How to kick a national habit.

If successful, President Clinton's election-inspired proposals to curb tobacco smoking by teenagers will help reduce the most preventable cause of ill health in America (an estimated 450,000 smoking-related deaths occur in the United States each year), as well as save more than $100 billion annually in federal, state, and private expenditures for health care and lost work. But recent revelations by the Liggett Group, Inc.--makers cigarettes--make it clear that much more action is needed.

In its March 20, 1997, legal settlement with the attorneys general of twenty two states seeking to recoup health care costs of treating smokers, Liggett admitted that it and other tobacco giants had known for decades that cigarettes cause cancer, they are addictive, and the tobacco industry had deliberately marketed them to teenagers to make up for slumping sales to adults.

It is thus time for the nation to adopt a comprehensive plan to dramatically reduce smoking and thereby improve general health. While those who still wish to smoke should be allowed to do so, the majority who desire neither this habit nor its high social costs are entitled to some relief. I believe my forty odd years of experience in the trenches of the tobacco war have given me the necessary long range perspective to offer a set of workable, constructive changes for the future.

In the late 1940s, as a youth in suburban New York, I joined several other neighborhood kids in taking my first furtive cigarette puffs in a nearby, empty wooded lot. This rite, kept secret from our (smoker) parents (and followed by Sen-Sen and cloves), seemed to us to be an exciting way to assert our prepubescent independence. Ubiquitous cigarette ads in papers and magazines at the time heralded smoking doctors touting "safe" cigarettes, lauded the salubrious effect of smoke on your "T-zone" (throat), assured you that "L.S.M.F.T.--Lucky Strike Means Fine Tobacco," and, through celebrity testimonials, promised youth, glamour, vigor, and good looks to smokers.

In the 1950s, as a high school student serving the summer as an orderly at White Plains Hospital in downstate New York, I first encountered unfiltered the deadly ravages of smoking. After I wheeled the bodies of dead lung cancer victims to the morgue and watched as the pathologist sliced white golf ball or melon sized tumors out of blackened lungs, I reviewed the patients' charts. The conclusion was crystal clear even then: all the lung cancer victims had a previous history of heavy smoking for many years. I gave up cigarettes then and there. However, as a magazine editor at Amherst College in the late 1950s, I was only too happy to accept a small subsidy for including preprinted, color back covers that proclaimed: "Join the men [ranch hands] who know: nothing satisfies like the big clean taste of top tobacco-Chesterfield Kings" or "Live Modern: Change to Modern L&M."

But as a medical student at the University of Rochester, New York, in the 1960s, I learned that the components of tobacco smoke's 4,000 chemicals include at least forty three different proven car cinogens (in humans and other animals) and more than 200 poisons, such as aromatic hydrocarbons and nitrosamines. I also learned that nicotine is addictive in the particulate phase and the gas phase de livers many more poisons--carbon monoxide (which displaces needed oxygen from red blood cells), formaldehyde, ammonia, nitrogen oxides, benzene, acrolein, pyridine, and hydrogen cyanide, to name a few--directly into the lungs' bronchial airways and alveoli (air sacs) and, thence, directly and quickly into the bloodstream.

Later, as an internal medical resident and fellow in pulmonary medicine at Boston City General, Boston Veterans Ad ministration, and Massachusetts General hospitals, I tried to help long term smokers, gasping from their smoking induced emphysema, bronchitis, and heart disease. Many passed their final days in the intensive care unit, hooked up with tubes from a tracheostomy (incision in their wind pipe) to a ventilator machine. I often treated heart failure patients after their premature, tobacco induced heart attacks. Many of the men--members of Senator Robert Dole's "experienced generation"--had started their smoking habits as soldiers during World War II after having received free or cheap cigarettes at the PX.

In 1964, the first surgeon general's report to note the link between widespread cigarette smoking and rapidly increasing rates of lung cancer appeared. Subsequent surgeon general's reports were to identify tobacco smoking as the major preventable cause of many disabling and often lethal diseases, in eluding emphysema, bronchitis, and cancers of the lung, larynx, and bladder. They also identified smoking as a major contributing factor in deaths from heart attacks (coronary heart disease), in peripheral vascular diseases and strokes, and in incurring billions of dollars in lost work days, medical expenses, disability, and death. Secondhand smoke was also later implicated as a definite health threat to both adults and children. And now Belgian scientists have found that new bores of mothers who smoked during pregnancy have adult nicotine levels in their bodies and thus need to be treated as ex smokers.

As an Air Force physician during the Vietnam War era, I saw a new generation of soldiers--recruits who were too patriotic or too poor to be successful draft-evading hippies or yippies--get hooked on free cigarette samples or cheap PX smokes. When I started medical practice at the Lahey Clinic in Boston during the 1970s, I dealt daily with both men and women smokers--business executives, workers, and home makers from all segments of society--who were fighting cigarette nicotine addiction and related illnesses. It became clear that smoking adversely affected almost every organ system in the body. Later, I started a comprehensive, ambulatory pulmonary rehabilitation clinic to aid tobacco afflicted bronchitis and emphysema sufferers, who were often too winded to slowly climb one flight of stairs.

After I witnessed daily the disabling results of long-term smoking, I realized that the need for prevention was just as great--or greater--as treatment. As chief of pulmonary medicine at the New England Deaconess Hospital in Boston, I fought to make the facility one of the first smoke free hospitals in the country. I was aided by other anti smoking pioneers, including Dr. Richard Overholt, a thoracic surgeon who, since the 1930s, had excised thousands of lungs riddled with smoking induced tumors, and Dr. Theodore Badger, an experienced chest specialist. Unbelievably, we had to battle many angry nurses who complained that their personal freedom would be violated by policies to exclude smoking from the facility. Some prominent hospital and clinic administrators feared they would lose the business of nicotine deprived patients, who they predicted would go elsewhere (though most didn't).

As a clinical researcher and teacher at Harvard and Tufts medical schools, I helped identify the growing menace of a cigarette related lung cancer epidemic in women. Liberated women had begun puffing tobacco in the 1940s and slowly developed their lung cancers over the next twenty years. As a result, lung cancer death rates in women soon surpassed those of breast cancer to become the number one cause of cancer death in women--as it had been in men for many years. In deed, women had truly "come a long way, baby" in dying by the tens of thousands from lung cancer. The American Cancer Society predicts that, over the next year, 192,000 Americans--110,000 men and 82,000 women--will be newly diagnosed with and 164,000 will die from lung and throat cancers, both strongly related to smoking, while another two million people worldwide will die from smoking related diseases.

I also helped analyze diagnostic techniques to detect lung cancer and concurred with other researchers that the then accepted, widespread screening techniques--such as chest x-rays and sputum exams (cytologies)--are very insensitive in detecting early, small, treatable tumors. Thus, by the time lung cancer is diagnosed, it has often metastasized elsewhere in the body. Thus I concluded once more: treatment is often too late; prevention is the key and should be the number one priority.

In the 1970s and 1980s, I appeared as a consultant before the Boston City Council and elsewhere to help legislators formulate effective laws prohibiting smoking in restaurants and public buildings. After other health experts and I gave voluminous objective data about the multiple injurious health effects and costs to society of smoking related illnesses, we were often followed by highly paid tobacco lobbyists, often ex legislators. They assured their ex colleagues that our health data, which implicated tobacco, was totally irrelevant because cigarettes were legal goods to be sold and smokers' freedom to smoke was protected by the Constitution and the Bill of Rights. Local laws restricting smoking were, therefore, legislated slowly at first and were often spotty.

Finally, in the 1990s, after more than forty years of accumulating vast scientific evidence proving the adverse and often fatal effects of long term smoking, as well as of second hand smoke, it is heartening to see grass roots public opinion and most politicians supporting policies to prevent children from starting smoking and to encourage adult smokers to quit. How ever, in spite of the growing awareness of the dangers of smoking, an increasing number of teens (35 percent), as well as 26 percent of adults (down from over 40 percent in 1965), still smoke.

Worldwide, the figures and trends are more alarming. The World Bank's 1993 World Development Report declares, "Unless smoking behavior changes, three decades from now premature deaths caused by tobacco in the developing world will exceed the expected deaths from AIDS, tuberculosis, and complications of childbirth combined" Epidemiologist Richard Peto of the Cancer Studies Unit at Oxford University estimates that, by 2025, tobacco use will kill at least ten million people per year--more than seven million of which will be in developing countries. The World Health Organisation states that tobacco use now constitutes "a global health emergency that many governments have yet to confront"

So President Clinton's current efforts to reduce smoking among teenagers and to recognize nicotine as an addictive drug under the jurisdiction of the U.S. Food and Drug Administration are a welcomed start. But much bolder, more creative, and more ambitious measures aimed at peacefully phasing out a major destructive industry are the next step.

The ethical reality we must face is this: the high profile, large scale traffic in tobacco is sufficiently harmful to society to warrant a deliberate effort to render it all but unprofitable. We don't need to prohibit tobacco entirely. Those individuals--after receiving complete and accurate consumer information--who still wish to avail themselves of tobacco products should be free to do so. And others should be free to manufacture and sell, at a fair profit, that which satisfies any lingering demand. Nor do we need to destroy the fortunes and livelihoods of tobacco farmers and workers. The aim should simply be to bring a gradual end to the active and knowing destruction of the public health.

The matter can be approached in much the same way we approach other harmful substances and products. And this is the spirit behind the following twelve step agenda to break America's smoking habit:

1. Create business incentives for farmers to make the transition from tobacco to alternative crops. As long as farmers keep growing tobacco, manufacturers will market tobacco products. Only when we approach the problem at its source and effectively scale down tobacco production will we succeed in decreasing tobacco consumption. While federal price supports for tobacco, which began in 1909, were terminated in the 1930s, current hereditary acreage allotments make it advantageous for certain farmers to continue specializing in the crop. Right now, about 124,000 tobacco farmers in the United States depend upon a federal system that parcels out shares of the total tobacco production. This restriction of cultivated tobacco acreage has the paradoxical effect of artificially making the crop highly profitable.

But the government doesn't have to keep doing things this way. Alternative incentives can replace current ones. Wayne Rasmussen, who was historian for the U.S. Department of Agriculture for fifty years, has suggested a possible replacement policy of providing a subsidy to tobacco farmers who convert to food crops like wheat and corn. According to the Worldwatch Institute's State of the World 1997 report, in the face of world hunger, governments would do well to question the practice of using farmland for nonessential crops. "For example," it says, "the 5 million hectares [12,355,000 acres] of cropland used to produce tobacco could produce 15 million tons of grain for human consumption."

2. Encourage economic incentives for consumers to quit smoking and disincentives for their habit to continue. Actuarial analyses showing much higher morbidity and mortality for smokers, and hence higher insurance payoffs, provide a factual foundation for the widespread life insurance industry practice of charging higher premium rates for smokers and lower rates for nonsmokers. Health insurance policies have been similarly affected. But what about fire insurance premiums? They, too, could reflect lower payouts for nonsmokers and, hence, become lower for businesses and institutions with effective no smoking policies.

3. Increase cigarette excise and other tax rates enough to cover the social costs of smoking. Currently, there is a significant gap between the high cigarette taxes in some states (82 [cts.] per pack in Washington, 76 [cts.] in Massachusetts, 75 [cts.] in Michigan), and the low rates in tobacco growing states (5 [cts.] in North Carolina, 3 [cts.] in Kentucky, 2.5 [cts.] in Virginia). Given a uniform federal tax of 24 [cts.] per pack, this variation makes little sense. According to the American Cancer Society and Action on Smoking and Health, there are a number of cogent reasons why both state and federal taxes of this type should be higher:

* Costs for health care and lost productivity come to about $100 billion annually in the United States. As argued in Worldwatch's State of the World 1997 report, "It simply does not make economic sense for a government to promote smoking while at the same time bearing the brunt of health care costs caused by tobacco use." Tobacco taxes can thus be considered more of a "user fee."

* Each 25 [cts.]-per-pack tax increase is estimated to reduce adult smoking rates by 4 percent and yoputh smoking by 10 percent. In California and Massachusetts, where voters approved citizen initiatives to increase pack taxes, the average number of cigarettes smoked by adults fell annually by 2.7 and 2.2 percent, respectively (or a 17 percent drop in Massachusetts since 1993), compared to an 0.8 percent yearly drop in other states.

* Decreased smoking rates would reduce disease and death rates both in teenagers under eighteen (projected at more than five million future preventable deaths by the U.S. Centers for Disease Control and Prevention) and in adults. Thus, the currently projected 450,000 tobacco-related deaths annually in the United States would be lower.

* Nicotine addiction in teenagers acts as a "gateway drug." Smoking teens are 100 times more likely to use marijuana and thirty times more likely to use cocaine, according to figures cited by the surgeon general.

* Taxes scaled to the level of tar and nicotine would en courage manufacturers to lower the percentages of these hazardous substances in their tobacco products.

4. Encourage further lawsuits by states to recover from the tobacco companies taxpayer dollars already spent on tobacco-related health costs. The recent out of court settlement by the Liggett Group, Inc., shows how states can recover millions of dollars in smoking related Medicaid health care costs. This successful approach should therefore be repeated by all other states. And since Liggett has agreed to add a warning to its packaging stating that smoking is addictive and to aid the Justice Department in its criminal investigation of perjury, fraud, and conspiracy allegations against the tobacco industry, the potential gains through this type of action involve far more than money.

5. Help individual tobacco victims recover their health care costs and compensate their families for tobacco-related deaths. The tobacco industry has poured millions of dollars into teams of high powered, high priced lawyers to de fend their interests against victims of tobacco related illness and death. "In more than 800 suits, initiated since 1954, the cigarette companies have gone to trial only twenty-three times, lost twice, and paid not a dime in damage payments" to individuals, the Nation reported in its September 28, 1995, issue. An example is the Cipollone case in New Jersey, on which the tobacco industry spent more than $50 million, dragging the case out over a ten year period, to deny damages to the family of a heavy smoker who died of lung cancer. It took the case to the Supreme Court, filed more than 100 delaying motions, and finally caused the exhausted plaintiff's firm, having futilely spent more than $5 million, to quit.

In 1996, a class action suit against the American Tobacco Company, now in the federal court in New Orleans, was launched by a world class group of product liability lawyers, led by Wendall Gautnier on behalf of Peter Castano, a smoker since age sixteen who died of lung cancer at age forty seven. If it goes before a jury, this case could represent ninety million current and former smokers and become the largest product liability suit in American history, with the potential of winning $40 billion in damages. The plaintiff's lawyers will attempt to defeat tobacco industry lawyers, who disclaim all responsibility and contend that all responsibility is the smoker's. The plaintiff's lawyers aim to prove fraud against the tobacco companies, which they allege withheld secret data about the addictive and injurious effects of smoking.

6. Promote divestiture of tobacco company stocks. When the pension plans and investment firms of teachers, executives, workers, and government employees do not divest their tobacco stocks, they give dollars to support disability and death from smoking. For example, Fidelity Investments of Boston encourages its many mutual funds to invest $7 billion in Philip Morris, the largest holding of many of its mutual funds. Fidelity also invests another $1 billion in RJR Nabisco, Joe Camel's home base. Fidelity touts Philip Morris' "strong growth attributes, despite future litigation threats" Years ago, South Africans and their U.S. sup porters fought successfully against apartheid by promoting divestiture of its formerly segregated firms. All individuals and corporations should be encouraged tn similarly divest all equities based on selling nicotine, tar, and carcinogens. A divestment restriction bill for state employees was passed by the Massachusetts House last year.

7. Reward honesty for revealing and penalize dishonesty for covering up cigarette ingredients and,corporate research results regarding the addictive and health perils of smoking. Tobacco companies reportedly have a long history of concealing scientific studies that demonstrate the addictive quality of nicotine and the many adverse health effects of smoking. Documentation has appeared in the Journal of the American Medical Association, the Nation, Dr. Stanton Glantz's Tobacco Papers (1996), and elsewhere. Effective laws would require tobacco companies to make public their scientific studies and list all chemical ingredients on packaging, as is done with most other consumer products. A tobacco disclosure law, requiring full listing of all ingredients, was passed by the Massachusetts legislature in 1996 and, not surprisingly, is under a challenge from the tobacco industry.

8. Expand education about the injurious consequences of smoking. The tobacco industry spends more than $6 billion annually to entice youngsters to start smoking and to keep smokers from quitting. Joe Camel grabs the attention of potential childhood smokers (90 percent of smokers started as teens), while the Marlboro Man spreads Madison Avenue macho across the United States and around the world. To counter these enticing tobacco images, effective education programs for both children and adults should communicate facts about tobacco induced illnesses, incapacity, and death, as well as teach effective techniques to quit smoking. For example, the Massachusetts Tobacco Control Program, funded by a 24 [cts.]-per-pack tax increase and approved by a voter referendum in 1992, gives grants to towns to fund educators who teach students why they should not start smoking and how to quit.

9. Discourage tobacco company advertising and promotions. Cigarette companies spend $6 billion per year for advertising and promotions. This includes their sponsorship of sporting events, such as Winston Cup Racing, and their use of billboards in baseball and football stadiums and basketball and hockey arenas. The latter are also seen "incidentally" by millions of television viewers. The tax deductible status of this outlay saves the industry more than $1 billion in taxes each year. President Clinton's new restrictions on cigarette advertising aimed at minors are currently being challenged by the tobacco industry on free speech grounds, but the administration is arguing a "substantial government interest to protect children."

Should this argument fail a constitutional test, however, other possibilities remain. Advertising media are often encouraged to voluntarily refuse to accept certain types of advertising. That's why we (unfortunately) don't often see condom ads on television--though they are perfectly legal and would generate lucrative advertising revenue. If similar pressure could be brought to bear on other media regarding tobacco advertising, the public could actually benefit this time. Additionally, just as anti smoking public service ads produced by the American Cancer Society drove cigarette advertisers off television in the 1960s, a similar approach could be applied in other advertising venues. Meanwhile, the very fact that cigarette billboards can be seen on television during sporting events is sufficient reason for television public service anti smoking ads to make an important comeback.

10. Further restrict tobacco sales. Just as states and municipalities can limit, through licensing and zoning, what sorts of stores sell liquor and where such outlets may be located (as well as limit and regulate other types of businesses in other ways), so various levels of government can restrict tobacco retailing. By this process, over the counter and vending machine sales of tobacco products can be prohibited at food markets, pharmacies, restaurants, workplaces, government facilities (especially military bases), hospitals, public schools, private universities, discount stores, and the like. Some local laws already exclude cigarette sales from many of these sites, but there is no systematic coordination between communities. Many businesses, such as Target stores, the nation's third largest discount retailer, have voluntarily ceased to sell tobacco, but Kmart and Walmart are still engaged in the trade. The ultimate goal should be to limit all tobacco sales to specially licensed smoke shops.

11. Ban smoking in all public places. While most hospitals have been smoke free for one or two decades, the great benefits of a totally smoke free environment to both the smoker and the secondhand smoke inhaling neighbor should be extended by statute to all factory and office workers and students, as well as to all military personnel. The total ban on smoking in the country's workplaces proposed by the Occupational Safety and Health Administration two years ago has been stalled in Congress by opposition from tobacco and restaurant interests.

12. Discourage tobacco exports by American cigarette makers to other countries. With the decline in the number of adult American smokers, stated strategic plans of American tobacco corporations call for increasing exports to "expanding markets"--such as China, Europe, and Africa. Reports from China today describe the omnipresence of large bill boards featuring those exemplary American character models, Joe Camel and the Marlboro Man. Past U.S. government trade policy has actually mandated that other countries accept minimum quotas of US. tobacco exports and allow unlimited advertising of U.S. tobacco products abroad. What to do? President Clinton now has an election mandate to be as strict about limiting U.S. tobacco exports and disclosing health risks abroad as he does at home. He should be encouraged to follow through.

This comprehensive twelve step plan to break America's, and perhaps the world's, smoking habit will quite naturally lack the blessing of leading tobacco product manufacturers. But then marketers of infant formula in the Third World weren't pleased by the public boycott against them a decade ago. Major oil companies would do more offshore drilling and pollute more beaches if the public let them. And automobile emission controls and safety requirements remain a pain in the neck for car manufacturers.

Big tobacco has no intention of giving up without a fight, either. During the 1996 elections, two tobacco companies--Philip Morris and RJR Nabisco--gave more than $3.1 million to influence political parties ($2.6 million to Republicans and $523,000 to Democrats). Philip Morris hosted receptions for delegates at both parties' conventions. Many more millions of dollars are spent on lobbyists to argue the tobacco industry's viewpoints directly and to influence federal and state representatives.

So my twelve step plan won't be easy to implement. But think where we once were in America. There was a time when just about everyone had to put up with smoking at work, in elevators, in every part of restaurants, and in an astonishing variety of other places. Television was saturated with uncriticized cigarette advertising. Smoking was the "in" thing to do, and people rarely asked if it was okay to smoke in another's presence. The public had no idea of the dangers, and government had no idea of the costs.

We've come a long way, baby! Now let's finish the job.

Joseph L. Andrews, Jr., M.D., is an internist and chest specialist in Concord, Massachusetts, and a lecturer in medicine at Tufts University Medical School in Boston.