**Background:** Alcohol-attributable deaths amount to three million globally per year, and this burden is expected to rise due to increased consumption in low- and middle-income countries (LMICs). Despite the availability of effective policies—including the WHO 'best buys' of restrictions on availability, marketing, and pricing, plus drink-driving prevention—uptake of these policies remains low. Composite indicators (policy indices) are widely used to benchmark country performance, but previous indices have shown only modest associations with alcohol per capita consumption (APC), particularly when including many policy dimensions. This study aimed to develop a policy index focused on a small number of the most effective policies, incorporating both legislative stringency and measures of real-world policy impact, using data collected in-country with minimal resources.
**Methods:** The study included 12 jurisdictions: England, Scotland, Australia, New Zealand, South Africa, St Kitts and Nevis, Vietnam, Thailand, Chile, the Netherlands, Mongolia, and Turkey—a convenience sample based on countries that had obtained funding for the IAC project. Data were collected for one year per site between 2012 and 2020. Four policy domains were examined: physical availability (trading hours/days, outlet density), pricing policy (tax rates, affordability), alcohol marketing (five modes: traditional advertising, digital advertising, product placement, sponsorship, sales promotions), and drink driving (BAC limits, enforcement). Stringency measures captured the level of restriction as legislated or regulated. Impact measures included actual trading hours, affordability (mid-price of 15ml absolute alcohol averaged across three beverages, weighted by market share, divided by per capita GDP), number of marketing modes present (out of 25), and percentage of vehicles stopped for random breath testing. Domains were weighted from 1 to 5 based on effectiveness evidence, with sensitivity analysis testing 19,683 different weight combinations to select final weights providing the largest correlation with recorded APC. The final index had a potential range of 0 to 25 points.
**Key Results:** The IAC Policy Index showed a very high negative correlation with recorded APC (-0.91). Turkey ranked highest (most restrictive) with a total score of 13.9, followed by Vietnam (11.8), Thailand (10.3), and Mongolia (9.7). The least restrictive countries were New Zealand (5.0), Netherlands (5.0), and England (5.1). For individual domains, the pricing impact measure (affordability) showed the strongest correlation with APC (-0.80), while pricing stringency (tax/price ratio) showed essentially no correlation (-0.02). Marketing showed strong correlations for both stringency (-0.57) and impact (-0.56), with the combined marketing score correlating at -0.68. Outlet density stringency correlated at -0.44, and drink driving stringency at -0.45. Hours and days of sale showed no association with APC (0.00). The overall correlation between stringency and impact measures across countries was 0.77. Sensitivity analysis showed the index was robust: the interquartile range for correlations with APC across all weighting iterations was 0.04 (-0.85 to -0.81), and leaving each country out one at a time had minimal effect.
**Clinical Implications:** The IAC Policy Index provides a relatively simple, resource-efficient tool for benchmarking alcohol policy across diverse country settings, including LMICs. The strong correlation with APC suggests that focusing on a small number of highly effective policies—particularly pricing (to reduce affordability), marketing restrictions, and outlet density regulation—can substantially reduce population-level alcohol consumption. The finding that affordability (price adjusted for GDP) was far more strongly associated with consumption than tax/price ratios has important implications for how pricing policy effectiveness should be monitored. The study also demonstrates that impact measures reflecting real-world implementation and enforcement add significant value beyond measuring legislative stringency alone. This tool can facilitate communication with policymakers, highlight where policy change is needed, and promote accountability. Future work will apply the index to cross-country survey data on specific drinking patterns and develop a youth-relevant policy index.