Watch any movie made before 1990, and it’s a little shocking to see how many people are smoking onscreen. Movie characters smoked at home, in restaurants, on airplanes, and at the office. They smoked while fighting wars, eating dinner, drinking in bars, having sex, and talking to the boss. Lighting up onscreen was acceptable practically everywhere, except maybe the hospital.

Saving Gotham: A Billionaire Mayor,
Activist Doctors, and
the Fight for Eight Million Lives

by Tom Farley, MD
W.W. Norton & Co., 320 pp.

All that changed in the 1980s and ’90s, during the “tobacco war,” as that period is sometimes called. Those of us who reported on it vividly remember the heroes who launched the public relations and legislative battles that transformed the way we view smoking: Stanton Glantz, professor at the University of California, the Ralph Nader of anti-smoking; David Kessler, former commissioner of the U.S. Food and Drug Administration, who made it his mission to put cigarettes under the FDA’s control; and all the state attorneys general who successfully sued the massively rich and powerful tobacco industry for the health costs of smoking.

The result has been a dramatic reduction in rates of smoking over the last twenty years. In 1981, 33 percent of Americans were smokers. By 2011, it was down to 19 percent. Today, actors in movies are no longer wreathed in clouds of cigarette smoke, and smoking is far less acceptable as a habit. More importantly, deaths from lung cancer have been declining since the 1980s, a triumph of public health.

In Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives, author Tom Farley, MD, tells the story of a new cadre of public health heroes—Mayor Michael Bloomberg and his merry band in the New York City Department of Public Health. Farley, a former epidemic intelligence service officer with the Centers for Disease Control and Prevention (CDC) and the best doctor-writer you’ve never heard of, has turned the department’s exploits into a compellingly readable tale. During Mayor Bloomberg’s tenure, smoking was banned from New York City restaurants and bars; cigarette displays were banned from stores; trans fats were banned from foods; and calorie counts were mandated on the menus in all fast food restaurants. The only campaign the mayor and the department lost was a regulation that would have reduced soda consumption.

Many of these measures have come to be seen as nothing out of the ordinary, but at the time they were nothing short of revolutionary. Bloomberg appointed Tom Frieden, a physician from the CDC who had worked on tuberculosis in India, to serve as chief of the Public Health Department. Frieden, a fast-talking, fast-walking, even fast-eating New York native, brought brains, creativity, and a sometimes-abrasive sense of urgency to the job. When Frieden and his staff first announced their plan to ban smoking in restaurants and bars, the mayor’s staff thought it was political suicide. Bloomberg, however, needed no convincing; he was already preparing to increase taxes on cigarettes from 8 cents a pack to $1.50. (Higher prices discourage smokers, especially the young, but the city also needed the tax revenue.) Restaurant and bar owners launched a furious campaign, lobbying the press, and the city council, maintaining that smokers would stay away from their establishments in droves and ruin their business.

In response, writes Farley, “Frieden and his allies approached the passing of the Smoke-Free Air Act as if it were an insurgent political campaign.” They wrote to supporters and opponents on the city council and in the state legislature, and assigned department staff the job of calling them individually. They scheduled press events, paid for polls, made pitches to newspaper editorial boards, and wrote scripts for ads, creating taglines like “There’s no such thing as a nonsmoking section.” Their efforts paid off; the ordinance passed. It turned out that the restaurant and bar owners were wrong: business was actually better when the smoke cleared. The health department then created a mass campaign to persuade New Yorkers to kick the habit, and offered them help in doing so.

New York was not the first city to ban smoking in restaurants and bars, but it was by far the largest and most influential, spurring similar regulations in many parts of the country. By 2004, entire states were making eating and drinking establishments smoke-free. Even European cities have begun to act.

Banning smoking was easy compared to the fights the Department of Public Health faced when it began to go after the way New Yorkers eat. Their first targets were getting calorie counts posted on menus, and removing trans fats from food. Restaurants fought both measures tooth and nail, as the New York State Restaurant Association poured money into the coffers of state politicians and city council members. Like Big Tobacco, Big Food has deep pockets and hordes of lawyers and marketers. McDonald’s and Applebee’s argued that banning trans fats would cause New Yorkers to flee to New Jersey (horrors!), or stop eating out altogether. Conservative political groups muttered darkly about the city’s “food police.” The New York Post warned that “French fries, chicken nuggets, pizza, cakes, cookies and many other beloved foods may never taste the same again.” This wasn’t the case: trans fats were easily replaced, and customers never tasted the difference.

New York City won both those battles, and in the process normalized a new set of food regulations that have since been adopted by the FDA. Now diners around the country, not just in New York, can see that the Double Whopper they are about to put in their mouths contains enough calories (1,800) to fuel the average woman for an entire day. That venti caramel Frappuccino (clocking in at 410 calories) is like eating two Snickers bars, but with half the protein. But when the Public Health Department turned to cutting the consumption of sugar that is contained in soda, it met its match in beverage makers and their teams of lawyers and lobbyists.

In the summer of 2007, author Farley joined the Department of Public Health (and would later take over as chief when Frieden left to head the CDC). Farley and his team began working on reducing soda consumption by city residents. Over the decades, mounds of scientific evidence has made clear that refined carbohydrates—white flour, white rice, and especially sugar—were a major contributing factor to escalating rates of obesity and diabetes. In 2000, the average New York City teenager drank 300 calories, or 24 ounces, of soda a day. Diabetes was costing the city $4.5 billion in medical bills annually.

Farley and the team were up against skewed public perceptions about soda and sugar. In focus groups, members of the public said soda could be part of a balanced diet. “Everything in moderation,” they said, a phrase that Big Soda had managed to get into the mouths of nutritionists by donating heavily to their professional societies and funding nutrition research. In addition, the misguided anti-fat nutrition campaigns of the last twenty years have persuaded the public that sugar, and therefore soda, could not possibly cause obesity. French fries and “bad genes” were to blame.

The Public Health Department was also battling the brilliant marketing minds of the beverage makers. Coke, after all, is about happiness, Santa Claus, fun, youth, and harmony. Right behind the marketers stood the lawyers and lobbyists of the American Beverage Association, who persuaded the courts to equate the right of companies to peddle soda to freedom of speech, and the opportunity for people to drink themselves into diabetes a civil right. The beverage lobby even got help from the Koch brothers’ Washington Legal Foundation.

The department was outmaneuvered by the soda industry three times, the last shortly before Bloomberg left office. But New York’s fight against soda has had an impact around the world. In 2013, the nonprofit foundation Bloomberg Philanthropies took the idea of a sugar tax to Mexico City, where per capita consumption of sugary drinks and the rate of diabetes is the highest in the world. “Against fierce resistance by the soda companies,” writes Farley, “health advocates sprinted a bill through the legislature with taxes on soda and junk food.” Early results suggest that purchases of sugary drinks have fallen by 10 percent.

These are the battles of public health of the future: the environment around us that breeds chronic illnesses like diabetes, heart disease, asthma, emphysema, and a host of other modern plagues. Conservatives like to argue that regulations like smoking bans, soda taxes, and calorie labels are an infringement on our rights as individuals—to smoke, to drink, to eat whatever we please, and by extension to be as unhealthy as we like. It’s an argument that makes ill health entirely a matter of individual responsibility, even as the costs of individual behavior are born collectively. We all pay for the nation’s rising rates of obesity, diabetes, lung disease, and asthma in the form of medical bills and a loss of human capital.

And while we like to imagine that we are masters of our own appetites and behavior, what we put in our mouths is influenced by the world and people around us. That world has been shaped powerfully by the wants and needs of manufacturers and their shareholders. As Tom Frieden puts it, “[D]efeating tobacco was much harder than defeating tuberculosis, because tuberculosis bacteria don’t bribe politicians. They don’t rebrand themselves as ‘lite’ bacteria. They don’t hire movie stars to make it look cool to have tuberculosis.” Saving Gotham shows that it is possible for activist health officials to stand up to industry and advocate for the public’s health.

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Shannon Brownlee is a lecturer at George Washington University School of Public Health and Special Advisor to the President of the Lown Institute.