by Tom Farley
The biggest share of the money would go to five populous countries where about half of the world’s smokers lived—China, India, Indonesia, Russia, and Bangladesh—but he would also fund ten medium-size countries like Turkey and Vietnam. Although the program was to start in two months, there were still just two people working on it, Frieden and Kelly Henning, both doing the work only on evenings and weekends.
Frieden penned an article about the initiative in the British medical journal The Lancet, with Bloomberg listed as a coauthor, entitled “How to Prevent 100 Million Deaths from Tobacco.” That was how many fewer people would die if the world’s nations dropped their smoking rates merely from 25 to 20 percent by the year 2020. Frieden wrote, “All nations and populations should be able to achieve this.”
• • •
The telephone surveys done in 2006, during and after the antismoking ad blitz, showed that New York City’s smoking rate had dropped to 17.5 percent, down 80,000 smokers from the year before and more than overcoming the 2005 uptick. The city now had 240,000 fewer smokers than it had in 2002, for an average of 60,000 quitters per year. The plummeting smoking rate outpaced declines in California and Massachusetts, which were thought to have the best antismoking programs in the country, and the fall was twice as large as that in the United States as a whole.
Looking back, the increase in 2005 might have been a statistical fluke, except for one astonishing finding. In 2006 the group that changed the most was Hispanic men, whose smoking rates plunged from 24.6 to 19.3 percent—meaning that roughly one in five smokers had quit in just that year. It was Ronaldo, Frieden thought. The Hispanic men were responding to Ronaldo. That particular ad, for some reason, was incredibly powerful. Frieden had the results of his “empirical experiment”: tough antismoking ads on TV work.
The experience taught his media team other lessons. The women in the focus groups had voted for Everybody Loves a Quitter because they liked it. But Jeffrey Escoffier and Beth Kilgore realized now that they had asked the wrong question. It didn’t matter if smokers liked an ad. The health department wasn’t trying to sell yogurt. They were trying to unsell smoking. What mattered was whether the ad made smokers squirm.
Smokers had many reasons to brush off health messages. Everyone dies someday. I’m not as old as the person in that ad. I can quit later if I get sick. Plenty of people smoke and live long lives. After the 2006 tests, Escoffier told the focus group moderators to stop asking the participants if they liked an ad and instead push hard on “Would this make you think about quitting?” More important, he just watched the smokers in the focus groups to see if they looked shaken. “You have about five seconds of actual response” before they figure out how to deny the message, said Sarah Perl. “If it makes me wince, ‘Ahhh, that’s horrible’, that’s what you want. . . . That makes you think twice about lighting up.”
Escoffier and Perl put Every Cigarette Is Doing You Damage back on the air. They imported more ads from Australia, these showing gangrenous toes and operations to unclog arteries filled with fat. And they created a new ad, entitled Cigarettes Are Eating You Alive, which showed how “smoking eats away at nearly every vital organ and tissue of the body.” It was the toughest ad they had ever seen, highlighting gruesome close-ups of a lung turned black, teeth turned rust-colored, a lip rotting from cancer, and a tennis-ball-size neck tumor. The Australian ads were ugly, but Beth Kilgore thought “we took it to the next level. . . . It was so graphic that I’m shocked that it went on the air.” In fact, some television stations refused to run it. When Cigarettes Are Eating You Alive did air, Kilgore said, “we saw call volume spike like we’ve never seen it before.”
Escoffier and Perl also reran Ronaldo. In a completely unrelated focus group, they got a crucial insight into why his ad was so powerful. The department had been testing an ad to encourage people to get flu shots. The line meant to scare people into getting vaccinated was that influenza was the third leading cause of death for New Yorkers. The focus group participants “weren’t fazed at all,” said Escoffier. Instead, they asked, “Okay, what are the first two?” Dying, the team realized, wasn’t frightening. “Death is incredibly abstract to people,” said Kilgore. The thought of death even offers an appealing peace and tranquility—a break from the struggles of everyday life.
On the other hand, no one wants to suffer. Ronaldo was suffering—not as much as someone with cancer but enough. “He wasn’t dying, but he couldn’t swim, he had a hole in his throat, he had to use a voice box,” said Escoffier. He couldn’t even take a shower without worrying about choking. And he would continue to suffer like that for a very long time.
The team went with it. They invited Ronaldo to come from Massachusetts to film their own spots. They ran his ads so much that Ronaldo became a minor celebrity in New York City. People stopped him on the street to thank him and ask how he was doing. And Sarah Perl started looking for more spokespeople like him.
5
“Are you sure this will save lives?”
In the early 2000s few people had heard of trans fats, but they did recognize the health crisis of human fat. Between 1978 and 2001 the percent of Americans who were obese doubled. By 2004 two-thirds of Americans were either overweight or obese, which meant that in America it was normal to be unhealthily overweight. The epidemic was afflicting nearly one in ten adults with type 2 diabetes and, by the best estimates, killing about 100,000 people a year. Public health experts across the country held conferences and tried small programs, but no one had a practical solution that matched the enormity of the problem.
But what could they do? The obesity epidemic reflected a collision between biology and economics. Humans have evolved through many more periods of famine than excess, so we are genetically programmed to gobble up any calories within arm’s reach. In the last half of the twentieth century—a blink of an eye over human history—food production was industrialized, driving down the price, particularly for foods like chips and soda made from subsidized commodities like corn, wheat, and sugar. Distributors of all types, from fast-food chains to fund-raising school cheerleaders, learned that when they put more food in more places and in larger portions, people bought more, and their profits rose. Every day the food industry tempted people with more food, and every day people grew fatter.
Fast-food restaurants were one piece of the problem. The chains had learned that they could drive up profits by charging more for larger portions that cost them virtually nothing more to deliver. They prodded Americans with “Would you like to supersize that combo for only 39 cents?” and usually got a yes in reply. From the 1970s to the 1990s, an average meal of a hamburger, fries, and a soft drink grew by more than 200 calories. Two hundred extra calories a day is enough to cause someone to gain 20 pounds over a year. Across a nation, it is enough to account for the entire obesity epidemic. By the turn of the century, calorie counts at chain restaurants were way off the scale of human needs. At Chili’s, some hamburger plates topped 2,000 calories—or more than enough for an average American for the entire day—not even counting the drink.
At the health department, Lynn Silver and her staff struggled with how to rein in fast-food restaurants. One day in 2005 she decided she should just talk to them. She called the head office of McDonald’s, who sent its lead nutritionist to the health department. Silver tried out some ideas. Could McDonald’s make a healthier children’s meal in New York City? Cut down the size of its sugary drinks? Offer healthier “combos,” with salad instead of fries, or at least make the default options for the combos healthier? The nutritionist “gave us a long spiel and a slide presentation about how difficult their supply chain was and how it took years to modify,” said Silver, and didn’t follow up.
Silver’s initial strategic plan to prevent chronic diseases included “evaluat[ing] food/calorie labeling on restaurant menus.” There were good reasons to think putting calorie counts on restaurant menus might at least slow the galloping epidemic. Most Americans considered themselves o
verweight, and nearly one-third were trying to lose weight. Even the most dedicated dieters, though, had no way of choosing lower-calorie foods when they ate at restaurants, because they had no idea how many calories the food contained. If they guessed, they were likely far off. In studies, people judging a food item by its appearance or by a description missed the mark by hundreds of calories, usually on the low side. In one study, people on average estimated that a patty melt with fries delivered 800 calories, when it actually packed 1,300. Even professional dietitians grossly underestimated the number of calories in food, guessing that a tuna sandwich had only 370 when in fact it had 700.
Nutrition advocates had been talking about requiring chain restaurants to give customers nutrition information since 1990, when the FDA mandated Nutrition Facts panels on packaged food. Congress had exempted restaurants then because their food often wasn’t standardized and because restaurants were traditionally the regulatory turf of state and local health departments. In 2005 anyone could turn over any bag of chips and—with some calculating—learn how many calories were inside, but fast-food customers had to go on a scavenger hunt to find out the number of calories in a Whopper. Chain restaurants did have standardized recipes, so they could calculate calories easily. Most chains put nutrition information on brochures or on websites, and some on densely packed posters on restaurant walls, but others didn’t even do that. Only a tiny fraction of customers ever found the numbers.
Posting calorie counts where restaurant customers could easily find them seemed the least the health department should do in the face of the tidal wave of obesity. The counts would justify themselves even if only one in ten customers swapped to a lower-calorie item. And a 10 percent drop in sales of higher-calorie items might prompt the fast-food chains to shrink their portions, or at least slow the arms race of supersizing, which would help even those customers not counting calories.
Since the early 2000s, legislators in at several states, from Maine to Texas, had been trying to pass laws requiring nutrition labeling in chain restaurants. In 2005 Senator Tom Harkin (D-Iowa) introduced a federal bill to do it. But the restaurant chains hated the idea. Their representatives complained their food was far too complicated (“We’re not a box of crackers, where every box is the same”) and ridiculed the labeling proposals as “the height of absurdity . . . They’ve been doing it on prepared foods for years, and obesity has increased.” With that opposition, the bill stalled.
That same year Brooklyn legislator Felix Ortiz introduced his own nutrition-labeling bill for New York State. The bill appeared in Lynn Silver’s inbox. Every year Ortiz introduced a flurry of health-promotion bills that made no progress. Still, his bill made Silver think harder about nutrition labeling. It hit her that the department could instead put the proposal before the Board of Health. Like the trans fat rule, a menu-labeling mandate would be an unusual use of the health code, but it looked legal.
The idea was simple. Translating it into practical rules would be complicated. The nutrition labels had to be prominent enough to hit customers in the face, but because the restaurants would probably sue, the rules could not be unfairly burdensome in the eyes of a judge. The tough decisions, as always, would be where to draw the lines. If the rules require posting of calorie counts at fast-food chains, what about sit-down chains like Ruby Tuesday and coffee shops like Starbucks? If a restaurant had only five city locations, did that count as a chain? Should the department force restaurants to post numbers beyond calories, like the amount of fat, saturated fat, and sodium? Must the restaurants post the counts on the menu board itself, or would a nearby sign do? Could sit-down places list the calorie counts on a separate page of the menu, or must the counts be next to the name of the item? Should Baskin-Robbins post numbers for each flavor or variety? Silver wanted strong requirements—more prominent placement and fewer exceptions. “I pushed pretty hard,” she told me. But General Counsel Lopez kept objecting. “And that was good because it raised all the legal obstacles.”
In the end the team decided that the location of the nutrition information was crucial. It had to be on the menu board or the menu, right next to the item name and price. The menu board was, they heard later from Burger King, “the single most valued piece of real estate in a Burger King restaurant . . . it is what customers look at, and it is what stimulates their decision to buy.” They also decided to apply the rule only to restaurants that already published nutrition information on brochures or websites. By not defining a chain restaurant by its size, they hoped to avoid a court ruling that the Board of Health had exceeded its authority by using economic—rather than health—criteria. And when restaurants complained that they couldn’t calculate calories, the health department could counter that the restaurants were already doing just that.
At first Frieden wasn’t much interested in nutrition labeling. But as the group got closer to a workable draft of the rule, “I don’t know what happened, but then he got really interested,” said Mary Bassett. He took over the detailed planning. As he did, he made a key decision. The others wanted to require the restaurants to post two numbers: calories and sodium. He thought that was too much clutter, and that what mattered most was obesity. It would be calories only.
• • •
The press release on trans fats in August 2005 solved the problem that few had ever heard of them. Afterward, stories appeared across the country. They weren’t exactly what the health department would have liked. Even though the appeal was voluntary, many papers painted it as a fight. The New York Times described it as “the latest salvo in the battle against trans fats.” The New York Post warned readers that “French fries, chicken nuggets, pizza, cakes, cookies and many other beloved foods may never taste the same again if the city gets its way.” The papers treated the health risk as trivial. In a follow-up story, the Times health reporter Gina Kolata mocked the scientific rationale, quoting experts who called it merely the “panic du jour.” The conservative chatter that followed was about personal choice. People had the right to eat unhealthy food if they wanted to, and the health department had no right to prevent them. Sonia Angell found that argument laughable. When people ordered fries at McDonald’s, the workers at the register never asked “Do you want trans fat with that?”
Nine months later, in April 2006, the health department checked to see what the restaurants had done with their request. Inspectors visited another thousand restaurants, looking for partially hydrogenated oils. “From day one we knew the voluntary thing wasn’t going to be enough,” said Frieden. “But I didn’t expect it to have no impact. It had no impact.” Half of the restaurants were still using the artificial chemicals. With that utter failure in hand, the team was ready to propose a ban.
As with calorie labeling, caught between technical and legal pressures, the team argued over every word of a trans fat ban. For example, General Counsel Lopez wanted to limit the ban to only “fry oils,” which were the easiest sources of trans fats for the restaurants to identify and to change; but Silver insisted that they also ban trans fats in baked products like pie crusts and hamburger buns. Disagreements like that, she said with a laugh, were “something I was very used to when I worked with lawyers in the past, you know, having fierce debate and back-and-forth.”
The pressures strained the team. Silver’s stubbornness and controlling style wore on others. One employee said the staff under her felt “terrorized.” Mary Bassett had to do shuttle diplomacy between Silver and the lawyers. Bassett told her once, “Lynn, you’re like a tugboat. You can pull a heavy load, but you churn up a lot of water.”
Silver, on the other hand, believed that she pushed hard for the same reason that Frieden was demanding—because lives were at stake. She thought that criticism of her was in part sexist. A man who stands firm for his beliefs is considered a strong leader, but a woman who does is a bitch. Bassett tried to smooth things over, defending Silver’s “tenacity” and trying to “absorb the bad dynamics when smart ambitious people work under pres
sure.”
At the same time, Bassett, like Donna Shelley, was becoming deeply frustrated by Frieden’s style. He constantly sought advice from people outside the department, then made decisions himself. Deputies like her were just “operational”—staff to carry out his orders. He routinely bypassed Bassett, contacting Lynn Silver or Sonia Angell directly to get information and issue instructions. “He’s a micromanager,” she said. “At least he’s able to do it. Some people are micromanagers and can’t keep up. With Tom it’s always a challenge to keep up with him.”
As they drew closer to a practical rule on trans fats, Frieden had to get approval from Mayor Bloomberg, which meant first showing the proposal to the deputy mayors in City Hall. They were appalled. “There was this horrible meeting,” said Frieden, in which four deputy mayors took him to a room “in some attic of City Hall,” and “worked me over.” Bloomberg would approve the idea, they told him, and then would be branded a health nut and a nanny-statist. By even proposing a trans fat ban, Frieden wasn’t being a team player. Ed Skyler, the former press secretary and now deputy mayor for operations, was “the heavy,” but the others chimed in. “I felt like I was being beaten up in an alleyway,” said Frieden. He apparently gave as good as he got, though. His staff had created a “one-pager on lives saved,” saying that the rule would prevent between 300 and 1,500 deaths a year. If the city didn’t ban trans fats, he argued, they—the deputy mayors—were responsible for those needless deaths. It was the line of argument that he made so often that some in City Hall nicknamed him “Dr. Death.”
In the end, they compromised: Frieden would delay the Board of Health proposal for three months while he tried a public education campaign. They “wanted me to get a groundswell of ‘get rid of our trans fat,’” he later grumbled.
All through the summer of 2006, as the health department staff prepared to present the trans fat ban to the Board of Health, they plotted a public and political campaign similar to that for the Smoke-Free Air Act. They worried not about the Board of Health but about the restaurants, which would fight the rule on whatever battleground they could find an advantage. That could mean the mayor’s office, the City Council, the state legislature, the courts, or the press. And the health department staff were trying to blunt the blowback on Bloomberg that the deputy mayors feared.
