The General's Warning Koop vows to win the war against smoking D r. C. Everett Koop, the colorfully .outspoken surgeon general of the United States, chuckles when he tells a story about two bartenders he met at a Maryland country club a few years ago. "They asked me if I was the one who put those [warning] signs on the cigarette boxes," Koop recalls, `and I said, `Sure, and they're also true.' House to the lushly appointed offices of the tobacco industry's barons, who con- sider Koop a half-cocked kook. Their ar- gument: No certifiable medical evidence links smoking to poor health, so get off our backs. No way, says Koop. "Well, they listened to me as I gave them the pitch for about five minutes. I came back four months later - same coun- try club, same two bartenders - and I went right up to them and I said, `Do you re- member me?' His incessant hammering lends signifi- cant prestige and weight to anti-smoking's burgeoning battalions, once manned only by so-called wimps and health freaks. And though many members of the anti- smoking forces blanche at some of the doctor's right-wing, fundamentalist views on issues like abortion, they need him to quit, but why don't they?' he asks. "They're addicted to the most addictive drug in our society. It isn't like telling people they shouldn't eat fudge . . . "In the war against cancer,' smoking is a high priority, primarily because it's something you can change so easily. You can't go out and change certain things in the environment. You can't change gene- tic things, but smoking is something you can. " `Do I remember you?' one of them says. `I ain't smoked since you were in here.' " "That's one of the things that makes my crusade a reasonable one. What you are eventually saying [to smokers] is, `For your own good, and that of those around you, would you change your behavior?' " Koop has seen cancer's rav- ages first-hand. Koop wishes it were only that easy to convince the rest of the nation's 55 million smokers. But give him cre- dit - he tries. For the last five years, from smoke-filled bars to the halls of Congress, the nation's top doctor has spread his grim-reaper message: Smoking kills. Just look at the evidence, Koop counsels: Tobacco con- sumption is responsible for the deaths of 350,000 Americans each year-nearly 142,000 from cancer alone - and leaves a multi-billion-dollar trail of health-related costs in its wake. His mother, a non-smoker, had breast cancer when she was 49. A radical mastectomy "which didn't leave much" helped her live to be 86. And the nurse who ran Koop's operating room at Children's Hospital in Philadelphia died last July from lung cancer, no thanks to a two-pack-a-day cigarette habit which Koop nagged her about "at least once a day." Koop passionately argues Ahab: With his grey beard, summer-white uniform of the Public Health Service and steely gaze, Koop looks like a modem-day Captain Ahab loaded for whale. But he's ac- tually a low-key fellow who that it needn't be this way: "I Koop: "My position is to encourage, exhort and to be catalyst. " cuts and polishes precious now realize that without stones to keep his surgeon's doubt, smoking is the number one public reach their goal of a smoke-free society eyes and hands in shape. health problem in this country. But by 2000-a time when, Koop says, "the His spacious office with a view of perhaps more important than that, the be- smoker will not smoke in the presence of Capitol Hill and the National Gallery of havior that leads to this terrible situation a non-smoker without obtaining permis- Art features a wallful of food for thought: is something that people enter into con- sion. The non-smoker's home will be his A print of a large yellow light bulb proc- sciously. And, it's behavior that can be castle and the smoker will not invade it." laims: "Think: Smoking Dims." Another changed. His is a crusade spurred by a physician's depicts a crumpled Marlboro cigarette "Smoking is the leading preventable regard for a patient's health, a commit- box. And one plaque proclajms the "1 lth cause of death in this country and that's ment to his three children and seven grand- Commandment: Thou Shalt Not Smoke." worth fighting for." children, common sense and a severe dis- Out on the stump, Koop hands out blue- Blunt: Koop is not, as they say in like for what he calls the "sleazy" tactics and-white lapel buttons, which he paid for Washington, "political." He's blunt, he's of the tobacco industry, which, if you lis- himself, stating: `The Surgeon General to the point and, sometimes, he's as subtle tened to Koop, would hand out a pack of personally asked me to quit smoking." If as a sledgehammer. cigarettes with every birth certificate. miscreants, like those country club barten- He has raised dust from the White "Ninety percent of all smokers want to ders, come, around, they get another pin 16 COPE MAGAZINE o OCTOBER 1986 saying, "And I did." Koop's office -not among the govem- ment's more powerful agencies -over- sees federal hospitals and research facilities, as well as programs dealing with health education and preventive medicine. As surgeon general, he's required to report to Congress each year on smoking and health. This year's topic: The sus- pected nasty effects of "sidestream" smoke on non-smokers. Koop isn't afraid to vent his controver- sial views on other touchy subjects: Por- nography is a moral cancer. Abortion is wrong. Television violence promotes ag- gressive behavior. Video games addict youngsters. Too many Americans kill themselves with sugary, fatty diets. Sparks: But despite the public's interest in those topics, it's smoking- an issue the Reagan Administration has ignored - that has won him the most press. This summer on Capitol Hill, the sparks flew over a Congressional bill that would ban all tobacco advertising in. this coun- try-an emotionally charged topic that wraps the concept of free speech around the threatened loss of billions of advertis- ing dollars. The surgeon general endorses the idea; the White House, still enjoying its long honeymoon with American big business, doesn't. So just before Koop hiked up Capitol Hill to testify before a House subcommit- tee, Reagan's chief of staff, Donald Regan, jerked the doctor's chain and or- dered him to heel. The resulting publicity Battle ribbom Fighting peer pressure. later forced Regan to relent-but not before he made it clear that Koop was speaking only as an informed citi- zen, not as a presidential emissary. Koop told the House Energy and Commerce Subcommittee on Health and the Environment that "cigarette ads have an insidious effect on the population as a whole by maintain- ing and encouraging use and under- mining health-education efforts." But the question remains: How can Koop operate in an administra- tion which subsidizes tobacco farm- ers and opposes any restrictions on an industry he says does more phys- ical harm than economic good? "I find it frustrating, but on the other hand, after you are in govem- ment for a while, you begin to realize that there are certain facts of life that you live with." Top dot: A modern-day Ahab, loadedfor whale. In Washington, however, there are some who will say Reagan got more than he bargained for when he appointed Koop in 1981. thanks, in part, to advertising. The industry swears it uses ads only to persuade smokers to switch brands. Koop sees it as a deadly enticement for the young: "Suppose you had never heard of a cigarette. And just suppose that people in Europe use cigarettes and you knew all the [bad] things about them and their ill effects. A Brooklyn native, Koop graduated from Dartmouth in 1937 and Cornell's med school in 1941. He went into chil- dren's medicine and surgery, where he concentrated on fixing birth defects. In- deed, Koop gained international fame in 1974 after he successfully separated Siamese twins in Philadelphia. He went on to become a professor of pediatric surgery at the University of Pennsylvania's School of Medicine and chief of surgery at Children's Hospital of Philadelphia. A strong voice in the anti- abortion movement, he came to Washington in 1980 as deputy assistant secretary for health in the Department of Health and Human Services. Women's groups and Planned Parent- hood, among others, opposed his nomina- tion as surgeon general. Sen. Edward Ken- nedy, the Massachusetts Democrat, said Koop was "out of touch" with modem-day society. Koop won the job anyway. After he took office, then-Gov. Jim Hunt of tobacco-rich North Carolina called for his resignation. Said Koop in response: "My position is to encourage, exhort and to be a catalyst." And, he might have added, to badger the tobacco industry. It's a business, he says, that tells "flat-footed lies, like `We don't really know what causes cancer."' Koop's opposition is noteworthy: To- bacco's place in society dates back to the 1700s when, as the colonies' top cash crop, it bankrolled the Revolution. Since then, its privileged place has held strong, "Tomorrow morning, you read in the newspaper, `U.S. to Import Cigarettes for the First Time. ' What would happen here? There would be a revolution." Mark Twain once cracked that quitting smoking was easy-he'd done it a thousand times. But Koop says a smoker has to want to do it. "I came home from college for a weekend in 1933, long before people talked about smoking and health. My mother stopped me in the kitchen and said, `What are we going to do about your father? He smokes more than two packs a day, has this terrible cough and I'm sure he's shortening his life.' Overheard: "I said, `Mom, forget it. Pop hasn't got the guts to quit.' What I didn't know is that he had walked in behind me and heard the conversation. "Well, he walked out, threw his cigar- ettes down the toilet, packed his parapher- nalia in a handkerchief and never smoked again in his life . . . You have to have a self-rewarding goal." . . *" The key, however, to a healthy life is never to start smoking-even though the American Academy of Pediatrics esti- mates that 90% of America's smokers started before they were 20. The average beginning age: 14. COPE MAGAZINE o OCTOBER 1986 17 And that's where education plays such an important part. Koop says it must begin as early as the first grade to combat peer pressure and advertising. "The greatest problem is the length of time before the insult and effect. If you died of cancer two weeks after you smoked, there would be no problem at all. "But the fact is that if you sit down and try to talk to a 16-year-old kid about the fact that he's going to die at 60 from lung cancer, he won't even talk to you. It doesn't impress him." Some of the message seems to be get- ting through. Testifying: ` `Z find it frustrating. ' ' A June Gallup poll showed that cigarette smoking dropped to its lowest point in 42 years - 3 1% of the adults ques- tioned, down from a high of 45% in the mid-1950s. For men, it stood at 35%; women, 28%. The biggest drop came in the 18-29 age group, which fell 11 points to 27%. And while the number of teenagers who smoke - 13% - has remained constant over the last four years, young survey re- spondents said they are smoking less. Congress, wary of smoking's hazards, could very well raise the federal excise tax on cigarettes 8 cents this year. And the National Academy of Science has called for a federal smoking ban on all domestic commercial flights. A Canadian airline already offers non- smoking flights; Continental Airlines' ,hands out fare discount coupons to passen- gers who don't smoke. The movement's future, then, will con- tinue to lie in the grassroots, not in federal government fiat. But Koop vows to keep up the fight. "The jury came in a long time ago. They found that the indictment was correct and that the tobacco industry was guilty as charged. I'm a poor loser and I'm in the fight against cigarettes. And I'll win." 18 COPE MAGAZINE o OCTOBER 1986