MS. DIANE REHMThanks for joining us. I'm Diane Rehm. The latest report from the surgeon general greatly expands the number of health conditions caused by cigarette smoking. The list now includes rheumatoid arthritis and vision loss. And while far fewer Americans smoke, the new report finds rising levels of cigarette smoking among young people.

MS. DIANE REHMJoining me in the studio to talk about the surgeon general's new report: Gregg Haifley of the American Cancer Society's Cancer Action Network, Catherine Hollander of National Journal magazine, Mitch Zeller of the U.S. Food and Drug Administration, and David Abrams of the American Legacy Foundation.

MS. DIANE REHMJoining us from a studio in Atlanta, Dr. Thomas Frieden of the Centers for Disease Control and Prevention. But first, joining us by phone, Rear Adm. Boris Lushniak. He's acting surgeon general of the U.S. And welcome to you, Dr. Lushniak. Thanks for joining us.

DR. BORIS LUSHNIAKGood morning, Diane. It's my pleasure.

REHMThank you. I'm interested that, even though your new report suggests that smoking is more dangerous than even we had thought, I'm not quite sure I understand exactly why.

LUSHNIAKWell, I think, you know, there's several components to all that. When we look at, you know, the positive trends that we have seen over the last 50 years, I mean, there has been some success. Smoking rates have gone down from 42 percent in 1965 to 18 percent now. So from a positive aspect, we have made some impact.

LUSHNIAKBut you have to still realize that 18 percent of our population still smokes. In the next 12 months, we'll have nearly a half million people will die because of smoking. So smoking has sort of maintained its major public health effect in our society. Part of that could be the fact that, you know, the whole smoking world still continues in terms of the marketing and media campaigns.

REHMMm.

LUSHNIAKTobacco industries put in over a million dollars an hour, 24/7, to market that product. In addition, there's been engineering changes that we know of within the cigarette itself so that, even though people smoke fewer cigarettes, however, the harms caused by the inhalation of those 7,000 chemicals and 70 carcinogens into the lungs result in all this public health impact.

REHMAnd what about the filters and the cigarettes themselves, the vent holes?

LUSHNIAKRight. The vent holes really do cause a major problem, from our perspective, in that they do induce deeper inhalation into the lung so that people take that bigger puff, particles get more deeply into the lung, and again that could be part of the cause of our major problem here.

REHMSo we used to think about cigarettes as associated most with lung cancer, heart disease, but there's a whole new list, I gather, of cigarette smoking associated problems.

LUSHNIAKYes. Since the first surgeon general's report -- Surgeon General Luther Terry's report in 1964, which really was a landmark report. And, you know, Diane, it had a very simple statement in 1964, after over a year of work, looking at 3,000 journal articles, having all these experts come in, the panel of 10, after a year's worth of work, decided that cigarette -- and this a quote from the report.

LUSHNIAK"Cigarette smoking is a health hazard of sufficient importance to warrant appropriate remedial action." That's circa 1964. 1964, the major finding was one cancer associated with smoking. That was lung cancer. In these 50 years, we've really seen how destructive this addiction is. So in addition to that first cancer in 1964, we now have identified 13 different cancers by 2014.

REHMI gather including colorectal and liver cancer?

LUSHNIAKYes. That's amongst the new findings in this latest surgeon general's report. But in addition to the cancers, you know, it's still quite astonishing, even to the scientists, that so many years later, we're still making all these new findings. So as of 2014, with the issuance of this new report last week, diabetes, rheumatoid arthritis and poor response to treatment of arthritis, erectile dysfunction, increased risk of tuberculosis, disease and death.

LUSHNIAKAs you mentioned, we're adding colon, rectal, and liver cancer to the long list of cancers. Stroke is now a known consequence of secondhand smoke exposure.

REHMSo it's really extraordinary that all of these diseases are now associated with cigarette smoking. Where is the proof? How has the provability been conducted?

LUSHNIAKWell, in sort of a simplistic fashion. I've been using epidemiological studies, so using the numbers, looking at populations. A lot of these studies boil down to the comparison of smokers and nonsmokers and seeing how these diseases develop.

REHMBut then you've got risk to nonsmokers as well.

LUSHNIAKOh, absolutely. And, again, that's an exposure assessment, if you will. It's determining -- and sometimes it's rather difficult to do -- individuals who do have that secondhand smoke exposure so that, for example, one of the new findings include this finding of stroke as a known consequence of secondhand smoke exposure.

REHMSo, Dr. Lushniak, even though overall smoking rates have declined, I gather you're concerned about how much that decline has actually slowed over the years. What do you think is causing that slowdown?

LUSHNIAKWell, I think, again, there's multiple factors. You know, I point the finger again at the tobacco companies in terms of their continuing marketing of what is known to be a deadly product. That's point number one. We still have an influx of new smokers. You know, each and every day, for every death, we have two replacement smokers who are being recruited into using this product. Each and every day, 3,200 children take their first puff of a cigarette. You know, this is, again, an indication that the problem still continues.

REHMAnd what about the cost to society? You've estimated something like $280 billion a year. How do you reach those calculations?

LUSHNIAKWell, we look at both indirect and direct cost, so direct cost from medical care due to smoking. So it's an amount that Americans will pay for smoking related diseases, and that is -- it comes to over $130 billion a year. The rest of the costs are lost productivity from people being sick as a result or dying early from smoking related diseases. So the total economic cost of smoking in the United States right now is $289 billion -- almost $300 billion.

LUSHNIAKSo on top of the effect that smoking has on the health of an individual, on the health of their family and loved ones, it really has an incredible effect on the health of our nation, both economically as well as from a public health perspective.

REHMAnd you talked about young people, including young children. What do you think is the enticement for these kids, hearing as they do from all quarters, not just the government, that cigarette smoking is bad for you? Where is this incentive to try coming from?

LUSHNIAKWell, it very well may be the same incentive that occurred in my generation and previous generation. Part of it is the idea of the peer pressure effect. Part of it is the idea of, you know, the "being cool," sort of doing something different, doing that something that, you know, is not necessarily accepted. Part of it is influences by the media in addition to, you know, the influences I mentioned, the tobacco dollars put into promotion and advertisement, but also the images seen, for example, on the movie screens.

REHMOn the movie screens. What about television?

LUSHNIAKAnd television as well. Anything that glamorizes this addiction, I think, you know, is something that on an impressionable young mind makes it look as if it is normal. Now, in these 50 years since our -- the release of the surgeon general's report in 1964, you have to realize we all acknowledge the world really has changed, right? We used to smoke in restaurants and bars across the country. We used to smoke on airplanes. We used to allow this as a normal part of our society. Fifty years, we've really changed, but we're still battling this addiction.

REHMSo what more do you think the government can or should do to try to alleviate these pressures that are coming from elsewhere?

LUSHNIAKWell, we know tobacco control measures do work. We've estimated that in the last 50 years, because of these measures, we've actually saved 8 million lives. So first and foremost is we have measures that currently work. We also have the idea that we have national goals. One of the recent goals is let's get down to 10 percent in 10 years. Another goal is to have a tobacco-free generation in a generation.

LUSHNIAKBut in terms of the tobacco control efforts that do save those lives, they include media campaigns, really full-out blitzes, year-round media campaigns getting out there and providing the necessary information to prove that this addiction is something that leads to all these effects. In addition, pricing of cigarettes plays a key role in terms of tobacco control.

LUSHNIAKWe know. It's quite simple. Price of cigarettes go up. Smoking rates come down. For the individual level, it's the whole concept of the cessation treatment programs should be available for all smokers. This includes not just nicotine replacement therapies as an example, but also counseling for those individuals, 100 percent indoor smoke-free laws. Do you realize that only half our population right now is protected by smoke-free laws?

LUSHNIAKThat's not acceptable. Tobacco control programs that are funded by the CDC -- I know you have Dr. Frieden on. He'll probably explain that a little bit more. But in essence, we are really underfunding the programs that we know work at the state level. And then finally, with Mitch Zeller being on as well, it's the full use of FDA's regulatory authority over tobacco products to reduce their harm.

LUSHNIAKYou know, this is a new law, the Tobacco Control Act, since 2009 that we have as a new tool to put into this. As acting surgeon general, I strongly believe that the concept of a tobacco-free generation is a real goal that we can attain.

REHMDo you expect to see a push for new taxes on cigarettes as a result of this report?

LUSHNIAKWell, in the fiscal year 2014 presidential budget, there actually is an increase of another 94 cents that the president has put forward to further increase the price of those cigarettes. So the answer is yes.

REHMRear Admiral and Dr. Boris Lushniak, he's acting U.S. surgeon general. Thank you for joining us.

LUSHNIAKThank you so much. It's a pleasure.

REHMAnd we'll take a short break. When we come back, we'll talk with our other guests. And, of course, you are always a guest on this program.

REHMAnd welcome back. We're talking about the new report from the Surgeon General's office that indicates smoking cigarettes is more dangerous than ever. Catherine Hollander of National Journal magazine. I want to talk to you and ask you how we got here. Go back to that first report and how things have intensified since then.

MS. CATHERINE HOLLANDERSure. So 50 years ago when the report came out, there had been growing scientific evidence about the effects of cigarettes on the lungs and on people that were smoking. And there was also a rise in smoking rates in the United States that was happening. And so the Kennedy Administration ordered this report done. And one of the things that they did that was interesting was they really wanted to make sure that the folks compiling the report didn't -- hadn't already expressed their views on tobacco and were sort of a good cross section of, you know, folks who worked in the medical field, and could review all of the existing studies to really put this together as this is the definitive, you know, government view on what smoking means for your health.

MS. CATHERINE HOLLANDERAnd so they did not do any new research for the report but they pulled everything that was existing together and came out and said, you know, what we heard which is that, we think that the health hazards of cigarettes are sufficient to warrant remedial action. They did not specify what kind of action should be taken. But a year later congress did pass a labeling and advertising law in response to the report.

MS. CATHERINE HOLLANDEROver the years, they've put out 32 reports since. In the 1970s there was a sort of growing awareness about some of the environmental effects of cigarette smoke. People were beginning to push for nonsmoking areas. In the 1980s they started talking about the effects of secondhand smoke in the report. They also began to recognize the addictive nature of cigarettes in the report again.

MS. CATHERINE HOLLANDERAnd so, you know, over the years this has reflected what scientific evidence has been saying and really giving it the weight necessary to maybe push congress to act or, you know, give the government sort of seal of approval to these scientific studies that the tobacco industry had been repeatedly pushing back on in the early days saying, you know, we don't think that the evidence is really there.

REHMAnd to you, Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, why do you believe that even given this latest report from the U.S. Surgeon General's office that young people and adults continue to smoke? Dr. Frieden, are you there? Oh, dear. I'm afraid we do not have Dr. Frieden yet. I'll turn that question to you, Mitch Zeller. What do you think?

MR. MITCH ZELLERI think that young people are initiating for a variety of reasons. I agree that part of the answer is marketing, but increasingly the kid that is experimenting and initiating today is turning to this as a coping mechanism to deal with other aspects of their lives that may not be going so well. They may live in a household where one or both parents smoke. They may be having trouble at school. They may be feeling all manner of social pressures and other pressures. And they may not be turning to cigarettes because it's a cool thing to do. They're turning to it maybe as a coping mechanism to deal with what's going on in the rest of their lives.

REHMA coping mechanism, David Abrams.

DR. DAVID ABRAMSYes, I agree with that. Smoking alleviates stress. It helps counter boredom. It also gives that image of self confidence and acceptance among your peers. So for all those reasons kids are attracted to it. You know, there's also still that rebellious element that all adolescents have. So unfortunately as we all know, the more you sometimes tell kids not to do something, the more they may want to try it. And because nicotine, when it's burnt in a cigarette, is so absolutely addictive, it's like freebase cocaine, and they don't realize that. You get hooked pretty quickly.

REHMGregg Haifley, like freebase cocaine?

MR. GREGG HAIFLEYYes, shockingly. And almost immediately the addiction begins. And then we deal with a lifetime cycle of smoking in a situation whereas the industry basically kills off its older consumers, they're in the business of getting younger kids to start because those are the replacement smokers that they rely on to continue to perpetuate their profits.

REHMMitch Zeller, do we know that cigarette smoking is as addictive as freebasing cocaine?

ZELLERWe know that there are ingredients added in the manufacturing process that have the same effect as turning regular cocaine into crack cocaine. And these are ammonia compounds that are added in the manufacturing process that convert the nicotine chemically from a bound chemical state to a free chemical state that makes it more pharmacologically active, and experts would say more addictive. So it's not that there's more nicotine. It's that there's more of a more addictive form of the nicotine in the finished product, which is exactly the way freebasing cocaine works.

REHMCatherine Hollander.

HOLLANDERYes, so one of the things that I've been following that's kind of a new thing that's interesting to me is the e-cigarette discussion. And I know that one of the issues there is sort of this feeling among the e-cigarette industry that nicotine is just like caffeine, and that if only we can get people this pure nicotine without these chemicals that are, you know, making it as addictive and terrible for you, it'll be okay. And it'll be just like drinking a cup of coffee. And I thought that that was one of the more interesting developments sort of in this space right now.

REHMAnd can it be as addictive without having the harmful effects, Dr. Abrams?

ABRAMSWell, this is a very tricky balance that you have to consider. It's very clear that in a non-combusted form, in other words when you don't burn the tobacco -- it's the burning of the tobacco that frees up the nicotine in its most addictive and lethal form -- that nicotine itself, for example, when sold in a pharmacy for nicotine replacement therapy is over the counter. And people have used it for very long periods of time with almost no serious side effects.

ABRAMSSo for example, we'd much rather that an addicted smoker, if they absolutely still need their nicotine because their brain has been so attracted to it that they can't give it up, we'd much rather they were using long term nicotine replacement therapy or another form of nicotine that's less addictive because it's not burned.

REHMTell me, Greg Haifley, how the American Cancer Society's Cancer Action Network feels about nicotine substitutes.

HAIFLEYWell, first of all, I think it's important to say that there are a number of FDA-approved nicotine replacement therapies that are proven safe and effective. The second point to make is that with electronic cigarettes, that rigorous science has not been done. And so people are using them without the benefit of knowing about the safety and effectiveness as a cessation product.

HAIFLEYAnd then on top of that, there are a number of concerns about the usage of e-cigarettes by youth, which can begin the nicotine addiction process. There are uncertainties about the long term use of electronic cigarettes and the chemicals that are inhaled and the long term health consequences of that. And we're very concerned about the behavior patterns of people who use them. Are there smokers who will use e-cigarettes when they're in smoke-free environments and then go back to smoking when they're not in smoke-free environments? Will e-cigarettes lead youth to start using cigarettes?

HAIFLEYSo there are a number of behavior questions that are very serious that need to be addressed by some rigorous research.

REHMGregg Haifley of the Cancer Action Network. And now I do believe we have Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention on the line. Are you there, Dr. Frieden?

DR. THOMAS FRIEDENYes, I am. I've been listening to your show but for some reason the audio wasn't working.

REHMWell, I'm so glad we have you now. I was interested to learn about the eye diseases associated with smoking. Outline those for us, if you would.

FRIEDENI think that the big picture is that smoking is even worse than we knew. There are new diseases being associated with it that includes a form of macular degeneration which causes blindness. But it also includes things like diabetes and birth defects. And for exposure to secondhand smoke, an increase in the risk of stroke by 20 to 30 percent. And with that we're able to calculate -- or the Surgeon General's report calculates that around 20 million people were killed by tobacco, including 2.5 million nonsmokers and 100,000 children or infants through sudden infant death and other severe illnesses of infancy.

FRIEDENSo I think the first real message from the Surgeon General's report is that second -- that smoking and secondhand smoke is even worse than we realized. And it affects virtually every part of the body. And not just cancer, but many chronic diseases as well, including age-related macular degeneration and cataracts and blindness, but also secondhand smoke with a wide variety of illnesses.

REHMDr. Frieden, I wonder if there's any way you can help me understand the mechanism by which, for example, smoking affects or brings on rheumatoid arthritis? How does that work?

FRIEDENWell, there are a wide variety of mechanisms by which smoking damages the body. It changes how the body reacts to inflammation and how effectively the body's defenses work in various situations that are also direct toxic effects of the thousands of chemicals that are in tobacco smoke. But really the bottom line is that 5.6 million of our kids will be killed by tobacco unless we act now. And the fact is that most Americans who've ever smoked have already quit. Most people who are smoking today want to quit and began smoking as kids.

FRIEDENSo preventing the next generation from becoming addicted and helping current smokers get free of addiction is the bottom line to reduce this terrible and very wide range of harms that tobacco causes.

REHMDr. Thomas Frieden. He's director of the U.S. Centers for Disease Control and Prevention. You can join us by phone, by email, follow us on Facebook or Twitter. And you're listening to "The Diane Rehm Show." Mitch Zeller, what does the FDA plan to do differently now that this new report has come out?

ZELLERThe report is a clarion call that the real harms are associated with the use of the combusted products and principally cigarettes. I think the challenge for all of us, regulators, other policymakers, educators, advocates is if cigarettes remain the fundamental cause of so much of the death and disease associated with tobacco use, what can all of us do to try to drive down the death and disease rate principally from cigarettes?

ZELLEROne of the opportunities that the Food and Drug Administration has under the legislation that was passed in 2009 is to both inform the public and use the tools of regulation to try to shift people away from the most harmful forms of nicotine delivery. And right now, the deadliest and most dangerous form of nicotine delivery is the ingeniously designed cigarette that delivers nicotine to the brain in about seven or eight seconds.

REHMAnd you use the word combustible.

ZELLERRight.

REHMSo you're talking about lighting a cigarette, inhaling...

ZELLER...and burning tobacco leaves.

REHM...and burning tobacco leaves. Does that mean for the moment you're leaving aside the electronic cigarette?

ZELLERFirst we have to regulate them. Right now electronic cigarettes are not regulated and...

REHMNot at all.

ZELLERNot at all unless a company makes a therapeutic or cessation claim, at which point they could be regulated by FDA as a drug or a device. Otherwise it's up to us as the regulators to create the regulatory framework for electronic cigarettes under the tobacco authorities under rulings by the courts. And we are in the process of being able to get those regulations out. The e-cigarette raises profound questions. They have the potential to do good, they have the potential to do harm.

ZELLERIf a current smoker, otherwise unable or unwilling to quit, completely substituted all of the combusting cigarettes that they smoked with an electronic cigarette at the individual level, that person would probably be significantly reducing their risk. The challenge to us as regulators is that's not where policy gets made. Policy gets made at the population level. And the law that we are responsible for enforcing mandates that we figure out what the net population level health impacts of any policy of any approach to any new or novel product is.

ZELLERAnd that means we have to know what's going on with kids and initiation. We have to know, as Gregg was talking about, whether current smokers instead of completely switching are engaging in what we call dual use. So that's something like the electronic cigarette actually could do harm because it becomes a bridge to get the smoker from their last cigarette to their next cigarette. It's our job as the regulators to figure all of that out and come to the bottom line of what are the net population level health impacts?

ZELLERAnd I would urge everybody looking and thinking about the e-cigarette phenomenon to maintain an open mind. Let us get the regulations out and let us get answers to these questions.

REHMAnd what about packaging? What about warnings on packaging? In 2009 there was supposed to be more vivid warnings. Where is that, Gregg Haifley?

HAIFLEYWell, first of all, as you mentioned, the statute that gave the FDA the authority to regulate tobacco mandated graphic warning labels that would cover 50 percent of the front and back of a pack. And if the United States did that we would be joining about 60 countries around the world that are doing that as well. The warning labels that are on the pack currently have not been changed in 25 years and they're basically hidden on the side of the pack.

HAIFLEYThe FDA did come out with some graphic warning labels to implement under the law. And of course the tobacco industry, as it typically does, sues to block progress on any kind of thing that we can do to get people to quit smoking. And so we want them -- the FDA wanted to do them but they've been blocked by the courts so far.

REHMWhere are we now?

ZELLERSp the case went up to the federal appellate court and the federal appellate court agreed with the district court that the final rule that FDA had put in place for graphic warnings was unconstitutional. And we were sent back to the drawing board. We're in the process of doing new research to support a new rule.

REHMMitch Zeller of the FDA and short break here. Your calls when we come back.

REHMAnd welcome back. Time to open the phones. First to Kathleen, in Naples, Texas. You're on the air.

KATHLEENGood morning. I want to know why, if cigarette smoking is so unhealthy -- and I'm not denying that it is (coughs) -- excuse me -- why has…

REHMIs that a smoker's cough, Kathleen?

KATHLEENNo, ma'am. Everybody in Naples, Texas has the flu these days.

REHMOkay. I'm sorry to hear that.

KATHLEENNo, it's all right. But why has not the government either banned the ingredients in tobacco or tobacco products themselves, as it has done in the past with everything saccharin, baby foods, birth control, so many products the government has taken…

REHMAll right. Okay. Mitch Zeller?

ZELLERThat's a fair question. It's really a political and societal question. Congress had the opportunity, when it passed the Family Smoking Prevention and Tobacco Control Act and gave FDA regulatory authority over tobacco products to address this. And they chose to address it. And they said FDA cannot ban entire categories of products. We have other powerful regulatory tools to try to reduce the addictiveness and the harms of tobacco products, but Congress ruled that FDA does not have the authority to ban entire categories of products. States and localities do have that authority.

REHMInteresting.

ZELLERBut we do not.

REHMAll right. Let's go to Alex, in Birmingham, Ala. I gather you're a young smoker, Alex.

ALEXI am. Thank you for having me on the show.

REHMSure.

ALEXWell, I'm currently trying to quit smoking cigarettes and I'm smoking an electronic cigarette. And I was just wondering if there are any studies going on right now to see if there are harmful effects with an e-cigarette.

REHMInteresting question. Dr. Abrams, what do we know so far?

ABRAMSWell, first, let me congratulate you. Trying to get off burnt tobacco, which kills half the people who use it, is the number one priority. And frankly, I almost don't care how you do it, as long as you get off burning the tobacco. So I congratulate you. Stay off of the burnt tobacco if you possibly can. Secondly, there is emerging research on e-cigarettes that suggests because they don't burn the tobacco, but produce nicotine in a warm aerosol from the battery, that they are much less harmful in terms of all the ingredients that you usually see in a burnt cigarette.

ABRAMSHowever, we don't have long-term studies of their long-term safety, especially of the propylene glycol which is the mist forming, but every evidence is that they are dramatically less harmful than burning a cigarette. Maybe not harmless, but less harmful than a cigarette. And if that's the way you use them, to get off cigarettes -- and eventually I hope you get off all of nicotine and tobacco products, whether they're e-cigarettes or burnt tobacco. But stay off the burnt tobacco. That's the killer.

REHMCatherine Hollander?

HOLLANDERI think another issue there, which is something that Mitch Zeller has spoken a lot about, is how right now the e-cigarette market is sort of the Wild, Wild West when it comes to regulation. One of the things that we don't know sort of on a brand-by-brand basis is which products are in the cigarettes. So I know the FDA in 2009 studied a few brands and found an ingredient in antifreeze present in one of them. So right now there aren't the requirements for safety there because they're not yet regulated by the FDA.

REHMDr. Frieden, I know you wanted to get in on that.

FRIEDENYes. I do want to say that if you want to quit smoking, there are seven FDA approved medicines with good evidence base that work. And there are lots of things that people can do that increase their likelihood of succeeding. There are medicines that will double or triple the likelihood that you'll succeed when you try. You can do certain things that are proven to work, like get even just 10 minutes of counseling four times though a quit line or a counselor, quit with a friend, figure out what the triggers are that result in your starting to smoke, look at the last time you tried to quit -- if you've tried before -- and what worked well and didn't work well from that.

FRIEDENSo I think we have to separate two different questions, here. One is what might the role of e-cigarettes be and the second is, if someone smokes, what can they do to quit, which is the single most important thing they can do for their health. So congratulations on taking that really important step. Bottom line here is that most Americans who've ever smoked have already quit and most smokers want to quit and everyone can quit. Whether e-cigarettes will play a role for some people, we still aren't sure. We do know there are theoretical benefits and theoretical harms, but the bottom line is there are proven medications that work very effectively and proven ways to increase your odds of success.

REHMAll right. Dr. Frieden, I smoked for 10 years from the time I was 15 until I was 25. I was smoking two packs a day. I quit out of sheer vanity. My husband could not stand the smell of cigarettes and couldn't stand the smell in my hair, on my clothes. So it was vanity, but I managed to quit cold turkey. Now, I'm wondering whether it's more difficult to quit today because there are -- or do you know that there are more addictive substances in those cigarettes today?

FRIEDENIt does appear that the tobacco industry figured out ways to make cigarettes more addictive. And research that we've done in our laboratory, here at the Centers for Disease Control and Prevention, has documented an increase in what has been termed free nicotine or crack nicotine in not only cigarette smoke, but also smokeless tobacco. So it does appear that cigarettes may have -- they're certainly very addictive and they may even have become more addictive in recent years.

REHMSo I was very fortunate to get out when I did. Let's go to Farmersville, Ohio. Hi there, Kurt.

KURTGood morning.

REHMHi.

KURTYeah, I was curious as to what your experts' studies have shown regarding the comparative damages done from organic tobacco versus the manufactured tobacco.

REHMDr. Abrams?

ABRAMSYes. I think that's one of the good examples of misleading advertising and marketing by the tobacco industry. We have done research that shows that that the so-called organic natural tobacco products are just as harmful as regular tobacco, but the public thinks that because they're organic they may be healthier or safer. So we have data to suggest that people who think they are buying those organic cigarettes -- over 60 percent of them believe they're safer than regular cigarettes and they are absolutely not.

REHMGregg?

HAIFLEYAnd that's another example of how the tobacco industry has used health claims of sorts to actually discourage some people who would otherwise quit, to continue using cigarettes. They did that with light, low and mild, terms that misled the public. And a federal judge has actually found that the tobacco industry very deliberately misled the public to continue the addiction, rather than people trying to quit.

REHMMitch?

ZELLERYou said something in the opening to the show about ventilation and we need to make the point about cigarette design. The public doesn't fully understand that even the companies can no longer use terms like light and low tar and mild, there are still cigarette design features out there -- principally something known as ventilation holes, laser perforated, tiny little holes that are very hard to see with the naked eye. And those holes were used to drive down so-called tar and nicotine deliveries for the sake of advertising years ago.

ZELLERThe companies can no longer claim that these are light and low tar, but the reason why that judge ruled the way she did in that case and why these companies are now all adjudicated racketeers, is because those holes were placed just so far from the lip end of the cigarette, so that when the smoker put the cigarette in their fingers or put the cigarette in their mouth they would cover the holes. And once those holes got covered it drove up tar and nicotine delivery. And we have the opportunity, as the regulators now, to look at all aspects of design features to see what possible role regulation could play.

ABRAMSI just want to add to this idea of misleading the public. One of the biggest things we're worried about, especially with kids and young adults, is little cigars and cigarillos that are exempt from some of the taxes and some of the ways that cigarettes are marketed because they're classified as cigars, which is a real boondoggle, because they're actually cigarettes wrapped in a little bit of cigar paper that meets the federal standard of calling them a cigar, but also kids are still very susceptible to flavored little cigars and cigarillos and we've seen a huge uptake in them.

ABRAMSThey're also sold in single or five-packs at a much cheaper rate than cigarettes. So it's a perfect starter product that we're very worried about. And it's another thing that I think FDA would like to more strictly regulate if the government would give it permission to do so.

REHMLet's go to Louisville, Ky. Hi, Brent. You're on the air.

BRENTThank you, Diane. My question is revolving around smokeless tobacco. I hear a lot of comments from your guests today about burned tobacco. I find that I'm addicted to smokeless tobacco, probably as much as my dad was to cigarettes. And, you know, I'm in the process of quitting. I'm working on it through peer pressure from my kids and some of the educational programs, but I guess what my question would be is does the research on smokeless tobacco, does it support -- are you seeing the smokeless tobacco companies putting additives in their product to make them more addictive or is it simply just the nicotine addiction on its own?

BRENTParticularly, I think smokeless tobacco has always been seen as the safe alternative, even though it's not. Particularly because you see athletes using it. You see a lot of baseball players, but you never…

REHMIsn't that associated with mouth and tongue cancer?

ZELLERThere are all manner of cancers associated with smokeless tobacco products. But to the question about addiction, over the years information came out -- and this is going back some decades -- that smokeless tobacco products were deliberately designed through something called a graduation strategy, so that young people would initiate with more candy-like, better tasting, lower nicotine delivering products as starter products. And then there was a graduation strategy, as they became addicted, to have them move up the ranks to higher nicotine, more highly addictive products.

ZELLERYes. In the abstract, a non-combusting tobacco product is going to be less harmful than a combusting tobacco product, but any initiation of any tobacco product, combusting or non-combusting, by a kid is bad for society and bad for public health. And one of the real challenges with smokeless tobacco and it's more on a regional basis than a national basis, is the degree to which these products can be very popular, especially with young boys.

REHMAnd why is it regionally popular?

ZELLERWe think it's associated with culture, with family, with history. Smokeless tobacco seems to be more of a regional issue than a national issue.

REHMMitch Zeller. He's director of the Center for Tobacco Products at the FDA. And you're listening to "The Diane Rehm Show." I want to go back to this question of packaging and labels. Do you believe that this new report will prompt the FDA to push anew for bigger and better warnings?

ZELLERWell, we were not waiting for the report to come out to be working on that. The litigation that I referred to ended spring of last year. And the administration has been on the record ever since as saying, basically, back to the drawing board for FDA. In light of the court decisions what we have to do is commission new research to support a final rule on graphic health warnings that will survive the inevitable litigation that will come. And we are in the process of doing that research now. There's nothing more that I can say about it.

REHMBut wouldn't you think that this new surgeon general's report would provide the data to go forward?

ZELLERWell, we're hopeful that the FDA will be able to move forward and satisfy the court requirements to be able to justify it, but not only is it a problem in the United States, but globally, as countries have been moving forward with trying to do large and graphic warning labels and plain packaging, frankly, to get the brand salesmanship off of the pack, the tobacco industry has been using trade disputes to initiate litigation against countries to try to block warning labels that way.

REHMAnd before we leave this discussion, let's go to Dave, in St. Petersburg, Fla. You're on the air.

DAVEI just had a quick question. If your guests to go into more detail about third-hand smoke and if there's any more research and studies being done on that.

REHMAll right. Go ahead.

ABRAMSThere is research on that. And for example, nicotine is a very sticky molecule. So once you smoke in a room it gets on the carpets, on the clothes and on the curtains and it stays there for 40, 50 years. So a baby crawling on the carpet of room that was previously used by smokers will nicotine on their skin and it can be found in their blood and urine.

REHMAnd what about the inhalation of the smoke itself by a non-smoker, et cetera?

ZELLERWell, one of the really alarming figures that's come out in the latest surgeon general's report is we now have to have a higher number of annual deaths associated with tobacco use. When you factor in the direct health affects to smokers and the indirect effects to non-smokers, it's now 480,000 people who are dying prematurely every year, either directly because they use tobacco products, or indirectly because they were exposed to smoke. This remains a huge problem and why so much of the focus of that report is really a challenge to society.

ZELLERWe can look back on the progress over the last 50 years, of which there's been a lot, but it's a time to pause and look forward to what are we going to do about something that remains the leading and preventable cause of death and disease?

REHMGreg Haifley?

HAIFLEYAnd from the American Cancer Society's perspective, we know the tools that work. We know that raising tobacco taxes is one of the best ways to stop youth from starting, and stimulate adults to quit. We know that comprehensive cessation and prevention programs can help the 70 percent of smokers who want to quit. We know that smoke-free policies can protect people from second-hand smoke, but can also be a tool to stimulate smokers to quit. And so we are aggressively working at the state, local and federal levels to do all of those thing to contribute to defeating this epidemic.

REHMAnd, Catherine, what about use of the press?

HOLLANDERPardon?

REHMWhat about use of the press?

HOLLANDERThe press, exactly. Well, one of the things that we're likely to see -- I believe people are thinking now more likely 2015 than 2014 -- are the tobacco industry's statements acknowledging we lied to the public. This was part of that court agreement related to the racketeering charges that we discussed earlier. These are going to be running in newspapers, on air, on television and radio. They have to admit that they had misled the public.

REHMCatherine Hollander of National Journal Magazine, Gregg Haifley of Cancer Action Network, Mitch Zeller of the FDA, David Abrams of the Tobacco Research and Policies Studies at the American Legacy Foundation and Dr. Thomas Frieden of the CDC, thank you all. Thanks for listening. I'm Diane Rehm.