Stress and Health 27: 89–91 (2011) © 2011 John Wiley & Sons, Ltd. 89

EDITORIAL

Stress and Non-communicable Disease: A Multi-pronged Approach to Building Healthier Coping SkillsOliver Harrison1, MA, MBBS & Cary L. Cooper2*†, CBE

1Director, Public Health and Policy, Health Authority – Abu Dhabi, PO Box 5674, Abu Dhabi, United Arab Emirates2Professor, Organizational Psychology and Health, Lancaster University Management School, Lancaster, LAI 47W, UK

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.1400

In global health, 2011 is building to be the year of non-

communicable diseases (NCD), with considerable

focus on a special session of the United Nations General

Assembly now scheduled for the 19–20 September and

a discussion of including specifi c targets for NCD

reduction in the next round of Millennium Develop-

ment Goals for 2015. When global leaders meet to

discuss NCD, much of their focus on reducing the

disease burden will centre on how to change just four

behaviours; these are poor diet, physical inactivity,

tobacco smoking and the excessive consumption of

alcohol. This is because reducing these four behaviours

together has been shown to reduce premature morbid-

ity and mortality by 70% [World Health Organization

(WHO), 2009)] since they act as ‘fi nal common path-

ways’ for a complex web of factors that link to both

stress and health. From a behaviourist perspective, these

are the four observed behaviours that we need to

change; the key questions are (1) how to change them

in individuals; and (2) how to do that at scale across

populations. To develop effective ways to do that, we

need to understand better the underlying causes and

particularly the modifi able causes.

It is a central tenet of work in our fi eld that stress

and health are closely related, with causal relationships

in both directions. As a journal, Stress and Health has a

strong track record in describing both the role of stress

in the pathogenesis of physical and mental disorders,

and the stress caused by ill-health (Rinaldi, Fontani,

Aravagli, & Margotti, 2010). The prominent models

emphasize the mediation of such relationships through

a blend of physiological, endocrine and psychological

processes (for example, Glaser & Kiecolt-Glaser, 2005;

Kozora, Ellison, & Sterling, 2009). With increasing

global attention on NCD, there is an opportunity for

our fi eld to make a signifi cant contribution to improv-

ing global health; now is the time for our discipline to

align around meeting some of the grand challenges in

NCD (Daar et al., 2007).

In the presence of life stressors, healthy individuals

develop a range of coping strategies that can mitigate

the potential psychological and physiological harm that

stress can cause. Such coping strategies classically

include those that are conscious (‘coping skills’) and

those that are unconscious (‘defence mechanisms’)

(Dewe, O’Driscoll, & Cooper, 2010). In everyday lan-

guage, we commonly apply a range of terms to such

coping strategies; these may be somewhat judgmental

if there is perceived harm (for example, behaviours

become a ‘habit’), or even be used in a language that

defi nes the individual themselves (for example, ‘smoker’

or ‘alcoholic’).

Coping skills may have a basis in hard-wired neuro-

logical systems related to attention (Posner & Rothbart,

2007), but the specifi c personal expression of the under-

lying behaviour is typically learned by modelling from

parents or peers, and may be perpetuated through per-

ceived social norms (Rosenbaum, 1990). For example,

in the United Kingdom, alcohol is regularly consumed

in the evenings and weekends as a coping strategy to

alleviate stress related to work; the same underlying

strategy may manifest as shisha smoking in the Middle

East or as marijuana smoking in the Caribbean.

In most societies worldwide, there is an increase in

certain unhealthy behaviours such as overeating,

tobacco smoking and the excessive consumption of

alcohol; the consequences of these are spiralling rates

*Correspondence to: Professor C.L. Cooper, CBE (Editor), Organi-

zational Psychology and Health, Lancaster University Management

School, Lancaster, LAI 47W, UK.†Email: c.cooper1@lancaster.ac.uk

A Multi-pronged Approach to Building Healthier Coping Skills O. Harrison and C. L. Cooper

90 Stress and Health 27: 89–91 (2011) © 2011 John Wiley & Sons, Ltd.

of cardiovascular and respiratory diseases and mental

health problems, including depression, anxiety and

substance misuse (WHO, 2009). Of course, we live in a

constantly changing world, with individual consumer

choices infl uenced by a complex web of drivers. Within

this web, what makes these behaviours unhealthy is rep-

etition over time and a lack of control. In many cases,

individuals describe eating as a tasty meal, putting their

feet up, smoking a cigarette or drinking alcohol in the

language of coping skills; that is, that engaging in such

behaviours ‘helps them through the day’ or is ‘one of

the pleasures in life’. In the long term, however, the

overuse of such coping strategies does not reduce stress;

when such behaviours become uncontrolled or stereo-

typical, they may, of course, actually contribute to stress

and ill-health. In this context, these unhealthy behav-

iours become maladaptive coping skills (of course,

tobacco consumption being an outlier as there is no safe

level of consumption). While such maladaptive coping

skills are not, in themselves, considered to be disorders

(in either the International Classifi cation of Diseases-

10th Revision or the Diagnostic and Statistical Manual

of Mental Disorders-Fifth Edition), poor self-control

may be precipitated or perpetuated by stress, and the

consequences may include stress and ill-health.

An effective roadmap for action against NCD will

require three key components. Firstly, a simple yet

durable model should be created to map the key drivers

of such unhealthy behaviours. Such a model should

include endogenous factors (such as genetics, physiology

and neurology) and exogenous factors (such as learned

behaviours, the economics of consumption and per-

ceived social norms). Secondly, building on the model

of behavioural drivers, modifi able factors should be

identifi ed, that is, those that may be proactively adapted.

Thirdly, practical tools for the adaptation of the modi-

fi able factors should be developed.

Towards a simple and durable model of the drivers of the four key unhealthy behaviours

Affi rmative action on NCD will require the participa-

tion of a wide range of stakeholders, including those

that are not clinicians, psychologists or health econo-

mists. In addition, it is critical that policy-makers

understand the drivers of maladaptive coping skills

(unhealthy behaviours), particularly those that are

amenable to economic or policy intervention. Creating

such a broad understanding requires the model to be

simple. At the same time, however, we know that there

are multiple factors at play, including those that are

endogenous to individuals and those that are exoge-

nous; an effective model must recognize this complex-

ity, plus the interdependencies that link together the

factors. The specifi c challenge here is that the model

must be both simple and robust, building on the con-

siderable theoretical and empirical work in the area,

and then distilling the content down so that it can be

widely understood by a broad set of stakeholders.

In developing such a model, it should be recognized

that maladaptive coping skills are learned behaviours,

with a strong infl uence possible from parents, siblings,

friends, colleagues and fi gures in the media (and resil-

ience playing a protective role at the individual, family

and community levels). Unhealthy behaviours may

become uncontrolled or stereotypical through the per-

petuating infl uence of ubiquity, lower-perceived cost of

consumption, social norms and marketing that appeals

to the ego; where individual susceptibility meets suit-

able products and/or environment, there may be a

frank addiction (Patterson, Krupitsky, Flood, Baker, &

Patterson, 1994). Critically, certain maladaptive behav-

iours are actively promoted by specifi c industries where

the economic incentives are misaligned with health. A

clear example is the tobacco industry (with companies

continuing to extol the ‘liberty’ encapsulated in a ciga-

rette), with additional examples including the alcohol

industry (marketing the ‘indulgence’ of certain prod-

ucts), and the food and beverage industries actively

driving the volume sales of products such as chocolate,

sweets and crisps.

It is certainly not all bad news, there are attempts at

public health intervention by industry, for example,

Drinkaware in the United Kingdom (set up and funded

by alcohol manufacturers and retailers). However, there

often remains a fundamental misalignment of incen-

tives; between industry and public health whereas indi-

viduals may consume an ‘excess’ defi ned according to the

negative effects on their health, for industry stakehold-

ers, higher sales typically equate to higher revenues.

Identifying the modifi able factors

The factors amenable to proactive adaptation should be

identifi ed within the model. Some of these modifi able

factors will, themselves, have underlying drivers, for

example the economics of those industries that promote

unhealthy behaviours. In the path to generating practical

O. Harrison and C. L. Cooper A Multi-pronged Approach to Building Healthier Coping Skills

Stress and Health 27: 89–91 (2011) © 2011 John Wiley & Sons, Ltd. 91

tools for intervention, there should be focused engage-

ment around specifi c challenges; this targeted problem-

solving approach has worked well in the global efforts to

tackle communicable diseases (Global Fund, 2010).

Developing practical tools for intervention

The ultimate goal of the process set-out here is the

development of practical tools for piloting, refi nement

and broad implementation. The development of such

tools must continue to involve academics working in

the idealized environment of a laboratory experiment

or a trial; however, we must recognise that impact at the

societal level will require effectiveness outside the con-

trolled experimental environments. Scalable impact

requires the active engagement of a range of stakehold-

ers. Key among these will be policy-makers who will

need to be convinced of the importance of affi rmative

action, and of both the effectiveness and the practicality

of intervention. For example, an outright ban on the

sale of tobacco certainly may reduce the prevalence of

smoking, but it would be an unpalatable step today for

most governments.

Practical strategies will align the behaviours of indus-

try, which typically spends far more on marketing its

products and services than public health practitioners,

and is often more effective at driving consumer behav-

iours. Critically, with industry on board and incentives

aligned, change may begin to propel itself. Without prej-

udice or blame, open engagement should simply ask the

question ‘what would it take to change the behaviour?’

To enable the participation of industry, interventions

should be implemented steadily and with clear time-

lines, allowing suffi cient time for early-adopter compa-

nies to come on board and actively drive the change. An

example is the steady change of focus for food and

beverage manufacturers towards healthier products; an

early adopter is PepsiCo (see http://www.pepsico.com/

Purpose/Human-Sustainability.html, last accessed 7

March 2011). While public health academics often

lambast industry, it is the industry that actually pro-

duces the goods and services we consume—they are

thus an essential force in shaping our behaviours.

In addition to regulating industries, adaptive coping

skills should be promoted through targeted interven-

tions aimed at new parents, the school curriculum, and

socially responsible media, products and services. Fur-

thermore, advertising standards might be amended to

prevent the active promotion of maladaptive coping

strategies. A core focus of future work on NCD should

be on building healthy coping skills (alongside limiting

unhealthy coping skills).

In summary, 2011 will see a strong global focus on

NCD, and through that focus, an interest in how we can

alter just four widespread behaviours effectively and at

scale. There are complex interrelationships linking

these risk factors to stress and to health, and this Journal

welcomes contributions that help create a simple and

robust model, identify the modifi able factors, and

develop practical tools for implementation.

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