Mervat Al-Mherat, the city manager and deputy for health and agricultural affairs for Amman
Mervat Al-Mherat, the city manager and deputy for health and agricultural affairs for Amman, says stress was identified as an underlying cause of her city's high smoking rate. Melanie Leigh Wilbur

In Amman, Jordan, officials want to look to underlying causes to address high smoking rates.

Public health campaigns in cities have long focused on changing individual behaviors: Don’t smoke. Use a condom. Don’t drink and drive.

But public health leaders from around the world are starting to acknowledge that the scope of their work must extend to underlying factors that cause risky behaviors.

“Our work can’t be limited to exhortations to eat better and stop smoking,” said Adam Karpati, a senior vice president at Vital Strategies, an organization that works to strengthen public health systems primarily in developing countries. “Public health practitioners need to be looking at more upstream determinants, too,” he added, speaking on a panel at CityLab Paris.

In Jordan, where some 60 percent of men smoke, tobacco use is a leading killer. Since 2012, the capital city of Amman has developed a tobacco licensing scheme, clearer smoking guidelines for restaurants and cafes, and public media campaigns to reduce local smoking rates. But one thing that’s still needed, according to Mervat Al-Mherat, the city manager and deputy for health and agricultural affairs for Amman, is a better understanding of why people smoke to begin with.

In a survey of Amman’s municipal staffers, in which some 70 percent reported smoking either tobacco or water pipes, many said that they smoke in order to relieve stress. “Some said they’re stressed because of their jobs, others said they’re stressed because of economic [factors],” Al-Mherat said, adding that she worries that social norms in Jordan do not allow much room for people to talk about what is stressing them. “Sometimes you need to know about what you are feeling, to understand the emotional issue that you are living in,” she said. “We don’t have this enough.”

Particularly in cities, a person’s health can be governed by psychological stressors in the environment, such as working conditions, housing, transportation, and access to childcare. Douglas Bettcher, the director of non-communicable disease prevention programs at the World Health Organization, said that leaders are just beginning to incorporate environmental and social factors that weigh on mental health into global policy frameworks.

“Stress adds onto [the threat] of other risk factors, like unhealthy diets, smoking, and obesity,” he said.  Some of the world’s most common and lethal noncommunicable conditions, such as cardiovascular disease, are closely linked to a person’s stress level. At the next meeting of heads of state, organized by WHO, mental health will be on the agenda, Bettcher stated.

Although the physiological links between mental and physical well-being are not all fully understood, there is growing acceptance among the medical community that the two should not be treated separately. For public health leaders, that means examining the effects of their citizens’ surroundings, and the role socioeconomic factors play, Karpati said. Proven strategies that work on changing individual behaviors should not be discarded, he added.

But at the local level especially, “economic development and social services matter,” he said. “Public health leaders need to be in those conversations.”

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