A gruesome image looms over Joe Fultz as he makes his daily rounds.

The security guard patrols a parking lot on Southwest Ninth Street in Des Moines beneath an anti-tobacco billboard featuring a graphic photograph of a lipless cancer victim. The billboard is part of a state-sponsored campaign that marks a new level of intensity for Iowa's anti-tobacco efforts. Health officials decided on a shocking approach to break through young peoples' skepticism. Some people think the ads go too far. "I hate it," said Fultz. The billboard shows the lower half of a face, the mouth open as if to scream. Black and green sores fester where the lips should be. The message: "Going without dip is hard, going without a lip is harder." Fultz, who smokes, dislikes having to work beneath such a disturbing image. He also objects to the goals of the campaign. "Sure it kills, but if you're over the age, you can make your own decisions," Fultz said. He e-mailed state health officials to ask that the billboard be taken down. "I don't recall a billboard campaign that has gotten this much comment," said Louie Laurent, president of the agency that designed the advertisement. Laurent says he has received two complaints similar to Fultz's. Laurent's Des Moines agency, Zimmerman Laurent and Richardson, designed the billboards in conjunction with the Iowa Department of Public Health and Just Eliminate Lies, a group of teen-age tobacco opponents. The campaign -- known as "Chew" for its emphasis on the effects of chewing tobacco -- features 140 billboards around western and central Iowa. They will remain up until the end of this month. The cost of the ads, about $93,500, came from the $9.3 million tobacco-prevention portion of the $55 million the state receives from tobacco companies as part of the 1999 national settlement. As part of the settlement, the state inherited a number of billboards leased by tobacco companies and used the space to put up less-controversial satirical anti-tobacco ads. For the Chew campaign, the state looked to programs in other states, according to Cathy Callaway, director of the Division of Tobacco Use, Prevention and Control. The graphic images have had success in states such as Florida, California, Oregon and Massachusetts, Callaway said. The teen-agers advising the health department and the advertising agency responded to the shocking visuals, she said. "Teen-agers are a moving target," Laurent said. "They are inundated with so many messages nationally and locally, you have to keep something in front of them that's new and interesting that gets their attention." When he fields complaints, Laurent explains why the stomach-churning billboards are worth the price. "There's no pretty picture of cancer," he said. "While it's not nice to look at, I'm a parent, and I'd rather have that image seeded in my son's psyche when he's tempted by whatever peer pressure comes around to chew or smoke." At Ingersoll Avenue and 37th Street, a Chew billboard displays a close-up of a set of teeth with a molten swamp of red and white gashes in place of the lower lip. The caption reads: "In a recent survey, girls preferred guys with lips." Randy Fears, an employee of Manhattan Deli, said he has not had any customers lose their appetites over the sign, but "personally I think it's pretty nasty." Next door at TVC Coffee, owner John Limke has no problem with the message. "To each his own," said Limke, a non-smoker. "When you do something like that you don't want to acknowledge the potentialities." Des Moines Police Officer Paul Tieszen took a break from his coffee to agree with Limke. He said it's necessary to "overshock people because they are desensitized." "It got one of our guys to quit," he said. "He saw the sign and I guess he's using the herbal stuff now."

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