Europeanization process impacts the patterns of alcohol consumption in the Western Balkans

Europeanization process impacts the patterns of alcohol consumption in the Western Balkans Abstract Background Western Balkan countries exhibit high levels of alcohol consumption, which constitutes a serious public health concern. We aimed to quantitatively assess the influence of the Europeanization process on levels of alcohol consumption in Western Balkans, an issue that has been under-researched. Methods The process of Europeanization was defined as the penetration of European dimension, procedures, policy paradigms, beliefs and norms in national arenas of politics and policy development. Data about alcohol consumption in six Western Balkan countries from 1991 to 2011 were gathered from the World Bank and World Health Organization databases. Azerbaijan and Georgia were considered control countries. A difference-in-differences approach was used to assess the impact of Europeanization process on levels of alcohol consumption. Results The Europeanization process impacts alcohol consumption in Western Balkan countries through the European Union directives and tax policies. After starting the Europeanization process, the spirits consumption in Croatia and The Former Yugoslav Republic of Macedonia decreased by 1.06 litter per capita (95% CI: from −1.63 to − 0.49) and 1.02 litter per capita in Serbia (95% CI: from −1.9 to − 0.1). Conclusion Our analysis provides useful evidence about the possible influence of Europeanization process especially on spirits consumption levels in Western Balkans. These findings draw attention to the need to implement new policies in order to prevent alcohol health-related harm due to the possible increase of wine and beer consumption. Introduction The European Union (EU) is expected to influence new member states and accession countries in economic, in political affairs and also in Public Health policies.1 The accession process can influence the level of alcohol consumption in candidate countries through three key aspects of alcohol policy: physical and economical availability, advertising and labelling.2 The penetration of European dimension, procedures, policy paradigms, styles, ‘ways of doing things’, shared beliefs and norms in national arenas of politics and policy is defined as Europeanization process.3,4 Europeanization has an impact on country domestic change by (a) ‘institutional compliance’—where European policy making prescribes specific institutional requirements which have to be implemented, (b) ‘changing the domestic opportunity structures’—where the EU changes the ‘domestic rules of the game’, and by (c) ‘a change in the beliefs and preferences of domestic actors’—a ‘framing integration’, affecting perceptions.5,6 Alcohol consumption is one of the major public health problems in the European region along with tobacco smoking, overweight and obesity. The high level of alcohol consumption in European Region is associated with the highest level of related harm in the world.7 Among new member states and accession countries, Western Balkans (WB) population has high levels of alcohol consumption.8 Alcohol related diseases caused 430 deaths in Serbia in 2012.9 There is evidence showing a decrease of pure alcohol consumption in Albania in the population above 15 years old from 2007 to 2010 (5.2 l in 2007, 5.4 in 2008, 5.6 in 2009 and 5 in 2010).10 Croatia and Serbia have had levels of alcohol consumption above the World Health Organization (WHO) European Region average for almost a decade, whereas Bosnia and Herzegovina, the Former Yugoslav Republic of Macedonia (FYROM) and Albania are clearly below the WHO European Region average. This difference may be explained by the fact that in the latter countries, there is a marked proportion of people who follow the Muslim faith.11 Studies compare data on the health status of WB countries, but there is a lack of information on the influence of the Europeanization process on public health policies, especially those potentially influencing alcohol consumption. According to WHO an association exists between the income level of a country and the overall levels of alcohol consumption.12 A study has shown that EU countries experiencing an increase of more than 3% in unemployment rate have experienced as much as a 28% increase in deaths from alcohol use disorders.1 Considering socio-economic factors at the ecological level when investigating determinants at national level, alcohol use is an important factor. As the EU accession process (i.e. Europeanization) can influence alcohol related policies, it is important to assess to which extent this policy process influenced quantitatively WB countries national level alcohol use. In addition, there is no documented evidence on the policy content that would inform about mechanisms through which alcohol consumption in the WB can be influenced by the Europeanization process. Such qualitative information is essential to provide explanations to findings that may arise from a quantitative policy evaluation. Therefore this study, using a quantitative policy evaluation, proposes to: firstly, document how the Europeanization process influences national policies designed to alter alcohol consumption in WB using different policy reports and secondly, to explore the impact of Europeanization process, concerning the trends of alcohol consumption among the Western Balkan countries from 1990 to 2011 taking advantage of a natural experiment in this region. Methods The study is based on a quantitative policy evaluation which is informed by a conceptual framework. First, we built a conceptual framework to explore how the Europeanization process influences national policies regarding alcohol in WB countries. Therefore, data from the EU country progress reports of Albania, Montenegro, Serbia, Bosnia and Herzegovina (BiH), FYROM and Croatia from 2005 to 2015 were used to understand in which ways/the EU influences national policies addressing alcohol consumption. We then collected quantitative data from World Bank and World Health Organization databases aiming to estimate the impact of the Europeanization process on alcohol related outcomes across six WB Countries from 1991 to 2011. Table 1 describes shows the source of data per each variable and the unit of measure. Table 1 List of variables Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Note: This table shows the variables according to the source of data and the unit of measurement. Table 1 List of variables Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Note: This table shows the variables according to the source of data and the unit of measurement. The conceptual framework The conceptual framework ’The Multi-nature and multi-level framework for population health’ by Huynen et al was used to inform the modelling of the influence of Europeanization process on alcohol consumption in WB countries.13 The framework discerns a contextual, distal and proximal level to impact population health. The contextual level addressed the EU policies regarding the European Market and taxation of alcohol. The distal level covered the policies built up in each country as national strategies and laws. The proximal level addressed local policies as regard to health services for alcohol disorders and physical environmental.13 The EU progress reports, (a joint effort of the EU and the respective country government) used for the conceptual framework are published annually to document the developments of accession countries towards meeting the requirements of the acquis communitaire. Chapter 28 on ‘Consumer and health protection’ was key to this analysis and any other chapters that contained the word ‘alcohol’, ‘alcohol consumption’, ‘alcohol beverages’ was considered in addition.14 In total, 63 reports were analysed and the findings were grouped based on the level of intervention: contextual, distal or proximal. Depicting the conceptual framework At the contextual level, the Europeanization process influences national alcohol policy through the EU directives that ask the accession countries to specify structures of duties, minimum rates and taxation.15–17 As well, reduced excise rates or reduced VAT rates to 0 or special VAT schemes for small producers of wine, intermediate products and alcohol are recommended as part of the code of conduct for business taxation.18,19 These directives leaded to changes in excise legislations in Albania, Serbia and Montenegro. At the distal level, the governments of the WB countries are building up national strategies on alcohol. FYROM (2009) and Albania (2011) approved a National strategy on preventing and minimizing the damage from alcohol.20,21 The environmental determinants show regulations that forbid the sale of alcoholic drinks to minors. FYROM in 2012 and Albania introduced a minimum age of 18 years for purchasing alcohol.22,23 Croatia has also drawn up action plans on alcohol.24 Albania, Montenegro and FYROM governments have set up new structures that monitor the implementation of legislation on alcohol.21,25,26 At the proximal level, the WB citizens have access to new services for the treatment of alcohol disorders including: public health programs at national level and health education about alcohol consumption organized at schools. The difference-in-differences analysis We focused on alcohol consumption in WB from 1991 to 2011.27 The start of Europeanization process was defined as the year in which each WB country signed the Association and Stabilization Agreement with the EU: Albania—2006; BiH—2008; Croatia—2001; FYROM—2001; Montenegro—2007; Serbia—2008. These years were considered as a point in time separating per each country the periods before and after start of the Europeanization process. Kosovo as a Potential Candidate Country was excluded from the analysis due to the late initiation of the Europeanization process in July 2014.28 The other European Countries that did not sign the agreement until 2011 were considered as control countries. In order to improve the baseline balance (before the treatment) between treated and control countries, the treated countries (WB that started the Europeanization process) were matched with control countries based on the similar Mean of Standardized Death Rate due to alcohol related disease (before the treatment, table 2). This matching process was also used to fulfil the parallelism assumption in our Difference in Difference approach (see below). This allowed for comparisons among countries.29 Croatia and FYROM were matched with Georgia and Azerbaijan; Albania, Montenegro and Serbia with Georgia. Table 2 Descriptive information on intervention and control countries Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Note: CC, Candidate Country; EU MS, European Union Member state; EPC, Eastern Partnership country; SD, standard deviation. Table 2 Descriptive information on intervention and control countries Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Note: CC, Candidate Country; EU MS, European Union Member state; EPC, Eastern Partnership country; SD, standard deviation. Data were retrieved from the World Bank and WHO databases.30,31 Pure alcohol, wine, spirits and beer were considered as outcomes of interest measured in litters per capita including the population >15 years.18 Other covariates included selected World Bank indicators such as the income level (GNI per capita) and overall unemployment (share of the jobless labour force seeking employment) (table 1).17 Data analysis Descriptive analysis was performed for WB and control countries (table 2). The distribution in years showed an unexplained decrease of pure alcohol and spirits consumption in BiH from 8.57 in 1999–3.96 in 2000. Therefore, it was decided not to include BiH in further analysis. Firstly, simple random effect models (without considering control groups) assessing the impact of Europeanization process on different alcohol related outcomes. The effect of Europeanization on alcohol consumption outcomes (i.e. pure alcohol, wine, beer and spirits) was estimated through an indicator for whether or not the country started the Europeanization process according to the operational definition. Then, a difference-in-differences (DID) approach with matching was used. The first regression model did not allow comparing the changes of the outcome of interest among countries that were treated and control countries nor considering time invariant unmeasured confounders.32 Therefore, DID approach (a quasi-experimental method that relies on the panel structure of the data usually two periods: baseline and follow up after the ‘intervention’, commonly used to evaluate public policies) was performed to estimate the effect of Europeanization on alcohol consumption during the pre- and post-Europeanization periods of time among WB and control countries. The previous regression model did not include confounding factors, therefore income and total unemployment are included in the following equation:1,12, Yct=α+β1Treatct+β2Postc+β3(Treat*Post)ct+β4Incomect*TotUnempct+ε, where Income and Total Unemployment were considered as continues variables. This equation was used to fit a DID regression model grouping the countries based on the year they started the Europeanization process and estimating the impact of the Europeanization process on alcohol consumption expressed in litters per capita. Countries were matched based on their trends in Standardized Death Rate due to alcohol related disease in order to make sure that the trends in the control group represent a good approximation for the counterfactual trend of the treated group in the absence of the treatment.33 STATA version 13 was used for the statistical analysis. Results The conceptual framework shows the general trends in all countries on how the Europeanization process influences policies regarding alcohol in WB. The EU suggests the WB countries as accession ones, to orient their legislations towards EU directives on excise, VAT taxation, and minimum duties. The governments of the WB countries are making changes in their regulations regarding alcohol and alcohol related harm protection. Our study finds an increase of alcohol related policies in WB that limit the physical access on alcoholic drinks, introduce a minimum age of 18 in all WB countries and ban alcohol sale during night hours.22,23 Studies mention taxation as a main tool for controlling alcohol economic availability.2 Increase of taxation influences the price and as consequence less alcohol is consumed.34,35 The WB countries have increased their excise tax on alcoholic beverages which is reflected in the increased alcohol prices. Impact of the Europeanization process on alcohol consumption Croatia is the richest country in WB (13 945 ± 4106) dollars per capita per year and reports the lowest unemployment rate during the study time (11.94% ± 2.85%). Furthermore, Croatia has the highest level of consumption of pure alcohol, wine and beer per capita in the region. Quantities are expressed in litres per capita respectively (11.8 ± 1.08), (5.46 ± 0.87) and (4.41 ± 0.55), among over 15 years old. Montenegro leads in the consumption of spirits (2.67 ± 0.07 l per capita). The lowest levels of pure alcohol consumption, spirits and wine consumption are reported in Albania respectively (3.61 ± 1.48), (1.6 ± 0.85) and (0.82 ± 0.23). Montenegro has the lowest beer consumption in the region (0.53 ± 0.3). The high level of alcohol consumption in Croatia is reflected in the highest standardized death rate due to alcohol related disease (SDR;108.8 ± 28.3). Montenegro reports the lowest levels of SDR (46.3 ± 6.62). The control countries Georgia and Azerbaijan show that pure alcohol is the favourite drink in these countries. Georgia shows the highest levels pure alcohol consumption per capita (3.95 ± 1.58) and SDR (61.71 ± 13.79). Azerbaijan has lower levels of consumption (1.38 ± 0.92) and SDR (100.5 ± 28.61) per capita. The results of the multilevel linear models are presented in table 3. Evidence shows that WB, after starting the Europeanization process, consume significantly less spirits and more beer, respectively, 0.83 l per capita less (95% CI: 1.59–0.077) and 0.6 l more (95% CI: 0.33–0.87) (table 3). Table 3 Random effect ANOVA; the effect of Europeanization on alcohol consumption (differences between before and after start of Europeanization process) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Note: CI, confidence interval. Table 3 Random effect ANOVA; the effect of Europeanization on alcohol consumption (differences between before and after start of Europeanization process) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Note: CI, confidence interval. The crude (unadjusted) DID analysis showed a decrease of 1 litter in the consumption of spirits for Croatia and FYROM that started the Europeanization process in 2001 (95% CI: from −1.65 to −0.35) comparing with Georgia and Azerbaijan as control countries (table 4). The income- and unemployment-adjusted DID models strengthened the findings, estimating a decrease of spirits consumption in Croatia and FYROM of 1.06 (95% CI: from −1.63 to −0.35) litters per capita. In Serbia too, there was evidence of a decrease in spirits consumption of 1.02 litters per capita (95% CI: from −1.9 to −0.1), in contrast to Georgia which was considered as a control country (table 4). Table 4 Difference-in-differences models; the effect of Europeanization on alcohol consumption Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Note: HRV, Croatia; MKD, Macedonia; GEO, Georgia; AZR, Azerbaijan; ALB, Albania; MONT, Montenegro; SRB, Serbia; DID, difference-in-difference; CI, Confidence interval. Table 4 Difference-in-differences models; the effect of Europeanization on alcohol consumption Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Note: HRV, Croatia; MKD, Macedonia; GEO, Georgia; AZR, Azerbaijan; ALB, Albania; MONT, Montenegro; SRB, Serbia; DID, difference-in-difference; CI, Confidence interval. Discussion The main findings of this study include a possible impact of the Europeanization process on levels of alcohol consumption in the WB region. The WB governments are making changes to their regulations regarding alcohol as excise, VAT taxation and physical availability due to the pressure to fulfil the EU criteria. Even in case of Croatia which has the highest pure alcohol, wine and beer per capita consumption level in the region, there is evidence of a decrease of spirits consumption. Similarly, FYROM and Serbia lowered the level of alcohol consumption by 1 l per capita since starting the Europeanization process. Our study results are consistent with similar descriptions from the literature. Greer et al. explain how the EU as an economic union influences the taxation and agricultural development of its member states resulting in a positive trade balance in the export of wine and spirits.34 Our study characterizes the way in which the EU policy influences taxation. It enables the WB governments to reduce the taxes for local producers of wine and alcoholic drinks. AsÖsterberg mentions, regulations on physical availability include special limits on opening times for retail alcohol sales.36 Our study finds the same limitations in WB. FYROM banned alcohol sale during night and all WB countries do not allow sell of alcohol to minors. It seems that the decrease of spirits consumption in WB countries might be explained through the difference in tax rates between spirits and other alcohol beverages decided by the Council Directive 92/84/EEC of 19 October 1992. It defined a minimum excise tax for spirits in the EU €550 per hectolitre of pure alcohol, €45 for intermediate products, €0.748 for beer and zero for wine.37 Governments of WB are interested to join EU and therefore, they have to follow the instructions of the EU. The policies of the EU regarding Alcohol consumption are part of Europeanization process. Governments of WB started to change their legislation including laws on alcohol consumption in order to satisfy the directives of the EU. Croatia and FYROM started the Europeanization process earlier in 2001 and had the necessary time until 2011 to measure the impact of the Europeanization process in spirits consumption. Serbia worked towards meeting the conditions, but the latter start of the Europeanization process (2008) came because of the necessity to resolve the Serbia–Kosovo deadlock since the 1999 conflict.38 Albania faces problems in implementing the rule of Law39 and Montenegro declared the independence in 2006 so it had not enough time to perform the same changes in legislation. Our study adds to the existing literature that the Europeanization process fosters the decrease of spirits consumption in WB and a possible increase of wine and beer consumption. However, the quantitative analysis was based on aggregate measures and, as such, no cross-level inferences (from ecological to individual level) can be assumed. Ecological analysis helps to build new hypothesis, but is not suitable for inferring causality. In addition, few data were available for the countries of interest. Yet, we proposed a quasi-experimental approach that considers the structure of the data to provide new evidence on this topic. In the future, it would be interesting to use panel data to evaluate the same hypotheses and check if the findings are robust. Alcohol consumption is considerably underestimated in most of WB countries, including FYROM and Montenegro because they do not account for unrecorded production and consumption. In our study we did not consider either unrecorded alcohol consumption or smuggling of alcohol beverages which should be addressed in future studies. Our study tries to explain the reason why time gaps exist between WB countries in starting the Europeanization process and how it can influence alcohol consumption. Further studies on this topic should as well consider the implication of differences in the accession process among WB and alcohol consumption trends. This study can inform the governments of the WB countries about current and possible future influence of the Europeanization process in alcohol consumption and can be used as a starting point of reflexion for new policies regarding protection of health alcohol related harm due to the possible increase of wine and beer consumption. In conclusion, the Europeanization influences the overall policies in the WB countries with an implication of health and alcohol related issues through the EU general politics, directives and legislations. WB countries have undertaken positive changes in alcohol-related legislations as increase of excise and VAT taxation, physical availability of alcohol through introducing a minimum age of 18 for alcohol consumption. However, it is necessary to strengthen the rule of law so that the current legislation is enforced and further positive impact can be measured on population health. We recommend other studies that would measure how the Europeanization process influences the alcohol consumption among adolescents and minors considering them as the future population of Europe. Acknowledgments We acknowledge Joy Seanehia and Nora Martenyi for their contribution in proof-reading. Conflicts of interest: None declared. Key points This is the first study conducted in the WB that attempts to explain how the Europeanization process influences the patterns of alcohol consumption. WB countries have changed alcohol-related legislations to increase excise and VAT taxation and limit the physical availability. Our study adds to the existing literature in that it points out that the Europeanization process fosters the decrease of spirits consumption in WB and a possible increase of wine and beer consumption. New policies in WB countries should address alcohol related harm due to the possible increase of wine and beer consumption. References 1 Anderson P . Alcohol. In: Mackenbach JP , McKee M , editors. Successes and Failures of Health Policy in Europe . Berkshire, England : Open University Press , 2013 . 2 Greer S , Fahy N , Elliot H , et al. Everything you always wanted to know about European Union health policies but were afraid to ask . London : European Observatory on Health Systems and Policies , 2014 . 3 Burzel TA . Towards convergence in Europe? Institutional adaptation to Europeanization in Germany and Spain . J Common Mark Stud 1999 ; 37 : 573 – 96 . Google Scholar CrossRef Search ADS 4 Featherstone K , Radaelli C , editors. The Politics of Europeanization . New York : Oxford University Press , 2003 . Google Scholar CrossRef Search ADS 5 Botetzagias I . Introduction: the Europeanisation of Southern Europe . J South Eur Balk 2005 ; 7 : 279 – 82 . Google Scholar CrossRef Search ADS 6 Knill C , Lehmkuhl D . The national impact of European Union regulatory policy: three Europeanization mechanisms . Eur J Polit Res 2002 ; 41 : 255 – 80 . Google Scholar CrossRef Search ADS 7 World Health Organization . The European health report 2015 Targets and beyond—reaching new frontiers in evidence—Highlights. Geneva, 2015 . 8 Rechel B , McKee M . Healing the Crisis: A Prescription for Public Health Action in South Eastern Europe . London : Open Society Institute , 2003 . 9 Jakovljevic MB , Jovanovic M , Lesch OM . Accessibility and affordability of alcohol dependency medical care in Serbia . Front Psychiatr 2015 ; 5 : 1 – 4 . Google Scholar CrossRef Search ADS 10 Burazeri G , Bregu A , Qirjako G , et al. National Health Report: Health status of Albanian population. Tirana, Albania, 2014 . 11 World Health Organization . Public health successes and missed opportunities Public health successes and missed opportunities. Copenhagen, 2014 . 12 World Health Organization . Global status report on alcohol and health. Geneva, 2011 . 13 Huynen MMTE , Martens P , Hilderink HBM . The health impacts of globalization: a conceptual framework . Global Health 2005 ; 1 : 14 . Google Scholar CrossRef Search ADS PubMed 14 European Commission . European Neighbourhood Policy and Enlargement Negotiations—Strategy and Reports—European Commission [Internet]. [cited 2016 Feb 29]. Available at: http://ec.europa.eu/enlargement/countries/package/index_en.htm (29 February 2016, date last accessed). 15 Eu ropean Commission . Commission Staff Working paper; Serbia 2011 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2011-2012 [Internet]. 2011 . Available at: http://www.ncbi.nlm.nih.gov/pubmed/19097363 (29 February 2016, date last accessed). 16 European Commission . Commission Staff Working paper; Albania 2010 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2010-2011. Brussels, 2010 . 17 European Commission . Commission Staff Working paper; Montenegro 2010 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2010-2011. 2010 . 18 European Commission . 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Commission Staff Working paper; The former Yugoslav republic of Macedonia 2009 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2009-2010. 2009 . 22 European Commission . Commission Staff Working paper; The former Yugoslav republic of Macedonia 2012 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2012-2013. 2012 . 23 Kuvendi i Republikës së Shqipërisë. Ligj nr.9518, datë 18.04.2006 Për mbrojtjen e të miturve nga përdorimi i alkoolit. Fletorja Zyrtare Albania; 2006 . 24 European Commission . Commission Staff Working paper; Croatia 2009 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2009-2010. Brussels, 2009 . 25 European Commission . Commission Staff Working paper; Albania 2012 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2012-2013. Brussels, 2012 . 26 European Commission . Commission Staff Working paper; Montenegro 2015 progress report; accompaying the Communication for the Commission to the European Parliament and the Council; Enlargement Strategy and Main Challenges 2015-2016 [Internet]. Brussels, 2015 . Available at: http://www.ncbi.nlm.nih.gov/pubmed/19097363 (29 February 2016, date last accessed). 27 Craig P , Cooper C , Gunnell D , et al. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance . J Epidemiol Commun Health [Internet] 2012 ; 66 : 1182 – 86 . Available at: http://jech.bmj.com/content/early/2012/05/10/jech-2011-200375.short (29 February 2016, date last accessed). Google Scholar CrossRef Search ADS 28 European Neighbourhood Policy and Enlargement Negotiations—Kosovo—European Commission [Internet]. [cited 2016 May 11]. Available at: http://ec.europa.eu/enlargement/countries/detailed-country-information/kosovo/index_en.htm (29 February 2016, date last accessed). 29 Naing NN . Easy way to learn standardization: direct and indirect methods . Malays J Med Sci [Internet] 2000 ; 7 : 10 – 5 . Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=3406211&tool=pmcentrez&rendertype=abstract (29 February 2016, date last accessed). 30 World Development Indicators| World DataBank [Internet]. [cited 2016 Jun 1]. Available at: http://databank.worldbank.org/data/reports.aspx? source=2&country=ARM&series=&period=# (29 February 2016, date last accessed). 31 European Health for All database (HFA-DB) . World Health Organization; 2016 Jun 1 [cited 2016 Jun 1]; Available at: http://www.euro.who.int/en/data-and-evidence/databases/european-health-for-all-database-hfa-db (29 February 2016, date last accessed). 32 Harper S , Strumpf EC , Kaufman JS . Do medical Marijuana laws increase Marijuana use? Replication study and extension . Ann Epidemiol [Internet]. Elsevier Inc 2012 ; 22 : 207 – 12 . Available at: http://dx.doi.org/10.1016/j.annepidem.2011.12.002 (29 February 2016, date last accessed). Google Scholar CrossRef Search ADS 33 Angrist JD , Pischke J-S . Mostly Harmless Econometrics: An Empiricist‘s Companion . New Jersey: Princeton University Press , 2009 , 392 p. 34 Greer SL , Kurzer P , editors. European Union Public Health Policy: Regional and Global Trends . London : Routledge , 2013 , 246 p. 35 Chaloupka FJ , Grossman M , Saffer H . The effects of price on alcohol consumption and alcohol-related problems . Alcohol Res Heal 2002 ; 26 : 22 – 34 . 36 Österberg E . Availability of alcohol. In: Anderson P , Møller L , Galea G , editors. Alcohol in the European Union; Consumption, Harm and Policy Approaches . Copenhagen : WHO Regional Office for Europe , 2012 . 37 EUR-Lex—31992L0084—EN. Off J L 316, 31/10/1992 P 0029 - 0031; Finnish Spec Ed Chapter 9 Vol. 2, P 0108; Swedish Spec Ed Chapter 9 Vol. 2, P 0108; OPOCE. 38 Obradović-Wochnik J , Wochnik A . Europeanising the “Kosovo Question”: Serbia‘s Policies in the Context of EU Integration . West Eur Polit 2012 ; 35 : 1158 – 81 . Google Scholar CrossRef Search ADS 39 Albania needs to improve rule of law [Internet]. Council of Europe; Commissioner for Human Rights. 2013. Available at: http://www.coe.int/en/web/commissioner/-/albania-needs-to-improve-rule-of-law (29 February 2016, date last accessed). © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Europeanization process impacts the patterns of alcohol consumption in the Western Balkans

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
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1464-360X
D.O.I.
10.1093/eurpub/ckx175
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Abstract

Abstract Background Western Balkan countries exhibit high levels of alcohol consumption, which constitutes a serious public health concern. We aimed to quantitatively assess the influence of the Europeanization process on levels of alcohol consumption in Western Balkans, an issue that has been under-researched. Methods The process of Europeanization was defined as the penetration of European dimension, procedures, policy paradigms, beliefs and norms in national arenas of politics and policy development. Data about alcohol consumption in six Western Balkan countries from 1991 to 2011 were gathered from the World Bank and World Health Organization databases. Azerbaijan and Georgia were considered control countries. A difference-in-differences approach was used to assess the impact of Europeanization process on levels of alcohol consumption. Results The Europeanization process impacts alcohol consumption in Western Balkan countries through the European Union directives and tax policies. After starting the Europeanization process, the spirits consumption in Croatia and The Former Yugoslav Republic of Macedonia decreased by 1.06 litter per capita (95% CI: from −1.63 to − 0.49) and 1.02 litter per capita in Serbia (95% CI: from −1.9 to − 0.1). Conclusion Our analysis provides useful evidence about the possible influence of Europeanization process especially on spirits consumption levels in Western Balkans. These findings draw attention to the need to implement new policies in order to prevent alcohol health-related harm due to the possible increase of wine and beer consumption. Introduction The European Union (EU) is expected to influence new member states and accession countries in economic, in political affairs and also in Public Health policies.1 The accession process can influence the level of alcohol consumption in candidate countries through three key aspects of alcohol policy: physical and economical availability, advertising and labelling.2 The penetration of European dimension, procedures, policy paradigms, styles, ‘ways of doing things’, shared beliefs and norms in national arenas of politics and policy is defined as Europeanization process.3,4 Europeanization has an impact on country domestic change by (a) ‘institutional compliance’—where European policy making prescribes specific institutional requirements which have to be implemented, (b) ‘changing the domestic opportunity structures’—where the EU changes the ‘domestic rules of the game’, and by (c) ‘a change in the beliefs and preferences of domestic actors’—a ‘framing integration’, affecting perceptions.5,6 Alcohol consumption is one of the major public health problems in the European region along with tobacco smoking, overweight and obesity. The high level of alcohol consumption in European Region is associated with the highest level of related harm in the world.7 Among new member states and accession countries, Western Balkans (WB) population has high levels of alcohol consumption.8 Alcohol related diseases caused 430 deaths in Serbia in 2012.9 There is evidence showing a decrease of pure alcohol consumption in Albania in the population above 15 years old from 2007 to 2010 (5.2 l in 2007, 5.4 in 2008, 5.6 in 2009 and 5 in 2010).10 Croatia and Serbia have had levels of alcohol consumption above the World Health Organization (WHO) European Region average for almost a decade, whereas Bosnia and Herzegovina, the Former Yugoslav Republic of Macedonia (FYROM) and Albania are clearly below the WHO European Region average. This difference may be explained by the fact that in the latter countries, there is a marked proportion of people who follow the Muslim faith.11 Studies compare data on the health status of WB countries, but there is a lack of information on the influence of the Europeanization process on public health policies, especially those potentially influencing alcohol consumption. According to WHO an association exists between the income level of a country and the overall levels of alcohol consumption.12 A study has shown that EU countries experiencing an increase of more than 3% in unemployment rate have experienced as much as a 28% increase in deaths from alcohol use disorders.1 Considering socio-economic factors at the ecological level when investigating determinants at national level, alcohol use is an important factor. As the EU accession process (i.e. Europeanization) can influence alcohol related policies, it is important to assess to which extent this policy process influenced quantitatively WB countries national level alcohol use. In addition, there is no documented evidence on the policy content that would inform about mechanisms through which alcohol consumption in the WB can be influenced by the Europeanization process. Such qualitative information is essential to provide explanations to findings that may arise from a quantitative policy evaluation. Therefore this study, using a quantitative policy evaluation, proposes to: firstly, document how the Europeanization process influences national policies designed to alter alcohol consumption in WB using different policy reports and secondly, to explore the impact of Europeanization process, concerning the trends of alcohol consumption among the Western Balkan countries from 1990 to 2011 taking advantage of a natural experiment in this region. Methods The study is based on a quantitative policy evaluation which is informed by a conceptual framework. First, we built a conceptual framework to explore how the Europeanization process influences national policies regarding alcohol in WB countries. Therefore, data from the EU country progress reports of Albania, Montenegro, Serbia, Bosnia and Herzegovina (BiH), FYROM and Croatia from 2005 to 2015 were used to understand in which ways/the EU influences national policies addressing alcohol consumption. We then collected quantitative data from World Bank and World Health Organization databases aiming to estimate the impact of the Europeanization process on alcohol related outcomes across six WB Countries from 1991 to 2011. Table 1 describes shows the source of data per each variable and the unit of measure. Table 1 List of variables Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Note: This table shows the variables according to the source of data and the unit of measurement. Table 1 List of variables Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Source of data Variable name Unit of measurement Health of all database Pure alcohol Liters per capita in the population older than 15 years Beer Liters per capita in the population older than 15 years Wine Liters per capita in the population older than 15 years Spirits Liters per capita in the population older than 15 years World Banks Indicators Income Gross national income per capita in international dollars Total unemployment % of the labor force that is without work but available for and seeking employment. Standardized death rate Alcohol related causes of death standardized with direct method per 100.000 habitants Note: This table shows the variables according to the source of data and the unit of measurement. The conceptual framework The conceptual framework ’The Multi-nature and multi-level framework for population health’ by Huynen et al was used to inform the modelling of the influence of Europeanization process on alcohol consumption in WB countries.13 The framework discerns a contextual, distal and proximal level to impact population health. The contextual level addressed the EU policies regarding the European Market and taxation of alcohol. The distal level covered the policies built up in each country as national strategies and laws. The proximal level addressed local policies as regard to health services for alcohol disorders and physical environmental.13 The EU progress reports, (a joint effort of the EU and the respective country government) used for the conceptual framework are published annually to document the developments of accession countries towards meeting the requirements of the acquis communitaire. Chapter 28 on ‘Consumer and health protection’ was key to this analysis and any other chapters that contained the word ‘alcohol’, ‘alcohol consumption’, ‘alcohol beverages’ was considered in addition.14 In total, 63 reports were analysed and the findings were grouped based on the level of intervention: contextual, distal or proximal. Depicting the conceptual framework At the contextual level, the Europeanization process influences national alcohol policy through the EU directives that ask the accession countries to specify structures of duties, minimum rates and taxation.15–17 As well, reduced excise rates or reduced VAT rates to 0 or special VAT schemes for small producers of wine, intermediate products and alcohol are recommended as part of the code of conduct for business taxation.18,19 These directives leaded to changes in excise legislations in Albania, Serbia and Montenegro. At the distal level, the governments of the WB countries are building up national strategies on alcohol. FYROM (2009) and Albania (2011) approved a National strategy on preventing and minimizing the damage from alcohol.20,21 The environmental determinants show regulations that forbid the sale of alcoholic drinks to minors. FYROM in 2012 and Albania introduced a minimum age of 18 years for purchasing alcohol.22,23 Croatia has also drawn up action plans on alcohol.24 Albania, Montenegro and FYROM governments have set up new structures that monitor the implementation of legislation on alcohol.21,25,26 At the proximal level, the WB citizens have access to new services for the treatment of alcohol disorders including: public health programs at national level and health education about alcohol consumption organized at schools. The difference-in-differences analysis We focused on alcohol consumption in WB from 1991 to 2011.27 The start of Europeanization process was defined as the year in which each WB country signed the Association and Stabilization Agreement with the EU: Albania—2006; BiH—2008; Croatia—2001; FYROM—2001; Montenegro—2007; Serbia—2008. These years were considered as a point in time separating per each country the periods before and after start of the Europeanization process. Kosovo as a Potential Candidate Country was excluded from the analysis due to the late initiation of the Europeanization process in July 2014.28 The other European Countries that did not sign the agreement until 2011 were considered as control countries. In order to improve the baseline balance (before the treatment) between treated and control countries, the treated countries (WB that started the Europeanization process) were matched with control countries based on the similar Mean of Standardized Death Rate due to alcohol related disease (before the treatment, table 2). This matching process was also used to fulfil the parallelism assumption in our Difference in Difference approach (see below). This allowed for comparisons among countries.29 Croatia and FYROM were matched with Georgia and Azerbaijan; Albania, Montenegro and Serbia with Georgia. Table 2 Descriptive information on intervention and control countries Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Note: CC, Candidate Country; EU MS, European Union Member state; EPC, Eastern Partnership country; SD, standard deviation. Table 2 Descriptive information on intervention and control countries Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Pure alcohol Spirits Wine Beer Unemployment (%) Income SDR Intervention cuntries Albania (CC) Mean 3.61 1.6 0.82 1.19 14.72 5120 57.82 SD 1.48 0.85 0.23 0.6 2.52 2626 15.13 Croatia (Eu MS) Mean 11.8 1.9 5.46 4.41 11.94 13945 108.8 SD 1.08 0.64 0.87 0.55 2.85 4106 28.3 Montene-gro (CC) Mean 5.97 2.67 2.73 0.53 18.64 12794 46.3 SD 0.72 0.07 0.49 0.3 1.17 1283 6.62 FYROM (CC) Mean 5.09 1.78 1.3 2 33.47 6952 50.1 SD 1.23 1.06 0.34 0.23 2.48 2182 3.88 Serbia (CC) Mean 8.63 2.46 1.97 4.19 16.54 8855 66.19 SD 1.28 0.09 0.46 0.88 3.11 2221 3.52 Control Countries Georgia (EPC) Mean 1.38 0.82 0.33 0.2 7.21 6373 100.5 SD 0.92 0.84 0.66 0.12 1.94 4492 28.61 Azerba-jian(EPC) Mean 3.95 1 2.5 0.44 13.36 3524 61.71 SD 1.48 0.57 1.26 0.38 1.65 1639 13.79 Note: CC, Candidate Country; EU MS, European Union Member state; EPC, Eastern Partnership country; SD, standard deviation. Data were retrieved from the World Bank and WHO databases.30,31 Pure alcohol, wine, spirits and beer were considered as outcomes of interest measured in litters per capita including the population >15 years.18 Other covariates included selected World Bank indicators such as the income level (GNI per capita) and overall unemployment (share of the jobless labour force seeking employment) (table 1).17 Data analysis Descriptive analysis was performed for WB and control countries (table 2). The distribution in years showed an unexplained decrease of pure alcohol and spirits consumption in BiH from 8.57 in 1999–3.96 in 2000. Therefore, it was decided not to include BiH in further analysis. Firstly, simple random effect models (without considering control groups) assessing the impact of Europeanization process on different alcohol related outcomes. The effect of Europeanization on alcohol consumption outcomes (i.e. pure alcohol, wine, beer and spirits) was estimated through an indicator for whether or not the country started the Europeanization process according to the operational definition. Then, a difference-in-differences (DID) approach with matching was used. The first regression model did not allow comparing the changes of the outcome of interest among countries that were treated and control countries nor considering time invariant unmeasured confounders.32 Therefore, DID approach (a quasi-experimental method that relies on the panel structure of the data usually two periods: baseline and follow up after the ‘intervention’, commonly used to evaluate public policies) was performed to estimate the effect of Europeanization on alcohol consumption during the pre- and post-Europeanization periods of time among WB and control countries. The previous regression model did not include confounding factors, therefore income and total unemployment are included in the following equation:1,12, Yct=α+β1Treatct+β2Postc+β3(Treat*Post)ct+β4Incomect*TotUnempct+ε, where Income and Total Unemployment were considered as continues variables. This equation was used to fit a DID regression model grouping the countries based on the year they started the Europeanization process and estimating the impact of the Europeanization process on alcohol consumption expressed in litters per capita. Countries were matched based on their trends in Standardized Death Rate due to alcohol related disease in order to make sure that the trends in the control group represent a good approximation for the counterfactual trend of the treated group in the absence of the treatment.33 STATA version 13 was used for the statistical analysis. Results The conceptual framework shows the general trends in all countries on how the Europeanization process influences policies regarding alcohol in WB. The EU suggests the WB countries as accession ones, to orient their legislations towards EU directives on excise, VAT taxation, and minimum duties. The governments of the WB countries are making changes in their regulations regarding alcohol and alcohol related harm protection. Our study finds an increase of alcohol related policies in WB that limit the physical access on alcoholic drinks, introduce a minimum age of 18 in all WB countries and ban alcohol sale during night hours.22,23 Studies mention taxation as a main tool for controlling alcohol economic availability.2 Increase of taxation influences the price and as consequence less alcohol is consumed.34,35 The WB countries have increased their excise tax on alcoholic beverages which is reflected in the increased alcohol prices. Impact of the Europeanization process on alcohol consumption Croatia is the richest country in WB (13 945 ± 4106) dollars per capita per year and reports the lowest unemployment rate during the study time (11.94% ± 2.85%). Furthermore, Croatia has the highest level of consumption of pure alcohol, wine and beer per capita in the region. Quantities are expressed in litres per capita respectively (11.8 ± 1.08), (5.46 ± 0.87) and (4.41 ± 0.55), among over 15 years old. Montenegro leads in the consumption of spirits (2.67 ± 0.07 l per capita). The lowest levels of pure alcohol consumption, spirits and wine consumption are reported in Albania respectively (3.61 ± 1.48), (1.6 ± 0.85) and (0.82 ± 0.23). Montenegro has the lowest beer consumption in the region (0.53 ± 0.3). The high level of alcohol consumption in Croatia is reflected in the highest standardized death rate due to alcohol related disease (SDR;108.8 ± 28.3). Montenegro reports the lowest levels of SDR (46.3 ± 6.62). The control countries Georgia and Azerbaijan show that pure alcohol is the favourite drink in these countries. Georgia shows the highest levels pure alcohol consumption per capita (3.95 ± 1.58) and SDR (61.71 ± 13.79). Azerbaijan has lower levels of consumption (1.38 ± 0.92) and SDR (100.5 ± 28.61) per capita. The results of the multilevel linear models are presented in table 3. Evidence shows that WB, after starting the Europeanization process, consume significantly less spirits and more beer, respectively, 0.83 l per capita less (95% CI: 1.59–0.077) and 0.6 l more (95% CI: 0.33–0.87) (table 3). Table 3 Random effect ANOVA; the effect of Europeanization on alcohol consumption (differences between before and after start of Europeanization process) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Note: CI, confidence interval. Table 3 Random effect ANOVA; the effect of Europeanization on alcohol consumption (differences between before and after start of Europeanization process) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Western Balkans Europeanization β 95% CI Pure alcohol −0.39 (−1.17 to 0.37) Spirits −0.83 (−1.59 to − 0.077) Wine 0.04 (−0.006 to 0.09) Beer 0.6 (0.33 to 0.87) Note: CI, confidence interval. The crude (unadjusted) DID analysis showed a decrease of 1 litter in the consumption of spirits for Croatia and FYROM that started the Europeanization process in 2001 (95% CI: from −1.65 to −0.35) comparing with Georgia and Azerbaijan as control countries (table 4). The income- and unemployment-adjusted DID models strengthened the findings, estimating a decrease of spirits consumption in Croatia and FYROM of 1.06 (95% CI: from −1.63 to −0.35) litters per capita. In Serbia too, there was evidence of a decrease in spirits consumption of 1.02 litters per capita (95% CI: from −1.9 to −0.1), in contrast to Georgia which was considered as a control country (table 4). Table 4 Difference-in-differences models; the effect of Europeanization on alcohol consumption Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Note: HRV, Croatia; MKD, Macedonia; GEO, Georgia; AZR, Azerbaijan; ALB, Albania; MONT, Montenegro; SRB, Serbia; DID, difference-in-difference; CI, Confidence interval. Table 4 Difference-in-differences models; the effect of Europeanization on alcohol consumption Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Europeanization 2001 2006 2007 2008 Treated: HRV, MKD Treated: ALB Treated: Mont Treated: SRB Controls: GEO; AZR Controls: GEO Controls: GEO Control: GEO DID estimate; DID estimate; DID estimate; DID estimate; 95% CI 95% CI 95% CI 95% CI Unadjusted DID Pure alcohol −0.66 0.52 −1 −0.3 (−3.17; 1.83) (−1.21; 2.26) (−4.29; 2.21) (2.81; 2.29 Spirits −1 0.4 −0.56 −0.7 (−1.65; −0.35) (−0.46; 1.27) (−1.77; 0.64) (−1.59; 0.022) Wine 0.39 −0.06 −0.43 0.14 (−1.2; 2) (−1.37; 1.23) (−3.57; 2.07) (−1.9; 2.1) Beer 0.07 0.17 −0.06 0.32 (−0.89; 0.74) (−0.34; 0.68) (−0.68; 0.56) (−0.67; 1.32) Adjusted DID (income and unemployment) Pure alcohol −0.37 0.13 −0.62 0.78 (−0.4; 1.65) (−1.82; 2.1) (−4.16; 2.9) (−1.79; 3.37) Spirits −1.06 −0.3 −0.6 −1.02 (−1.63; −0.49) (−1.12; 0.51) (−1.94; 0.74) (−1.9; −0.1) Wine 0.8 0.55 −0.118 1.35 (−0.62; 2.24) (−0.95; 2.6) (−3.24; 3) (−0.8; 3.51) Beer −0.14 −0.12 −0.068 0.43 (−0.62; 0.43) (−0.55; 0.3) (−0.45; 0.58) (−0.31; 1.19) Note: HRV, Croatia; MKD, Macedonia; GEO, Georgia; AZR, Azerbaijan; ALB, Albania; MONT, Montenegro; SRB, Serbia; DID, difference-in-difference; CI, Confidence interval. Discussion The main findings of this study include a possible impact of the Europeanization process on levels of alcohol consumption in the WB region. The WB governments are making changes to their regulations regarding alcohol as excise, VAT taxation and physical availability due to the pressure to fulfil the EU criteria. Even in case of Croatia which has the highest pure alcohol, wine and beer per capita consumption level in the region, there is evidence of a decrease of spirits consumption. Similarly, FYROM and Serbia lowered the level of alcohol consumption by 1 l per capita since starting the Europeanization process. Our study results are consistent with similar descriptions from the literature. Greer et al. explain how the EU as an economic union influences the taxation and agricultural development of its member states resulting in a positive trade balance in the export of wine and spirits.34 Our study characterizes the way in which the EU policy influences taxation. It enables the WB governments to reduce the taxes for local producers of wine and alcoholic drinks. AsÖsterberg mentions, regulations on physical availability include special limits on opening times for retail alcohol sales.36 Our study finds the same limitations in WB. FYROM banned alcohol sale during night and all WB countries do not allow sell of alcohol to minors. It seems that the decrease of spirits consumption in WB countries might be explained through the difference in tax rates between spirits and other alcohol beverages decided by the Council Directive 92/84/EEC of 19 October 1992. It defined a minimum excise tax for spirits in the EU €550 per hectolitre of pure alcohol, €45 for intermediate products, €0.748 for beer and zero for wine.37 Governments of WB are interested to join EU and therefore, they have to follow the instructions of the EU. The policies of the EU regarding Alcohol consumption are part of Europeanization process. Governments of WB started to change their legislation including laws on alcohol consumption in order to satisfy the directives of the EU. Croatia and FYROM started the Europeanization process earlier in 2001 and had the necessary time until 2011 to measure the impact of the Europeanization process in spirits consumption. Serbia worked towards meeting the conditions, but the latter start of the Europeanization process (2008) came because of the necessity to resolve the Serbia–Kosovo deadlock since the 1999 conflict.38 Albania faces problems in implementing the rule of Law39 and Montenegro declared the independence in 2006 so it had not enough time to perform the same changes in legislation. Our study adds to the existing literature that the Europeanization process fosters the decrease of spirits consumption in WB and a possible increase of wine and beer consumption. However, the quantitative analysis was based on aggregate measures and, as such, no cross-level inferences (from ecological to individual level) can be assumed. Ecological analysis helps to build new hypothesis, but is not suitable for inferring causality. In addition, few data were available for the countries of interest. Yet, we proposed a quasi-experimental approach that considers the structure of the data to provide new evidence on this topic. In the future, it would be interesting to use panel data to evaluate the same hypotheses and check if the findings are robust. Alcohol consumption is considerably underestimated in most of WB countries, including FYROM and Montenegro because they do not account for unrecorded production and consumption. In our study we did not consider either unrecorded alcohol consumption or smuggling of alcohol beverages which should be addressed in future studies. Our study tries to explain the reason why time gaps exist between WB countries in starting the Europeanization process and how it can influence alcohol consumption. Further studies on this topic should as well consider the implication of differences in the accession process among WB and alcohol consumption trends. This study can inform the governments of the WB countries about current and possible future influence of the Europeanization process in alcohol consumption and can be used as a starting point of reflexion for new policies regarding protection of health alcohol related harm due to the possible increase of wine and beer consumption. In conclusion, the Europeanization influences the overall policies in the WB countries with an implication of health and alcohol related issues through the EU general politics, directives and legislations. WB countries have undertaken positive changes in alcohol-related legislations as increase of excise and VAT taxation, physical availability of alcohol through introducing a minimum age of 18 for alcohol consumption. However, it is necessary to strengthen the rule of law so that the current legislation is enforced and further positive impact can be measured on population health. We recommend other studies that would measure how the Europeanization process influences the alcohol consumption among adolescents and minors considering them as the future population of Europe. Acknowledgments We acknowledge Joy Seanehia and Nora Martenyi for their contribution in proof-reading. Conflicts of interest: None declared. Key points This is the first study conducted in the WB that attempts to explain how the Europeanization process influences the patterns of alcohol consumption. WB countries have changed alcohol-related legislations to increase excise and VAT taxation and limit the physical availability. Our study adds to the existing literature in that it points out that the Europeanization process fosters the decrease of spirits consumption in WB and a possible increase of wine and beer consumption. New policies in WB countries should address alcohol related harm due to the possible increase of wine and beer consumption. References 1 Anderson P . Alcohol. In: Mackenbach JP , McKee M , editors. Successes and Failures of Health Policy in Europe . Berkshire, England : Open University Press , 2013 . 2 Greer S , Fahy N , Elliot H , et al. Everything you always wanted to know about European Union health policies but were afraid to ask . London : European Observatory on Health Systems and Policies , 2014 . 3 Burzel TA . Towards convergence in Europe? Institutional adaptation to Europeanization in Germany and Spain . J Common Mark Stud 1999 ; 37 : 573 – 96 . 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Published: Oct 20, 2017

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