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 know and admire.
"She urged Greg not to worry about that stuff," Pat Tarbox said. "The pictures were pretty graphic and people shied away from them. But she knew those pictures would speak volumes after she was gone."
But whether exposure to unvarnished truth can persuade a person to change his or her behavior is a key, and much debated, question. There is a fine line between images that are striking and memorable and images that are so disturbing or outlandish that they undermine the credibility of the intended message or leave people too discouraged to change, said Joseph Cappella, a health communications researcher at the University of Pennsylvania.
Tarbox's deathbed picture went too far for some who offered their feedback to the FDA. "Some comments noted that the image 'offend[s] against human dignity,' while one stated that it was 'too sensational to be effective,' " the FDA reported in its final ruling.
Cappella said the obvious realism of the Tarbox image may save it from being dismissed by smokers as overdone or contrived. Then again, "you want images and text that require very little mental effort," he said. Smokers would easily detect Tarbox's anguish, but they might take an extra moment to recognize cancer as the cause of her pain, and in that instant, their attention could easily slip away.
In choosing its first round of images — a fresh crop may be chosen in as little as a year — the FDA focused heavily on how well they meshed with text messages that were dictated in advance by Congress: "Cigarettes cause strokes and heart disease," for example, and "Tobacco smoke causes fatal lung disease in nonsmokers." The result is a mixed bag of images.
Some of them encourage (a tough-guy rips open his shirt to reveal an "I Quit" message on his T-shirt beneath). Some are cautionary (a well-dressed heart attack victim's shirt and tie are undone as he is administered oxygen). Some make you wince (lips ravaged by cancer frame a mouthful of rotting teeth).
But none shock the way the Tarbox image does.
In FDA tests, "deathly ill woman" scored highly with adults, young adults and youths on scales of emotional impact, comprehension of the warning's message and the "difficult-to-look-at measure." But the regulators ultimately concluded that the image they called "cancerous lesion on lip" was a better vehicle for the message "Cigarettes cause cancer."
The FDA's first round of choices are not unlike the first round of graphic images required by Canada, which started using such cigarette-pack warnings in 2001. Ten years later, that country's warnings — still unchanged — have ceased to attract much attention from smokers. But at the time they were launched, a market sprang up overnight for sleeves that would cover the cigarette packs' new look.
Such hiding of anti-smoking messages may seem to make them a sure bet to fail, but scientists say it is a sign of a campaign's probable success. Avoidant behavior shows a message is working, said psychologist Geoffrey Fong of Waterloo University in Ontario, who has studied the effect of warning labels in Canada and many of about 40 other countries that preceded the U.S. in requiring them. The harder people try to avoid graphic warnings, he said, the more likely they are to try quitting.
Tarbox's picture "was the one I had most hoped the United States would adopt," Fong said, because it demonstrates the misery of a smoking-related death. And yet he acknowledges that U.S. consumers, a new audience for these images, may not be ready for this one.
In December, the Canadian government ordered a new round of images for cigarette packs sold there and selected the photo of Tarbox as one of them. The warning being considered by Canada would wring far more emotion from the image than the FDA's "Cigarettes cause cancer."
The text will read, "This is what dying of lung cancer looks like."
In her last eight months, Tarbox spoke before audiences totaling at least 50,000, and many more if you count those who heard or saw her on radio and television. Among the latter, recalls Pat Tarbox, was a grizzled long-haul trucker who later told Tarbox's family that after listening to her on the radio, he threw his cigarettes out the window and never smoked again.
Southam, who took the picture of Tarbox on May 13, 2003, remembers well the first time he saw it. The photograph, taken in the waning days of film use, had been developed, and he and Edmonton Journal reporter David Staples wandered down to the photo room to take a look at the day's shots.
When the image popped up on a computer screen, both men fell silent.
Photos: Barb Tarbox
"I said to Dave, 'You've got to turn that off. I can't stand to look at it,' " Southam recalled. Staples remembers thinking, "We should destroy that. We could never run that. This is wrong."
And then they remembered that this is what Tarbox had asked for: the truth.
"It might get a little annoying after a while for a smoker to look at that," Southam said last week. "I hope it does. That was Barb's dream: to touch a few more people, even after she was gone."