by Tom Farley
Frieden came to his role skeptical that education could change behavior, and he wasn’t completely persuaded by the smoking campaign evaluations. Still, he felt he had to give counter-ads a try. That meant paying for ad time; there was no point to public service announcements airing at three a.m. “I’m going to run ten million dollars of counter-advertising and see what happens,” he later recalled thinking. “It was done very specifically as an empirical experiment.” By holding down hiring, he was able to bank the money he needed, but because of government budgeting rules, he had to spend it within six months. He sent his staff on a search for ads. The CDC kept a trove of antismoking TV ads and shipped them a big box of VHS tapes and DVDs.
The people who watched those first ads came from worlds very different from those of Frieden’s doctors. Jeffrey Escoffier, who had directed the department’s health media and marketing unit for many years, had the most unusual background. Trained as an economist, Escoffier had authored five books, ranging from a biography of John Maynard Keynes to a history of gay pornography (entitled Bigger Than Life). He was in his sixties and usually wore black shirts and gray ties, which with his gray beard gave him the look of an aging revolutionary, but he was actually mild-mannered, sunny, and curious. Sarah Perl, who ran the Bureau of Tobacco Control, had the tough, hurried manner of a newspaper reporter, which she had been for years.
Escoffier and Perl had to choose which ads in the CDC’s box—if any—were worth spending millions of dollars on airing. All smokers know that smoking is bad for their health, but they find creative reasons to deny that it matters. The ads tried different ways to make the risk immediate and personal. The Australian campaign attacked the excuse that it takes decades for smoking to kill you. Every Cigarette Is Doing You Damage showed young people inhaling deep drags of smoke and then followed that smoke into their bodies and the organs that it damaged. Hands wearing latex surgeons’ gloves opened body organs on screen—a brain oozing blood from a stroke, a lung with a year’s worth of tar poured over it, an aorta out of which the hands squeezed a snake of yellow cholesterol goo.
The Massachusetts ads, by contrast, were testimonials. A man named Mike Sams told how it felt to be dying of lung cancer at thirty-seven. A woman named Pam Laffin, her face moonlike and pink from steroid treatments, was suffering after a lung transplant in her twenties. “Oh my god, the fear of breathing, or not being able to breathe, is worse than anything in the world,” she tells the viewer. At the end the text appears silently, “Pam died of emphysema.” Another featured a man who was not dying. Ronaldo Martinez, stricken with throat cancer at age thirty, had a tracheotomy—a hole in his throat—and without a larynx spoke in a computerized monotone using an electronic gadget he held to his neck. The ad showed him protecting his tracheotomy while taking a shower so the water didn’t choke him, then cleaning and dressing it afterward. “Nothing will ever be the same again,” his computer voice says. “Not even the simple things.”
Studying the ads forced Escoffier and Perl to consider whether they wanted negative or positive messages. The Australian and Massachusetts ads tried to scare smokers into quitting. But as Escoffier explained to me later, advertising had always been seen as “aspirational.” Commercial ads sell Pepsi, pickup trucks, and lipstick by linking them to ideas and feelings that we cherish, like happiness, friendship, respect, and love. Health educators, in a very different world from commercial advertisers, accept as gospel that “scare tactics don’t work.” Escoffier’s earlier campaigns had all been positive, selling the good life that comes from healthy actions.
With no time to spare, Perl and Escoffier ran the negative ads anyway. They aired Every Cigarette Is Doing You Damage just after Christmas 2005 and followed up with Pam Laffin and Mike Sams. As they were running them, they hired an advertising agency to come up with other ideas. The agency’s first try took a positive tack. Everybody Loves a Quitter showed how much smokers’ children, parents, and spouses would appreciate them if they gave up smoking. “My man,” a woman says, giving her husband a hug. “A quitter—that’s so sexy. Mmmm.”
Perl and Escoffier asked Beth Kilgore to test the ads with smokers, testing that was too late for this round but might teach them something for future campaigns. Kilgore is a quiet and thoughtful woman, trained as a sociologist to do qualitative research, who worked in Farzad Mostashari’s epidemiology unit. When she started, she admitted, “We didn’t really know what we were doing.” She organized a dozen focus groups—sessions used by advertisers and marketers to understand how potential customers respond to an idea, an image, or a product. In the groups, a professional moderator leads a conversation with six to twelve volunteers chosen by their age, sex, and habits. Researchers behind a one-way mirror study the volunteers’ words and demeanor, searching for flickers of deep emotions.
Every Cigarette Is Doing You Damage provoked the smokers in nearly every group. It was “disgusting.” “Serious kind of nasty,” said one man. Some smokers thought the nastiness was exactly what made the ad powerful. One man called the oozing brain ad “mind-altering. It made me think about quitting. I’m a heavy smoker. I mean, my brain is kind of messed up now.” But others said the ad would just make them change the channel. The ad featuring Pam Laffin, who had died after a lung transplant, also hit hard. The one with Ronaldo, with the hole in his throat, hit even harder. Those ads were already on the air, and some smokers recalled Ronaldo too well. “Not the man with the hole,” cried one woman when the moderator cued up the ad. “Please don’t show me that man because I’m running out of here. . . . He scares me.”
The health department team had been excited about Everybody Loves a Quitter “because it seemed very positive and kind of an uplifting thing,” said Escoffier. “It’s a lovely ad,” said Beth Kilgore. “It looks like a pharmaceutical ad, it looks like an ad for ‘I Can’t Believe It’s Not Butter,’ whatever.” In the focus groups, many of the women loved it. “It made me feel happy and hopeful,” said one. “It takes away the embarrassment that the other commercials make you feel,” said another woman. “The other ones just make you feel guilty.” But most of the men were skeptical. “I mean, who needs a hug?”
Advertising agencies measure the dose of TV ads that an audience gets with gross rating points (GRPs), which estimate the percent of the population watching when the ad was shown once, on average. If an agency bought 200 GRPs, it meant that New Yorkers on average saw an ad twice. The health department bought a rapid series of four-week ad blitzes with about 400 GRPs per week, which is about as hefty a dose as political candidates buy during the heat of an election campaign. One woman in a focus group felt as if Ronaldo were everywhere. “I don’t want to see him on my TV. Like the one night, I swear, I was turning on my TV, and he came. Hurried it up, changed it. He was on the next station. Oh, hell no! I can’t take him . . . And if I’m going to quit again, he will be the reason.” At around the same time, the New York State health department ran its own antismoking ad campaign, with some ads focusing on the damage from smoking and others emphasizing the dangers of secondhand smoke. Combined, the two health departments hit New Yorkers during 2006 with nearly 11,000 GRPs—on average 110 times—which is about as heavy a blanketing with antismoking ads as anyone had ever done.
Sarah Perl discovered a way to measure the effect of the ads that was less subjective than focus groups. Each ad ended with a plea for smokers to call the city’s 311 information line for help quitting. When the Pam Laffin ad hit the air, calls shot up from about 200 per week to over 1,000. Mike Sams drove them up past 1,500. But—something the media team didn’t understand at the time—the best was Ronaldo, who propelled nearly 3,000 calls a week.
Most smokers didn’t call, though. Frieden wanted to know how the ads affected typical smokers. He had his staff survey 2,000 smokers and more than 400 recent quitters over the telephone. The survey left no doubt that people had felt the ad blitz. Ninety-two percent said they had seen at least one of the antitobacco spots, and half had seen
at least three of them. Of those who had seen an ad, 94 percent thought the ad had “said something important” to them, and over half said it had made them want to quit. Ronaldo spurred people to quit the most.
Despite the warm reception it got in the focus group, Everybody Loves a Quitter was a dud. Kilgore believes it got lost among all the pharmaceutical ads that it resembled. “We don’t have the budgets of those companies,” she said, “so we have to look and sound different.” “We had that on the air, and the call volume was dying,” said Sarah Perl. “But when we put Ronaldo on the air, the call volume spiked back up.” It was a lesson they never forgot. Positive messages fail. Done right, scare tactics work. After that, Perl said, “we pretty much abandoned anything that we didn’t think was quite hard-hitting.”
• • •
When the city passed the Smoke-Free Air Act in 2002, Bloomberg’s chief of staff Peter Madonia had worried about political fallout in the next election, November 2005. But the mayor had told him “over and over and over again” that by that time no one would remember the controversy. Bloomberg was right. Within a year of the law’s passage, bars and smokers had adapted fully. The mayor told reporters on the anniversary, “I can’t go into a bar or restaurant where I don’t have people come up to me who work in the restaurant and say, ‘I want to give you a kiss, you saved my life.’” The restaurant and bar business was growing. Even former Bronx borough president Fernando “Freddy” Ferrer, a Democratic candidate for mayor, admitted that the smoking ban wouldn’t hurt Bloomberg’s reelection chances.
In the heated 2005 Democratic primary, Ferrer beat Council Speaker Gifford Miller, Representative Anthony Weiner, and others. In the general election, Bloomberg had so much more money to spend than his opponent that one political scientist called it a “vertical playing field.” Ferrer and Bloomberg fought over typical issues—education, jobs, crime, housing, and the city budget—plus Bloomberg’s bid to build a stadium on the West Side of Manhattan and host the Olympics. Neither talked about public health. As the election approached, Frieden talked to the mayor’s campaign staff, willing to help. By then the communications people saw Frieden as nothing but trouble, the chief nanny in the nanny state. The health commissioner could be most helpful, they told him, by allowing them to “put duct tape over your mouth and put you in a closet.”
Bloomberg crushed Ferrer by twenty points. Despite being a white billionaire facing a Hispanic populist, Bloomberg got roughly half of the vote of African Americans and three in ten votes of Hispanics. Two and a half years earlier, after he raised property taxes, his approval ratings had sunk to near 30 percent, and they remained below 50 percent for most of his first term, but shortly after the reelection they soared to 75 percent.
After Bloomberg’s victory, Frieden remembers the mayor gathering all his commissioners in City Hall to inspire them for the second term. He told them that the high approval rating wasn’t necessarily a good sign. We have to do big things, he said, things that no one else would do, like passing the Smoke-Free Air Act and building a new aqueduct to bring water from upstate into the city. Big things are controversial. You could argue that if we were really doing a good job, the mayor said, our approval ratings should fall.
And then Ed Skyler, Bloomberg’s press guy, called out, “We’re counting on you, Tom.”
• • •
In June 2006, after Bloomberg gave the speech to the public health law conference that I witnessed, he headed home in his private jet, with Frieden along for the ride. In this rare moment away from the crowds, the mayor was thinking expansively. His foundation had been sprinkling out money for many little things, he told Frieden. But with the foundation, as with his mayoralty, he wanted to do big things. Like eradicate a disease. Could Frieden come up with an idea?
A request like that from a billionaire wasn’t something Frieden would let pass. He wanted time to think about it, he said. Bloomberg agreed, then said, “And now I’m going to do a very good imitation of a sixty-four-year-old man taking a nap.” And he stretched out and fell asleep.
It didn’t take long for Frieden to think up a big thing. Despite the upsetting results from the most recent survey, he figured his antismoking crusade was saving lives by the tens of thousands. The tax increase had worked beautifully. The counter-ads were still unproven, but the calls to the Smokers’ Quitline looked promising. And the Smoke-free Air Act was an unqualified success.
The smoke-free law was even spreading. Instead of driving New Yorkers to the suburbs so that they could smoke with their meals, it soon prompted the suburban counties of Westchester, Nassau, and Suffolk to pass their own smoke-free ordinances. Later in 2003 the entire states of New York, Connecticut, and Florida had gone smoke-free. Eight other states followed in 2004 and 2005.
And instead of causing European tourists to avoid New York City, the law was beginning to change Europe. Soon after the city passed it, a delegation from Ireland flew in and met with Christina Chang and others to learn exactly how they had pulled it off. The Irish had been considering a smoking restriction, but after a day of meetings a consulate representative told Chang that his delegation was now determined to push it through. To most people, an Irish pub without smoking was inconceivable. “It’s a bad idea,” an Irish bartender was quoted as saying. “Cigarettes and alcohol are synonymous, at least in Irish culture.” Ireland became the first European country to ban smoking in pubs in 2003, shortly after its leaders visited New York. Then health officials from other European countries contacted Chang to hear the story behind New York’s law for themselves.
Frieden thought, what if he were to take the smoke-free law and the rest of the antismoking package to the entire world? Or as he put it later, “What if we had a vaccine that could prevent one in ten deaths worldwide? We already do.” Even the world’s poorest countries could do it, because indoor smoking bans cost nothing, and cigarette taxes could pay for counter-ads with plenty to spare. All they needed was a political push.
The World Health Organization (WHO) was now calling tobacco the leading cause of death worldwide. It killed nearly twice as many people as AIDS, three times as many as tuberculosis, and five times as many as malaria. But while smoking rates were falling slowly in high-income countries, the tobacco companies were marketing heavily in the world’s poorest countries, driving up smoking rates.
Frieden’s big idea was to use Bloomberg’s money to pay governments (and nonprofit organizations lobbying them) to do what he had done in New York City. “The basic concept was you strengthen the government, you strengthen the civil society, and you put in objective systems to see if it’s working . . . and you hold countries accountable.” Accountable, that is, for raising cigarette taxes, banning tobacco ads, running counter-ads, passing smoke-free laws, and preventing smuggling. Later he summarized it with the acronym MPOWER, for Monitor (with surveys), Protect (with smoke-free air laws), Offer (help with cessation), Warn (with counter-ads), Enforce (bans on tobacco ads), and Raise (tobacco taxes).
Frieden’s proposal was no one-pager. He analyzed data on smoking rates around the world and asked for advice from many experts. Because the city’s rules prohibited a city employee from working for someone else during city time, he labored over the proposal on evenings and weekends, mostly alone but sometimes with help from Kelly Henning, another former CDC Epidemic Intelligence Service officer in the health department to whom Frieden often turned for advice and help.
“This was a major, major undertaking,” Frieden told me. The final version included the basic strategy, the rollout, milestones, detailed budgets, tables on smoking rates around the world, and even a “risk mitigation” section. He assembled his proposal by hand in black binders of acetate pages at the conference table in his office. It was the kind of secretarial work that would otherwise infuriate Frieden, but he didn’t complain. “It was exciting.”
“Mr. Mayor,” his cover memo began. “As you know, tobacco is now the world’s leading killer. Billions of dollars ar
e going to international health but virtually nothing to global tobacco control.” His plan would spring from the Framework Convention on Tobacco Control, the first international health treaty negotiated by the WHO. He proposed channeling money to four U.S.-based nonprofits, which in turn would give grants to the WHO, national governments, and advocacy groups. Those organizations would pass the laws, run the ads, and do the surveys to measure the impact. It would all happen in twenty-four months, and it would cost Bloomberg $125 million.
When Frieden presented his case, Bloomberg took it all in. He asked many questions. And then he said he needed to think about it. Even for a billionaire mayor of New York City, this was big.
• • •
In August 2006, in a news conference in NBC Studios, Mike Bloomberg announced that he would donate $125 million over two years to fight smoking in low- and middle-income countries around the world. If the world ignored smoking and current trends continued through the twenty-first century, he said, tobacco would kill one billion people. Seven in ten of those killed would live in developing countries. Bloomberg’s nine-figure pledge to stop that was many times greater than any previous donation for tobacco control anywhere. “I think we’ve learned some important things about how we convince people to stop smoking,” Bloomberg said. “If this kind of progress can be made on a global scale, we can save many millions of lives.”