Implementing sustainable liver health in Europe: a second EASL–Lancet Commission

In December 2021, the European Association for the Study of the Liver (EASL)-Lancet Commission on liver disease in Europe launched its first report, which highlighted an alarming increase in liver-related mortality in many European countries. The Commission proposed a roadmap for addressing the documented negative trends. However, quoting one of the accompanying Comment articles, "gaining consensus on what needs to be done is perhaps the easiest step. Implementing change will be much harder, with many vested interests, both professional and commercial, to overcome." This Commission aimed to evaluate and advance the enactment of the previously proposed recommendations. We evaluated a range of evidence to update and refine the current burden and future projections of liver disease in Europe. This evidence included the 2023 update to the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), a dedicated modelling framework developed bythe Organisation for Economic Co-operation and Development (OECD), and data from both public (eg, UN and WHO) and modelling-based research databases (eg, Polaris Observatory). Cirrhosis and liver cancer cause almost 780 deaths per day in the WHO European Region, accounting for 3% of all deaths. Between 2000 and 2023, rates of liver cancer mortality have increased by more than 50%, and mortality from cirrhosis has remained persistently high. Liver disease burden has a pronounced negative effect on population-level health and life expectancy, and in the absence of liver diseases, the combined economies of the EU27 countries and Norway, Iceland, the UK, and Switzerland (otherwise known as the EU27+4) would be larger by an estimated & euro;55 billion per year, highlighting the unsustainable economic and societal cost of inaction. Liver disease encapsulates many of the challenges and opportunities that apply to a range of other chronic conditions, which share common risk factors and potential preventative solutions. Eliminating risk factors related to health behaviour (ie, lifestyle) alone would almost halve the burden of liver diseases in the EU27+4 and increase life expectancy. When accounting for the benefits of reducing alcohol consumption and excess weight on other major non-communicable diseases (such as cardiovascular diseases and type 2 diabetes), and cancers, average life expectancy would increase by 10 & centerdot;8 months (range 2 & centerdot;7 to 25 & centerdot;6 months across countries). Using GBD estimates for 2023, we show that threequarters of the alcohol-attributable disability-adjusted life years lost in the WHO European region relate to non-liver-related causes such as other non-communicable diseases (47%), cancers (13%), and injuries (12%), reinforcing that addressing liver-related risk factors also results in broader health and longevity benefits to individuals and society. By examining the varied landscape of health-related policies and health systems across Europe, we show the complexity of the challenge and the need for common actions to support the implementation of an updated set of evidence-based recommendations. A fundamental shift is needed, moving away from traditional, fragmented hepatology services towards integrated care models that embed both liver disease prevention and management within broader health-care delivery that focuses on common risk factors.Notable progress includes integrated care pathways in countries such as the UK and Denmark, involving primary care, endocrinology, psychiatry, and cardiology, supported by precision diagnostics, non-invasive fibrosis assessments, and artificial intelligence-driven risk stratification. However, clinical innovation alone is insufficient without robust implementation of public health policies. Policy makers across Europe must act decisively to address liver disease through the implementation of comprehensive and consistent policies, as proposed throughout this report. These initiatives align closely with the WHO Europe best buy policies on non-communicable diseases, including taxation and stricter restrictions on advertising and availability of alcohol and unhealthy foods, and with efforts to enhance transparency of medicine prices throughout Europe. The EU and WHO Europe should lead by developing standardised liver health indicators, monitoring outcomes transparently, and guiding states to implement and adjust policies based on the evidence presented in this report. Building upon experience gained from tobacco control, the EU and national governments must urgently address commercial and other structural determinants of health, including digital marketing targeted at children and adolescents. Exposure to social media algorithms often promotes unhealthy behaviours, which pose severe long-term risks. Comprehensive bans on digital marketing to children, coupled with initiatives to foster health literacy from early childhood, will help protect exposed populations from adopting harmful health behaviour patterns. To achieve measurable progress, clear benchmarks with accountability frameworks should be established at the European level. Such initiatives must explicitly integrate liver disease into broader public health agendas, such as Europe's Beating Cancer Plan and non-communicable disease strategies. Our modelling highlights that WHO viral hepatitis elimination targets will not be achieved in Europe unless testing is expanded to all migrants. Migration to Europe is complex in terms of the pathways and dynamics, with a large influx of refugees, asylum seekers, and undocumented migrants in recent years due to political conflicts. The WHO European region hosts an estimated 101 million migrants (people living in a different country from where they were born, including refugees and asylum seekers), representing the largest regional share (approximately 36%) of the global international migrant population. Using hepatitis B virus and hepatitis delta virus infection as examples, we show the considerable effect of migration on health and how this varies throughout selected European countries. European governments must integrate liver health into migrant health policies, ensuring universal access to hepatitis screening, vaccination, and continuity of care. Europe stands at a critical juncture. The prevalence and burden of liver diseases and their close links with broader health and social issues in Europe present both a stark challenge and a historic opportunity. European policy makers, health-care systems, communities with lived experience, patient groups, and other individuals must collaborate urgently and decisively. Substantially reducing liver disease burden and mortality across the continent is possible by leveraging Europe's potential for coordinated action, strong governance, and evidence-based policy interventions.This effort requires immediate, sustained commitment, reflecting democratic values of solidarity, equity, and the right to health for all. It also requires a compelling narrative that faces down spurious accusations of paternalism, and articulates the benefits to all from such interventions. This effort would, as shown throughout the report, have profound and broad health and societal benefits far beyond hepatology.