by Tom Farley
The HHC hospitals ran smoking cessation clinics, but the results were pitiful. Frieden estimated that every quarter 115,000 smokers visited doctors within the mammoth system, but only about 2,000—less than 2 percent—ended up in the cessation clinics. A report that he requested offered a long list of reasons: doctors didn’t refer patients to the clinics, patients had trouble getting there, the patients spoke Spanish but the counselors didn’t, there was no budget for brochures, and patients’ insurance didn’t pay for the medications.
Both Frieden and HHC’s president wanted the health care system to do better. Urged on both by Frieden and by their own supervisors, more doctors began referring smoking patients to the cessation clinics, and the clinics did a better job of treating them—teaching them ways to quit and giving them nicotine patches and other medications that roughly doubled the quit rate. By late 2004, the clinics had tripled the number of smokers they were seeing, and about 90 percent of those seen received medications. Still, that amounted to only about 5,500 smokers every quarter—less than half a percent of smokers citywide. “That was a searing experience,” Frieden said years later. “No matter how hard you pushed on cessation, you never moved the number.”
So in the spring of 2003, Frieden decided to leapfrog the doctors and give medications straight to smokers. He got a donation of tens of thousands of nicotine patches and sent out a press release announcing six weeks of free patches (which otherwise cost over $100 each) for smokers who called the city’s new 311 information line. Answering the calls and shipping the patches nearly overwhelmed his small tobacco team, but by the time the giveaway ended, they had mailed patches to 34,000 smokers. Six months later Frieden had his team survey 1,300 smokers who had received the patches and 160 smokers who had asked for patches but never got them. Amazingly, one-third of those who had got the patches had quit, compared to only 6 percent of those who never got them. The team estimated that the giveaways had caused 6,000 smokers to quit. That was more quitters than all of HHC’s smoking cessation clinics produced in a year, at a fraction of the cost. But even that success was bittersweet, because Frieden wanted to reach all 1.3 million of the city’s smokers. If he ran the patch giveaway twice a year, reaching them all would take more than a hundred years.
The Smoke-Free Air Act, on the other hand, was working far better than anyone had hoped. The panic about it had continued up until the day it went into effect. Smokers like Chris Gallin, who at that point had not yet had his heart attack, were outraged: “We felt our life was going to end.” Others had predicted that bars and restaurants would just ignore the rule, or if not, that bars would roil with fights between bouncers and smokers. They were wrong. Most bars and restaurants put up no-smoking signs and began enforcing the ban on the day it went into effect. While some customers grumbled, nearly all smokers just held off while they were eating dinner or drinking and then took their puffs outdoors. Some admitted that the rule cut down their smoking and might help them quit. Later Chris Gallin said, “I hated the smoking ban, and I think it was one of the greatest things [the Bloomberg administration] ever did.”
By the fourth month after the law went into effect, of fifteen hundred bars and restaurants inspected by the health department, only twenty were found breaking the rules. As people became accustomed to the clean air in restaurants and bars, polls showed support for the law rising to 62 percent. Meanwhile, despite the predictions of doom, sales in restaurants and bars actually rose 9 percent. And the city’s higher cigarette tax (even after the state took half the revenue) was bringing in $130 million per year to the city.
But the most stunning numbers came from Mostashari’s telephone surveys. The percent of adults in New York City who smoked fell from 21.6 percent in 2002 (before the big tax increase and the Smoke-Free Air Act) to 19.2 percent in 2003. That amounted to a drop of nearly 140,000 smokers in a single year. At first Frieden wasn’t sure whether to believe it. Could the tax increase and the smoking ban have been so traumatic that a small city’s worth of smokers quit almost at once? On the 2003 survey, the health department had asked former smokers why they had quit. Based on their answers, Frieden’s team estimated that 59,000 former smokers credited the tax increase for their quitting, 13,000 the Smoke-Free Air Act, and 16,000 both. Maybe the plummeting smoking rate wasn’t a fluke.
Many people in public health would have celebrated privately and waited another year to see if the smoking drop continued. Frieden instead declared victory immediately. His team published three papers, one describing the campaign to pass the Smoke-Free Air Act, one showing how well the nicotine patch giveaway worked, and one summarizing the success of the overall smoking program. In the third article, he wrote that “because roughly one-third of smokers die prematurely from tobacco-related disease, this decline, if sustained, will result in 45,000 fewer premature deaths.”
• • •
Lynn Silver doesn’t look the slightest bit like a militant. A sandy-haired woman in her fifties who speaks softly and giggles frequently, she could be a Cub Scout den mother. One of her staff nicknamed her “Mama Bear.” But underneath that manner she is tenacious, and she proved to be an unrelenting warrior on unhealthy food.
Silver was from New York but began traveling to Latin America to agitate for health even before finishing medical school at Johns Hopkins. She landed in Nicaragua two days after the Sandinista revolution in 1979 and immediately found herself “running a network of community health workers.” While in Central America she ran into “a youngster at Columbia” named Tom Frieden, who was putting out his health newsletter. After a stint with the Pan American Health Organization, she signed on with Public Citizen, the advocacy organization founded by Ralph Nader. Silver was in the Health Research Group, which was directed Sidney Wolfe, a scathing critic of drug companies and the FDA. In her job interview, Wolfe asked her, “Are you prepared to work nights and weekends and Sundays and be excoriated in the press?” Silver was. During her time there she wrote muckraking pieces on the high rates of cesarean sections and took the federal government to task for allowing drug companies to charge it exorbitant rates for AIDS drugs that the government itself had paid to develop.
After spending some years in Brazil, where she taught food and drug law at a university, Silver wanted to come back to New York. She sent her résumé to Mary Bassett, who hired her in early 2004 to become her assistant commissioner for chronic diseases.
While the city bureaucracy churned through the hiring paperwork, Bassett paid Silver as a consultant to develop a strategic plan to prevent chronic diseases. Silver’s plan showed that she also had very different ideas from Tom Frieden. Like Bassett, she thought it was wrong to blame people for making unhealthy choices. People were just behaving normally in an unhealthy world. The source of Americans’ unhealthy eating habits was a toxic “food environment”—a world bursting with alluring, processed, junky food. The health department needed to push for the “gradual elimination of . . . a ‘toxic environment.’”
Unlike the health department’s other doctors, Silver had legal skills, self-taught from her time at Public Citizen, that could transform vague concepts into concrete proposals. In her plan, she offered a long list of provocative ideas to create a healthier environment in New York City, including changing zoning requirements to encourage more supermarkets in poor neighborhoods, forcing grocery stores to stock healthier items, taxing soda and snack foods, “evaluat[ing] food/calorie labeling on restaurant menus,” and “work[ing] toward smaller portion sizes in industrialized foods and in restaurants.”
As radical as the plan was, it said nothing about trans fats. When Bassett asked her about them, Silver later said, “my first challenge was figuring out what trans fats were.”
Around the time Lynn Silver arrived, General Counsel Wilfredo Lopez had begun a task that only Frieden would have assigned him: to update the city’s health code, the compilation of Board of Health regulations. The code was the size of the Bible and about as well organized. The bo
ard had added layers upon layers of rules since the 1800s. It banned spitting (1800s), required that cases of syphilis be reported (1920s), regulated swimming pools (1960s), and specified testing procedures for HIV (1980s). It hadn’t been overhauled in fifty years.
Lopez asked all the department’s assistant commissioners for ideas on what should be revised. With Silver he got more than he bargained for. Lopez, she later recalled, “wanted to know whether we should get rid of the chapter that says if you go to Weight Watchers, you had to have a doctor’s note.” But when she learned about the health code, “a light bulb went on in my head.” It was just the tool the department needed to clean up the toxic environment. The code was purely about health, it was enforced by the health department, and—most important—it was written by the Board of Health, which was insulated from political pressures. The city charter even said that the board could write health code rules to control “chronic diseases and conditions hazardous to life and health”—that is, for more than just infectious diseases. The board had used that authority in 1960 to ban lead paint in homes and in 1976 to require landlords to install window guards in buildings to protect toddlers from falls, and the state courts had upheld its authority.
Unlike Lopez, Lynn Silver was convinced that the board had the power to ban trans fats in restaurants, even if trans fats weren’t declared a hazardous substance. The FDA regulated packaged food but left restaurants to states and cities. Silver believed the board could add a ban on trans fats to the restaurant section of the health code.
Silver knew how to argue with lawyers, but took another tack. She figured that if Tom Frieden wanted to rid the city’s restaurants of trans fats, Wilfredo Lopez would take another look at the health code. So while talking with Lopez, she also pushed Frieden.
It took some work. At first Frieden was unimpressed with trans fats. “I thought it was hype,” he said. On top of that, it didn’t mesh with his doctorly instincts to just give people medicines to bring down their cholesterol. “I thought, this nutrition stuff is so controversial,” he groaned.
The way to convince Frieden was with data. The job of marshaling the data fell mainly to Sonia Angell, whom Mary Bassett and Lynn Silver hired to be their director of cardiovascular disease prevention. Angell was nearly a generation younger than Bassett and two generations younger than Coke McCord. In college, Angell had majored in journalism and political science, with the career dream of making documentaries on human rights violations. After spending two years as a Peace Corps volunteer and two more as a community organizer, she decided health was her calling. She went back to school, got degrees in medicine and public health, and after her residency studied for two years with academic “social epidemiologists.” She was too much of an activist to become a researcher, though.
Angell quickly became the department’s expert on trans fats. She studied not just health effects but also food technology, telling Christina Chang at one point, “I can’t believe I went to medical school and I know this much about pies.” She and Silver fed Frieden a fat binder full of scientific papers on trans fats. He devoured the studies, puzzling over the fine print of their methods, contemplating the details, and probing the researchers’ conclusions. Angell and Silver “kept briefing me and briefing me and briefing me,” he said. Finally, he was convinced: trans fats kill.
But two questions loomed. First, if the health department banned trans fats, would restaurants switch to saturated fats, which might be worse? Second, could restaurants make the food that New Yorkers were accustomed to with trans-fat-free oils and spreads? The data Angell showed Frieden convinced him that the first question was moot. In feeding studies, eating trans fats raised “bad” cholesterol and lowered “good” cholesterol, while eating saturated fats raised both. “You can replace trans fats with lard and do better,” Frieden said. On the second question, Frieden read the papers but was finally persuaded by a story. Bloomberg’s chief of staff Peter Madonia came from a family that ran a Bronx bakery known for its cannoli. Frieden asked him how hard it would be for the bakery to get rid of trans fats. A couple of weeks later Madonia reported back that “it was not complicated at all.”
Sonia Angell had to figure out if the city’s restaurant suppliers had enough trans-fat-free products to meet demand. So she, Gail Goldstein (whom she had hired), and a few interns called every restaurant supply company they could reach in the city—more than a hundred of them—and asked about oils, shortening, and spreads. What they heard was surprising. Plenty of trans-fat-free “fry oils” were available, but many suppliers didn’t stock them because restaurants weren’t asking for them. Trans-fat-free shortening for baking might be a little harder to find, but new oils and fats were coming on the market, and the supply could quickly catch up with any increased demand.
Angell also needed to know how many of the city’s thousands of restaurants cooked with trans fats. So Gail Goldstein had the health department’s 150 restaurant inspectors, while checking for mice and faulty refrigerators, poke into pantries to study labels for cooking oils, hamburger buns, pie crusts, and pancake mixes. Inspectors found the words partially hydrogenated on labels in about half the restaurants.
Lynn Silver thought the survey showed that the restaurants could handle a ban. After all, half the restaurants already weren’t using trans fats, and they were doing just fine. With Frieden now interested, Wilfredo Lopez took another look. “It took me a long time to get Wilfredo on board with these alternative uses of the code,” said Silver. He still worried that the city might lose a lawsuit over a ban, but he finally came around.
Still, Frieden felt he couldn’t drop a ban on trans fats on the city without first asking restaurants to give them up voluntarily. By then it was 2005, and Bloomberg would soon run for reelection; no one wanted the mayor’s campaign hobbled by attacks over trans fats. Silver, convinced that a ban was necessary, nonetheless saw advantages of starting with something voluntary. If none of the restaurants dropped trans fats, it would prove that the ban was necessary. If many restaurants dropped them, it would prove that trans fats weren’t needed and would justify the ban so that the rest would follow.
Angell and her team wrote letters and brochures for suppliers, restaurants, and city residents with the same message: trans fats cause heart disease, the city’s biggest killer, so get rid of them. In August 2005, after nearly three years of thinking and planning, they mailed the brochures to 20,000 restaurants, 14,000 suppliers and supermarkets, and some 100,000 citizens. Angell said, “We were sending letters to Iowa—or wherever they were—saying ‘by the way, in New York City we are asking that restaurants eliminate the use of artificial trans fats.’” At the same time they released a training program on trans fats for restaurant staff that ultimately was completed by 7,000 workers. They sent out a press release announcing both the mailing and the training program. The release included a quote from E. Charles Hunt, the executive vice president of the New York State Restaurant Association, about how they were “working together to reduce trans fat from our kitchens.” This was the last time Hunt would say the restaurant association and Bloomberg’s health department were “working together” on anything.
4
“We were failing and we didn’t know why, and we had to succeed.”
When Tom Frieden saw the smoking rate for 2005, he was stunned. It was 18.9 percent, up from 18.5 percent the year before. The uptick could have been statistical noise, but he couldn’t accept that. The year before, seeing the 18.5 percent number (down 0.8 percent and 50,000 smokers from the year before that) had been “the high point of the year” for him. At a dinner at Gracie Mansion that night, he excitedly wrote the number on a napkin and passed it to Bloomberg. He was certain then that the smoking rate would keep falling. But now Frieden had to face the awful possibility that the win had been only temporary: “We were failing and we didn’t know why, and we had to succeed.”
He remembered from his “round table” three years earlier that the Massachusetts hea
lth department people had touted their antismoking TV ads. For nearly a century, the tobacco companies had sold cigarettes with advertising that showed smokers as sexy, sophisticated, and independent—think the Marlboro man and the Virginia Slims woman. “Counter-advertisements” were meant to replace those images in people’s minds with the far uglier truth about smoking.
Almost no health departments were running counter-ads on television in 2005, but it was an old idea. In 1967 the Federal Communications Commission decided to apply its Fairness Doctrine—designed to present alternative opinions on contentious issues—to cigarette ads. It had forced television and radio stations to air one counter-ad for free for every three cigarette ads. Unlike standard public service announcements, these counter-ads ran in prime time. Over the next three years, per capita cigarette sales in the United States had fallen 7 percent. With that, the tobacco companies suddenly had a change of heart. They volunteered for a congressional ban on cigarette ads on television and radio; that action wiped out the counter-ads too, after which cigarette sales bounced back up. The lesson some antismoking advocates took was that public health agencies could win with counter-ads even if the tobacco companies outspent them. As one advocate put it, “It’s easier to sell the truth than to sell a lie.”
In the 1970s and 1980s researchers in California, Australia, and South Africa ran three very similar studies to test more scientifically whether counter-ads worked. Each study was done in a group of three small towns. Residents of one town saw antismoking counter-ads, those in a second town saw those ads and also received in-person antismoking education, and those in a third “control” town got neither. All three studies found that smoking rates fell faster in the counter-ad towns than in the control towns. (In two of the studies, the community programs helped cut smoking rates further.) Health departments in the United States didn’t act on these studies, but public health agencies in Sydney and Melbourne, Australia, followed up with citywide campaigns, and in both cities smoking rates fell within six months. In the late 1990s, the Australian government expanded them into a national TV campaign. At about the same time, state health departments in Massachusetts and Florida began running TV ads aimed at teenagers, and in both states smoking rates fell among teens who saw the ads.
