Discussion

The estimated score for Armenia on TCS for smoke-free public places, advertising ban, health warnings and treatment categories are below the European average in 2005 and 2007. However, the price score estimates are above average in 2005 and 2007 and so the score on public spending in 2007. This is unexpected finding since in the European region, the countries where price of cigarettes remains very low are postsovietⁱ countries, including Armenia.14 However, the affordability of tobacco products cannot be determined by price alone. Only when price assessed along with real income of population and standards of living in a specific country, then it may provide a relatively accurate measure of cigarette affordability.15 The TCS price score is based on this concept, and, therefore, the estimated high score for price of cigarettes in Armenia reflects the low real income of the population.

Nevertheless, while interpreting these findings, other potential sources of bias needs to be taken into account, including a potential measurement error. As the scale assigns equal weights to two selected brands, Marlboro and the MPPC, important information may be missing if the market is dominated by one of those brands; for example, in case of Armenia, less expensive domestic cigarettes have a greater share on the market (up to 75% in 2000).16

Another issue could be inadequate accuracy and comparability of data. Thus, there is a good chance that Armenia's gross domestic product (GDP) data do not capture a considerable amount of remittances to Armenia from household members abroad due to seasonal or longer term migration of the labour force.17 In this case, underestimation of the real income in Armenia would mask a greater, than reflected in our estimates, affordability of cigarettes. Affordability could increase also due to cigarette smuggling; however, no convincing evidence on smuggling to Armenia is available.18

Finally, the estimates could have been affected by exchange rates fluctuations. Thus, the 42% increase in the price of Marlboro pack in Armenia assessed in US$ (US$0.93 in 2005 to US$1.32 in 2009) was equivalent to only 11% of its retail price in local currency. Our previous research suggested that the affordability of cigarettes has increased from 2005 to 2007 in Armenia.19 Therefore, the calculated price score for Armenia might be considerably overestimated due to reasons discussed above.

Armenia's score for smoke-free public places in 2005 was much lower than the European average score in this category (5 vs 8). Many European countries have significantly improved their smoke-free scores from 2005 to 2007, including formerly soviet Lithuania, Latvia and Estonia, an advancement that was greatly facilitated by the European integration process and the EU Directives on tobacco control.20 Thus, Armenia lags on smoke-free policies behind the majority of EU countries, failing to provide a complete and effective protection from exposure to secondhand smoke at worksites and public places.

In category of public spending in tobacco control, Armenia earns a score of 13 of possible 15 in 2007, thus exceeding the average public spending score for about three times. The score reflects the significant allocations made by the Armenian government in 2006–2008 following the accession to the FCTC and approval of the state programme on tobacco control. For instance, in 2007 the amount of 100 millions of Armenian drams per annum would be roughly equivalent to US$275 000 comprising about 0.038% of Armenia's GDP (in national currency). However, outcomes of the highly segmented and irregular antitobacco campaign are questionable.10 Thus, the amount of public spending on tobacco control information campaigns, though indicates the government's commitment to tobacco control, may not necessarily be a measure of success in raising public awareness on tobacco issue as it does not account for the campaign's effectiveness and the implementation. Therefore, we suggest complementing this merely monetary score with other measures, such as density, timeline and area covered by media campaign, based on expert opinion.

Armenia is doing relatively well on advertising ban, having banned tobacco advertising in all electronic media since 2002 and outside advertising in 2006. The score increase by 2 in 2007 is congruent with overall improvement in this category among 30 countries. However, the majority of eastern European countries had higher scores in 2007 than Armenia with Estonia attaining the maximum possible score of 13. The main challenge ahead for Armenian tobacco control community would be banning point of sale advertising and all types of indirect advertising, promotion and sponsorship.

Larger health warnings were required by the national law since 2005; however, the law granted a long gray period for the implementation of the requirement; the packs with 4% warnings became outlawed only in February 2008. Thus, though with a 4-year delay, Armenia reached the European average score on health warnings. Pictorial health warnings on cigarette pack are shown to be a highly cost-effective way in raising awareness on health hazards of smoking and many countries across the world have successfully implemented this strategy; however, Armenia did not. Presently, the EU Tobacco Products Directive (2001/37/EC) only recommends pictorial warning, while mandating them would benefit not only member and candidate states but also the EU neighbourhood countries, including Armenia.

No progress was revealed in the area of tobacco dependence treatment from 2005 to 2009 when measured on the TCS. Nevertheless, in 2009 the country did a step forward by developing national guidelines on treatment of tobacco dependence. Several first-line pharmacological treatments for tobacco dependence were available over the counter, including nicotine replacement therapy and Zyban (bupropion). Tabex (cytisine), better known in Eastern Europe, has been on market as well as, more recently, Chantix. Therefore, we suggest that the scale's sensitivity in treatment-related section could be enhanced by adding more components to the questionnaire. Specifically, national guidelines on smoking cessation, training of smoking cessation specialists, smoking cessation components in medical school curriculum and system-based approach towards smoking cessation (ie, integrating it into healthcare) are essential parts of tobacco dependence treatment and need to be reflected in the score. As it currently is, the scale also does not count for availability of pharmaceutical aids, while in many countries this also might be a problem. Some of these concerns were already addressed in the new 2010 scoring system on treatment, such as reporting smoking status in medical charts.21

To sum up the main points made above, Armenia's total score on TCS has considerably improved from 2005 to 2009, most notably due to larger health warnings and advertising ban, as well as increased public spending on tobacco control. Progress in passage of the laws but no progress in implementing smoke-free policies or establishing a smoking cessation infrastructure has been made in Armenia. The FCTC suggests that the process of policy change can be accelerated by combining multiple important strategies, including education and legislation. In Armenia, however, the increased public spending did not translate into meaningful educational campaigns and inadequate implementation of the FCTC obligations resulted in weak (partial) smoke-free legislation. Weak policies cannot bring the desired reduction in tobacco consumption. This conforms to data from two nationwide surveys, the Armenian Health System Performance Assessment Report 2012 and the Demographic and Health Survey that found no change in smoking prevalence among men from 2005 through 2010.22 ,23 Therefore, the study finding of no relationship between TCS score and per capita cigarette consumption supports our view of overestimated values of the score for Armenia.

The implementation of smoke-free policy in a nation with high smoking rates poses a challenge that is not unique for Armenia. Transition to social democracy and effective public governance has been slow in many postsoviet countries and this could partly explain the ineffective implementation of the tobacco control measures in Armenia. However, the high rates of male smoking and social normalcy of smoking behaviour are unequivocally a major challenge for the smoke-free policy implementation. Other important reasons to be noted are the remarkable presence of the tobacco industry (local manufacturers and tobacco importers) on Armenia's business and political scene, including a strong tobacco lobby in the legislative, that could interfere with the political commitment to comply with the FCTC obligations and lead to passage of weak laws with no enforcement mechanisms. Adopted but not properly enforced, even the best policy cannot translate into desired reduction in tobacco consumption. Finally, transition economies such as Armenia may have substantially different tobacco markets (eg, different market shares for expensive and cheaper brands) and related regulations (such as tax policies favouring local product) as compared with high-income countries.