For American smokers, her portrait is a glimpse of a future perhaps too frightening to ponder, and for American health officials, too powerful to foist on an unprepared public: an unsparing photograph of a person scarcely recognizable as a woman, her body wasted by cancer, her hair gone, her blue eyes fixed in a thousand-mile stare.
She was Barb Tarbox, and she died of lung cancer on May 18, 2003, at age 42. From October 2002, two months after she was diagnosed, to the moment of her death, the Edmonton, Alberta, homemaker set about making her ordeal a lesson to others about the dangers of smoking.
In her final months, she maintained a punishing schedule of public speeches to schoolchildren and allowed the local newspaper to chronicle her slide toward death.
The photograph, taken five days before Tarbox died, was one of 36 warnings the Food and Drug Administration considered in the runup to last month's unveiling of nine graphic messages that will appear on the covers of cigarette packs starting in fall 2012.
The fine print of the FDA's final ruling notes that among all of the images considered, the photograph blandly dubbed by regulators "deathly ill woman" was among the most widely recalled by adults and high schoolers in tests. But it was not among the nine that made the cut.
Some scientists who study how public health messages work — or don't work — to make people change their behavior were disappointed by the FDA's decision. Others professed relief. Both camps, however, agreed that such emotionally laden images will be a powerful weapon going forward in moving smokers to give up the habit and persuading others to not start.
Because for all of the power of facts, people react to health messages emotionally, said Paul Slovic, a pioneer in the field of health communications at the University of Oregon.
The "ugly, disturbing image" of a cancer patient at death's door is a perfect counter to tobacco advertising, he said, which for decades has depicted attractive people engaged in fun activities with cigarettes in hand.
Barb Tarbox could have been a model in one of those ads. Six feet tall and willowy, with a head of honey hair and fierce blue eyes, she picked up gigs as a runway model while living in Ireland in her early 20s, and then back in Canada when she returned to help care for her mother, who died of smoking-induced lung cancer at 46.
Tarbox started smoking at age 11 and didn't stop when doctors warned she faced a higher-than-normal risk because of her family history. At the time of her diagnosis, she was a two-pack-a-day smoker, said her husband, Pat Tarbox, a 53-year-old restaurateur in Calgary who has since remarried.
She was a devoted mother of three, including a baby, Patrick, who died two weeks after his premature birth and his twin, Michael, who was diagnosed with autism and died suddenly of a heart defect at 8. Her daughter, Mackenzie, was 9 when Barb Tarbox died, and has just graduated from high school. Pat Tarbox says his wife was racked with guilt that she had allowed cigarettes to leave Mackenzie motherless.
Within a month of learning that the cancer had spread to her brain and neck and was inoperable, she took her shame and grief on the road. Crisscrossing Canada, she warned any group that would invite her about smoking.
"Her message was hard. It was, 'Look at me: This is what can happen to you,' " said Bruce Buruma, executive director of an educational foundation that organized Barb Tarbox's most well-attended speech, which packed some 5,000 kids into a hockey arena in the Alberta city of Red Deer. "She had a gift for talking to kids."
She would saunter across the stage with an unlit cigarette and a big hat and tell kids they were looking at "the biggest idiot in the world." She would draw listeners in with tales of the life and looks she had before her diagnosis. Then with a flourish, she'd snatch off her hat or wig and stand bald and gaunt before a stunned audience.
"She would throw herself in front of a bus to help a kid, and if she could just get one kid to stop smoking, she always said, it'd all be worth it," Pat Tarbox said. "But she did not varnish the truth."
She was just as unflinching with Greg Southam, the Edmonton Journal photographer who, near the end, often balked at recording images of the wraith he had grown to admire.
"She urged Greg not to worry about that stuff," Pat Tarbox said. "The pictures were pretty graphic . . . but she knew those pictures would speak volumes after she was gone."
In December, the Canadian government ordered a fresh round of images for cigarette packs sold there, and selected the photo of Barb Tarbox as one of them. The warning being considered by Canada: "This is what dying of lung cancer looks like."
Southam, who took the picture of Barb Tarbox on May 13, 2003, well remembers the first time he saw it. The photograph, taken in the last days of film, had been developed, and he and reporter David Staples wandered down to the photo room.
"I said to Dave, 'You've got to turn that off. I can't stand to look at it,' " Southam recalls. Staples remembers thinking, "We should destroy that. We could never run that. This is wrong."
And then the two men remembered that this is what Barb Tarbox had asked for: the truth.