Differentiated regulation and health spending growth: European evidence from the new SCORE index

Introduction: Rising healthcare expenditure poses a major fiscal challenge for European governments, driven in part by preventable diseases associated with tobacco use, alcohol consumption, and sugar-sweetened beverages (SSBs). Although regulatory interventions are widely used to address these risk factors, most evaluations focus on overall policy stringency and implicitly assume homogeneity within product categories. This overlooks the potential importance of risk-proportional regulatory designs that differentiate products according to their relative health risks. Methods: This study investigates whether differences in the design of regulatory frameworks for tobacco, alcohol, and SSBs are associated with variations in healthcare spending growth across European countries. Specifically, it compares conventional measures of regulatory restrictiveness with a riskproportional approach that calibrates regulatory burdens according to the relative risks of products within each category. The relationship between regulatory design, healthcare expenditure growth, and population health outcomes is examined using cross-country statistical analysis. Results: The analysis indicates that risk-proportional regulatory frameworks are more strongly associated with lower healthcare spending growth and improved population health outcomes than uniform measures of policy stringency. Regulatory systems that incentivize substitution toward lower-risk alternatives are associated with a more favourable overall risk profile of consumption. Discussion: These findings suggest that the design of health regulations, rather than their overall restrictiveness alone, may play an important role in promoting fiscal sustainability. By encouraging harm reduction within product categories, risk-proportional regulation may contribute to reducing the long-term burden of preventable diseases and the associated pressure on national healthcare budgets.