Role of commercial determinants in shaping alcohol consumption and health outcomes in Rajasthan: a convergent mixed-methods study

Background: Rajasthan being India's highest-revenue alcohol states, with approximate excise collections exceeding INR 9,229 crore by November 2023-24 and sales of 876.86 lakh bulk litres of total country liquor and 413.69 lakh bulk liters of Indian-Made Foreign Liquor (IMFL). Commercial determinants like excise policies, outlet density, pricing strategies, and surrogate advertising are increasingly recognized as structural drivers of consumption and health harm. Objectives of the study were to map commercial determinants against alcohol sales trends and health indicators in Rajasthan; to identify stakeholder perceptions of industry influence and regulatory barriers; and to recommend targeted mitigation strategies. Methods: A convergent parallel mixed-methods design was employed, adhering to COREQ guidelines. Secondary data from the Rajasthan State Excise Department, NFHS-5, and health records were analysed using descriptive statistics and multiple linear regression. Primary data comprised semi-structured interviews with 20-25 purposively sampled key informants, analysed thematically in NVivo 14. Results: Sales volumes grew approximately 18% between 2018 and 2023, closely tracking revenue-maximizing excise reforms. Outlet density was positively correlated with alcohol- attributable domestic violence (r=0.67, p<0.01). Surrogate advertising was identified by 78% of informants as the primary industry marketing channel. ABV awareness was absent in 41% of consumers. Conclusions: Commercial determinants substantially shape consumption patterns and health burdens in Rajasthan. A multi-pronged response combining outlet regulation, surrogate.