Alcohol is a major preventable cause of injury worldwide and contributes substantially to mortality in the WHO European Region, which has the highest alcohol consumption levels globally. In 2019 alcohol caused almost 145 000 injury deaths, or 31.1% of all injury deaths in the Region. The greatest contributors were self-harm (about 43 650 deaths), road injuries (about 24 000 deaths) and falls (about 19 600 deaths). Heavy episodic drinking, which is widespread in the Region, sharply increases the risk of unintentional injuries such as traffic injuries, falls and drownings, as well as intentional injuries such self-harm and interpersonal violence. Men account for most alcohol attributable injury deaths because they drink more frequently, consume larger quantities and are more likely to have alcohol use disorders. Harms to others, particularly to women and children, include intimate partner violence, neglect, and other forms of physical and emotional harm. Young people face elevated risks because of the way alcohol contributes to risky behaviours and injury burden. Country-specific injury data are presented in a separate web annex. Despite progress in reducing alcohol consumption since 2000, large east–west inequalities persist, reflecting differences in drinking patterns. Evidence-based measures such as raising excise taxes, reducing the availability of retailed alcohol, limiting marketing, strengthening drink–driving measures, and expanding screening and brief interventions can significantly reduce alcohol-attributable harm and prevent avoidable deaths.