IT IS both quite simple and somehow difficult to write about cigarette smoking. The simple part is this: Smoking kills. Cigarettes are, as Dr. Louis W. Sullivan, the secretary of Health and Human Services, once said, "the only legal product that when used as intended cause death."
It is lung cancer, not breast cancer, that is now the number one cancer killer of American women. "Smoking is associated with more death and illness than drugs, alcohol, automobile accidents and AIDS combined."
That last is from the memoirs of C. Everett Koop, who as surgeon general did more to promote a smoke-free America than anyone.
This is the difficult part: Why do we allow the sale of a product that has no beneficial effects and many fatal ones? Why do we allow cigarette advertising to be a tissue of lies? Why do we tolerate an industry that attracts and addicts consumers when young, many too young to legally purchase the product?
I can't recall hearing a president inveigh publicly against smoking. While President Bush talks of the "behavior" that must be modified if AIDS is to be conquered, I don't recall hearing him decry the "behavior" that causes emphysema.
Jimmy Carter, in a speech earlier this year, spoke of his intimate interest in the problem. "My father, my mother, both sisters and my brother all died of cancer," he said. "And all smoked cigarettes."
On television not long ago Al Gore had to fight to maintain his composure as he talked of watching his sister, Nancy, die of lung cancer.
Neighbors of the Gores have said that the family stopped growing tobacco on their farm after Nancy's death. But the Clinton-Gore campaign will benefit from contributions of more than $680,000 given to Democratic Party committees by various tobacco interests. Republicans have received more than $1.2 million in such contributions, according to the Center for Responsive Politics.
(In his memoirs Dr. Koop describes heavy-handed efforts by elected officials friendly to the tobacco industry to persuade him to ditch his crusade.)
"Everywhere there were reminders about the cozy relationship between tobacco and politics," Dr. Koop writes. "At Republican fund-raiser dinners each table offered free cigarettes, complete with the president's profile embossed in gold.")
The tobacco companies have been enormous beneficiaries of the American system. Our emphasis on personal responsibility means that even activists oppose outright prohibition.
The tension between human services and the economy means that we have both a Health and Human Services smoking office, budgeted last year at around $8 million, and a Department of Agriculture tobacco program with a budget of nearly five times that for support services like crop insurance subsidies and research and development.
One in four Americans smokes. Many started as teen-agers, anxious to show how grown-up they were. Then they couldn't stop, even after they saw the dark spot on the X-ray. One way to prevent tobacco addiction is to fight it as zealously in schools and in advertising as we do drugs. There must be some lung cancer patients willing to show kids how glamorous and grown-up radiation can be.
The biggest change in recent years, people will say, is that everyone knows now that cigarettes cause cancer. But only 10 )) years ago the chairman of R.J. Reynolds was still saying that "no causal link between smoking and disease has been established."
Today the official line from the Tobacco Institute is: "We recognize the risks associated with smoking; at the same time there is virtual universal awareness by the public of those risks."
But there isn't universal awareness of how tenacious cigarette addiction can be. And there is little awareness among kids of how mortality can come knocking at your door. Will we ever have a president who speaks fiercely to this issue? Or a First Lady who looks at how many brands are targeted to women, and at how many women die, and takes up the fight as her personal cause?
That would be politically difficult, given the enormous power of the tobacco lobby. But to balance the difficult, there is the simple truth: Cigarettes contribute to the deaths of hundreds of thousands of people every year. One of them may be someone you love. And if you hold a person's hand and watch her die, it seems to me that your only choice afterward is to go after the killer.
Anna Quindlen is a columnist for the New York Times.