Harmful alcohol consumption is an important public health problem. Globally alcohol consumption was responsible for 4.6% of total disability-adjusted life years (DALYs) in 2019 (1), with alcohol a risk factor for over 200 conditions including cardiovascular diseases, cancers, mental and neurological disorders as well as transport injuries (2). Beyond health consequences, the harmful use of alcohol is associated with significant social and economic losses to individuals and society (3, 4).

Although rates of age-standardized DALYs from alcohol use are lower in low- and middle- income (LMIC) settings than high income countries, these countries accounted for 76% of alcohol-attributable deaths in 2021 (5). With alcohol consumption reducing in many high-income countries, the global alcohol industry has increasingly turned its focus toward emerging markets where regulations to control alcohol use are less stringent (6). In these regions, alcohol companies employ campaigns and tactics like those used in wealthier countries, combining global themes with local cultural icons and celebrations to attract consumers (7). Additionally, some multinational alcohol companies form partnerships with global health organizations, presenting themselves as socially responsible, yet often without reducing alcohol availability or consumption (8). This poses a challenge to the global goal of reducing the harmful effects of alcohol as expressed by the WHO Global Alcohol Action Plan 2022–2030 (9). Reducing alcohol consumption is also highly relevant to achieving many of the health-related targets of the Sustainable Development Goals (1).

Effective alcohol policy measures exist that can significantly reduce alcohol consumption and mitigate alcohol-related harm. However, limited literature is available focusing specifically on LMIC countries. Only two recent studies have reviewed literature on effectiveness of interventions to reduce harmful alcohol use, specifically in LMIC countries. A systematic review by Staton et al. assessed the effectiveness of patient-level interventions, finding that brief interventions were the most commonly studied and consistently showed positive results (10). The second study, a Cochrane review, focused on psychosocial and pharmacological treatments for reducing harmful alcohol use in LMICs. Certainty of evidence on effectiveness was found to be low (11). These reviews suggest limited strong evidence is available on the effectiveness of alcohol harm reduction strategies in LMICs (12); even less is available on the cost-effectiveness of policies.

Given the limited budgets available for public health measures, cost-effectiveness becomes an important factor for policy makers to consider in decisions about allocating scarce resources to prevent excessive alcohol consumption. Evidence from high-income countries demonstrates that interventions such as implementing pricing and taxation policies, regulating alcohol sales hours and outlet density, and enforcing drink-driving laws can be successful in reducing alcohol-related harm (13, 14). While contextual factors are likely to impact on the transferability of findings on return on investment from high- to LMIC countries (15), an evidence-based list of policy options, together with applying a logical reasoning approach for each country, can be helpful in developing a portfolio of policy options that are evidence-based and likely to be cost-beneficial in these settings (12).

This study builds on existing literature about successful initiatives that have reduced alcohol-related harm, producing comparable cost-outcome estimates localized to the Western Australian context, a jurisdiction in a high-income country. These estimates can serve as a reference for LMIC countries, helping to identify interventions that offer good value for money when adapted to local contexts and cultural considerations. Furthermore, using benefit transfer methods, cost-outcome measures from this study can be adjusted and applied, with caution, to generate return on investment estimates in the context of other settings (16).

This section outlines the methodology adopted in producing cost-outcome measures of interventions to reduce alcohol-attributable harm. The first task was to produce a “What Works?” list of proven interventions. For these interventions, economic evaluations were conducted to assess cost-effectiveness.

The remainder of this section describes the methods used, including how interventions were selected, adjustments made to some findings to ensure consistency, and steps taken in generating return on investment ratios.

Measures used to assess the extent to which an intervention represents value for money were the benefit–cost ratio (BCR) and incremental cost-effectiveness ratio (ICER). A benefit–cost ratio greater than one indicates monetary benefits from implementing the intervention exceed monetary costs, with higher positive BCRs representing a better return (49). Interpreting the level at which the ICER represents value for money is less straightforward. One approach used to draw conclusions about an intervention’s cost-effectiveness is that of a threshold or reference value for the ICER, above which an intervention is not considered cost-effective and below which it would be considered cost-effective (50). While objections have been raised against the notion of an ICER threshold value, it is commonly used as a benchmark value against which to compare ICERs. While no official statement has been made about a threshold value for health services in Australia, an estimated willingness to pay threshold of A$50,000 (US$33,500) per QALY compared to the best alternative is commonly cited in Australian policy reviews (51).

Within each of the categories and types of alcohol harm prevention programs, several interventions were found to represent value for money (Tables 4, 5). The following interventions were found to be cost saving from a societal perspective:

This study estimates the cost–benefit and cost per QALY saved for 49 alcohol misuse prevention and harm reduction strategies. From an economic standpoint, promising interventions were identified across all categories; however, the expected return on investment should be interpreted in the light of the quality of underlying studies. For example, while all pricing policies were found to generate net savings, only the intervention ‘replacing price-based wine tax with excise tax at beer rate’ received an “A” quality rating. Additionally, the analysis adopted a societal perspective, meaning that the calculated return on investment would differ from narrower perspectives such as government, heavy drinkers, or the alcohol industry.

The benefit–cost estimates related to alcohol tax interventions rely on published estimates of the substitution between alcoholic beverages based on relative prices; however, these studies considered smaller price changes than those proposed here. As a result, the estimated costs to consumers may be understated. Nevertheless, increased taxation appears to offer an excellent return on societal investment.

Other reviews of the cost-effectiveness of alcohol harm reduction policies report broadly similar findings. In their rapid evidence review, Burton et al. focused on alcohol control policies from an England and Wales perspective (52) with support found for cost-effectiveness of measures addressing affordability (i.e., pricing and tax policies), marketing and availability. Similarly, a rapid synthesis by Guindon et al. (53) and a recent systematic review of economic evaluations of interventions to prevent alcohol use by Le et al. (54) had similar findings, with Le et al. adding selective screening with or without brief interventions for at-risk adults and some school-based interventions combined with parent/carer interventions to the list of cost-effective interventions.

While our analysis draws on studies from high income countries, the findings are relevant to LMIC settings. The SAFER initiative launched in 2018 by the World Health Organization and international partners was established to provide support for member states in reducing the harmful use of alcohol (55). Its focus was on the most cost-effective priority interventions (“best buys”) to prevent and reduce alcohol-related harm across each of the following: strengthen restrictions on alcohol availability; advance and enforce drink driving countermeasures; facilitate access to screening, brief interventions, and treatment; enforce bans or comprehensive restrictions on alcohol advertising, sponsorship, and promotion; and raise prices on alcohol through excise taxes and pricing policies. Specific interventions within these categories have been examined to provide comparative value for money estimates to use in prioritizing interventions for funding.

A strength of this study lies in producing a consistent set of cost-effectiveness estimates across and within each broad category of interventions, achieved by adjusting published data for comparability. Most other reviews report findings without standardizing cost-effectiveness estimates across studies. Covering a wide range of policies, the study offers an evidence base to guide decision on interventions most likely to be both technically efficient (i.e., which drink driving policy is likely to be most cost-effective) and allocatively efficient (i.e., what package of alcohol harm reduction provides best return on investment) (56). Presenting consistently calculated return on investment for a broad range of interventions facilitates policy debate and priority-setting.

However, limitations include the age and variable quality of some data on intervention costs and effectiveness, and the sensitivity of benefit–cost ratios to the value of statistical life used to monetize QALY losses. Moreover, the 3% discount rate applied to future cost savings aligns with international standards (57),but might be higher than the typical differential between inflation and the return on safe investments. Lack of data on standard errors, especially for intervention costs, precluded calculating confidence intervals around the estimates.

Future research should focus on refining these estimates by incorporating emerging data, especially from low- and middle-income countries. Furthermore, expanding the analysis to include long-term societal and economic impacts, as well as equity considerations, would offer a more comprehensive understanding of intervention benefits. Developing dynamic models that account for changing social, economic, and policy contexts could also bolster the robustness and relevance of future evaluations, ultimately strengthening evidence-based decision-making in alcohol harm reduction.

Economic evaluation enables policy and program managers to make informed resource allocation decisions for alcohol harm reduction. This study offers the most comprehensive estimates of the costs and benefits associated with various prevention strategies, drawing on recent published studies.

Harmful and hazardous alcohol consumption results in a wide range of adverse consequences, which can be mitigated through effective prevention programs and strategies. Given the diversity of proven interventions, optimal resource allocation requires selecting complementary, politically feasible, and culturally and demographically relevant measures to maximize return on investment within available funding. Developing a coherent package that complements existing interventions is of particular importance (13).

To translate these findings into effective action, policymakers should prioritize implementing a combination of interventions targeting multiple aspects of alcohol-related harm. For example, combining measures that prevent underage drinking with those targeting repeat impaired drivers can amplify overall impact (58).

A structured decision-making approach can improve practical application. Policymakers should first use the cost-effectiveness estimates to eliminate interventions with questionable return on investment. Then, considerations such as political feasibility, local priorities, appropriateness for the target population, cultural sensitivity, affordability, and impact timing (weeks versus years) should guide final selection. Political feasibility is especially important. A slightly less cost-beneficial program can be superior if the alternative with the higher return has a lower chance of widespread implementation or involves a long delay in implementation. All things are not equal when selecting a package that yields the maximum gains at the lowest possible price. Other factors, such as aggregate benefits obtained, overlapping effects, spillover costs and benefits (e.g., a youth alcohol misuse prevention program that also reduces tobacco use), equity, and government cost can outweigh the gain differential. For example, alcohol pricing interventions evaluated here tend to be inequitable, disproportionately affecting low-income drinkers. Taxation changes can generate substantial government revenues, but also could face a political quagmire (13).

In practical terms, the insights from this research can guide the prioritization of interventions that are not only cost-effective but also feasible and culturally sensitive. By aligning economic evidence with contextual realities, policymakers and stakeholders can develop a comprehensive package of alcohol harm reduction strategies that deliver tangible benefits in diverse settings.