Exposure to legitimate and illegal online medicine vendors via search engines in 30 European countries

Online medicine sales have not only improved access but also expose consumers to illegal online medicine vendors (IOMVs) selling substandard/falsified products. This study provides the first pan-European assessment of exposure to legitimate online pharmacies (LOPs) and IOMVs in search engine results (SERs). We scraped the top-50 Google results in 30 European countries for six tracer active pharmaceutical ingredients across three categories: controlled substances, prescription-only medicines (POMs), and over-the-counter products (OTCs). Links were categorised as LOPs or IOMVs based on official registries. From 9000 SERs, 3839 linked to medicine-selling websites (63.7% LOPs, 36.3% IOMVs). LOPs outnumbered and outranked IOMVs, though IOMV:LOP ratios reached 2.37 (Norway) and 2.18 (Cyprus). Search engine redirection affected 56.6% of IOMV links. IOMV prevalence increased with regulatory control: 1.4% (paracetamol), 5.5% (ibuprofen), 10.2% (omeprazole), 55.1% (amoxicillin), 76.2% (alprazolam) and 77.5% (clonazepam). IOMV links were less likely to be highest-ranked and less common in the top-10 SERs in countries permitting online OTC and POM sales, than in those prohibiting them. Despite LOP dominance, Europeans face substantial exposure to IOMV links, higher for controlled substances and in countries prohibiting online sales. Harmonised regulatory action, supported by search engine providers, is needed for safer online medication access.