Decline In Smoking Prevalence Research Articles

Prevalence of smoking habits, attitudes and knowledge on counteractive strategies among a sample of healthcare employees: results of the smoking-free health environments project in the province of Palermo, Italy.

Tobacco use is responsible for over 7 million deaths annually, making smoking the leading cause of preventable mortality globally. Over the last two decades in Italy, the prevalence of smoking among physicians has consistently decreased, while it remains higher and is gradually decreasing among non-physician healthcare workers. The aim of this study was to investigate the Prevalence of smoking habits, attitudes, and knowledge on counteractive strategies among employees in the Primary Healthcare Facilities in the Province of Palermo, Italy. A cross-sectional survey was conducted between June 2020 and December 2020 through a previously validated anonymous questionnaire structured in four sections including 34 items. Data were analyzed using Stata/MP 12.1 statistical software. Overall, 2,645 participants answered the questionnaire. The prevalence of either current or former smokers was 18.6%. Based on the multivariable analysis conducted, a significantly higher frequency of current smokers was observed among male participants (AdjOR: 1.29; CI95%: 1.02-1.64) and those belonging to the Surgical Unit (AdjOR: 1.92; CI95%: 1.27-2.90). Conversely, the prevalence of current smokers was significantly lower among those with at least one child (AdjOR: 0.67; CI95%: 0.49-0.91), with an educational qualification equal to or greater than a graduation degree (AdjOR: 0.56; CI95%: 0.43-0.73), those who considered second-hand smoke harmful (AdjOR: 0.06; CI95%: 0.008-0.60), those who had observed smoking or detected the smell of smoke in their workplace (AdjOR: 0.64; CI95%: 0.45-0.91). Furthermore, the prevalence of current smokers was significantly lower among participants who believed that healthcare professionals could play a crucial role in influencing their patients' lifestyles (AdjOR: 0.67; CI95%: 0.50-0.90) and among those who recommend their patients to quit smoking (AdjOR: 0.35; CI95%: 0.24-0.51). The results of the current research demonstrate that, despite the decline in smoking prevalence among physicians, the rate of smokers among healthcare facility employees remains unacceptably high. This underscores the need to re-evaluate current anti-tobacco strategies in the workplace.

A multicenter prospective randomized controlled trial investigating the effects of combustion-free nicotine alternatives on cardiovascular risk factors and metabolic parameters in individuals with type 2 diabetes who smoke: the DiaSmokeFree study protocol

Stopping smoking is crucial for public health and especially for individuals with diabetes. Combustion-free nicotine alternatives like e-cigarettes and heated tobacco products are increasingly being used as substitutes for conventional cigarettes, contributing to the decline in smoking prevalence. However, there is limited information about the long-term health impact of those products in patients with diabetes. This randomized controlled trial aims to investigate whether switching from conventional cigarettes to combustion-free nicotine alternatives will lead to a measurable improvement in cardiovascular risk factors and metabolic parameters over a period of 2 years in smokers with type 2 diabetes. The multicenter study will be conducted in seven sites across four countries. A total of 576 smokers with type 2 diabetes will be randomly assigned (1:2 ratio) to either standard of care with brief cessation advice (Control Arm) or combustion-free nicotine alternatives use (Intervention Arm). The primary end point is the change in the proportion of patients with metabolic syndrome between baseline and the 2-year follow-up. Additionally, the study will analyze the absolute change in the sum of the individual factors of metabolic syndrome at each study time point. Patient recruitment has started in September 2021 and enrollment is expected to be completed by December 2023. Results will be reported in 2026. This study may provide valuable insights into cardiovascular and metabolic health benefits or risks associated with using combustion-free nicotine alternatives for individuals with type 2 diabetes who are seeking alternatives to tobacco cigarette smoking. The study protocol, informed consent forms, and relevant documents were approved by seven ethical review boards. Study results will be disseminated through articles published in high-quality, peer-reviewed journals and presentations at conferences.

Effects of Ovarian Hormone Levels on Stress, Cigarette Craving, and Smoking in a Laboratory Relapse Paradigm Among Females Who Smoke Daily.

Females, versus males, have shown a slower decline in smoking prevalence, greater smoking-related mortality and morbidity, and tend to have more difficulty achieving and maintaining abstinence. Identifying sex-specific risk factors is needed to improve outcomes. Though ovarian hormones have been evaluated for their role in smoking and relapse, measures tend to be static and infrequent, failing to capture the influence of increasing or decreasing levels. The present study evaluated the effect of static and fluctuating levels of ovarian hormones (ie, progesterone, estradiol, and estrogen to progesterone [E/P] ratio) on stress reactivity, cigarette craving, and smoking during a laboratory relapse paradigm. Female participants (assigned female at birth) reporting daily cigarette smoking (N = 91, ages 18-45) were recruited from the community. Participants provided daily salivary ovarian hormone levels leading up to a laboratory session, in which stress was induced and stress reactivity, cigarette craving, latency to smoke, and ad-libitum smoking were measured. Static levels of estradiol were associated with stress reactivity (β = 0.28, SE = 0.13) and static E/P ratio was associated with smoking in the laboratory (HR = 1.4). Preceding 3-day changes in estradiol and E/P ratio, but neither static levels nor preceding 3-day changes in progesterone were associated with stress reactivity, cigarette craving, or smoking in a relapse paradigm. Ovarian hormones are among several sex-specific factors involved in the complex neuroendocrine response to stress, and their interaction with other biological, social, and psychological factors in the real-world environment is not yet fully understood. Findings of the present study provide novel information regarding the role of ovarian hormones among female participants who smoke daily in stress reactivity and smoking in the context of a laboratory relapse paradigm and highlight several avenues for future research. We found that same-day estradiol levels were associated with increased subjective stress reactivity and same-day estrogen to progesterone ratio was associated with increased likelihood of smoking in a relapse paradigm. Ovarian hormones are among several sex-specific factors contributing to the complex neuroendocrine response to stress, and their interaction with other biological, social, and psychological factors in the real-world environment is not yet fully understood.

Global, regional, and national deaths, disability-adjusted life years, years lived with disability, and years of life lost for the global disease burden attributable to second-hand smoke, 1990–2019: A systematic analysis for the Global Burden of Disease Study

BackgroundSmoke-free policies have led to a decline in smoking prevalence. Nevertheless, as the global population grows, more non-smokers are exposed to second-hand smoke (SHS) hazards. Mitigating SHS hazards requires a systematic analysis of the global disease burden attributable to SHS. MethodsData on SHS was extracted from the Global Burden of Disease Study 2019. First, we measured the disease burden of SHS by the number of cases and age-standardized rates of deaths, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) from 1990 to 2019. Second, trends in the disease burden of SHS in different periods were estimated based on the annual percentage change (APC) by joinpoint regression analysis. Finally, using histogram plots, world maps, Pearson correlation analysis, and population attributable fraction (PAF), we conducted a stratified analysis of SHS exposure by sex, age, geographic location, sociodemographic index (SDI) level, and disease. ResultsThe number of deaths caused by SHS remained stable between 1990 and 2019, and the number of YLDs more than doubled in three decades. In contrast, the number of DALYs and YLLs caused by SHS decreased. The declining trend in deaths (APC = −1.42 % [95 % UI −1.79 %, −1.05 %]), DALYs (APC = −1.91 % [95 % UI −2.15 %, −1.67 %]), and YLLs (APC = −1.28 % [95 % UI −1.93 %, −0.64 %]) had slowed down in recent years, while SHS-related YLDs were still increasing (APC = 1.84 % [95 % UI 0.74 %, 2.96 %]). From 2010 to 2019, we found that SHS exposure increased the risk of tracheal, bronchus, and lung cancer (PAF increased by 11.75 %), breast cancer (PAF increased by 5.36 %), diabetes mellitus (PAF increased by 8.24 %), and ischemic heart disease (PAF increased by 4.46 %). In addition, the disease burden caused by SHS was highest in middle SDI and low-middle SDI countries. ConclusionThe global disease burden attributable to SHS is still severe, and policymakers need to implement more effective measures to reduce the harm of SHS.

Country differences in the cross-sectional associations between smoking and depressive symptoms in adolescence.

The aim of the present study was to compare the cross-sectional association between smoking and depressive symptoms among adolescents between Sweden and Italy, two countries historically characterized by different norms about tobacco use and different tobacco control efforts. A cross-sectional study including 3283 adolescents 15-16 years of age participating in the Swedish KUPOL study and 1947 same-age adolescents from the Italian BE-TEEN study. Current smoking was defined as any smoking in the past 30 days. Depressive symptoms were assessed using the Centre for Epidemiological Studies Depression Scale for Children (CES-DC) and the internalizing score of the Strengths and Difficulties Questionnaire (SDQ). Country differences were explored in stratified and interaction analyses. Current smoking was associated with a 2- to 3-fold increased odds of depressive symptoms among Swedish adolescents using both CES-DC and SDQ internalizing scale. Among Italian adolescents, slightly lower increased odds of 1.5-2.5 for depressive symptoms with smoking were found using the CES-DC but not the SDQ scale. Both multiplicative and additive interactions for country were significant. The association between smoking and depressive symptoms was weaker among Italian compared with Swedish adolescents for both scores. Countries with different tobacco norms and control show different associations between smoking and depressive symptoms in adolescence, probably due to different psychosocial profiles of smokers. These findings need to be considered when planning tobacco prevention programmes, e.g. by focusing on early detection of mental health distress among adolescents in settings with declining smoking prevalence and restrictive tobacco control environments.

The 1964 US Surgeon General's report on smoking and health.

The 1964 report of the US Surgeon General on smoking and health made an authoritative case that tobacco smoking was a cause of premature deaths from lung cancer and chronic bronchitis. It justified the practice of drawing causal inferences from epidemiological studies, specified influential criteria for doing so, and made use of an early form of meta-analysis.

Intratumoral Heterogeneity and Immune Modulation in Lung Adenocarcinoma in Female Smokers and Never Smokers.

Single-cell analysis of healthy lung tissue and lung cancer reveals distinct tumor cell populations, including cells with differential immune modulating capacity between smokers and never smokers, which could guide future therapeutic strategies.

Smoking in social housing among adults in England, 2015–2020: a nationally representative survey

ObjectivesTo analyse associations between living in social housing and smoking in England and to evaluate progress towards reducing disparities in smoking prevalence among residents of social housing compared with other...

Monitoring the Increase in the U.S. Smoking Cessation Rate and Its Implication for Future Smoking Prevalence.

We calculate the U.S. adult smoking cessation rate for 2014-2019, compare it to the historical trend, and estimate the implication for future smoking prevalence. We repeated an earlier analysis, which examined the cessation rate from 1990 to 2014, extending the period to 2019. Employing National Health Interview Survey (NHIS) and National Survey on Drug Use and Health (NSDUH) data, we estimated the adult cessation rate in 6-year intervals, using weighted nonlinear least squares. We then employed a meta-regression model to test whether the cessation rate has increased beyond expectation. We used cessation rate estimates and smoking initiation rate estimates to project smoking prevalence in 2030 and eventual steady-state prevalence. The annual cessation rate increased 29% using NHIS data (from 4.2% in 2008-2013 to 5.4% in 2014-2019) and 33% with NSDUH data (4.2%-5.6%). The cessation rate increase accounts for 60% of a smoking prevalence decline in the most recent period exceeding the 1990-2013 predicted trend. The remaining 40% owes to declining smoking initiation. With current initiation and cessation rates, smoking prevalence should fall to 8.3% in 2030 and eventually reach a steady state of 3.53%. The smoking cessation rate continued to increase during 2014-2019. NHIS and NSDUH results are practically identical. The larger share (60%) of the smoking prevalence decrease, beyond expectation, attributable to the increased cessation rate is encouraging since the positive health effects of cessation occur much sooner than those derived from declining initiation. The smoking cessation rate in the United States continues to increase, accelerating the decline in smoking prevalence. This increase suggests that the Healthy People 2030 goal of 5% adult smoking prevalence, while ambitious, is attainable. Our findings can be used in simulation and statistical models that aim to predict future prevalence and population health effects due to smoking under various scenarios.

Co-Plot Method: A Research on Tobacco Control in the European Region

BACKGROUND: The aim of this study is to introduce the uncommonly used Co-Plot method which is called the multivariate graphical analysis and to apply this method to a data set including tobacco control in European region.METHODS: This study uses the data from the World Health Organization database according to Human Development Index of European countries. It takes into account variables such as smoking prevalence in young people and adults, the proportion of smoking-related deaths and domestic legislations casespertaining to tobacco products and analyses the data using the Co-Plot method.RESULTS: Results of the study demonstrated that smoking prevalence and restrictions on advertising of tobacco products were highly negatively correlated. The proportion of deaths associated with smoking-related diseases increased parallel to the increase in the smoking prevalence in young people and adults. Norway, France and Finland have enforced legal limitations on direct and indirect advertising, and thus there has been a decline in smoking prevalence among young people andadults. In some countries, including Ireland, Italy and Serbia, the prevalence of smoking among the young has decreased due to the new or increased legal restrictions on the sale distribution of tobacco products. The governments in the Czech Republic, Kazakhstan, Estonia, Croatia, the Netherlands,Belgium, and Poland have placed restrictions on direct and indirect advertising. The distribution of other causes-related deaths and lung cancer-related deaths are high.CONCLUSION: The restrictions on tobacco products were tightened in time with the increased prevalence of smoking and proportion of smoking-related deaths. It can be said that the significantrelationships identified in this study have even more pertinence in developed countries. Consequently, Co-Plot method has enabled deeper data interpretations of the relationships between the countries and the variables in this study.

FCTC ratification, smoking prevalence, and GDP per capita: lessons for Indonesia and the rest of the world

BackgroundIndonesia’s stagnated progress towards tobacco control could be addressed through the implementation of a comprehensive national framework, such as the World Health Organization’s (WHO) Framework Convention of Tobacco Control (FCTC). However, national tobacco industry supporters argue that accepting the FCTC will have negative economic implications for the country. These arguments have, thus far, discouraged the Indonesian government from ratifying the FCTC. Drawing from an analysis of the impact of the FCTC on other countries’ smoking rates and Gross Domestic Product (GDP) per capita, this study offers empirical evidence against industry arguments concerning the potential negative economic impacts of FCTC adoption. This study applies a two stage least square estimation strategy to unbalanced panel data at country level. In the first stage we estimate the impact of FCTC ratification on smoking rates, and in the second step, we estimate the influence of smoking activity on macroeconomic performance.ResultsThe result of this study shows that FCTC ratification has a negative impact on a country’s smoking prevalence. While FCTC ratification positively correlates with reduced smoking prevalence, a decline in smoking prevalence is not related to a decline in GDP per capita.ConclusionsThe results of this study shows that FCTC ratification, which can be an important driver for more effective tobacco control, does not necessarily have a negative impact on the economy. Instead, FCTC ratification may be beneficial for both health and economic outcomes, as it provides comprehensive guidance for reducing smoking prevalence that take into account social and economic factors.

Low-intensity cigarette smoking and mortality risks.

In ‘Low-intensity cigarette smoking and mortality risks: a pooled analysis of prospective cohort studies in Japan’, the authors pool multiple prospective cohort studies to assess the relationship between low-intensity smoking and mortality risk. This study refutes the common belief that low-intensity smoking is not harmful and found a higher risk of mortality among all causes in low-intensity smokers versus never smokers.1 However, the study could be improved in the following ways. Although the authors do acknowledge that the cohorts included in this study only included a smoking status assessment at baseline (with the exception of the Japan Public Health Center-based Prospective Study Cohorts I and II, which re-assessed smoking status at 5 years of follow-up), the study could be improved with more elaboration regarding the impact of this limitation on the study findings. The authors discuss the large decline in smoking prevalence over the recent decades and make the claim that it is likely that many participants reduced or quit smoking, which would improve the observed effect measures; however, all cohorts included individuals over 40 years of age at the time of enrollment, with no stratification by the authors to account for differences in smoking habits by age groups. Research is still unclear as to whether or not the elderly are just as likely as the general population to quit or reduce their smoking. A study conducted in South Korea found that advancing age was not associated with a decline in prevalence of smokers, regardless of gender.2 Given that the readers cannot ascertain the age distribution of the included cohorts from the article, it is difficult to tell whether or not the majority of included participants fall into the age range of elderly or if most are between 40 and 64 years of age. If many of the participants were elderly at baseline, it cannot be safely assumed that many of them quit or reduced their smoking during the follow-up period.

Heated tobacco products for smoking cessation and reducing smoking prevalence.

Heated tobacco products for smoking cessation and reducing smoking prevalence.

Do Epigenetic Clocks Provide Explanations for Sex Differences in Life Span? A Cross-Sectional Twin Study.

The sex gap in life expectancy has been narrowing in Finland over the past 4-5 decades; however, on average, women still live longer than men. Epigenetic clocks are markers for biological aging which predict life span. In this study, we examined the mediating role of lifestyle factors on the association between sex and biological aging in younger and older adults. Our sample consists of younger and older twins (21‒42 years, n = 1 477; 50‒76 years, n = 763) including 151 complete younger opposite-sex twin pairs (21‒30 years). Blood-based DNA methylation was used to compute epigenetic age acceleration by 4 epigenetic clocks as a measure of biological aging. Path modeling was used to study whether the association between sex and biological aging is mediated through lifestyle-related factors, that is, education, body mass index, smoking, alcohol use, and physical activity. In comparison to women, men were biologically older and, in general, they had unhealthier life habits. The effect of sex on biological aging was partly mediated by body mass index and, in older twins, by smoking. Sex was directly associated with biological aging and the association was stronger in older twins. Previously reported sex differences in life span are also evident in biological aging. Declining smoking prevalence among men is a plausible explanation for the narrowing of the difference in life expectancy between the sexes. Data generated by the epigenetic clocks may help in estimating the effects of lifestyle and environmental factors on aging and in predicting aging in future generations.

Rise and fall of lung cancers in relation to tobacco smoking and air pollution: A global trend analysis from 1990 to 2012

Lung cancer remains the leading cancer in incidence and mortality in both genders and most countries. Global cancer statistics show a declining trend of lung squamous cell carcinoma (LSCC) but an uprising trend of lung adenocarcinoma (LADC). The reasons behind their opposite trends are unclear. This study aims to analyze the global trends of LSCC and LADC during 1990–2012 in relation to tobacco consumption and air pollution. Results show a 1% decline of smoking prevalence of 7 years ago is associated with a 9% (95% confidence interval: 8%, 10%) drop in the LSCC incidence globally, whereas a 0.1 μg/m3 increment of BC of 7 years ago is associated with a 12% (9%, 16%) increase in LADC incidence globally. Association between BC and LSCC (or LADC) is more prominent in females, with a 14% (7%, 20%) increase in LSCC [or 14% (11%, 19%) increase in LADC] incidence for a 0.1 μg/m3 increment of BC of 8 (or 6) years ago. Associations vary with different genders across different continents. For instance, concentration of BC is positively associated with incidence of both LSCC and LADC in Europe and North America, whereas concentration of sulfate is positively associated with LSCC incidence in Europe and Oceania, and with LADC incidence in Asia, Oceania and South America. We conclude global decreasing LSCC incidence is associated with the reduced tobacco consumption, whereas the global increasing LADC incidence is likely associated with air pollution. Various particulate species have divergent effects on LADC incidence in different continents.

Changes in adult smoking behaviours in ten global adult tobacco survey (GATS) countries during 2008\u20132018 - a test of \u2018hardening\u2019 hypothesis\u2019

BackgroundHardcore smoking behaviours and test of hardening are seldom reported from low-and-middle-income countries (LMICs). We report country-wise changes in smoking behaviors between two sequential surveys and explored ecologically the relationship between MPOWER scores and smoking behaviors including hardcore smoking.MethodsWe analysed sequential Global Adult Tobacco Survey (GATS) data done at least at five years interval in 10 countries namely India, Bangladesh, China, Mexico, Philippines, Russia, Turkey, Ukraine, Uruguay, and Vietnam. We estimated weighted prevalence rates of smoking behaviors namely current smoking (both daily and non-daily), prevalence of hardcore smoking (HCS) among current smokers (HCSs%) and entire surveyed population (HCSp%), quit ratios (QR), and the number of cigarettes smoked per day (CPD). We calculated absolute and relative (%) change in rates between two surveys in each country. Using aggregate data, we correlated relative change in current smoking prevalence with relative change in HCSs% and HCSp% as well as explored the relationship of MPOWER score with relative change in smoking behaviors using Spearman’ rank correlation test.ResultsOverall daily smoking has declined in all ten countries lead by a 23% decline in Russia. In India, Bangladesh, and Philippines HCSs% decreased as the smoking rate decreased while HCSs% increased in Turkey (66%), Vietnam (33%) and Ukraine (15%). In most countries, CPD ranged from 15 to 20 sticks except in Mexico (7.8), and India (10.4) where CPD declined by 18 and 22% respectively. MPOWER scores were moderately correlated with HCSs% in both sexes (r = 0.644, p = 0.044) and HCSp% (r = 0.632, p = 0.05) and among women only HCSs% (r = 0.804, p = 0.005) was significantly correlated with MPOWER score.ConclusionWith declining smoking prevalence, HCS had also decreased and quit rates improved. Ecologically, a positive linear relationship between changes in smoking and HCS is a possible evidence against ‘hardening’. Continued monitoring of the changes in quitting and hardcore smoking behaviours is required to plan cessation services.

An estimation of the harm of menthol cigarettes in the United States from 1980 to 2018

BackgroundMenthol cigarettes are thought to encourage smoking initiation among youths and young adults and make it more difficult for smokers to quit, thus increasing cigarette harm. However, no study to...

The social gradient in smoking: individual behaviour, norms and nicotine dependence in the later stages of the cigarette epidemic

The cigarette epidemic tends to develop in a similar pattern across diverse populations in different parts of the world. First, the prevalence of smoking increases, then it plateaus and finally it declines. The decline in smoking prevalence tends to be more pronounced in higher social strata. The later stages of the cigarette epidemic are characterized by emerging and persisting socioeconomic gradients in smoking. Due to its detrimental health consequences, smoking has been the subject of extensive research in a broad range of academic disciplines. I draw on literature from both the social and medical sciences in order to develop a model in which physiological nicotine dependence, individual smoking behaviour and norms surrounding smoking in the immediate social environment are related through reflexive processes. I argue that the emergence and persistence of social gradients in smoking at the later stages of the cigarette epidemic can be attributed to a combination of the pharmacological properties of nicotine, network homophily and the unequal distribution of material and non-material resources across social strata.

Abstract 14445: The Prevalence of Coronary Risk Factors Among Patients Undergoing Their First Percutaneous Coronary Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

Background: Coronary artery disease (CAD) is the leading cause of death globally and risk factors for CAD are well established. Although there has been a decline in the incidence of CAD in recent years, understanding the risk factor profile of patients presenting with cardiac disease in contemporary practice may help define current unmet challenges in preventing CAD. Objectives: To evaluate the prevalence of CAD risk factors among patients undergoing percutaneous coronary intervention (PCI) and assess how they have changed over time. Methods: We assessed the prevalence of risk factors among patients without a history of prior myocardial infarction, PCI, or coronary artery bypass graft surgery who underwent PCI at 47 non-federal hospitals in the state of Michigan between 1/1/2010 and 3/31/2018 using the BMC2 PCI registry. Results: Our study cohort included 69,970 men and 39,106 women. Traditional risk factors were highly prevalent in this population: 34.4% of men and 31.0% of women were current or recent smokers, hypertension was present in 71.8% of men and 80.6% of women, hyperlipidemia was present in 65.0% of men and 68.9% of women, diabetes was present in 27.8% of men and 35.5% of women, and 44.8% of men and 48.0% of women were obese. Over the study period, the prevalence of diabetes (29% to 32%) and obesity (45% to 48%) increased while a decline in smoking prevalence was noted (34% to 31%). Most patients had 2 or more risk factors with 51.2% having three or more risk factors. Compared with nonsmokers, smokers presented over a decade earlier (age 56.8 versus 66.9 years, p < 0.0001) and obese patients presented 4.0 years earlier (age 61.4 versus 65.4 years, p < 0.0001) (Figure). Conclusions: Modifiable risk factors are widely prevalent among patients undergoing their first PCI. Population-level interventions aimed at controlling obesity and preventing smoking could significantly delay the onset of CAD and the need for PCI.

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

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. 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. 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. 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.