Based on most recent statistics, excessive drinking cost the United States about $249 billion in 2010 ($348 billion in 2023 dollars).¹ Costs for opioid use disorder and fatal opioid overdose in 2017 were estimated to be $1.02 trillion ($1.3 trillion in 2023 dollars), the majority of which was due to reduced quality of life and the value of life lost due to fatal overdose.² Based on the 2021 Global Burden of Diseases study, disability-adjusted life years lost due to drug use disorders in the U.S. was 6.5 million, which was 41.7% of the global total. More than 15% of this burden arose in the 10-24 year age group and about 17% in the 25-29 year age group.³

Youth substance use is associated with increased risk for behavioral and academic problems, teen pregnancy, sexually transmitted infections, perpetrating or experiencing violence, injuries, and mental health symptoms such as anxiety and depression.⁴ Preventing or delaying substance use initiation among youth can reduce later risk for substance use, substance use disorders, and overdose.⁴

In 2023, substance use was common among U.S. high school students and varied by categories of substance. Approximately one-fourth of students (22%) reported currently drinking alcohol, 17% currently used marijuana, and 12% ever misused prescription opioids.⁵ In 2023, almost 3 million middle and high school students reported currently using a commercial tobacco product⁶ and 8% of 8th graders reported past year use of marijuana.⁷

Intervention research highlights parenting as a key protective factor against substance use that can be enhanced through skill-based training interventions.^4,8 Interventions designed to strengthen preventive skills and practices among parents and caregivers such as communication, positive relationship interactions, monitoring and control have the potential to protect youth from substance use and other risk behaviors.^4,9

The Community Preventive Services Task Force (CPSTF) recently recommended family-based interventions that provide instruction or training to parents and caregivers to enhance substance use preventive skills and practices for children and adolescents. The CPSTF is an independent, non-federal panel of public health and prevention experts¹⁰ that provides guidance on public health intervention approaches that work, based on available scientific evidence.¹¹ The CPSTF recommendation was based on a systematic review which found the family-based interventions were effective in preventing initiation and use among youth.^12,13 A separate systematic economic review of the interventions was conducted following the CPSTF recommendation. Based on the results from the systematic economic review, the CPSTF found that the societal economic benefits exceed the cost of these interventions.^12,13 The present study describes the methods, results, and conclusions from the systematic economic review.

This study was conducted using established methods for Community Guide systematic economic reviews developed by the Centers for Disease Control and Prevention (CDC) and approved by the CPSTF.^14,15 The study team included subject matter experts on substance use from CDC’s National Center for Injury Prevention and Control and various agencies, organizations, and academic institutions; members of the CPSTF; and experts in systematic economic reviews from the Community Guide Program at the CDC. Three reviewers (VJ, JR, SKC) worked in pairs and independently screened the search yield and abstracted information from the included studies. Unresolved disagreements between reviewers were taken to the full review team for final adjudication.

Figure 2 shows the search yield for the economic review that resulted in 11 peer-reviewed studies^19–29 and 2 government reports, the first from the Washington State Institute for Public Policy (WSIPP 2023)³⁰ and the second from the Substance Abuse and Mental Health Services Administration (SAMHSA 2008).³¹ Appendix Table B.1 shows there were 23 unique programs or combinations of programs evaluated across the 3 sources, but with substantial overlap. More information about the reports from WSIPP 2023 (Washington state focus) and SAMHSA (national focus) including objectives, methods, and economic outcomes reported are in Appendix B and Appendix Table B.2 in supplementary materials.

The present review considers the evaluations in peer-reviewed studies and the 2 government reports as separate sources of evidence because the reports did not undergo traditional peer-review, the 2 reports used different methods in their economic evaluations, and WSIPP updated its evaluations on its website in December 2023 while the SAMHSA 2008 report has remained static.

Table 1 shows the various evaluated programs, beginning with peer-reviewed studies that evaluated 14 programs,^19–29 followed by WSIPP 2023 that evaluated 14 programs, and SAMHSA 2008 that evaluated 8 programs. Some programs had components in addition to improving parent or caregiver skills to prevent youth substance use, 5 programs from peer-reviewed studies, 6 from WSIPP 2023, and 5 from SAMHSA 2008. The most frequent additional component was school-based substance use prevention curricula while others added components such as referrals to community services, academic services for youth, and enhanced services for youth justice system encounters. All programs were based in the U.S., except for 1 study that was based in the U.K.²⁸

Table 1 also shows intervention and demographic characteristics. Among the peer-reviewed studies, the substance of focus for the interventions was most commonly alcohol,^{19,20,23,25,26,29} followed by illicit substances,^24,25 tobacco,^19,20,26 and cannabis.^19,25 The studies that did not specify a substance^13,21,27 or indicated several substances^19,25,28 as part of their prevention efforts were construed to target substance use in general. The median number of 7.5 sessions occurred mostly as group meetings. The interventions were about equally divided among home, community, and school settings. In the peer-reviewed studies 6 interventions were implemented in predominantly White,^22,24,29 four in African American,^19,21,25 and 1 in Latino populations.²⁷ Among the programs evaluated by WSIPP 2023,³⁰ the substance of focus were most frequently alcohol, followed by cannabis, and tobacco. The median number of sessions was 9.0, mostly in groups, and equally divided among home, community, and school settings. Programs evaluated by WSIPP 2023 included 2 tailored for African American and 1 for Latino families. Most of the programs evaluated in the peer-reviewed studies and WSIPP were between 1 and 3 months in duration while others were 24 months or longer and extended over multiple school grades. Among the programs evaluated by SAMHSA 2008,³¹ most focused on alcohol, followed by tobacco and cannabis. Other intervention and demographic information were very infrequently reported.

Table 2 shows programs evaluated in peer-reviewed studies were in rural settings,^19,22,24,29 small towns,²⁶or mixed urban-rural settings,²⁰ with a smaller number evaluated in large urban areas.^23,25,27 Note that the WSIPP 2023 and SAMHSA 2008 reports were evaluated from the standpoint of the Washington state and United States, respectively. Sex of the parent or caregiver was infrequently reported but both males and females were about equally represented among the youth.

Table 2 shows the estimates for intervention cost, intervention benefit, benefit to cost ratio, and cost-effectiveness for the evaluated programs. As in Table 1, peer-reviewed studies are shown first, followed by evaluations from WSIPP 2023 and SAMHSA 2008. Among the peer-reviewed studies, 9 provided estimates for intervention cost (14 estimates),^19–26,29 3 for intervention benefit (5 estimates), ^22,24,26 3 for cost-benefit (5 estimates),^24,26,29 and 1 for cost-effectiveness (1 estimate).²⁸ WSIPP 2023 provided 14 estimates each for intervention cost, intervention benefit, and cost-benefit. SAMHSA 2008 provided 8 estimates each for intervention cost, intervention benefit, cost-benefit, and cost-effectiveness.

The economic evidence showed the societal benefits of family-based interventions to prevent substance use among youth exceed the societal cost to implement the interventions in the U.S. The evidence was drawn from peer-reviewed studies and 2 government reports from the US. The conclusion of favorable cost-benefit was judged to be consistent within and across the sources of evidence. The CPSTF did not issue a statement on cost-effectiveness given there was only one study from the peer-reviewed literature and the evaluations from the 2008 SAMHSA report were judged to be dated for this purpose.³¹

Societal cost-benefit sums costs over implementers and benefits over beneficiaries who can be from different sectors and jurisdictions. On the cost side, the interventions covered in the present review included those where health professionals provided parenting skills training and school systems delivered substance use prevention curricula. On the benefits side, averted costs due to substance use prevention accrued to the healthcare system and judicial systems and youth benefitted through productivity gains as working adults.

WSIPP 2023 produced negative cost-benefit estimates for two programs, CASASTART and New Beginnings. In addition, WSIPP 2023 found the PROSPER program produced benefits just short of cost neutrality (cost-benefit = 0.9). The intervention cost for the CASASTART program was likely high because it was developed as a comprehensive program for high-risk youth and involved healthcare, justice, and social services systems in its delivery. The WSIPP 2023 cost-benefit model for New Beginnings produced positive benefits only in healthcare cost averted and negative benefits (i.e., net cost increases) in other sectors. A substantial part of the cost of the PROSPER program was the monitoring and technical assistance provided by academic researchers.

The benefit to cost ratios reported by SAMHSA 2008 were consistently higher than those reported by WSIPP 2023. Only the SAMHSA report included a monetary valuation of reduced quality of life due to adolescent substance use; this increased estimated total benefits.³² However, only WSIPP 2023 estimated the value of deadweight loss due to taxation in cost-benefit analysis, assuming it to equal 50% of intervention cost for each evaluated program. None of the peer-reviewed studies or SAMHSA 2008 accounted for deadweight loss of taxation to fund the programs, which may be considered an omission resulting in their overestimation of benefit to cost ratios.

Cost per QALY gained was reported by SAMHSA 2008 and in one peer-reviewed study. SAMHSA 2008 reported a cost per QALY gained of $293,000 for the CASASTART program. This intervention was a comprehensive one-on-one intervention involving healthcare, justice, and social services systems that may have contributed to its large intervention cost. One peer-reviewed study²⁸ found the intervention itself was not effective and hence not cost-effective. The comparison and intervention groups in this study received substantial services from the healthcare system and other family assistance programs within the UK, and this may have dampened intervention effectiveness. The authors also noted that the study had implementation challenges because the intervention was universal while the usual practice of agencies charged with implementation was to target services to those in greater need.

The review followed a $50,000 per QALY gained benchmark for cost-effectiveness. This is a very conservative benchmark, given it was first introduced some decades ago and persists in the literature without adjustment for inflation or economic growth^15,33.

Many estimates of intervention cost did not include the cost of parent or caregiver time spent participating in the interventions. The opportunity cost of parent or caregiver time for participation in the Familias Unidas program in 2009 was estimated at $812 per family in 2023 US dollars,²⁷ a non-negligible cost that needs to be accounted. Table 2 identifies programs where intervention cost did not include parent or caregiver time. A cursory examination shows that intervention cost would exceed intervention benefit in the case of Project Northland reported by WSIPP 2023 and Stars for Families reported by SAMHSA 2008 once parent or caregiver time is added to cost. CASASTART as reported by SAMHSA 2008 would remain not cost-beneficial. In summary, the overall cost-beneficial conclusion is not controverted even when the full $812 cost of parent or caregiver time is added to intervention cost of these programs because the first quartile of cost-benefit ratios would still be ≥ 1.0.

Some family-based programs were enhanced with school-based substance use prevention curricula. Though they would add to total cost, the additional school curricula would also increase benefits, and thus maintain a favorable benefit to cost ratio.

The review of economic evidence identified some gaps in the research. There is need for cost-effectiveness evaluations based on more recent data. There is a dearth of economic evaluations for Latino, Asian, and American Indian and Native Alaskan populations as well as populations in large urban areas, also noted for American Indian and Native Alaskan populations in the review of effectiveness.¹³ This research gap handicaps efforts to tailor programs to varied needs, demographics, and cultural contexts.

The systematic economic review found the societal economic benefits of family-based interventions to prevent substance use among youth exceeded the cost to implement these interventions.