Traditional neoclassical economics suggests possible explanations such as a lack of relevant information or large countervailing costs. In turn, policy makers and researchers have often focused on the health system, user fees, or information, in seeking to remove external obstacles and encourage healthy behaviors. But, while effective, these actions alone have been insufficient to address the full complexity of health behavior change and habit formation. Relative ignorance or limited knowledge on these issues might once have been widespread and undoubtedly still exist among certain population groups. However, in most countries, the majority of adults are now aware of the health risks of, for example, tobacco and alcohol use (i.e., WHO Global Adult and Youth Tobacco Surveys). Hence, lack of knowledge is unlikely to be a driving explanation of unhealthy behaviors. Similarly, although for some people in some situations the actual cost of a behavior change (e.g., giving up smoking) might be high enough that the ‘rational’ decision is not to do so, this is not the case across all such behaviors, nor for most people. A modest reduction in unhealthy behaviors such as high calorie consumption, or a modest increase in healthy behaviors such as walking more, generally has both a low cost and often also some direct near-term benefits such as improved energy and sleep, entirely independent of long-term health outcomes. Hence this is again unlikely to be a driving explanation, and indeed many people report that they wish they acted differently in these respects (Faries M. D. 2016), strongly suggesting that they are not in fact optimizing their utility according to the traditional framework.

Policy efforts towards behavioral and psychological obstacles that influence unhealthy lifestyles and habit formation are needed. Unlike many other causes of morbidity and mortality, NCDs are typically delayed - in the sense that negative outcomes occur years or even decades after the precipitating behaviors- and are often only weakly linked to identifiable individual moments in time. Why would I then change my behavior today for something that might (or might not) happen in the future? On the other hand, both accidents and communicable diseases tend to impact one’s life in the short-run (sometimes immediately) and are, for the most part, possible to link to a single causal event -which is therefore both salient and clearly amenable to prevention. This feedback can and often does trigger a suite of self-initiated behavioral adjustments to reduce recurrence.

Behavioral ‘biases’ such as impatience, time inconsistency, and over-optimism are more congruent with weighting long-term consequences in a mistakenly low manner, evaluated by the lights of the individuals themselves. Similarly, other relevant individual biases predict heightened difficulty to assess very small probabilities, as well as a tendency to focus disproportionately on concrete, identifiable consequences at the expense of diffuse accumulated outcomes.

Behavioral science insights into psychological barriers, mental models, biases, and other factors at play in individual decision-making and action can add to the understanding on how to modify habits that lead to NCDs and support a policy and intervention agenda to inform long-term investments in healthy longevity. Long-run flourishing depends as much on what individuals do or do not do as it does on their interactions with health systems – from seeking and obtaining preventive care to treatment adherence and follow-up. Both domains display the same characteristic of delayed and uncertain consequences that leave people vulnerable to inaction and/or repeated deferral.

Furthermore, by applying a behavioral lens to groups as well as individuals, elements such as peer effects and social norms can be considered. Mental health is directly affected by, among other factors, a sense of community connectedness and of agency and confidence about the future (not to mention the emotional disposition of the members of one’s network). Physical health is at minimum indirectly affected by local information flows and self-efficacy: only if someone believes that their actions can make a difference to 3