Defense Date


Document Type


Degree Name

Doctor of Philosophy


Pharmacy - Dean's Office

First Advisor

Dr. Norman V Carroll



Cigarette smoking poses a great economic cost on the U.S. health care system by incurring high health care expenditure and health care utilization in the adult population. Although there is a sufficient amount of information on the health care cost associated with cigarette smoking there is a gap in how other forms of tobacco use may impact healthcare expenditures and utilization in comparison to cigarette smoking. The main objectives of this study were: 1) to estimate and compare health care expenditure and health care utilization across different tobacco use groups using nationally representative data 2) to estimate and compare health care utilization across different tobacco use groups.


Data used in this study was obtained from linking individual-level data from two nationally representative data sources, 2009–2016 Medical Expenditure Panel Survey (MEPS) with 2011–2017 National Health Interview Survey (NHIS). The outcomes of interest were health care expenditure and health care utilization. Sociodemographic, health status, selected comorbidity and tobacco use status variables were collected from the NHIS and MEPS data. Tobacco use groups were categorized into three groups based on self-reported tobacco use history as exclusive current cigarette smoker and smokeless tobacco use and never tobacco users. Econometric models were used to estimate annual mean total health care expenditures and health care utilization by tobacco use status adjusting for several covariates.


Current exclusive cigarette smokers tended to be more likely to have one or more ER visits than current exclusive smokeless tobacco users (p-value =0.0161) and never tobacco users (p-value =0.0009). Modeling results adjusting for sociodemographic and health status variables indicated that current exclusive smokeless tobacco users and current exclusive cigarette smokers were not statistically significantly different than never tobacco users in their utilization of the health care services measured. Although no statistical association was found between total health care expenditure and tobacco use status at a 5% significant level. The highest annual mean total health care expenditure in US 2017 dollars was observed in the current exclusive cigarette smoking group $5627.64 (95% CI = $4068.50, $7186.78) followed by current exclusive smokeless users $4478.33 (95% CI = $3035.05, $5921.62) and never tobacco users had the lowest annual mean cost $4426.89 (95% CI = $3514.19, $5339.59).


Cigarette smoking has a heavy economic burden on the U.S. population. This study is the first to compare medical expenditure and health care utilization associated with current exclusive use of different tobacco products of in U.S. adults’ over time. More data may be needed to obtain more conclusive results. This study shows the promise in the potential of reducing healthcare expenditure and utilization by aiding cigarette smokers down the continuum of risk of nicotine containing products to non-combustible tobacco products with less associated risk.


© The Author

Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission