Estonia’s effective policies in tackling noncommunicable diseases: lessons learned

Estonia has made remarkable progress in reducing premature mortality from noncommunicable diseases (NCDs) such as cardiovascular diseases and cancer. It is one of 10 Member States of the WHO European Region that have reached the 2025 NCD Global Monitoring Framework target of reducing premature mortality from NCDs by 25%.

Despite being a small country with limited resources, Estonia has demonstrated a level of commitment to evidence-based policies, cross-sectoral collaboration and public health interventions that offers invaluable lessons for the WHO European Region and beyond. A recent report from the WHO Regional Office for Europe titled "Avoidable mortality, risk factors and policies for tackling noncommunicable diseases - leveraging data for impact" highlights Estonia's comprehensive approach to NCD prevention and management.

Comprehensive tobacco and alcohol policies

Estonia's success in tackling tobacco use and reducing alcohol consumption is rooted in its national strategy. Launched in 2014, this strategy prioritized public health interventions, combining legislative measures with targeted public awareness campaigns.

Estonia implemented strict regulations on tobacco, including:

• banning flavoured tobacco products
• prohibiting distance selling
• enforcing stringent age limits and marketing restrictions.

The approach not only reduced tobacco consumption but also highlighted the importance of aligning national policies with European regulations. However, Estonia faces emerging challenges with new nicotine products marketed aggressively to younger demographics. As Riina Sikkut, Estonia's former Minister of Health, pointed out, "European policies can be much more effective than national ones in combating these products."

Reducing alcohol consumption, a culturally sensitive issue in Estonia, required bold measures. Between 2014 and 2019, the Government implemented:

• significant excise tax increases
• advertising restrictions
• limits on the availability of alcohol.

These interventions resulted in a consistent drop in alcohol consumption and related health issues. However, political changes in 2019 led to excise tax reductions, which correlated with an uptick in alcohol use and its associated harms. In 2024, Estonia resumed excise tax increases, with additional hikes planned for the coming years. As Riina Sikkut emphasized, "Consensus can be built around protecting children's health, ensuring that the next generation benefits from these restrictions."

Addressing obesity and promoting nutrition

Despite progress in other areas, obesity remains a growing concern in Estonia. The country's efforts focus on promoting healthy diets and physical activity through initiatives such as:

• free school meals and fruit and vegetable programmes; and
• subsidized physical activity and hobby programmes for children, especially in underserved regions.

While these measures have shown some results, overall obesity rates continue to rise. Efforts to introduce a sugar-sweetened beverage tax failed twice due to political opposition. Instead, Estonia is pursuing reformulation agreements with food manufacturers to reduce the sugar, salt and fat content in for-sale products and enforcing a voluntary agreement to limit children's exposure to food marketing. Riina Sikkut acknowledged the challenges: "Self-regulation efforts by the industry have fallen short, with nearly 70% of advertising targeting children failing to meet agreed standards."

Strengthening primary health care

Estonia's low-threshold, no-out-of-pocket primary health care system has been instrumental in reducing treatable mortality from cardiovascular diseases. Clinical guidelines ensure that patients receive standardized, high-quality care. Additionally, proactive pharmaceutical benefits have made essential medications like statins more affordable, ensuring that cost is not a barrier to treatment.

Looking ahead, Estonia plans to integrate nutritional counselling into primary care, empowering patients to make healthier lifestyle choices. "By adding nutrition experts to primary care teams, we can tackle obesity and lifestyle-related issues more effectively," noted Riina Sikkut.

Lessons learned from Estonia's success

Estonia's achievements in NCD prevention and management underscore the importance of a comprehensive, evidence-based approach. Key takeaways are listed below.

1. Cross-sectoral collaboration: Estonia's strategies for reducing alcohol and tobacco use involved cooperation between health, education and social affairs ministries. This collaboration ensured that policies addressed the root causes of health risks.
2. Balancing national and European policies: Aligning national strategies with European regulations enhanced their effectiveness, particularly in tobacco control. Estonia's example demonstrates the value of regional cooperation in addressing cross-border challenges.
3. Adapting to political realities: Political will and societal attitudes significantly impact public health initiatives. Estonia navigated these challenges by building consensus around protecting children's health, which resonated with the public and policy-makers alike.
4. Proactive use of evidence: Estonia's commitment to evidence-informed policy-making enabled the country to implement interventions with proven effectiveness. This approach not only built public trust but also ensured measurable health outcomes.

The way forward

Estonia's journey highlights the power of persistence in public health. Despite setbacks, the country continues to innovate and adapt its strategies, demonstrating that even small nations can achieve significant progress against NCDs. Riina Sikkut's optimism is clear: "If you stay on the evidence-based track and seize political windows of opportunity, you can achieve better health outcomes for everyone."

Estonia's story serves as a model for other countries seeking to reduce the burden of NCDs. By prioritizing prevention, fostering cross-sectoral collaboration and aligning national policies with regional frameworks, countries can build healthier futures for their populations. Estonia's experience proves that effective policies, grounded in evidence and adapted to local contexts, are key to tackling the NCD epidemic.