The voice of our Elders: the outspoken Surgeon General Jocelyn Elders is using her "bully pulpit" to take on the tobacco companies.

It didn't take long for Jocelyn Elders, the first black and second woman to hold the position of U.S. Surgeon General, to stir up controversy. In fact, this determined woman in the uniform of a three-star admiral did it less than a year into Bill Clinton's presidency, speaking out on drug legalization (she's for it) and abortion rights (she wants to keep coverage in the Clinton health plan). Elders has also been just as critical of the tobacco industry as her predecessor, Reagan appointee C. Everett Koop.

Dr. Elders, a longtime Clinton protege, grew up in rural School, Arkansas. One of eight kids, she didn't see a doctor herself until she was in college. After serving in the Army as a physical therapist, Elders entered the University of Arkansas under the G.I. Bill, graduating in 1960. She later became a professor of pediatrics at the medical school, and then, in 1987, was appointed by Clinton as director of the Arkansas Department of Health.

While in office, Dr. Elders earned a progressive reputation for, among other things, drastically increasing prenatal care for poor women, and expanding HIV testing, mammography and in-home care for terminally ill patients.

In a fairly conservative Democratic cabinet, the outspoken Dr. Elders has been a lightning rod for conservative ire. She has voiced support for medicinal use of marijuana, advocated the sale of the "morning after" abortion pill RU-486 in the U.S., urged parents not to buy toy guns for their children, told the Girl Scouts they should admit lesbians and linked legalized drug use to reduced crime.

But Dr. Elders' favorite target has been the tobacco industry, which she has lambasted for aiming advertising at teenagers. In our conversation, Dr. Elders was blunt. "Tobacco kills," she said. "It's that simple. It's the leading cause of preventable death in the United States today....My first order of business is to share these alarming facts with every parent."

E: Tell us about your background--education, jobs, pivotal life experience? What does being the first African-American and only the second woman to hold the surgeon General's post mean to you?

ELDERS: I'm the oldest of eight children. I grew up in Schaal, a small town in rural Arkansas where modern conveniences like indoor plumbing were rare. We were sharecroppers, and the whole family pitched in. Even as children we helped with the chores. We picked and chopped cotton, pulled corn, stripped cane, sawed wood, baled hay and helped our father stretch raccoon hides for money to buy food.

Still, in the ways that really count, it was a wonderful childhood. I was blessed with a terrific family. Even though we were poor by most people's standards, we weren't poor in love. There were always lots of people around who cared. My brothers, sisters, cousins and I never lacked for attention or guidance. Too many young people today don't have that kind of support system at home. Their environments are poor spiritually as well as materially.

Because my parents wanted life to be better for their children than it had been for them, when the opportunity came for me to attend Philander Smith College on a United Methodist Church scholarship, they shared my enthusiasm. It was while I was there that I heard a medical student named Edith Irby speak. She changed the direction of my life. I had set my sights on becoming a physical therapist, but she raised my sights and help me believe that the daughter of sharecroppers could become a doctor.

Being an African-American woman doesn't change the responsibilities of the office of the Surgeon General. My predecessors were committed professionals who worked hard during their tenures to promote the health of every American, using the benefit of their lives and experiences. My experience has given me a special empathy for disenfranchised Americans who have been left out of the American dream. Only when we all work together to solve our problems will the nation fulfill its potential.

It seems that the Surgeon Generals' positions on smoking have been getting progressively tougher. Are you planning on cracking down even harder on the tobacco industry? How much power does your office have to effect change?

Frankly, I wouldn't be doing my job if I didn't do everything within my power to control a product that can cause so much death, pain and suffering to our people. As to power, it depends on how you define it. If you mean legislative power or the power of the purse strings, then the office of the Surgeon General is sadly lacking. But if you're talking about the power of the pulpit--or the pen--then we've got plenty. I'm not now, nor have I ever been, afraid to speak the truth. Tobacco kills. It's that simple. It's the leading cause of preventable death in the United States today. One out of every five deaths--more than 420,000 annually--is from smoking-related causes.

Our children are particularly vulnerable. They can't negotiate for smoke-free environments, nor can they get up and walk out of smoke-filled rooms. In essence, when adults smoke around our children, they're forcing children to smoke. Nine million American children under the age of five are exposed to secondhand smoke in their homes, and nearly 800,000 more breathe secondhand smoke in day care centers or schools.

Tobacco regulation must be explored. As you probably know, the Food and Drug Administration (FDA), an agency of the Public Health Service, is currently reviewing legal avenues that would allow us to regulate tobacco. If we're successful, I can assure you, the tobacco industry won't be doing business as usual much longer. And it's a good thing--43 chemicals in cigarette smoke are proven carcinogens. In January, 1992, environmental smoke joined asbestos, benzene and vinyl chloride as "Group A" carcinogens. These are carcinogens for which no safe level of exposure has been established.

I have gone before Congress numerous times within the past few months and presented the ample scientific base--hundreds of articles and 23 reports by the Surgeon General--that serves as the basis for new federal policy.

Any comment on the recent disclosure that Morris withheld valuable research data, including safe alternatives to nicotine?

Because the tobacco industry is fighting for its life, I'm not the least surprised that cigarette manufacturers haven't disclosed damaging research data. Nor am I surprised they decided not to continue researching the production of less-hazardous cigarettes. For them to market a "safe" alternative to common cigarettes is a blatant admission that their product is unsafe. They're just not going to do that. Even when they were called on the carpet by a congressional committee earlier this spring, tobacco executives were very careful to craft their responses to avoid incriminating themselves or their product.

Given the Federal Trade Commission (FTC) recent disclosure that smokers may be getting more nicotine than they bargained for in "low tar" cigarettes, do you think that the manufacturers need to change their advertising and promotion of these brands? Is there such a thing as a safe level of smoking?

Frankly, I would like to see, not just a change, but an end to tobacco advertising. But until Congress decrees otherwise, tobacco advertising doesn't fall under our purview. Nor is tobacco subject to the new Nutrition Labeling and Education Act of 1990, which requires that manufacturers provide accurate information about the nutritional content of foods. Medical researchers haven't found a safe level for tobacco smoke, so people who think that they're being health conscious to smoke low-tar cigarettes are simply fooling themselves.

You went on record lost February saying that the campaign against cigarette smoking would shift to stopping young people and minorities from smoking. What specifically have you done since then to make that happen?

Last January we celebrated the 30th anniversary of the landmark report on smoking and health issued by Surgeon General Luther Terry. Although we've made tremendous progress since that time reducing smoking among adults, we've made no progress in reducing the rate of smoking among young people. In fact, in the past two years we've seen a slight rising trend. That's not good news because nearly all first uses of tobacco occur before high school graduation. While white adolescents are more likely to use tobacco and much more likely to be heavy or frequent users than black or Hispanic adolescents, young people who smoke, no matter what their race, become addicted to nicotine. Thus, if we can stop teenagers from picking up the habit, then we will have won the battle, not only against tobacco, but possibly against alcohol and illegal drug use.

Tobacco is what we call a gateway drug. It's often the first drug used by young people who use alcohol and illegal drugs, and its use can be viewed as an "early warning sign" for other risky behaviors.

Last February I released the first Surgeon General's report on preventing tobacco use among young people. The report found that cigarette advertising appears to increase young people's risk of smoking by convincing them that smoking has social benefits and that "everybody is doing it," two very persuasive messages for vulnerable young people, particularly those with low self esteem. The report also found that the most effective prevention programs combine education and tough public policies.

I have used and will continue to use the Surgeon General's office to warn the public, particularly parents, about the hazards of tobacco. I have also testified before Congress on several recent occasions on the need for tobacco prevention education K-12, as part of comprehensive health education, as well the need for public action to raise the price of cigarettes and implement no-smoking policies in schools, daycare centers, workplaces and restaurants.

Do you see a connection between environment and health issues? Does your office work together with environmental groups on issues that are of mutual concern? Are any efforts in the works to form closer alliances?

While my contact has been primarily with individuals and groups dedicated to ridding the environment of secondhand smoke, I would welcome the opportunity to engage in dialogue and activities committed to making other aspects of the environment less hazardous and more healthy.

My responsibility as Surgeon General is to promote and protect the health of Americans based on the best science available. An Institute of Medicine study on the causes of premature death identified a direct correlation between the environment and people's health. According to the study, while only 10 percent of premature deaths could have been avoided through improvements in access to medical treatment, and 20 percent were attributed to inherited or genetic factors, 50 percent could have been avoided by changes in individual behaviors and another 20 percent were attributed to environmental factors.

In total, 70 percent of premature deaths are amenable to prevention activities--the 50 percent precipitated by behavior and the 20 percent related to environment. That's both good news and bad news: good news because of the potential to eliminate so much suffering and death; and bad news because it's never easy to change personal or public behavior.

How much do you think the nation's health is dependent on good nutrition; do you think the medical profession gives too little value to a balanced diet as a preventive health measures?

There is a remarkable consensus in the scientific community about the association between diet and major diseases. We've known for a long time that diseases like rickets, pellagra, scurvy, beriberi and goiter are caused by dietary deficiencies. But only recently have we identified the relationship between dietary excesses--most notably fat--and the increased risk for five out of the leading 10 causes of death. Changes in American's dietary practices could reduce the incidence of such major causes of death as heart disease, stroke, atherosclerosis, cancer, high blood pressure, obesity, osteoporosis, diabetes mellitus and liver disease.

While many of us look to the miracles of modern medicine and the medical profession to keep us healthy, ultimately individuals are responsible for their own health. Americans need clear, concise dietary guidelines on what is healthy and what isn't. The new food labels are a huge step in the right direction. The public should familiarize themselves with the labels and use the information to select healthy diets.

You've taken a strong stand on abortion rights and teen pregnancy. Your thoughts on the world population conference in Cairo?

Three cheers for the Cairo conference. I've always said that if I could achieve one goal in my lifetime it would be to have every baby born in the United States a planned, wanted child. How much better if every baby born in every country around the globe were a planned, wanted child. That would be a real milestone in the history of humanity. I think it's wonderful that the leaders of nations are working together to achieve that goal. So much unnecessary poverty, pain and suffering could be avoided.

What was the response to your advocating that parents not buy toy guns for their children?

Actually, it caused very little flap. The press picked up on it, but the public wasn't very vocal. Undoubtedly, those who agreed with me felt justified and were pleased to have their opinion reinforced by the Surgeon General. And those who disagreed avoided making their views known, probably because deep down they knew I was right.

What do you think of the proposed health care plans being floated about? How would you alter them?

I believe that health care reform is an idea whose time has come. The American people want the security of knowing that they will have the health care they require throughout their lives, no matter what their circumstances. Although Americans pioneered many of the technologies and procedures that are used worldwide to keep people healthy, we are not the healthiest people in the world. In fact, we're the only industrialized country that doesn't provide basic, primary health care to all its citizens. I consider it totally unconscionable that nearly 16 percent of our citizens are uninsured, that a fourth of all mothers receive late or no prenatal care, that family planning is not available to many women who need it the most, and that the underserved are forced to wait until a health problem becomes a crisis before seeking care in a hospital emergency room.

While all the plans that I've seen are better than what we've currently got, none is perfect. The importance of increasing efficiency, improving quality, and guaranteeing all Americans have health insurance cannot be overstated. Yet if reform relies exclusively on coming up with better ways to pay for expensive, high technology treatments of preventable diseases, it will fall short of its goals. The public health aspect of health care reform--what we do to keep people healthy longer--will be very important.

And the pieces of health care reform I have personally shepherded--which I believe are key pieces to any real reform--are proposals for comprehensive school health education K-12 and school-related health services for young people ages 10 to 19, so our bright young people will stay healthy and able to learn.