), Efstathios Papachristou (Directorate of Epidemiology and Prevention of Non-Communicable Diseases and Injuries, National Public Health Organization (NPHO), Athens, Greece), Elena Demosthenous (Cyprus National Addictions Authority, Nicosia, Cyprus), Emilia Nunes (General Directorate of Health, Ministry of Health, Lisbon, Portugal), Esteve Fernández (Grupo de Investigación en Control del Tabaco, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, (CIBERES), Madrid, Spain; Programa de Prevenció i Control del Càncer, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; School of Medicine and Health Sciences, Campus de Bellvitge, Universitat de Barcelona, L’Hospitalet de Llobregat, Spain), Giulia Carreras (Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy), Giuseppe Gorini (Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy), Helma Slingerland (Ministry of Health, Welfare and Sport, the Hague, the Netherlands), Judit Tisza (National Korányi Institute of Pulmonology, Budapest, Hungary), Lorenzo Spizzichino (Ministry of Health, Rome, Italy), Maria-Alejandra Cardenas (Ministry of Health and Prevention, Paris, France), Maria Karekla (University of Cyprus, Nicosia, Cyprus), Maurice Mulcahy (National Environmental Health Service, Health Service Executive (HSE), Galway Business Park, Dangan, Ireland), Milena Vasic (Institute of Public Health of Serbia “Dr Milan Jovanovic Batut”, Belgrade, Serbia), Salla-Maaria Pätsi (Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland), Silvano Gallus (Department of Medical Epidemiology; Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy), Sotiria Schoretsaniti (Directorate of Epidemiology and Prevention of Non-Communicable Diseases and Injuries, National Public Health Organization (NPHO), Athens, Greece), Zsuzsa Cselkó (National Korányi Institute of Pulmonology, Budapest, Hungary).

Contributors Salla-Maaria Pätsi conducted initial analyses from the data. HO analysed the data for this manuscript and wrote the first draft. OR, TL and HK reviewed the first draft. HO developed and revised the following drafts as per the review and contributions from all other authors. All authors approved the final version of the paper. HO is responsible for the overall conduct of the study and the contents of this manuscript.

Funding This work was supported by the European Union’s Health Program (2014-2020) under grant agreement N°101035968. The content of this document represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the European Health and Digital Executive Agency (HaDEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains. DCP, AML and EF are partly supported by the Ministry of Universities and Research, Government of Catalonia (grant number: 2021SGR00906) and thank the CERCA programme for institutional support to IDIBELL.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer-reviewed.

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