Paradox of sustainability in tobacco control in Thailand: A comprehensive assessment of three-decade experiences

Abstract

Background: Over the past 3 decades of tobacco control, Thailand has gained international recognition as a middle-income country with sustained achievement of declining smoking prevalence. However, the number of key Framework Convention on Tobacco Control measures implementation is still far away from the highest-level implementation. As a result, we aim to explore explanatory factors for the paradoxical phenomenon of sustainability in tobacco control in Thailand, to understand what the paradox means, why it happens, and how to take further steps in minimizing the paradox. Methods: We used a mixed-method approach comprising qualitative (review of literature and documents plus Program Sustainability Assessment Tool [PSAT] guided key informant interviews) and semi-quantitative methods (PSAT scoring, Theory of Change [TOC], and causal-loop diagram [CLD]) to synthesize all the findings from the qualitative data. Results: Across all eight domains, sustainability scores at the local level are lower than the national level. The highest total score was in three domains: political support, partnership, and organizational capacity. The lowest total score was for the strategic planning domain. We propose a set of key strategic elements and drivers for future strategic planning. Discussion: Using CLD, we capture a high-level view of tobacco control with dynamic interactions between contexts, mechanisms, interventions, and outcomes. We believe the deep understanding of tobacco control and the proposed strategy to counteract transnational tobacco companies in Thailand will guide future sustainable actions to reduce the prevalence of smoking, especially in the strategic planning domain that has the lowest PSAT score.