Introduction:
Smoking prevalence is high in many Balkan countries. (i.e. Serbia=40.9%; Greece=39.6%; Bulgaria 39.5%, Bosnia and Herzegovina=38.7%; Croatia 36.5%, etc.). Tobacco taxation plays an important role in both decreasing tobacco consumption and increasing quitting rates, especially among youth. The World Health Organization (WHO) considers a total tax of 75% of the retail price to be best practice. This work aimed to examine trends in cigarette prices, affordability, and taxation from 2008 to 2018 in nine Balkan countries.

Methods:
Data from the latest (2019) available WHO report on the global tobacco epidemic for nine Balkan countries (Albania, Bosnia and Herzegovina-BiH, Bulgaria, Croatia, Greece, Montenegro, Romania, Serbia, and North Macedonia) were examined. Prices of a 20-pack of cigarettes of the most sold brand are in US dollars ($). Affordability was measured as percentage of GDP per capita required to purchase 100 packs. Total tax is presented as a percentage of the total retail price of a pack.

Results:
Cigarettes were most affordable in North Macedonia (2.55%) and Croatia (2.69%) and least affordable in BiH (5.85%). Except Romania, Bulgaria, and North Macedonia (no change), in all other countries, cigarettes were less affordable in 2018 compared to 2008. The price of one 20 cigarette-pack of the cheapest cigarette brand ranged from 1.43 US dollars in North Macedonia to 4.63 US dollars in Greece. Similar discrepancies were found in the most sold brand of cigarettes (1.50 dollars in North Macedonia and 5.40 dollars in Greece). From 2008 to 2018, total tax increased from below to above 75% in BiH, Croatia, Greece, Montenegro, North Macedonia, and Serbia, while remained above 75% in Bulgaria. Total tax increased in Albania (50% to 67%) but slightly decreased in Romania (72% to 69%).

Conclusions:
There is heterogeneity in taxation between the studied Balkan countries. While cigarette taxation rates reached WHO best practices in all but two countries, improvement of tobacco taxation in order to reduce affordability of cigarettes should be a priority for these countries where smoking prevalence remains high.