by Tom Farley
By the time Mike Bloomberg was finishing his third term, articles were appearing in scientific journals trying to explain New York City’s increasing life expectancy. One theory credited New York’s strong economy, poverty being linked to disease and earlier death. But life expectancy had climbed even while New York City’s poverty rate barely budged. A pair of demographers attributed the longer life expectancy in 2010 to immigration, because New York has many newcomers, and immigrants traditionally are healthier than people born in the United States. But from 2000 to 2010, as life expectancy in the city surged, the proportion of New Yorkers born abroad did not change, and it was actually U.S.-born New Yorkers whose life expectancy grew faster than that of Americans elsewhere.
Of the city’s increase in life expectancy during this decade, 50 percent was due to declines in heart disease and 16 percent to falls in cancer, the causes of death that Tom Frieden had decided to attack in 2002. Those were also the two disease categories most directly linked to smoking. From 2000 until 2012, the number of New Yorkers who died annually of ischemic heart disease (the type caused by smoking, unhealthy diet, and physical inactivity) dropped by more than 8,000. Tom Frieden would count those as lives saved.
No one can be certain what caused New Yorkers’ life expectancy to grow so quickly during the Bloomberg years. Most of the years of healthy life that city residents will enjoy from lower smoking rates, healthier diets, and more physical activity will show up far in the future. The long life of New Yorkers today, though, is a hopeful sign of even more gains to come.
At the outset of our administration, we recognized that noncommunicable diseases—especially heart disease and cancer—far outstripped all other causes of death in our city and that the single most effective thing that we could do to reduce them was to discourage smoking.
In New York City in 2014, people did not smoke in restaurants. They did not smoke in bars. They could not smoke on hospital grounds. Far fewer than before smoked in parks and on beaches. In bodegas, cigarettes costs about $11 per pack. On television and in subways, ads reminded children and adults of the suffering that comes from smoking. And a dozen years after Tom Frieden demanded that doctors offer treatment to their smoking patients, the health department was assisting more than half the city’s doctors do that. Those doctors were asking about 8 in 10 patients about smoking and counseling half their smoking patients to quit.
In the later Bloomberg years, the city became a proving ground for new ideas to fight smoking. Some, like the mandated warning signs and the ban on pack displays in stores, didn’t survive legal or political battles, but they remain ready for others to try. Others, like raising the age of cigarette sales to twenty-one and ending discount coupons, became law.
Three months after the City Council passed the discount ban, the National Association of Tobacco Outlets sued, attempting to detonate both nuclear weapons. It argued that the law was preempted because it interfered with cigarette “promotion and advertising,” and that it violated tobacco companies’ First Amendment right to free speech by blocking their ability to tell customers that they were “getting a deal.” This time the city won. In 2014 the coupons and the “$2 off!” signs disappeared from bodegas. Appearing in their place were signs demanding that cigarette customers prove they were over twenty-one.
The Bloomberg administration’s antismoking policies worked. Between 2002 and 2011, smoking among adult New Yorkers fell by 31 percent, compared to 16 percent among all Americans. Smoking rates among New York’s high school students fell 52 percent—compared to 36 percent in the United States as a whole—to a rate that was less than half the national rate. But the tobacco industry adapted, using every legal technique of marketing to push sales back up. Racks of shiny cigarette packs and eye-catching cigarette ads stood behind the cash registers at Walgreens. While little cigarette-like cigars now sold for at least $10.50 a pack because of the new city law, slightly larger cigarillos appeared in bodegas selling in four-packs for 99 cents. Onscreen smoking by movie actors stayed high, and smoking filled many television shows. Meanwhile, e-cigarettes were beginning to look like a fad, as national sales in 2014 leveled and market researchers said that regular smokers, after experimenting, were going back to the real thing.
In New York City, the rebound in smoking continued into 2013—rising by 0.6 percent to 16.1 percent—as did the downshift toward nondaily smoking. In 2014 the health department’s newest ad campaign slogan tried to speak directly to nondaily smokers with taglines like “cancer doesn’t care you ‘don’t smoke that much.’”
By the end of the decade, the WHO [World Health Organization] expects 7.5 million tobacco-related deaths worldwide, every year. Some 80 percent of these deaths will take place in the world’s low- and middle-income nations—nations where tobacco companies have stepped up their marketing briskly. . . . That’s why I’ve also made tobacco control a major priority of Bloomberg Philanthropies.
By 2014, two-thirds of the U.S. population lived in places with smoke-free restaurants and bars, and most of Europe was covered by smoke-free air laws. The Bloomberg money took the New York City program to the rest of the world. Between 2007 and 2012, Bloomberg Philanthropies spent $375 million to train government officials, advocates, reporters, and lawyers in dozens of poorer countries in the MPOWER strategy. In 2012, Kelly Henning traveled to Bangladesh, a country of over 150 million in which nearly half of men smoked, to meet with its health minister. A year before, the foundation had paid for the health minister’s assistant to come to the United States for training. On the wall of the room where the assistant worked—the only thing on the wall—was a picture of him receiving his course certificate. That assistant was crucial to Bangladesh’s passing a law that required graphic warnings on cigarette packs and that banned smoking in many indoor places.
Between 2007 and 2012, twenty-six low- and middle-income countries passed comprehensive smoke-free air laws. That quadrupled the number of people worldwide protected from secondhand smoke to 1.1 billion, or 16 percent of the world’s population. In 2014, in what may become the biggest win, Beijing passed a strong indoor smoking ban, and China published draft regulations for a national ban.
The Bloomberg foundation also paid for antismoking ad campaigns in poorer countries, often using ads from New York City. By 2012 more than half of the world’s population lived in countries that were running national media campaigns against smoking. After Vietnam aired Cigarettes Are Eating You Alive, a survey showed that most of the nation remembered seeing it, and more than three-quarters of the smokers who had seen it said the ad made them more likely to quit.
Turkey tried every element of MPOWER, banning smoking in restaurants and bars, banning tobacco retail ads, raising its cigarette tax to 80 percent of the retail price, and requiring television stations to run antitobacco programs in prime time. Within four years the country’s smoking rate dropped from 32 to 27 percent, a fall of 1.2 million smokers.
A researcher from Georgetown, working with the Bloomberg foundation, estimated that the declines in smoking between 2007 and 2012 from use of the MPOWER strategy in sixty-five countries would prevent 14 million premature deaths.
The progress we’re seeing on tobacco is encouraging action on other fronts as well. To attack diabetes and heart attacks, for example, in New York, we have also taken the lead in promoting healthier eating.
In 2013 a huge study on health risks around the world blamed unhealthy eating in America for 675,000 annual deaths, or one-fourth of all deaths. Americans consume way too much sodium, processed meat, trans fat, and sugar—especially from sugary drinks—and not nearly enough fruit, vegetables, nuts, seeds, whole grains, or fiber. Most of the biological havoc wreaked by unhealthy eating is invisible until people are stricken by heart disease, stroke, cancer, or diabetes, but the most visible harm—obesity—is frighteningly common.
When Frieden started, he drew on proven ideas to fight smoking, but he had no rulebook for promoting healthier eating across a cit
y of eight million. Most public health experts were still focused on educating people, usually one at a time, to choose healthier food. Around that time, though, some experts like Mary Bassett and Lynn Silver saw the problem not as a lack of education but instead as a “toxic food environment.” In the Bloomberg years, the New York City health department tried to detoxify that environment.
That meant banning trans fats in restaurants, requiring calorie labels on menu boards, licensing Green Carts, cutting salt in processed food, writing healthy food standards wherever the city had influence, and pushing policies to blunt the marketing of soda. Most of those ideas succeeded. No one in New York City is eating doughnuts soaked in trans fats, and none go to New Jersey to buy their French fries. The calorie labels on menu boards, while making only a small difference, seem to be having a greater impact as people get familiar with them. On a typical day, as Mike Bloomberg finished his term, about 250 Green Carts sold fresh produce on the sidewalks of the city’s poorest neighborhoods. While the bodegas had protested that the competition would hurt them, it seems to have helped their customers; in neighborhoods where the Green Carts were active, the brick-and-mortar stores’ offerings of fruits and vegetables actually increased. “I don’t know, did their Cheetos sales go down?” asked Christine Quinn. “I hope so.”
The city’s food policy coordinator, working with the health department, quietly expanded the reach of the city’s food standards. By 2013 the city had a single set of detailed health criteria for the food and beverages that were distributed by twelve city agencies or sold in more than 3,000 vending machines in government buildings. For the first time, the schools paid attention to how much sugar, sodium, and fiber were in the breakfast cereal they served. Some manufacturers altered junk food to barely meet the criteria—like creating reduced-sugar, whole-grain Pop-Tarts—but overall the foods were healthier. Deep-fried potato chips disappeared from vending machines, replaced by almonds and raisins. In 2010 the health department packaged a set of healthy food standards for hospitals, including rules for patient meals, vending machines, and cafeteria foods. By 2013, more than thirty of the city’s fifty hospitals were following one or more standards.
In the fall of 2014, the health department was still working with twenty-three companies to cut salt in processed food. Christine Curtis thought the city’s salt targets themselves—high enough to be feasible but low enough to matter—were an accomplishment, because before them the sky had been the limit. Food companies started checking the targets as they developed new recipes.
But the National Salt Reduction Initiative desperately needed the FDA in order to succeed, because only the FDA could set requirements for packaged food. Through 2014, we heard rumors that the FDA was poised to start a voluntary salt-reduction program, but that the White House was blocking the plan. By November 2014—more than three years after the FDA released its sodium docket, and more than six years after New York City’s Salt Summit—the FDA still had done nothing on salt. Meanwhile other countries made headway; in 2013 the government of South Africa became the first to pass a sodium-reduction law with food standards that were mandatory.
In fact, the actions most needed to protect people from unhealthy food of all kinds had to come from the FDA and the other big federal food agency, the Department of Agriculture. Unfortunately, the USDA saw its mission as promoting agriculture, not health, and the FDA had been muzzled by a White House that listened far too much to the food companies. In late 2013 the FDA issued a “preliminary determination” on trans fats that might someday lead to a ban but a year later had not taken additional steps. The agency did finally act on menu calorie labeling in December 2014, shortly after the midterm election and nearly five years after Congress passed the law requiring it. Under the rules, not only restaurants but also grocery stores, bodegas, and convenience stores that sell prepared food—like 7-Elevens—would be required to post calorie labels. Those stores criticized the rules and persuaded friends in Congress to propose bills that would roll back the requirements.
The New York City health department spent more time on sugary drinks than on any other problem. In the last months of the Bloomberg administration, the department continued to run counter-ads on television and on subways, encouraged hundreds of community groups to rid themselves of sugary drinks, and extended a prohibition from day care centers to day camps.
As the term wound down, the sugary drink portion cap became a headache for Bloomberg. Other politicians ribbed him about it at events. The annual press satire of City Hall was entitled “Last Gulp.” The New Yorker ran covers on it. The late-night comics couldn’t resist coming back to it. Newspaper retrospectives listed it as an example of Bloomberg’s tendency to overreach. Bloomberg, ever game, went with it: when Seth Meyers on Saturday Night Live asked him about his future, he said he would be “fulfilling a lifelong dream of enjoying a small soda on a nonsmoking beach.” Through it all, he never once complained to me or to his deputy mayors about the spin.
In June 2014 six judges of New York State’s highest court heard arguments over the portion cap. This last round of the case had become a magnet for advocates and legal experts. Coming to the city’s side were professors of New York constitutional law, national public health advocates, and a group of New York City–based minority organizations. The last group wrote, “For the one of every three children born in 2000 who will develop type 2 diabetes, and for the one of every two African-American and Hispanic girls who will get the disease, the question is not whether the Rule was justified, but rather ‘What else is being done?’” Joining the soda companies were thirty-two members of the City Council and the Washington Legal Foundation, a group funded by the Koch brothers.
After a courtroom scene in which the judges hammered both sides with questions and allowed them no time to answer, the justices voted 4 to 2 that the Board of Health had exceeded its authority. The four-judge majority had to go through logical contortions to get there, though. The board had inappropriately “legislated” because the rule required “choosing among competing policy goals,” they wrote. At the same time, they agreed that the board did have the authority to “balance costs and benefits” when writing rules. And the board had acted within its authority when it passed rules banning lead paint in residences, requiring chain restaurants to post calorie labels, and requiring landlords to install window guards, because, they claimed, for these rules “the choices are not very difficult or complex.”
The remaining two judges penned a scornful dissent. “There is no question that the Portion Cap Rule falls comfortably within the broad delegation granted to the board by the legislature,” they wrote. “What petitioners have truly asked the courts to do is to strike down an unpopular regulation, not an illegal one.” The majority’s decision to strike down the rule was little more than “camouflage for enforcement of judicial preferences.”
It was our third loss over sugary drinks—the excise tax, the SNAP restriction, and now the portion cap—losses that bared the political and legal might of the soda companies. Staff in the health department were crushed. But we took solace that the department had begun something important. As Andy Goodman put it, “We put sugary drinks on the map” and pointed a finger at the soda companies as bearing some responsibility for obesity. “I think we fired a pretty big shot across their bow,” said Tom Merrill. “We got the country and everybody talking about it.” The many press stories on the battles effectively became counter-ads that gave sugary drinks an increasingly evil image.
In what mattered most, public health was winning. From 2007 to 2013, the fraction of adult New Yorkers saying that they drank sugary drinks daily fell by more than a third, from 36 to 23 percent, and the proportion of high school students drinking them dropped by more than a quarter, from 57 to 42 percent. Obesity rates in schoolchildren continued to edge down. And after rising from 2002 to 2012, the obesity rate in adult New Yorkers in 2013 dropped by a half percentage point. Maybe it was just a statistical fluke, or maybe it
was a sign that the city had reached the high-water mark.
For all the health department’s efforts, though, the food environment in New York City is still poisonous. Fast-food joints—many not part of any national chain—litter the city, pushing fried chicken and sodas. Grocery stores still load their highest-selling end aisles with bags of chips and huge bottles of sugar water. Even worse are the bodegas in poor neighborhoods. A typical one in Harlem sells bags of potato chips (120 calories and 2 grams of saturated fat) for 25 cents. A package of two Hostess cupcakes (360 calories) costs 50 cents. If you have only a quarter in your pocket, you can get a plain 4-ounce plastic bottle of sugar water. Or if you have two dollars, you can grab a 3-liter bottle of Tropical Fantasy Fruit Punch, flavored with “glycerol ester of wood rosin” and delivering 1,440 calories of high-fructose corn syrup. No wonder poor people suffer most from obesity and every other diet-related disease. Add to this junk food the power walls of cigarettes and the coolers of 40-ounce beer bottles, and bodegas look to me like toxic waste dumps. That is what comes to my mind when others ask if the Bloomberg administration overreached.
Obesity is now an epidemic around the world, with some countries rivaling the United States. From 1990 to 2010, as economies developed, the number of deaths globally from excess weight rose from fewer than those caused by childhood undernutrition to four times as many. In 2013 Kelly Henning at Bloomberg Philanthropies took the New York City obesity ideas to Mexico, where per capita sugary drink consumption was the world’s highest. Compared to the trench warfare in New York, the Mexican campaign was a laser-guided-missile strike. Against fierce resistance by the soda companies, Mexican health advocates sprinted a bill through the legislature with taxes on soda and junk food. Early results of an evaluation of the soda tax by the Mexican National Institute of Public Health showed sugary drink purchases falling 10 percent, which is about what the studies that we used for New York’s tax proposal predicted would happen.
