title: Quantifying tobacco related health care expenditures in the Republic of the Marshall Islands: a case study in determining health costs in a developing US associated island nation.
abstract: OBJECTIVE
  This case study examines the advantages, disadvantages, and utility of three research methods to measure the medical costs of tobacco use in the Republic of the Marshall Islands (RMI).
  
  
  METHODS
  The authors used the morbidity-based models, models based on the difference in utilization of medical facilities between smokers and non-smokers, and models of inter-country comparisons.
  
  
  RESULTS
  In the RMI, morbidity models would have a propensity to grossly under-estimate the medical costs of tobacco use. Models that measure the difference in medical service utilization between smokers and non-smokers can be confounded by cultural factors and by the level of health care that is provided. The RMI population structure affected the sampling methods. The external validity of the survey instrument may be increased through measuring more parameters with greater precision. Inter-country comparisons may be used to approximate and set upper and lower limits of costs for past medical costs, and may be the only method to determine future health care costs from tobacco use.
  
  
  CONCLUSIONS
  Determining medical costs of tobacco use in an US Associated island nation with an under-developed health care infrastructure has not been previously attempted. There were significant methodological challenges that were encountered. Health, economic, cultural, and research environments in the RMI are unique and require innovative methods to determine medical costs associated with tobacco use. Direct application of the methodologies utilized in the United States to determine medical costs of tobacco use may grossly under-estimate the medical cost of tobacco use in the RMI. The research challenges can be addressed.
authors.affiliation: Department of Family Practice and Community Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA. palfoxna@hawaii.rr.com
authors.forename: N A
authors.initials: NA
authors.lastname: Palafox
authors.forename: A C
authors.initials: AC
authors.lastname: Ou
authors.forename: H
authors.initials: H
authors.lastname: Haberle
authors.forename: T H
authors.initials: TH
authors.lastname: Chen
mesh_terms: D003906:Developing Countries; D005102:Health Expenditures; D006296:Health Services / Q000706:statistics & numerical data*; D006306:Health Surveys; D006801:Humans; D008849:Micronesia / Q000453:epidemiology; D012907:Smoking / Q000009:adverse effects* / Q000191:economics*