Addiction, editorial;
Between 2000 and 2022, Lithuania, Estonia and, to a lesser degree, Latvia have implemented 16 major alcohol policies reducing availability and increasing alcohol excise taxes (for an overview: Rehm et al.) [1]. These policies were shown to have successfully reduced, beyond secular regional trends, alcohol consumption per capita [2], all-cause [3] and alcohol-attributable mortality [4], changed patterns of drinking [5] and reduced mortality inequalities [1]. This editorial will focus on new evidence since 2022 and provides a perspective on what other high-income countries, within the European Union (EU) and beyond, can learn from the Baltic, particularly Lithuanian, experiences.
EVIDENCE ON THE IMPACT OF THE MARKETING BAN OF 2018
Lithuania’s national ban on alcohol marketing, implemented in 2018, is among the most comprehensive restrictions on alcohol marketing in Europe. Using harmonised data from repeated cross-sectional survey waves [6], a recent study shows that adolescent drinking indicators in Lithuania—including drinking prevalence and frequency of intoxication—declined more rapidly following the ban when compared to other European Union (EU) countries over the same period, even after accounting for secular trends and other alcohol policies [7]. Theses controls were achieved by using other EU countries—which had implemented the relevant policies regarding minimum drinking age, availability and taxation—as a comparison group [8]. Contrary to initial hypotheses regarding the timeline of impact [9], consistent declines across multiple indicators now show a shift in behaviour within just 1 year. This change is particularly significant among adolescents, who are both disproportionately exposed to and particularly susceptible to marketing [10], with implications that may prove even more far-reaching over time.
These findings provide rare and rigorous real-world evidence supporting comprehensive alcohol marketing bans—covering all media and promotional activities—as a central component of alcohol control, particularly in the digital environment where partial restrictions are easily circumvented. Lithuania’s policy approach aligns with the World Health Organization’s recommended ‘best buys’, having implemented all three recommended policy measures in this category for alcohol concurrently within a single year. With the evaluation of the marketing ban, it has been demonstrated that all three ‘best buys’ have been shown to effectively reduce alcohol-attributable harm in Lithuania, both as individual policies and as part of an integrated package (see below) [11].
THE IMPORTANCE OF MONITORING THE IMPLEMENTATION OF ALCOHOL CONTROL POLICIES
Monitoring implementation enables the detection of non-compliance and facilitates corrective action, yet it remains an underappreciated part of alcohol policy. Following the national ban on alcohol marketing, an assessment of social media content revealed strong adherence, with few violations detected [12]. This success was largely attributed to a clearly defined legal framework and a centralised enforcement system. Yet, while alcohol advertisements rapidly disappeared, marketing for non-alcoholic beverages labelled similarly to alcoholic counterparts increased, highlighting how loopholes can emerge and require continued stakeholder attention. In contrast, a mystery shopper study in 2022 found that alcohol was sold without age verification in nearly half of all purchase attempts [13], despite a minimum legal purchasing age regulation, and a follow-up assessment in 2024 showed persistently high non-compliance, at approximately 40% [14]. The Baltic experience, therefore, underscores the need for continuous monitoring, strong enforcement, and the necessity of timely health advocacy activities responding to emerging counter-initiatives in a post-policy environment.
PUBLIC HEALTH MUST CONVINCE THE MINISTER OF FINANCE
Alcohol control policies are often discussed exclusively from a public health perspective. However, an important concern for their sustainability is the economic dimension. Analyses of the societal costs of alcohol before and after enactment of all three best buys in Lithuania showed clear reductions in these costs following implementation [15, 16]. Specifically, the 2017 tax increase was associated with a return on investment of 420 Euros gained for every Euro invested after 1 year [16].
Return on investment studies may have even greater value in predicting the effects of planned policy interventions, especially if different options are considered. This was conducted for Estonia [17], where a comparison of different policy options enabled decision-makers to choose based on their priorities. Without going into details regarding Estonian policy considerations, all policy options considered showed positive returns (i.e. the returns were larger than the amount invested), albeit with lower ratios than the policy analysed for Lithuania above. Tax revenue was a key element in determining the return [17]. The importance of revenue generation also became apparent in a recent parliamentary decision in Lithuania, when increases in alcohol excise taxation were agreed on to solidify the national defence budget.
THE IMPORTANCE OF BENCHMARKING SUCCESS STORIES FOR FUTURE DEVELOPMENT
Some of the success of the policies described above should be attributed to their integration [11, 18]: that policies are consistent, structurally connected and interdependent, addressing health, social and economic impacts. Although single policies are expected to lose their impact quickly, integrated policies may have more of a sustained impact, likely via their greater impact on de-normalising the role of alcohol in society [19].
Given this success, Lithuania quickly became a benchmark for integrated alcohol policy within the EU [20]. Latvia is a prime example among neighbouring countries that have introduced comprehensive alcohol policy packages anchored in new availability and marketing restrictions, while Poland and Estonia are expected to introduce further important policies in the near future. These implementations, along with renewed discussions about alcohol control across the European Union, underline the importance of regional success stories, which can inform, motivate and accelerate alcohol control policy development in other countries.
AUTHOR CONTRIBUTIONS
Jürgen Rehm: Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); project administration (equal); supervision (equal); writing—original draft (lead); writing—review and editing (equal). Daniela Correia: Data curation (equal); formal analysis (lead); methodology (equal); writing—review and editing (equal). Shannon Lange: Conceptualization (equal); formal analysis (equal); funding acquisition (equal); writing—review and editing (equal). Laura Miščikienė: Conceptualization (equal); data curation (equal); formal analysis (equal); methodology (equal). Mindaugas Štelemėkas: Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); project administration (equal); writing—review and editing (equal).
ACKNOWLEDGMENTS
Research reported in this publication was also supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIAAA), grant numbers 1R01AA028224 and 1R01AA028224-S1. The content is the responsibility of the authors and does not reflect official positions of NIAAA or the National Institutes of Health. We also would like to thank Ms. Astrid Otto for copy-editing and referencing.
DECLARATION OF INTERESTS
None.