Invitation

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ Date: 08 February 2022 REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L’EUROPE REGIONALBÜRO FÜR EUROPA Mr Tanel Kiik ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Minister of Health and Labour Head office: Ministry of Social Affairs UN City, Marmorvej 51, Suur-Ameerika 1 DK-2100 Copenhagen Ø, Denmark Tallinn 10129 Tel.: +45 45 33 70 00; Fax: +45 45 33 70 01 Email: [email protected] Estonia Website: http://www.euro.who.int Our reference: Your reference: Notre référence: Votre référence: Unser Zeichen: Ihr Zeichen: См. наш номер: На Ваш номер: Dear Sir, Invitation to participate in a high-level panel discussion at the launch of the Alcohol Signature Initiative of the WHO/Europe NCD Advisory Council in Vilnius, Lithuania, 23 February 2022 In response to the pressing need to reduce noncommunicable diseases (NCDs) and their risk factors across the Region, I have established the Advisory Council on Innovation for Noncommunicable Diseases. The Council Members, who are leading experts from governments, academia, think tanks, and professional and civil society organizations, are currently developing an energized roadmap centred on Signature Initiatives to accelerate progress towards the NCD targets. It is with great pleasure that I invite you to the launch of the Alcohol Tax Signature Initiative, which aims to accelerate the implementation of alcohol tax in the Region. As part of the launch, we will present the main findings of a modelling study on alcohol taxation and mortality, which is going to be published in Lancet Regional Health Europe, a copy of which you can find in the attachment. We invite you to participate in a moderated panel discussion alongside other representatives of Member States, which will take place online at 12:00−13:30 CET. We will also be grateful for the assistance in reaching out to a representative of the Ministry of Finance, considering the profile of the event and with the aim of developing an intersectoral dialogue in the field of pricing policies. We hope that you will be able to accept this invitation and we look forward to your response. Yours very truly, Dr Hans Henri P. Kluge Regional Director UN City, Marmorvej 51 Tel.: +45 45 33 70 00 Email: [email protected] DK-2100 Copenhagen Ø Fax: +45 45 33 70 01 Website: http://www.euro.who.int Denmark Enclosures: Scope and purpose Provisional programme Unpublished manuscript of the alcohol tax share modelling study to appear in the Lancet Regional Health Europe Copy for information to: Ms Elen Ohov, Adviser, European Union Affairs and International Co-operation Department, Ministry of Social Affairs, Suur-Ameerika 1, Tallinn 10122, Estonia Ms Triin Uusberg, Head, European and International Coordination Department, Ministry of Social Affairs, Suur-Ameerika 1, Tallinn 10129, Estonia H.E. Ms Katrin Saarsalu-Layachi, Ambassador Extraordinary and Plenipotentiary, Permanent Representative Permanent Mission of the Republic of Estonia to the United Nations Office and other international organizations in Geneva, Chemin du Petit-Saconnex 28A, Genève CH-1209, Switzerland H.E. Mr William Mart Laanemäe, Ambassador Extraordinary and Plenipotentiary Embassy of the Republic of Estonia, Frederiksgade 19, 4th floor, Copenhagen K 1265, Denmark Ms Kristina Köhler, Liaison Officer, WHO Country Office, Estonia, Paldiski Road 81, Tallinn 10617, Estonia –2– Saatja: KONOVALOVA, Natalia <[email protected]> Saadetud: 10.02.2022 11:15 Adressaat: Tanel Kiik <[email protected]>; Triin Uusberg <[email protected]>; Elen Ohov <[email protected]> Koopia: Triin Uusberg <[email protected]>; SM Info <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; <[email protected]>; KÖHLER, Kristina <[email protected]>; Carina Ferreira-Borges <[email protected]>; NEUFELD, Maria <[email protected]> Teema: Invitation to a high-level panel discussion at the launch of the Alcohol Signature Initiative of the WHO/Europe NCD Advisory Council in Vilnius, Lithuania, 23 February 2022. Dear Sir, I am honored to share the invitation from Dr Hans Henri P. Kluge, the WHO Regional Director for Europe, to participate in a high-level panel discussion at the launch of the Alcohol Signature Initiative of the WHO/Europe NCD Advisory Council in Vilnius, Lithuania, 23 February 2022. Thank you, Best regards, Natalia Konovalova Programme Assistant WHO European Office for Prevention and Control of Noncommunicable Diseases (NCD Office) Moscow, Russian Federation Office:&#43; 7495 787 21 16 E-mail: GPN: 78135 WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L'EUROPE WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ REGIONALBÜRO FÜR EUROPA ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Alcohol taxes to save lives: a best practice /3 symposium for the WHO European Region Launch of the alcohol signature initiative of the WHO/Europe NCD Advisory Council 4 February 2022 Hybrid event, Vilnius, Lithuania 23 February 2022 Original: English 09.00 – 13.30 CET Provisional programme 09.00-09.15 Opening and welcome remarks Arūnas Dulkys, Minister of Health, Republic of Lithuania [TBC] Ingrida Zurlytė, Head, WHO Country Office in Lithuania Nino Berdzuli, Director of the Division of Country Health Programmes, WHO Regional Office for Europe 09.15-10.15 Demonstrating impact for policy change – the Baltics alcohol mortality project 10 minutes Mindaugas Štelemėkas Saving lives and generating revenue: the success of alcohol taxation in Lithuania and on overview of the Baltics mortality project Relika Stoppel 10 minutes Economic implications of changing in sales policy in Estonia Laura Isajeva 10 minutes Alcohol taxation policy changes in Latvia: past and future Kinga Janik-Koncewicz [TBC] The cost on non-action: the rise of alcohol-related deaths in Poland and 10 minutes opportunities for alcohol taxation 10 minutes Questions from the floor and discussion 10.15-10.30 Short active break 10.30-11.50 Launch of the alcohol signature initiative of the WHO/Europe NCD Advisory Council 3 minutes Eric Carlin, WHO European Office for NCDs Provisional programme Page 2 Welcome remarks by moderator and brief introduction of the alcohol taxation SI of WHO/Europe 8 minutes Franco Sassi, Professor, Centre for Health Economics and Policy Innovation, Imperial College Business School, UK, Member of WHO/Europe NCD Advisory Council Alcohol taxes as health taxes: the current state of pricing policies for alcohol, 8 minutes tobacco and sugar-sweetened beverages in the WHO European Region Sara Seranno-Zuazua, Directorate General for Taxation and Customs Union, European Commission [TBC] Review of tax legislation on alcohol and the cross-border purchase of alcohol 8 minutes product in the EU to inform the EU beating cancer plan: opportunities for improved public health Jürgen Rehm, Professor, Institute for Mental Health Policy Research & 8 minutes Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), Canada, Member of WHO/Europe NCD Advisory Council Alcohol taxes to save lives: what would happen to mortality in WHO/Europe 8 minutes if we had a minimum level of alcohol taxation? Michele Cecchini, Organisation for Economic Co-operation and Development Alcohol taxes to spend less: what would happen to healthcare expenditures 8 minutes and workforce productivity in WHO/Europe if we had a minimum level of alcohol taxation? Jenni Oksanen, Ministerial Adviser, Finnish Ministry of Finance [TBC] What can be learned from raising alcohol tax in Finland – implications for intersectoral dialogue Aurelijus Veryga, Parliament of the Republic of Lithuania, Member of WHO/Europe NCD Advisory Council [TBC] Addressing barriers for alcohol taxation and resisting the industry’s' pressure for better health policies – the Lithuanian experience Questions from the floor and discussion 11.50-12.00 Short break 12.00-13.25 Implications for alcohol policies in Europe and beyond – a high level round table discussion Welcome address by WHO Regional Director for Europe Hans Kluge, WHO Regional Director for Europe Welcome remarks by moderator and brief explanation of panel discussion format Ilona Kickbusch, Director, Global Health Centre, Graduate Institute of International and Development Studies in Geneva [TBC]  Provisional programme Page 3 Success stories and missed opportunities for alcohol pricing in the Baltic States Lithuania Arūnas Dulkys, Minister of Health, Republic of Lithuania [TBC] Gintarė Skaistė, Minister of Finance, Republic of Lithuania [TBC] Ingrida Zurlytė, Head, WHO Country Office in Lithuania Latvia Daniels Pavļuts, Minister of Health, Republic of Latvia [TBC] Jānis Reirs, Minister of Finance, Republic of Latvia [TBC] Uldis Mitenbergs, Liaison Officer, WHO Country Office in Latvia [TBC] Estonia Tanel Kiik, Minister of Health, Republic of Estonia [TBC] Keit Pentus-Rosimannus, Minister of Finance, Republic of Estonia [TBC] Kristina Köhler, Liaison Office, WHO Country Office in Estonia [TBC] The potential of alcohol pricing policies to improve public health in Germany Burkhard Blienert, Federal Government Commissioner for Addiction and Drug Issues [TBC] “It’s Everywhere’—Alcohol’s Public Face and Private Harm”: main findings of the 2019 Commission report and opportunities for better polies Baroness Finlay of Llandaff, Chair of the Commission on Alcohol Harm [TBC] 13.25-13.30 Closing statement Carina Ferreira-Borges, a.i. Director for NCDs, Programme Manager Alcohol and Illicit Drugs, WHO Regional Office for Europe WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ REGIONAL OFFICE FOR EUROPE BUREAU RÉGIONAL DE L'EUROPE WELTGESUNDHEITSORGANISATION ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ REGIONALBÜRO FÜR EUROPA ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Alcohol taxes to save lives: best practice symposium for the WHO European Region Launch of the alcohol signature initiative of the WHO/Europe NCD Advisory Council Hybrid event, Vilnius, Lithuania 4 February 2022 23 February 2022 Original: English 09:00–13:30 CET Scope and purpose The most effective and cost-effective way to control noncommunicable diseases (NCDs) is to tax products that represent major risk factors for public health, such as alcohol, tobacco and sugar-sweetened beverages. The main goal of such taxes is to improve public health and strengthen disease prevention; however, the fiscal impact is positive as well. Unlike tobacco, where a clear recommendation exists that tax should make up at least 75% of the retail price of the most common cigarette brands to reduce the harms of tobacco, alcohol taxes have historically been regarded as fiscal measures, rather than health taxes that are levied on harmful products. Compared with other evidence-based policy measures recommended by WHO, alcohol pricing policies are the least implemented interventions in the WHO European Region. As well as this, many countries do not adjust their tax on alcohol for inflation. Some and have very low excise tax or no tax on certain alcoholic beverages. This hybrid symposium will take place in Vilnius, Lithuania and bring together experts from the international project "Evaluation of the impact of alcohol control policies on morbidity and mortality in Lithuania and other Baltic states", which is funded by the US National Institute on Alcohol Abuse and Alcoholism to investigate the effects of alcohol policies implemented in Lithuania, Latvia and Estonia. The meeting will provide the opportunity to reflect on the evidence emerging from this project, including thinking about lessons that can be learned for other geographical contexts. The findings of a new modelling study published in the Lancet Regional Health Europe will also be presented; estimating how many lives could be saved annually if countries across the WHO European Region were to introduce a minimum level of tax in the final retail prices of alcohol. Optimizing alcohol pricing policies through introducing a WHO benchmark for a minimum tax share in prices of alcoholic beverages, similar to that outlined for tobacco, can yield benefits for the health and economic sectors. To encourage and support such moves, as part of this event, the WHO Regional Office for Europe will launch its NCD Advisory Council Signature Initiative on alcohol tax as health tax. The presentation of the signature initiative will be followed by discussions of high-level representatives from Member States, the European Commission and the OECD, which will include exploration of how the evidence that is emerging can inform public health policies at Member State, regional and global levels. The working language of the meeting will be English, and simultaneous interpretation into Lithuanian and Russian will be provided. The Lancet Regional Health - Europe Impact of introducing a minimum alcohol tax share in retail prices on alcohol- attributable mortality in the WHO European Region: a modelling study --Manuscript Draft-- Manuscript Number: Article Type: Article (Original Research) Section/Category: Keywords: Alcohol; alcohol-attributable burden; Europe; health tax; taxation Corresponding Author: Maria Neufeld Moscow, Москва RUSSIAN FEDERATION First Author: Maria Neufeld Order of Authors: Maria Neufeld Pol Rovira, MSc Carina Ferreira-Borges, PhD Carolin Kilian, PhD Franco Sassi, PhD Aurelijus Veryga, PhD Jürgen Rehm, PhD Manuscript Region of Origin: RUSSIAN FEDERATION Abstract: Background Alcohol use and its burden constitute one of the largest public health challenges in the WHO European Region. Raising alcohol taxes is a cost-effective “best buy” measure to reduce alcohol consumption, but its implementation remains uneven. This paper provides an overview of existing tax structures in 50 countries and subregions of the Region, estimates their proportions of tax on retail prices of beer, wine, and spirits, and quantifies the number of deaths that could be averted annually if these tax shares were raised to a minimum level. Methods Review of databases and statistical reports on taxes and mean retail prices of alcohol beverages in the Region. Affordability was calculated based on alcohol prices, adjusted for differences in purchasing power. Consumption changes and averted mortality were modelled assuming two scenarios. In Scenario 1, a minimum excise tax share level of 25% of the beverage-specific retail price was assumed for all countries. In Scenario 2, in addition to a minimum excise tax share level of 15% it was assumed that per unit of ethanol minimal retail prices were the same irrespective of alcoholic beverages (equalisation). Sensitivity analyses were conducted for different price elasticities. Findings Alcohol is very affordable in the Region and alcohol taxes have clearly been under- utilized as a public health measure, constituting on average only 5·7%, 14·0% and 31·3% of the retail prices of wine, beer, and spirits, respectively. Tax shares were higher in the eastern part of the Region compared to the EU, where various countries did not have excise taxes on wine. Annually, the introduction of a minimum tax share of 25% (Scenario 1) could avert 40,033 (95% CI: 38,054-46,097) deaths in the WHO European Region (with 753,454,300 inhabitants older than 15 years of age). If a 15% tax share with equalisation were implemented (Scenario 2), 132,906 (95% CI: (124,691-151,674) deaths could be averted. All sensitivity analyses with different Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation  elasticities yielded outcomes close to those of the main analyses. Interpretation Similar to tobacco taxes, increasing alcohol taxes should be considered to be a health- based measure aimed at saving lives. Many countries have hesitated to apply higher taxes to alcohol, but the present results show a clear health benefit as a result of implementing a minimum tax share. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Manuscript Click here to view linked References Impact of introducing a minimum alcohol tax share in retail prices on alcohol-attributable mortality in the WHO European Region: a modelling study Maria Neufeld (MSc)1, Pol Rovira (MSc)2, Carina Ferreira-Borges (PhD)1, Carolin Kilian (PhD)3, Franco Sassi (PhD)4, Aurelijus Veryga (PhD)5, Jürgen Rehm (PhD)2,4, 6-10 1. WHO European Office for the Prevention and Control of Noncommunicable Diseases, 9 Leontyevsky Pereulok, 125009 Moscow, Russian Federation 2. Program on Substance Abuse & designated WHO Collaborating Centre, Public Health Agency of Catalonia, 81-95 Roc Boronat St., 08005, Barcelona, Spain 3. Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Chemnitzer Straße 46, Dresden, 01187, Germany 4. Centre for Health Economics and Policy Innovation, Imperial College Business School, Exhibition Road, London SW7 2AZ, United Kingdom 5. Parliament of the Republic of Lithuania, Committee of Health, Gedimino pr. 53, Vilnius, Lithuania 6. Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin Street, Toronto, Ontario, Canada, M5S 2S1 7. Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf (UKE), Martinistraße 52, 20246 Hamburg, Germany 8. Dalla Lana School of Public Health & Department of Psychiatry, University of Toronto, 155 College Street, 6th Floor, Toronto, Ontario, Canada, M5T 3M7 9. Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 33 Ursula Franklin Street Street, Toronto, Ontario, M5S 3M1, Canada 10. I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Street 8, b. 2, Moscow, 119991, Russian Federation Corresponding author: Maria Neufeld Address: WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office), 9 Leontyevsky Pereulok, 125009 Moscow, Russian Federation Email: [email protected] Phone: +7 916 9872013 1 Abstract Background Alcohol use and its burden constitute one of the largest public health challenges in the WHO European Region. Raising alcohol taxes is a cost-effective “best buy” measure to reduce alcohol consumption, but its implementation remains uneven. This paper provides an overview of existing tax structures in 50 countries and subregions of the Region, estimates their proportions of tax on retail prices of beer, wine, and spirits, and quantifies the number of deaths that could be averted annually if these tax shares were raised to a minimum level. Methods Review of databases and statistical reports on taxes and mean retail prices of alcohol beverages in the Region. Affordability was calculated based on alcohol prices, adjusted for differences in purchasing power. Consumption changes and averted mortality were modelled assuming two scenarios. In Scenario 1, a minimum excise tax share level of 25% of the beverage-specific retail price was assumed for all countries. In Scenario 2, in addition to a minimum excise tax share level of 15% it was assumed that per unit of ethanol minimal retail prices were the same irrespective of alcoholic beverages (equalisation). Sensitivity analyses were conducted for different price elasticities. Findings Alcohol is very affordable in the Region and alcohol taxes have clearly been under-utilized as a public health measure, constituting on average only 5·7%, 14·0% and 31·3% of the retail prices of wine, beer, and spirits, respectively. Tax shares were higher in the eastern part of the Region compared to the EU, where various countries did not have excise taxes on wine. Annually, the introduction of a minimum tax share of 25% (Scenario 1) could avert 40,033 (95% CI: 38,054-46,097) deaths in the WHO European Region (with 753,454,300 inhabitants older than 15 years of age). If a 15% tax share with equalisation were implemented (Scenario 2), 132,906 (95% CI: (124,691-151,674) deaths could be averted. All sensitivity analyses with different elasticities yielded outcomes close to those of the main analyses. Interpretation Similar to tobacco taxes, increasing alcohol taxes should be considered to be a health-based measure aimed at saving lives. Many countries have hesitated to apply higher taxes to alcohol, but the present results show a clear health benefit as a result of implementing a minimum tax share. 2 Funding This work was supported by the National Institute on Alcohol Abuse and Alcoholism (1R01AA028224) and the Canadian Institutes of Health Research, Institute of Neurosciences, and Mental Health and Addiction (SMN-13950). Key words Alcohol, alcohol-attributable burden, Europe, health tax, taxation 3 Introduction Alcohol use has been identified as one of the most important risk factors for burden of disease and injury in all comparative risk assessments to date.1-3 Despite some reductions in recent decades, the WHO European Region has the highest alcohol consumption level of all WHO Regions, and reduction of alcohol-attributable burden is one of its priorities.4 To reduce alcohol-attributable burden, the World Health Organization has recommended a number of alcohol control measures, and highlighted three of them as the so-called “best-buys”: restricting alcohol availability, increasing the price of alcoholic beverages, and banning advertising.5 We will focus the discussion on the control policies related to alcohol taxation, as this “best buy” has been shown to be the most cost-effective both in low- and middle- income and high-income countries.6 As mentioned above, there is strong and compelling evidence that increasing the price of alcoholic beverages through taxation is one of the most effective and cost-effective policies used to lower alcohol consumption and alcohol-attributable harm.6,7 Through taxation, governments can influence the price of alcoholic beverages, and higher prices ceteris paribus lead to lower levels of alcohol consumption and attributable harm.8 The exact impact of alcohol taxation on harm will depend on a number of factors, the most important one being the level of taxation in relation to the disposable income of consumers, usually denoted by the term affordability. It has been shown that a reduced affordability is key to reducing harm.9 Given the high costs to European societies due to alcohol consumption,10 part of the economic rationale for the taxation of alcohol has been to compensate for negative externalities.8 Therefore, a further important aspect of alcohol taxation is fiscal revenue generation, which will be discussed in further detail below. All Member States of the WHO European Region have established some form of excise taxation on alcohol, which is added to general consumption taxes (mostly value-added taxes) charged on traded products, including beverages.4 However, despite the overwhelming evidence on its potential to improve public health, reduce burden, and generate revenue, many countries underutilise alcohol taxation measures—globally and in the WHO European Region in particular. Out of all available interventions, pricing policies were found to be the least frequently implemented alcohol control measures, as revealed by the latest WHO report on the implementation of alcohol control policy measures in the Region (4 ; see Appendix Text T1 for the underlying methodology; for detailed results, see Appendix Figure A1). The report also suggests, in line with previous findings, that alcohol has become more affordable over time because the majority of countries neither increase nor adjust their alcohol tax levels to reflect fluctuations in inflation or disposable income. In addition, countries of the European Union (EU) have traditionally 4 had very low shares of taxes included in the final consumer price of alcoholic beverages.11 Thus, the real values of excise duties in the EU, as well as alcohol prices in general, have steadily decreased since the mid-1990s in most EU countries.12 At the same time, more country-specific trends in alcohol affordability have been observed in the eastern and non-EU countries of the Region, where alcohol control policies affecting the price of alcoholic beverages have been more consistently applied.13,14 The present contribution aims to document the current state of alcohol taxation structures and the proportion of excise tax in the retail prices of alcoholic beverages in all countries and subregions (political unions across the Region) of the WHO European Region, with the subregional analysis focusing on the following political unions: the Commonwealth of Independent States (CIS); the Eurasian Economic Union (EAEU) and the European Union (EU). It also provides an estimate of how many lives could theoretically be saved each year if countries in the Region were to adopt a minimum level of excise tax shares on their retail prices of beer, wine, and spirits, following the example of tobacco, where a minimum level recommended by WHO exists.15 In addition to introducing a minimum tax share for all alcoholic beverages, we modelled a minimum tax share where the average price of one unit of alcohol would be the same irrespective of beverage type.16,17 This equalisation of price per unit of alcohol leads to much higher tax shares on average given a minimum tax share. To our knowledge, this is the first comprehensive overview of the alcohol price levels and structures for the entire Region, which goes beyond EU countries, and the first modelling study that estimates the effects of an introduced minimum excise tax share for alcoholic beverages. Methods Determining the tax share of alcohol prices in the WHO European Region For an overview of the current share of alcohol excise tax in all Member States of the WHO European Region, a comprehensive search was carried out between November and December of 2020 by two independent researchers in order to obtain (a) the tax structure (i.e., specific, unitary, or ad valorem; for definitions, see 8,11), b) the level of taxation, and (c) the mean retail prices (off-premise) per litre of the finished product for beer, wine, and spirits for each country. Taxes not specific to alcohol such as value- added taxes were excluded from the tax share indicator. In a first step, databases covering tax or price information for the year 2020 for multiple countries were searched, namely the excise tax regulation of the European Commission,18 the OECD Consumption Tax 5 Trend 2020,19 and the Statista webpage.20 For the remaining countries, webpages of national statistical offices or other government agencies were searched; and finally, local experts were consulted. Data were then cross-checked using secondary information such as the pricing update report 21 from the WHO Regional Office for Europe. A comprehensive overview of sources by country is provided in the Appendix Table A1. Data was identified for all Member States of the WHO European Region except for Andorra, Monaco, and San Marino, and can be found in the Appendix 2 spreadsheets. Comparing affordability of alcohol in Europe To generate an indicator for comparing affordability, the prices of alcoholic beverages, weighted by the relative share of the three main beverage types consumed in a country,22 was put into relation with the Gross Domestic Product Purchasing Power Parity (GDP PPP) per capita.23 Concretely, we divided the monthly GDP-PPP per capita by the price of 100g ethanol (pure alcohol). For GDP-PPP per capita, the year 2019 was used as it was the last year data was available from The World Bank. The higher this indicator, i.e., the more ethanol that could be bought with the average GDP PPP of a country, the more affordable the alcoholic beverages were considered to be. Methodology for translating taxation increases into changes in alcohol consumption To quantify the deaths which could be averted in the WHO European Region assuming a new scenario in which all countries have a minimum tax share of alcohol prices (defined as the proportion of alcohol excise taxes in the final price), the following steps were taken (see Appendix Text T2 for a detailed description of the methodology, including formulas):  Defining the new minimum tax share of alcohol prices (Scenario 1: 25%), and an alternative scenario of 15% tax share with equalisation of the price per unit of ethanol (pure alcohol; Scenario 2). Prices which already exceeded the minimum tax share were not changed;  Modelling the impact of the new prices on consumption;  Modelling the impact of consumption on alcohol-attributable mortality. In Scenario 1, the model set the minimum tax share for alcohol prices at 25%, which is one third of the recommended tax share for tobacco. In this scenario, no equalisation of the excise taxes across beverage types was applied.. In addition, as indicated above, we followed best practice recommendations for taxation to achieve the same price per unit of ethanol, irrespective of beverage type (equalisation).16,17 In Scenario 2, national taxes per unit of ethanol were calculated on the basis of a minimum tax share of 15% 6 for the beverage which had the highest price per unit of alcohol independent of taxation (i.e., for production, transport, trade and profit), In most countries (n = 40), this was wine. Then, the excise taxes for the remaining beverage types (in the overwhelming majority of countries, these are beer and spirits) were calculated in such a way that the final price per unit of alcohol was the same. The final share of alcohol excise taxes corresponds to the share of these newly obtained alcohol excise taxes in the consumer price, which includes excise taxes plus other taxes plus production/distribution/sales costs plus profits for the economic operators. We chose rather low tax shares for our analyses despite the fact that, for tobacco, another psychoactive substance, which in many counties has incurred similar costs to society (e.g. 24), much higher tax shares had been implemented in the Region (see Appendix Table A2). However, since governments in the European Region have traditionally been reluctant to increase excise taxation on alcohol, a stepwise increase seems to be more realistic. The resulting tax shares for each country and the WHO European Region can be found in Appendix Tables 3a and 3b. The increase in taxes were translated into an increase in the prices of alcoholic beverages, assuming that 100% of the taxes were passed through to the price. However, there may be some under- or over-shifting meaning that either the producers increased or decreased the prices overproportionally, depending on the beverage type and the market situation (25; see Appendix T2 for references justifying this procedure). The impact of the price increases on consumption (based on recorded alcohol statistics) were modelled using price elasticities based on meta-analyses with two specific considerations: we assumed that the more- preferred beverage types were less elastic than less-preferred types,26,27 and we assumed higher inelasticity for heavy drinkers and people with alcohol use dependence (based on a meta-analysis 28). We also assumed that heavy episodic drinking, a drinking pattern which impacts on some disease categories over and above average volume of drinking,29 would decrease proportionally with the average consumption level. The resulting price elasticities were −0·36 (95% CI: −0·48, −0·24) for the most preferred beverage type (beer, wine or spirits) in a country; −0·6 (95% CI: −0·72, −0·48) for the middle preference, and −1·2 (95% CI: −1·44, −0·96) for the least preferred beverage type. However, for all heavy drinkers, the price elasticity was set lower at −0·28 (95% CI: −0·37, −0·19), irrespective of beverage type.26-28,30 As detailed below, we conducted sensitivity analyses where elasticities were only based on beverage type, irrespective of the country. Finally, the changes in consumption level were then translated into estimates of alcohol-attributable mortality using comparative risk assessment methodology.2 While the exact formulas can be found in the Appendix Text T2, we describe here the logic of the stepwise procedure we undertook for diseases not fully attributable to alcohol: first, we estimated the alcohol-attributable fractions on sex, age, and cause- specific numbers of death, given the current exposure based on the distribution of consumption and the 7 associated Relative Risks for each consumption level.31 We then repeated this procedure with the new distribution of alcohol consumption resulting from the tax increases. The difference between these calculations is the number of deaths averted. Data sources for population size, mortality, and alcohol exposure Mortality and population data were taken from the Global Burden of Disease 2019 Study for the year 2019.32 Recorded per capita consumption data were obtained from Manthey et al. (2019).22 Sensitivity analyses We conducted two sensitivity analyses with different price elasticities based on the comprehensive meta- analyses of Wagenaar and colleagues 28 and Nelson30 to test the stability of our results with respect to different assumptions of stability. Also, as all meta-analyses on price elasticities of alcoholic beverages are fairly old, it is not clear to what degree they correspond to the current price elasticities. These two meta-analyses were selected as they constitute, to our knowledge, the most cited 28 and the most conservative meta-analyses in the field.30 Appendix Table A4 gives details of the price elasticities we used for these sensitivity analyses. Role of the funding source The funding source had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Results There are three main tax structures in place in the Member States of the WHO European Region: unitary taxation, where the alcohol duty is levied on the basis of the volume of a product—for instance, per litre of finished product; specific taxation, where alcohol duty is levied on the basis of the alcohol content of a product; and, ad valorem taxation, where alcohol duty is levied on the basis of the value of a product, usually determined by the price. The different tax structures and the proportion of tax in the mean final 8 retail price by alcoholic beverage for all Member States of the WHO European Region are presented in Appendix Table A2 and Appendix Figure A2. For beer and wine, most countries outside the EU have a unitary tax in place, while in the EU alcohol taxation rules require beer excise duties to be a distinct tax. For wine, the EU imposes no minimum tax rate per litre of the finished product, and 15 countries in the EU impose no excise taxes on wine (22 in the WHO European Region as a whole). For spirits, most of the countries have specific taxation rates in place, which involve higher taxation on spirits having higher alcohol levels by volume. An overview of the different tax shares in the final retail prices for beer, wine, and spirits are presented in Appendix Figures A3-A5. Figure 1 presents the average tax shares of alcohol prices over all three beverage types (weighted by proportion of use). Overall, the proportion of tax in the final consumer prices varied across countries, with countries in the northern and eastern part of the Region having generally higher tax shares included in their final retail prices of alcoholic beverages. The median (mean) tax shares of alcohol prices for beer, wine, and spirits for the WHO European Region were 10·8% (14·0%), 0·8% (5·7%), and 30·6% (31·3%), respectively. These are very low, especially for wine, with 22 out of all the countries having no alcohol excise taxes at all, and the majority of them located in the EU. 9 Figure 1: Tax share as % of the retail prices for alcoholic beverages in the WHO European Region in 2020 (weighted average for beer, wine, and spirits) A subregional analysis of the tax share of alcohol prices corroborates the differences of the visual inspection of Figure 2. There are significant differences with the EU having lower tax shares than the other subregions, namely the 10 countries of the Commonwealth of the Independent States (CIS), and the five countries of the Eurasian Economic Union (EAEU), which are also part of the CIS (t-tests EU vs· CIS: -2·5941; df= 36; p = 0·0136; EU vs· EAUA: -3·8063; df=31; p = 0·000624; for distribution, see boxplots Figure 2; separate figures for beer, wine, and spirits can be found in Appendix Figures A6–A8). 10 Legend: CIS: Commonwealth of Independent States; EAEU: Eurasian Economic Union; EU: European Union Figure 2: Boxplots of tax share in % of the retail prices for selected subregions of the WHO European Region in 2020 The mean tax share of alcohol prices for the WHO European Region was 14·27%, with the EU being the subregion with the lowest mean share at 10·86%. Comparing affordability Overall affordability as measured by the GDP PPP per capita divided by the price of 100 g ethanol did not vary as much as the tax share of alcohol prices. The following countries showed the highest affordability for alcohol: Luxembourg, Germany, Czech Republic, Slovakia, and Austria. The countries with the least affordability were: Tajikistan, Georgia, Turkey, Kyrgyzstan, and Albania (for details, see Appendix Figure A9). 11  Mortality averted by introducing a minimum tax share on alcohol prices In total, 40,033 (95% confidence interval CI: 38,054-46,097) and 132,906 (95% CI: (124,691-151,674) deaths could be saved in one year in the WHO European Region by implementing the proposed scenario 1 (a minimum tax share of 24% with no equalisation) and Scenario 2 (a minimum tax share of 15% and no equalisation per unit of ethanol, irrespective of alcoholic beverage). Appendix Tables A5 and A6 provide the details by country, both in number of deaths averted, and in their proportion of all alcohol- attributable deaths. Tables 1a and 1b show the details by subregion. Table 1a: Number of annual deaths averted by introducing a minimum tax share of alcohol prices of 25% (Scenario 1) or by introducing a tax share of 15% with equalisation of price per unit of pure alcohol (based on 2019) Other Diseases Rates per Infectious Cardiovascular Gastrointestinal (including Total Deaths Cancers Injuries 100,000 Diseases Diseases Diseases Alcohol Use Averted Population# Disorders) Scenario 1 (25% tax share, no equalisation) EU 750 3,434 7,774 2,416 2,443 3,229 20,046 4·67 (429,130,200 (244-1,292) (2,963-3,965) (7,168-10,763) (2,251-2,733) (1,847-2,968) (3,021-3,616) (19,163-23,571) (4·47-5·49) inhabitants*) CIS 359 567 5,335 1,570 1,887 4,315 14,034 7·43 (188,827,700 (196-518) (463-682) (4,613-7,172) (1,346-1,822) (1,412-2,250) (3,653-5,499) (12,257-17,223) (6·49-9·12) inhabitants*) EAEU 300 503 5,074 1,078 1,710 4,101 12,766 8·80 (145,091,800 (168-427) (408-620) (4,348-6,861) (889-1,300) (1,274-2,038) (3,449-5,286) (10,986-15,970) (7·57-11·01) inhabitants*) WHO European 1,265 4,447 15,719 4,699 4,922 8,982 40,033 5·31 Region (569-1,978) (3,887-5,073) (14,916-20,233) (4,355-5,162) (3,711-5,836) (8,341-10,308) (38,054-46,097) (5·05-6·12) (753,454,300 inhabitants*) Scenario 2 (15% tax share, equalisation per alcohol unit) EU 2,149 9,042 18,850 7,494 7,020 8,958 53,513 12·47 (429,130,200 (715-3,792) (7,874-10,623) (17,534-26,422) (7,010-8,513) (5,239-8,596) (8,496-9,930) (50,534-62,323) (11·78-14·52) inhabitants*) CIS 1,746 2,830 22,599 7,870 9,471 18,541 63,056 33·39 (188,827,700 (869-2,560) (2,250-3,548) (19,743-28,903) (6,649-9,384) (6,926-11,852) (16,079-22,081) (55,411-74,247) (29·34-39·32) inhabitants*) EAEU 1,551 2,648 21,753 6,246 8,887 17,722 58,807 40·53 (145,091,800 (789-2,252) (2,094-3,360) (18,899-27,984) (5,111-7,748) (6,495-11,158) (15,250-21,281) (50,885-69,703) (35·07-48·04) inhabitants*) WHO European 132,906 17·64 4,359 13,143 48,227 17,735 18,302 31,142 Region (124,691- (1,936-6,892) (11,476-15,360) (45,185-61,778) (16,205-19,887) (13,697-22,110) (28,630-35,038) (16·55-20·13) (753,454,300 151,674) inhabitants*) Legend: CIS: Commonwealth of Independent States; EAEU: Eurasian Economic Union; EU: European Union; numbers in parentheses denote 95% confidence intervals # Rates were calculated for the population 15 years and older. * Inhabitants are for 2019 for the population 15 years and older, and exclude countries for which we had no per capita consumption and/or taxation data (for Andorra, Monaco, and San Marino). 12  Table 1b: Proportion of annual deaths averted by introducing a minimum tax share of alcohol prices of 25% (Scenario 1) or by introducing a tax share of 15% with equalisation of price per unit of pure alcohol (based on 2019) Other Diseases Infectious Cardiovascular Gastrointestinal (including Total Deaths Cancers Injuries Diseases Diseases Diseases Alcohol Use Averted Disorders) Scenario 1 (25% tax share, no equalisation) 5·31 5·44 12·98 3·30 4·91 12·36 7·01 EU (4·88-5·82) (5·12-5·93) (10·56-15·50) (2·97-3·87) (4·43-5·50) (11·65-13·85) (6·64-7·97) 4·97 3·36 11·33 3·70 3·83 12·29 7·09 CIS (3·85-6·13) (2·80-4·08) (9·43-14·53) (3·17-4·52) (3·12-4·62) (10·49-15·52) (6·13-8·77) 4·65 3·11 11·25 3·06 3·65 12·12 6·95 EAEU (3·28-5·94) (2·55-3·86) (9·27-14·56) (2·47-3·92) (2·91-4·47) (10·28-15·42) (5·91-8·78) 5·27 5·02 12·62 3·58 4·46 12·73 7·29 WHO EUR (4·58-5·77) (4·73-5·42) (10·62-14·73) (3·28-4·06) (3·93-5·03) (11·79-14·56) (6·87-8·19) Scenario 2 (15% tax share, equalisation per alcohol unit) 15·21 14·33 31·48 10·25 14·12 34·30 18·71 EU (14·15-16·71) (13·58-15·56) (26·50-35·98) (9·34-11·84) (12·79-15·94) (32·67-37·94) (17·79-20·83) 24·17 16·79 47·99 18·55 19·23 52·81 31·85 CIS (19·46-29·96) (13·59-20·83) (40·34-57·29) (15·76-22·42) (15·63-23·21) (45·73-62·34) (27·31-37·86) 24·04 16·35 48·25 17·73 18·97 52·37 32·02 EAEU (18·77-30·38) (13·07-20·69) (40·36-58·00) (14·42-22·28) (15·20-23·21) (44·99-62·23) (27·20-38·46) WHO 18·18 14·83 38·72 13·49 16·59 44·12 24·19 European Region (16·59-20·48) (14·02-16·07) (32·54-43·55) (12·39-15·20) (14·48-19·01) (40·57-49·62) (22·34-27·06) Legend: EAEU: Eurasian Economic Union; CIS: Commonwealth of Independent States; EU: European Union; numbers in parentheses denote 95% confidence intervals The 40,033 and 132,906 potentially averted deaths in Scenarios 1 and 2 correspond to 7·29% (95% CI: 6·87-8·19%) and 24·19% (95% CI: 22·34-27·06%) of the total number of alcohol-attributable deaths, respectively. The number of deaths averted, and in their proportion of all alcohol-attributable deaths under Scenario 2 can be found in Appendix Tables A7 and A8. The difference between the two scenarios is that equalisation results in much higher tax shares overall. A minimum tax share of 25% without equalisation increases the tax shares of all beverage types to 25% in most countries, resulting in an average tax share of 29.06% (the difference to 25% is due to instances where some countries had already had higher tax shares for some beverage types). However, if the price per unit of pure alcohol is equalised for all beverage types, a minimum tax share of 15% leads to an average tax share of 45.28%. The reason for this is the higher non-tax components for wine (i.e., higher production, transport, and trading costs) compared to other beverages, especially spirits. 13 In all jurisdictions, the category with the highest numbers of deaths averted was either the rest category of “other disease”, mainly made up of alcohol use disorders, or cardiovascular disease (including alcoholic cardiomyopathy), but the ranking of the other categories differed by region. The five largest groups of causes of alcohol-attributable deaths made up more than 90% of the causes averted in each region: cancers, cardiovascular deaths, gastrointestinal deaths (mainly liver cirrhosis), injuries, and alcohol use disorders. Of these, liver cirrhosis and alcohol use disorders have the highest alcohol-attributable fractions, whereas alcohol use is one of many-contributing causes in the larger cause-of-death categories of cancer and cardiovascular disease. Sensitivity analyses Finally, in the sensitivity analyses for Scenario 1 using the price elasticities from Nelson 30 and Wagenaar and colleagues 28, 31,867 (95% CI: 30,429-36,149) and 48,813 (95% CI: 45,769-55,209) deaths were averted for the same minimum tax share of 25%. Details of these results can be found in Appendix Tables A9 and A10. Proportionally similar, the sensitivity analyses for Scenario 2 yielded results of 136,546 (95% CI: 127,866-152,333) and 203,856 (95% CI: 186,382-224,808; detailed results in Tables A11 and A12). Overall, the sensitivity analyses showed that under all assumptions—even assuming the most conservative estimates for price elasticity found in the literature—the numbers of alcohol-attributable deaths averted by all scenarios are considerable, with proportions of avoidable alcohol-attributable deaths minimally amounting to 6% out of all alcohol-attributable deaths. Discussion The present contribution is the first comprehensive overview of the current state of alcohol taxation implementation for the WHO European Region, highlighting the untapped potential of tax measures to benefit public health. Despite the fact that alcohol is a psychoactive substance and a known carcinogen, which causes substantial harms to drinkers, their families, communities, as well as societies and economies in general,3,10 it is far less regulated than tobacco or any other psychoactive substance.33,34 This includes the regulations on the level of taxation. For instance, the WHO recommends that for tobacco the proportion of tax should represent at least 75% of the retail price of the most popular brand of cigarettes. In the WHO European Region, more than half of the Member States follow this 14 recommendation.15 However, no such WHO recommendation exists for alcohol and the modelling exercises suggest that alcohol taxation should be considered a priority for public health given the substantial number of lives potentially saved, especially given that pricing policies remain the most under-utilized of all available policy options to reduce alcohol consumption and harms (Appendix Figure A1). Before we move on to further interpretation of results, some limitations need to be addressed. While we tried to find the best data sources available for prices and taxation levels, and double-checked all the sources, we cannot exclude the existence of better sources. The WHO should formalize data collection of the mean retail prices to provide more standardized indicators in the future. With respect to the modelling of the mortality avoided, we used price elasticities derived from meta-analyses which were applied to countries with variations between countries solely derived from preferences for particular alcoholic beverage types. In other words, the prices of less preferred types of alcoholic beverages were assumed to be more elastic. However, acknowledging considerable differences in the results of different meta- analyses on price elasticities for different beverage types, 26-28,30 we conducted two sensitivity analyses based on the most frequently cited 28 and the most conservative meta-analyses.30 The results were reassuring in the sense that, independent of the meta-analyses used, the overall conclusion of significant public health impact persisted, indicated by the considerable number of averted deaths they estimated. However, future work may add sex-, age- and/or country-specific elasticities based on empirical studies, once they become available. Also, future investigations may include potential cross-elasticities with other psychoactive drug use. The alcohol-attributable fraction methodology is based on risk functions, which are largely not country-specific (for an exception, see 35). This may introduce some bias, as different countries may show different risk functions based on interactions with other risk factors. This may especially be relevant for countries with patterns of irregular heavy drinking, which seems to particularly affect cardiovascular diseases. 36 Another limitation, which generally applies to all mortality studies based on cause of death categories: there is misspecification, especially in older age groups, when often large and unspecific codes, such as heart failure, are used. While this problem cannot be fully overcome, use of data corrected for unspecific codes, as those underlying our analyses were, at least improves reliability.37 A final limitation may be that for equalisation we set the price per unit of pure alcohol to be equal for all beverage types (per country). In countries with high degrees of alcohol poisoning and violence, outcomes more closely related to spirits consumption (by setting proportionally higher prices for spirits via higher tax shares) may be worth considering.34 To give flexibility to the countries, a tax share of 25% on average, based on the distribution of beverage in the respective country, may be advisable. 15 Despite these limitations, comparisons of cases of alcohol taxation increases in the WHO European Region countries such the increases in Lithuania in 2017,9 or in Russia in the years 2010-2013 38 showed much larger effects than would be predicted by the calculation methodology used here. It should be noted that in both Lithuania and in Russia, there were multiple alcohol control measures put in place within relatively short time spans, and the effects may be synergetic, thus outperforming predictions mainly based on single measures which were the basis of the meta-analyses. One argument against increasing taxation frequently mentioned by the alcohol industry 39 is that it may result in an increase in unrecorded consumption. However, a recent review did not find much evidence for such increases associated with taxation increases in the Region.40 In any case, there are effective countermeasures against unrecorded consumption, which may be considered in countries where unrecorded consumption is a potential threat.39,40 As already mentioned, the WHO European Region has the highest prevalence of drinkers globally, the highest drinking levels, and the highest proportion of all- cause mortality caused by alcohol.3,41 At the same time, drinking levels, frequency of heavy episodic drinking, and alcohol-attributable fractions for mortality and disability vary strongly by country. Countries in the eastern part of the Region—particularly in Eastern European countries of the former Soviet Union—experience greater alcohol-attributable harm than countries in the western part despite similar or lower levels of drinking.4 Nonetheless, these Eastern European countries were the main drivers of the overall regional reduction in alcohol per capita consumption in recent years as they have substantially reduced both drinking and alcohol-attributable harm.42 The introduction of various alcohol control policies, which included not only taxation measures to increase prices but also comprehensive marketing and availability restrictions, contributed to this development, although improved access to healthcare and quality of care as well as other factors were also at play.14 Moreover, it is sometimes difficult to evaluate the impact of single measures like taxation increases or marketing restrictions because of their interacting effects, and because different measures are usually implemented at the same time as part of a broader policy package.4,9 It is noteworthy that the WHO European Region is also where the majority of international alcohol producers are located, which may explain its low alcohol taxation share. Raising alcohol taxes is a powerful tool to counteract mortality harm caused by alcohol use, as the provided analyses have shown, and is a tool which has clearly not been used to its full potential in the WHO European Region. For example, the absence of any tax rate for wine in almost half of the countries (most of them EU countries), and the median tax share of <1% for wine for the entire Region, is unacceptable from a public health standpoint. This is exacerbated by the EU’s longstanding financial support for the wine industry, where it is estimated that from 2007 to 2012 every litre of wine produced in the EU was supported by 0.15 EUR.43 16 Excise taxation is not only potentially relevant for public health, it also has the potential to increase state revenue. For instance, the recent substantial increase of excise taxation in Lithuania by more than 100% for beer and wine, and over 20% for spirits, resulted not only in decreases in both consumption and mortality,9 but also in an increase in tax revenue.44 Similarly, we found increases in revenues for almost all major taxation increases for psychoactive substances.45 Also, a recent review showed that taxation increases in several countries—despite warnings from the alcohol industry—did not result in increases in unrecorded consumption, or a net increase in overall alcohol use, or in alcohol-attributable harm.40 However, if a minimum excise tax share for alcoholic beverages were to be implemented, this should be done in conjunction with measures against unrecorded consumption in countries where such increases are anticipated.40 The gap in regulation and risk awareness between alcohol and tobacco is enormous. With the adoption of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) in May 2003, the tobacco epidemic was globally recognized as a health, economic, and development issue and subsequent measures similar to this legally binding treaty have followed, decreasing tobacco use and its burden worldwide. Compared to the tax share of tobacco, the average tax share of alcohol prices for the Region is about four times lower, as shown in the Appendix Table A2. While tobacco taxes are clearly seen as health taxes to be levied on products that have negative public health impacts, alcohol taxes have historically45 been seen as a fiscal measure first and foremost, even in countries that have considerably increased their alcohol tax rates in the past years.13 A paradigm shift for alcohol taxation is clearly warranted and needed. Alcohol taxes should be a public health prerogative, to be implemented as part of a comprehensive policy intervention package and within a global framework convention 33 to overcome the known implementation challenges at the national level. Alcohol taxes should be considered to be health taxes, and thus viewed as an investment, not a burden. Investing in health was not only critical during the recent COVID pandemic, it will be even more important as part of a “building back better” approach for a sustainable and more resilient economic recovery. 17 Conclusion Alcohol is very affordable in the WHO European Region, and in many of its countries, taxation has a limited impact on retail prices. There is significant scope for alcohol taxes to play a larger role in raising the prices of alcohol beverages and thereby moderating drinking behaviours and mitigating attributable harm. Alcohol, like tobacco, is not an ordinary commodity, and thus it should be treated differently from other commodities in public policies.7 This includes taxation based on public health goals. Developing and establishing a minimum recommended level of tax in the final consumer price of alcohol, following the example of tobacco, is an important step in establishing an implementation framework for alcohol taxes based on these principles. The full potential of taxation increases to reduce alcohol use and alcohol- attributable burden is far from being realized in the WHO European Region. 18 Contributors MN, CFB and JR conceived the study and provided overall guidance. MN and JR prepared the first draft. MN and CK extracted data. PR, JR and FS developed models and initiated modelling. AV, CFB, CK, FS and MN reviewed results. All authors reviewed the manuscript and have contributed to several iterations of the text, and have approved of the final revised version. Declaration of interests The authors declare no conflict of interest. Funding and acknowledgements Research reported in this publication was also supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIAAA) [Award Number 1R01AA028224]. This contribution was also supported by funding from the Canadian Institutes of Health Research, Institute of Neurosciences, and Mental Health and Addiction (CRISM Ontario Node grant no. SMN-13950) to the last author. We would like to thank Maxim Yermalovich for his contributions to the Working Group on Alcohol Taxation of the Regional Director’s Advisory Council on Innovation for Noncommunicable Diseases and Astrid Otto for referencing and copy-editing the manuscript. Carina Ferreira-Borges and Maria Neufeld are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and these do not necessarily represent the decisions or the stated policy of the World Health Organization or of the National Institutes of Health. Data sharing statement Data collected for the study are made available to others in the Appendices. The code used in the statistical analyses will be made available upon request sent to the corresponding author. 19 References 1. Rehm J, Imtiaz S. Alcohol consumption as a risk factor for global burden of disease. A narrative review. Substance Abuse Treatment, Prevention and Policy 2016; 11(1): 37. 2. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020; 396(10258): 1223-49. 3. Shield KD, Manthey J, Rylett M, et al. National, regional, and global burdens of disease from 2000 to 2016 attributable to alcohol use: a comparative risk assessment study. Lancet Public Health 2020; 5(1): e51-e61. 4. WHO Regional Office for Europe. Making the European Region Safer: developments in alcohol control policies, 2010–2019. 2021. https://www.euro.who.int/en/health-topics/disease- prevention/alcohol-use/publications/2021/making-the-european-region-safer-developments-in-alcohol- control-policies,-20102019-2021 (accessed 29/04/2021. 5. World Health Organization. 'Best buys' and other recommended interventions for the prevention and control of noncommunicable diseases: Updated (2017) Appendix 3 of the global action plan for the prevention and control of noncommunicable diseases 2013-20202017. https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdf (accessed 16/01/2021). 6. Chisholm D, Moro D, Bertram M, et al. Are the "Best Buys" for Alcohol Control Still Valid? An Update on the Comparative Cost-Effectiveness of Alcohol Control Strategies at the Global Level. J Stud Alcohol Drugs 2018; 79(4): 514-22. 7. Babor TF, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity. Research and public policy. 2nd ed. Oxford: Oxford University Press; 2010. 8. Sornpaisarn B, Shield KD, Österberg E, Rehm J. Resource tool on alcohol taxation and pricing policies. Geneva: World Health Organization and others 2017. 9. Štelemėkas M, Manthey J, Badaras R, et al. Alcohol control policy measures and all-cause mortality in Lithuania: an interrupted time-series analysis. Addiction 2021; 116(10): 2673-84. 10. Manthey J, Hassan SA, Carr S, Kilian C, Kuitunen-Paul S, Rehm J. What are the Economic Costs to Society Attributable to Alcohol Use? A Systematic Review and Modelling Study. Pharmacoeconomics 2021; 39(7): 809-22. 11. Angus C, Holmes J, Meier PS. Comparing alcohol taxation throughout the European Union. Addiction 2019; 114(8): 1489-94. 12. Rabinovich L, Brutscher PB, de Vries H, Tiessen J, Clift J, Reding A. The affordability of alcoholic beverages in the European Union: Understanding the link between alcohol affordability, consumption and harms. RAND Technical Report. 2009. http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_rand_en.pdf (accessed 15/09/2020. 13. Moskalewicz J, Österberg E. Changes in alcohol affordability and availability: Twenty years of transitions in Eastern Europe. 2016. https://www.julkari.fi/bitstream/handle/10024/131245/URN_ISBN_978-952-245-772- 1.pdf?sequence=1&isAllowed=y (accessed 04/05/2021. 14. Neufeld M, Bobrova A, Davletov K, et al. Alcohol control policies in Former Soviet Union countries: A narrative review of three decades of policy changes and their apparent effects. Drug Alcohol Rev 2021; 40(3): 350-67. 15. World Health Organization. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. 2021. https://www.who.int/publications/i/item/9789240032095 (accessed 03/01/2022. 20 16. Cook PJ. Paying the tab: The costs and benefits of alcohol control. Princeton, New Jersey: Princeton University Press; 2007. 17. Saffer H, Chaloupka F. Alcohol tax equalization and social costs. Eastern Economic Journal 1994; 20(1): 33-43. 18. ec.europa.eu. Excise Duty on Alcohol. 2020. https://ec.europa.eu/taxation_customs/business/excise-duties-alcohol-tobacco-energy/excise-duties- alcohol_en (accessed 29/04/2021. 19. OECD. Consumption Tax Trends 2020. VAT/GST and Excise Rates, Trends and Policy Issues. 2020. https://doi.org/10.1787/152def2d-en (accessed 29/04/2021. 20. Statista. Alcoholic Drinks - Price per Unit. Europe. 2020. https://www.statista.com/outlook/10000000/102/alcoholic-drinks/europe (accessed 30/07/2020. 21. WHO Regional Office for Europe. Alcohol Pricing in the WHO European Region. Update Report on the Evidence and Recommended Policy Actions. 2020. 2020. https://www.euro.who.int/en/health- topics/disease-prevention/alcohol-use/news/news/2020/06/new-who-report-on-alcohol-pricing- europe-ignores-cost-effective-ways-to-lower-health-risks (accessed 03/05/2021. 22. Manthey J, Shield KD, Rylett M, Hasan OSM, Probst C, Rehm J. Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. The Lancet 2019; 393(10190): 2493-502. 23. The World Bank. GDP per capita, PPP (current international $). 2021. https://data.worldbank.org/indicator/NY.GDP.PCAP.PP.CD?most_recent_value_desc=true (accessed 03/05/2021. 24. Canadian Centre on Substance Use and Addiction. Substance Use in Canada Costs Almost $46 Billion a Year According to Latest Data. 2020 July 7. https://www.globenewswire.com/news- release/2020/07/07/2058630/0/en/Substance-Use-in-Canada-Costs-Almost-46-Billion-a-Year-According- to-Latest-Data.html (accessed 27/09/2021. 25. Shang C, Ngo A, Chaloupka FJ. The pass-through of alcohol excise taxes to prices in OECD countries. The European Journal of Health Economics 2020; 21(6): 855-67. 26. Fogarty J. The demand for beer, wine and spirits: a survey of the literature. Journal of Economic Surveys 2010; 24(3): 428-78. 27. Ornstein SI, Levy D. Price and income elasticities of demand for alcoholic beverages. Recent developments in alcoholism : an official publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism 1983; 1: 303-45. 28. Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta‐analysis of 1003 estimates from 112 studies. Addiction 2009; 104(2): 179-90. 29. Rehm J, Gmel Sr GE, Gmel G, et al. The relationship between different dimensions of alcohol use and the burden of disease—an update. Addiction 2017; 112(6): 968-1001. 30. Nelson JP. Meta-analysis of alcohol price and income elasticities - with corrections for publication bias. Health Econ Rev 2013; 3(1): 17. 31. Rehm J, Kehoe T, Gmel G, Stinson F, Grant B, Gmel G. Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example. Popul Health Metr 2010; 8(1): 3. 32. Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. 2020. http://ghdx.healthdata.org/gbd-results-tool. (accessed 16/09/2021. 33. Room R, Schmidt L, Rehm J, Mäkelä P. International regulation of alcohol. BMJ 2008; 337: a2364. 34. Rehm J, Crépault J-F, Hasan OSM, Lachenmeier DW, Room R, Sornpaisarn B. Regulatory policies for alcohol, other psychoactive substances and addictive behaviours: the role of level of use and potency. A systematic review. International journal of environmental research and public health 2019; 16(19): 3749. 21 35. Shield KD, Rehm J. Russia-specific relative risks and their effects on the estimated alcohol- attributable burden of disease. BMC Public Health 2015; 15(1): 1-10. 36. Rehm J, Roerecke M. Cardiovascular effects of alcohol consumption. Trends in Cardiovascular Medicine 2017; 27(8): 534-8. 37. Naghavi M, Richards N, Chowdhury H, et al. Improving the quality of cause of death data for public health policy: are all ‘garbage’codes equally problematic? BMC Medicine 2020; 18: 55. 38. Neufeld M, Ferreira-Borges C, Gil A, Manthey J, Rehm J. Alcohol policy has saved lives in the Russian Federation. Int J Drug Policy 2020; 80: 102636. 39. Lachenmeier DW, Neufeld M, Rehm J. The impact of unrecorded alcohol use on health: What do we know in 2020? Journal of Studies on Alcohol and Drugs 2021; 82(1): 28-41. 40. Rehm J, Neufeld M, Room R, et al. The impact of alcohol taxation changes on unrecorded alcohol consumption: a review and recommendations. International Journal of Drug Policy 2021 [Epub ahead of print Aug 27]: 103420. 41. World Health Organization. Global status report on alcohol and health 2018.2018. https://www.who.int/substance_abuse/publications/global_alcohol_report/en/ (accessed 05/20/2019). 42. Probst C, Manthey J, Neufeld M, et al. Meeting the Global NCD Target of at Least 10% Relative Reduction in the Harmful Use of Alcohol: Is the WHO European Region on Track? International Journal of Environmental Research and Public Health 2020; 17(10): 3423. 43. Anderson K, Jensen HG. How much government assistance do European wine producers receive? Journal of Wine Economics 2016; 11(2): 289-305. 44. Lithuanian Tobacco and Alcohol Control Coalition. An Appeal of the NGOs to the Lithuanian Government and Parliament To Maintain Current Alcohol Control Policies [Lietuvos nevyriausybinės organizacijos kreipėsi į LRV ir Seimą dėl alkoholio kontrolės politikos tęstinumo]. 2020. https://www.ntakk.lt/lietuvos-nevyriausybines-organizacijos-kreipesi-i-lrv-ir-seima-del-alkoholio- kontroles-politikos-testinumo/ (accessed 25/05/2021. 45. The Task Force on Fiscal Policy for Health. Health Taxes to Save Lives: Employing Effective Excise Taxes on Tobacco, Alcohol, and Sugary Beverages. 2019. https://www.bloomberg.org/program/public- health/task-force-fiscal-policy-health/ (accessed 21/05/2021. 22 Supplemental Data Click here to access/download Supplemental Data Annex 1_Additional files.docx Supplemental Data Click here to access/download Supplemental Data Annex 2_Original data on tax shares.xlsx Suggestion for a graphical abstract/cover Click here to access/download Supplemental Data Artwork alcohol tax.rar GATHER checklist Click here to access/download Supplemental Data GATHER-checklist_tax_share.docx Supplemental Data - Translated Abstract Click here to access/download Supplemental Data - Translated Abstract Abstracts.rar Figure 1: Tax share as % of the retail prices for alcoholic beverages in the WHO Click here to access/download;Figure;Figure1_Mean_Map_Tax.tiff European Region in 2020 (weighted average for beer, wine, and spirits) Figure 2: Boxplots of tax share in % of the retail prices for selected subregions of the Click here to access/download;Figure;Figure 2.png WHO European Region in 2020 Figure A1. Average policy scores for the 10 action areas of alcohol control in the WHO Click here to access/download;Figure;Figure A1.png European Region in 2019 Figure A2. Tax share in % per mean retail price (off-premise) by alcoholic beverage by Click here to access/download;Figure;Figure A2.png county in 2020 Figure A3. Tax share of beer prices in % of the retail prices in countries of the WHO Click here to access/download;Figure;FigureA3_Beer_Map_Tax.tiff European Region in 2020 Figure A4. Tax share of wine prices in % of the retail prices in countries of the WHO Click here to access/download;Figure;FigureA4_Wine_Map_Tax.tiff European Region in 2020 Figure A5. Tax share of spirit prices in % of the retail prices in countries of the WHO Click here to access/download;Figure;FigureA5_Spirits_Map_Tax.tiff European Region in 2020 Figure A6. Boxplots of tax share of beer prices in % of the retail prices for selected Click here to access/download;Figure;Figure A6.png subregions of the WHO European Region in 2020 Figure A7. Boxplots of tax share of wine prices in % of the retail prices for selected Click here to access/download;Figure;Figure A7.png subregions of the WHO European Region in 2020 Figure A8. Boxplots of tax share of spirit prices in % of the retail prices for selected Click here to access/download;Figure;Figure A8.png subregions of the WHO European Region in 2020 Figure A9. Map for the affordability (GDP PPP per month/price of 100 g ethanol) Click here to access/download;Figure;FigureA9_Aff_Map.tiff