among the population. This view considers that tobacco price increase prevents tobacco initiation and induces cessation among younger groups of the population.

Several studies have analyzed the cost of smoking in each country or globally such as WHO has done. To estimate the cost of smoking in Moldova, the present study uses official calculations of the government. In 2001, the Ministry of Health estimated that the amount of health care expenditure associated with tobacco was MDL 360.4 million or $27.6 million.<sup>7</sup> Moreover, the estimated economic costs because of lost productivity associated with premature death, outpatient treatment, and hospitalization was MDL 430 million or $32.9 million. The total yearly cost of tobacco use would thus be $60.5 million.

Public-sector expenditure on health in 2014 was 51.4 percent of total health expenditures. The study assumed that 48.6 percent of this cost—$29.4 million—is covered directly by households[28].

A more conservative option would involve estimating the economic cost of the treatment of tobacco disease by multiplying the value of treatment by the number of deaths attributed to tobacco (assuming that most of the individuals were treated at some point). The major causes of death in Moldova are cardiovascular disease (59 percent), cancers (14 percent), injuries (7 percent), chronic respiratory disease (3 percent), diabetes (1 percent), and other noncommunicable diseases (12 percent) [42]. WHO estimates the the number of deaths per 100,000 population in Moldova attributable to tobacco at 613. Because the population of Moldova is 3.52 million (2016 data of the World Bank), it can be inferred that more than 21,600 deaths per year may be attributed to tobacco consumption.

No direct estimates exist of the cost or out-of-pocket expenditures for the treatment of cardiovascular disease, cancer, or respiratory diseases in Moldova. Denisova and Kuznetsova (2012) estimate the treatment costs in Ukraine based on estimates for Russia, arguing that the medical systems of the two countries are similar in personnel, infrastructure, and other inputs[43]. The similarity in size, personnel, and inputs between Ukraine and Moldova in medical systems shows that Ukraine may be a good candidate for extrapolating specific costs in Moldova. Following the methodology of Denisova and Kuznetsova, this study calculated the costs in Moldova in this way (table 5). The treatment costs in Ukraine are indexed to the ratio of per capita public health expenditure in Moldova. The total cost and the total cost per household associated with tobacco and selected diseases are estimated at $10.2 million, which is more conservative than previous government estimates.<sup>8</sup>

**Table 5 – Tobaco Related Medical Costs in Ukraine and Moldova**

|_Disease_|_Treatment cost, Ukraine_|_Treatment cost, Moldova_|_Private sector cost_|_Number_|_Total cost, $_|
|---|---|---|---|---|---|
|Cardiovascular disease|684|524|492|16,760|8,241,911|
|Cancer|633|485|455|3,977|1,809,887|
|Chronic respiratory infection|244|187|175|852|149,496|
|Total||||21,589|10,201,295|

_Sources:_ Denisova and Kutznetzova 2012; WHO 2012. _Note:_ Per capita national health care expenditure, Moldova: $341; Ukraine: $445. Government expenditure, 51.4 percent. Cardiovascular disease: 59 percent; cancer: 14 percent; chronic respiratory infection: 3 percent at the national level.

> 7 The exchange rate on December 1, 2001 was MDL 13.07 = $1.

> 8 The medical cost estimation in this paper can be considered as a lower-bound cost. Given the available data, these are the closest estimates that could be calculated. Other papers for countries like Ukraine, Colombia, Chile or the United States consider many more diseases and medical problems associated to tobacco consumption [25,44–46].

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