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Advocacy Policy

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Explain how your policy can promote the health of the chosen population, using a public health or health promotion framework (e.g. Ottawa Charter). 

Section 1: Background
National Tobacco Control Program: The National Tobacco Control Program (NTCP) is the initiative that was put forward and formed for the development and implementation of the different smoking control programs for reducing the rates of smoking in Singapore. The National Tobacco Control Program, also known as, NTCP, is a comprehensive and long-term program which was launched in 1986 for control of smoking and with the theme that was “Towards a Nation of Nonsmokers,” and was led by the Ministry of Health. The National Smoking Control Co-ordinating Committee was set up in the year 1996, which was chaired by the MOH for formulation of the policies, coordinating the activities, as well as, for monitoring the National Tobacco Control Program (Wisotzky, Albuquerque, Pechacek, & Park, 2004). The Committee consists of the representatives from the eight different government ministries, private sector employers, as well as, the trade unions.
The Health Promotion Board was developed in the year 2001 to oversee, as well as, to coordinate the health promotion programs, involving the National Tobacco Control Program, in Singapore. The National Tobacco Control Program utilizes the multi-pronged approach for combating smoking. The NTCP main aim is to reduce the prevalence of smoking in Singapore with the help of different measures, which includes prevention of the initiation of smoking between different young individuals and groups, educating, motivating, as well as, assisting the individuals who smoke to quit smoking, promoting the climate that is conducive for all the non-smokers to prevent them from the various harmful effects occurring due to the environmental tobacco (Veeranki, Mamudu, Anderson, & Zheng, 2014).
Health issue: The increase rate of smoking prevalence, especially observed in the youngsters.
Smoking has the harmful effects on both the smokers, as well as, the non-smokers, thus posing a harmful threat to the humans and affecting the health and lifestyle of the humans. Smoking is becoming the substantial economic burden due to the losses incurred in the cost of the healthcare, as well as, in its productivity (Gavin, 2004). Hence, it requires the combined efforts of each and every individual or group of the healthcare industry, the community, as well as, the workplace to tackle all the issues related to the smoking. Each country or city put forward the lot of efforts in  tackling the issues related to the smoking as use of tobacco results in the huge social losses. It has been found that Singapore has a very long history in the development of the policies related to the anti-smoking promotion (Wakefield & Liberman, 2008).
Evidence of smoking: According to the Health Promotion Board surveys, it was evidenced that in the year of 2001, around 8% of the women who were in between the age group of 18 years to 24 years were involved in smoking. This percentage was about two percent more as compared to the National Health Survey conducted in the year 1998. The Youth Tobacco Survey in the Singapore in the year 2000 involved about 13,000 students of secondary school in the Singapore, and it was observed that about one in every four under-aged youngsters had a history of smoking or they have smoked before. Around 11.2% of the total students involved in the survey were involved in the smoking activity at least once every month prior to the survey, and about 2.4%  of them were involved in daily smoking activity. The surveyors evidenced that around 13.4% of the smokers were boys and about 8.8% of the smokers were girls. Despite the rule of not selling the cigarettes to the individuals who are under 18 years of age and being illegal, half of the population that were surveyed reported that they could buy the cigarettes easily from the shops. Moreover, among females, it was observed that the females between the age group of 18 years to 29 years were more involved in the activity of smoking, and the increase of percentage from 5% in the year of 1998 to 7% in the year 2004 was being observed (“Explaining recent trends in smoking prevalence”, 2005).
According to the National Health Survey (NHS) in the year 2010, it has been observed that the smoking prevalence in Singapore arose from about 12.3% in the year 2004 to around 14.3% in the year 2010, thus reversing the past long-term decline. The rise in the prevalence of smoking is driven by the factors involving the significant increase in the activity of smoking among the youngsters, mostly in the age group of 18 years to 39 years of age. It has been observed that the social influencers like older peers, as well as, parents have been mentioned as the causes for  picking up the activity of smoking in the youngsters. Moreover, the Student Health Survey that was conducted by the Health Promotion Board has observed that about 58% of youth who are involved in the activity of smoking have at least a single parent who is involved in smoking in comparison to about 27% of the youth who were non-smokers. Further, Health Promotion Board has been working in partnership with the Singapore National Employers Federations for conducting different sectoral studies and surveys among the workforce, like employees belonging to the hospitality sector. For instance, one of the surveys that were conducted showed  that about 31.5% of the total hotel employees were involved in smoking. Moreover, stress was found to be the main cause of smoking observed among this sub-group (Cohen, Chaiton, & Planinac, 2010).
So far, the implementation of NTCP was successful in reduction of the rate of prevalence of smoking from 20%, which included about 37% of males and about 3% of females in the year 1984 to 12.6%, including 21.9% of males and about 3.4% of females in the year of 2004. Further, it has also been observed that the prevalence  of smoking among Singaporean men, as well as, the women are considered to be the lowest overall globally when compared with other countries like Canada, United Kingdom, Australia, United States, Thailand, South Korea, Germany, Japan, Italy, as well as, Switzerland. The ongoing health education programmes related to the public health with the use of various health promotion measures like the utilization of the legislation, control of the sale, control of non-smoking areas, fiscal measures, as well as, provision of cessation activities have worked together in keeping the prevalence of smoking acitivities lowest in Singapore in the world (Choo, Ong, & Lee, 2004). 
Section 2: Aims and Objectives
The main objective of the National Tobacco Control Programme is the reduction in both the supply, as well as, demand of the cigarette for ensuring attainment of higher standards of public health. It aims to reduce the prevalence of smoking in Singapore and is working towards the accomplishment of its aims and objectives (Milne, 2005). It aims at preventing the starting of smoking in the adults and youths, educates and motivates the individuals for smoking cessation, as well as, also aim to provide the environment that keeps the non-smokers away from the potential harmful effects of the tobacco use. Apart from dissuading both the youths, as well as, the old age groups  to refrain themselves from taking their first puff of smoke, the aim of this program is also to provide the conducive environment for the individuals who smoke to seek any kind of help in smoking cessation, as well as, to help in the process of quitting smoking (Loyola, 2008).
Section 3: Health promotion framework
 The National Tobacco Control Programme is the multi-pronged combination of strategies for the promotion of the non-smoking agenda in Singapore. It is developed with the aim and objectives of reducing the smoking prevalence and works in accordance with the framework adopted by the World Health Organization, which is the Framework on Tobacco Control (Wipfli, 2004). This framework is the foremost evidence-based treaty that was being negotiated under World Health Organization’s auspices in the development of the various regulatory strategies for addressing the addictive substances. Thus, the National Tobacco Contol Program includes the of five different strategies, which are: Taxation, Legislation, Public Education, Partnerships, and Provision of quit smoking services for achieving their aims of reducing the prevalence of smoking in the country (Eckhardt, Holden, & Callard, 2015).
Taxation: The Health Promotion Board has an important and active role in the advocating, as well as, in recommending different tobacco taxation strategies. It has developed partnerships with two bodies, which are the Ministry of Health, as well as, Ministry of Finance for the working on tobacco taxation strategies on the regular basis. It has been observed that taxation tends to be the most cost effective strategy in the reduction of rates of prevalence of smoking (Hastings & Liberman, 2009). The study conducted by the World Bank revealed that for about every 10% increase done in the real inflation altered cost, the decrease of two percent to eight percent will be observed in the cigarette consumption. Moreover, the local data also revealed that an increase in the price of cigarettes correspond to the decrease in per capita consumption. It has been observed that there is a regular increase in the tobacco since 1987 for the aim of discouraging the non-smokers to pick up the habit of smoking, as well as, to encourage the individuals who are current smokers to quit smoking or to smoke less (Dewhirst, 2012).
Legislation: The second strategy followed by the NTCP is the launch of tobacco control legislation. The tobacco control legislations consist of the Tobacco Act, i.e., Control of Advertisements and Sale of Tobacco Act, which is put forward and regulated by the Health Sciences Authority. This act involves the prohibition of all the advertisements, as well as, promotion of the tobacco, and also the prohibition of tobacco supply, as well as, the use of products having tobacco in it by the individuals who are under 18 years of age. As per this tobacco act, the warnings related to the health by the use of all the products including tobacco should be mentioned at the upper 50% both in front, as well as, on the back of the tobacco product in English (Heloma, Nurminen, Reijula, & Rantanen, 2004). These legislations formed for the prohibition of advertisements by the use of media that can create a positive image of the product, as well as, could stimulate smoking behaviors and activities may help in reducing the consumption of cigarettes and smoking behaviors. Further, it has been observed that the potential downward shift was seen in the response of consumption of the cigarette, as well as, the smoking behaviors of the individuals with the advertising bans. Furthermore, other legislation that is formed is the Prohibition on Smoking in Certain Places Act that enforced and regulated by the National Environment Agency. This act prohibits smoking activities in certain designated public places, which includes  all the public transport, non-air-conditioned places, mostly indoors, indoor restaurants and workplaces, hospitals, pubs, educational facilities, bars, as well as, some outdoor places (Fallin & Glantz, 2015).
Public Education: The third strategy followed by NTCP is public education. The purpose of public education is the prevention of initiating the smoking, and also to provide all the information related to the smoking to both smokers, as well as, the non-smokers. It has been observed that Singapore has the highest ratio of educated people, public health messages such as the consequences and outcomes of smoking, as well as, the impacts of using second-hand smoking can be better received, as well as, translated for putting the concerned proposal into action. The Singaporean government utilizes the media in the promotion of public health that is called counter-advertising, and it has been observed that there is the negative relationship existed between the counter-advertising, as well as, the consumption of smoking. Moreover, public education is one of the important tool that is used to inform the public about the risk factors associated with smoking, as well as, with second-hand smoking (Hammond, 2003). Various studies have suggested that the inaccurate perceptions of the risk associated with smoking may result more in case of the inherent difficulties related to the learning of potential harmful risks to the public. Moreover, the psychological research has found that individuals tend to underestimate all the potential risks associated with the one of the most common death causes and thus prolong their use of tobacco (Koh, Leung, Ang, & Thumboo, 2013). However, the Singapore government has adopted a large number of information policies that are meant for delivering all the negative consequences and outcomes of tobacco use on one’s health. For instance, counter-advertising campaigns are used as the public interventions, which informs the citizens about the risks, as well as, discourage the smoking behaviors. The studies showed that public education is capable of raising the public awareness, as well as, encourages the individuals to help the smokers to quit smoking (Fong, 2006).
Partnerships: The fourth strategy by the NTCP is forming partnerships. NTCP that works under the HPB actively involves educational institutions, youth organizations, private workplaces, healthcare professionals, the uniformed groups, parents, community, as well as, the religious groups to promote the lifestyle that is smoke-free. It has been observed that the positive and significant effect in encouraging the non-smoking behavior was observed for programs related to the social reinforcement, as well as, social norms oriented. Further, the social reinforcement, as well as, the social norms oriented events refer to the development of all the abilities that helps in recognition and resistance of the social pressures for using drugs, as well as, for minimizing the consumption of the cigarettes. It has also been observed that these programs have encouraged students who even give advice to  their parents for smoking cessation after they learn and became familiar with the consequences related to the smoking from the programs in their school (Glantz, 2000).
Provision of quit smoking services: The fifth strategy followed by NTCP is providing smoking cessation services. In collaboration with the HPB, it offers affordable, as well as, accessible smoking cessation available services to the smokers. Further, these smoking cessation services are integrated in the healthcare settings like the hospitals, as well as, the polyclinics for the longest period since the 1990s. Moreover, it also avails the personalized advice with the help of the training, which is “Quit Advisors through a QuitLine” based on the methods to quit smoking. It has also developed the “I Quit” mobile app that helps the smokers to make the most efficient approach for quitting smoking. This mobile app will reveal that for how long the individuals who smoke have been proceeding in the smoking cessation process. The provision of smoking cessation services is one of the most direct and effective ways for assisting the smoker in the process of quitting smoking. Moreover, the community smoking cessation services mostly include the mass population. These services raise the public awareness, includes the widespread provision of various self-help things made available by medical, as well as, non-medical channel, and encourages the health professionals for improving their efforts on the individual patients involved in smoking. Singapore adopts various strategies for achieving the aims and objectives of the NTCP which are helpful in preventing smoking initiation in the youngsters, promotes the smoking cessation process among the smokers, and also protects the non-smokers having bad and harmful effects related to the secondhand smoking. 
Section 4: Recommendations to the government
As it has been observed that there is frequent increase in the rate of prevalence of smoking, despite of the implementation of the NTCP, following recommendations can be made:
The government should conduct frequent inspection of the public areas to evaluate if there is any smoking in the prohibited area to increase the effect of this policy. Further, the government should give monetary awards for the individuals participating in the smoking cessation practices who are successful in quitting the smoking. This in turn would encourage the individual to quit smoking. Moreover, as the surveys showed that the individuals who were under 18 years of age can easily purchase cigarettes from the shops, so the government should impose stricter rules, and no cigarette packs should be sold without confirming the age of the individuals by means of identity cards. Thirdly, although in Singapore the tax is high, but still it is unable to bring the desired and favorable effects in the reduction of smoking, and it has been observed that most of the individuals who are involved in smoking can still afford the cost of cigarette. Hence, to change the result, the government should increase the tax rate also (Gartner & Mcneill, 2010). 
Choo, Y., Ong, K., & Lee, W. (2004). Effectiveness of a smoking cessation program among hospitalized patients in Singapore. Chest, 126(4), 713Sb.
Cohen, J., Chaiton, M., & Planinac, L. (2010). Tobacco control and the epidemiological framework.Tobacco Control, 20(4), 318-318.
Dewhirst, T. (2012). Price and tobacco marketing strategy: lessons from ‘dark’ markets and implications for the WHO Framework Convention on Tobacco Control. Tobacco Control, 21(6), 519-523.
Eckhardt, J., Holden, C., & Callard, C. (2015). Tobacco control and the World Trade Organization: mapping member states’ positions after the framework convention on tobacco control. Tobacco Control, tobaccocontrol-2015-052486.
Explaining recent trends in smoking prevalence. (2005). Addiction, 100(10), 1394-1395.
FALLIN, A. & GLANTZ, S. (2015). Tobacco-Control Policies in Tobacco-Growing States: Where Tobacco Was King. Milbank Quarterly, 93(2), 319-358.
Fong, G. (2006). The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project. Tobacco Control, 15(suppl_3), iii3-iii11.
GARTNER, C. & MCNEILL, A. (2010). Options for global tobacco control beyond the Framework Convention in Tobacco Control. Addiction, 105(1), 1-3.
Gavin, A. (2004). Smoking is a major cause of premature death worldwide. Evidence-Based Healthcare, 8(2), 95-96.
GLANTZ, S. (2000). Tobacco Related Disease Research Program. Tobacco Control, 9(90002), 2ii-3.
Hammond, R. (2003). The Framework Convention on Tobacco Control: promising start, uncertain future. Tobacco Control, 12(3), 241-242.
Hastings, G. & Liberman, J. (2009). Tobacco corporate social responsibility and fairy godmothers: the Framework Convention on Tobacco Control slays a modern myth. Tobacco Control, 18(2), 73-74.
Heloma, A., Nurminen, M., Reijula, K., & Rantanen, J. (2004). Smoking Prevalence, Smoking-Related Lung Diseases, and National Tobacco Control Legislation. Chest, 126(6), 1825-1831.
Koh, W., Leung, K., Ang, L., & Thumboo, J. (2013). Cigarette smoking and risk of severe osteoarthritis among Chinese in Singapore – the Singapore Chinese Health Study. Osteoarthritis And Cartilage,21, S153.
Loyola, E. (2008). Linking Global Youth Tobacco Survey (GYTS) Data to the WHO Framework Convention on Tobacco Control. Preventive Medicine, 47, S1.
Milne, E. (2005). NHS smoking cessation services and smoking prevalence: observational study. BMJ,330(7494), 760-760.
Veeranki, S., Mamudu, H., Anderson, J., & Zheng, S. (2014). Worldwide Never-Smoking Youth Susceptibility to Smoking. Journal Of Adolescent Health, 54(2), 144-150.
Wakefield, M. & Liberman, J. (2008). Back to the future: tobacco industry interference, evidence and the Framework Convention on Tobacco Control. Tobacco Control, 17(3), 145-146.
Wipfli, H. (2004). Achieving the Framework Convention on Tobacco Control’s potential by investing in national capacity. Tobacco Control, 13(4), 433-437.
Wisotzky, M., Albuquerque, M., Pechacek, T., & Park, B. (2004). The National Tobacco Control Program: focusing on policy to broaden impact. Public Health Reports, 119(3), 303-310.

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