MS. DIANE REHMThanks for joining us. I'm Diane Rehm. An increasing number of Americans believe both public and private smoking should be illegal. The tobacco industry and others had taken note by creating electronic and lower-nicotine cigarettes. Meanwhile, new screening standards aimed to save more smokers from lung cancer. Joining me to talk about the latest trends in smoking, Mitch Zeller of the Food and Drug Administration and Michael Felberbaum of The Associated Press, on the phone from Palo Alto, Calif., Dr. Thomas Glynn of the American Cancer Society.

MS. DIANE REHMI do want you to know that we did invite tobacco manufacturers, Altria, previously Philip Morris, and Reynolds America declined our invitation to be on the program this morning. Lorillard did not respond. Before we begin our conversation with our guests, let me welcome from his office in Atlanta, Ga., Dr. Tim McAfee. He's director of the Office of Smoking and Health with the Centers for Disease Control and Prevention. Thanks for joining us, Dr. McAfee.

DR. TIM MCAFEEThank you very much, Diane, for having me and for having this incredibly important show this morning.

REHMIt is indeed important. Give us some of the latest statistics on smoking in the U.S.

MCAFEEWell, we're at a very important point because we're coming up on the anniversary of the 50th anniversary of the first surgeon general's report that established the link between smoking and lung cancer. And at the time that that report came out -- it's hard to remember or believe this, but three out of four men in the generation who served in World War II smoked cigarettes at that time. So we've come a long way now with less than one in five men and women now smoking.

REHMHmm.

MCAFEEBut we can't kind of delude ourselves into thinking that this 20th century disaster of death and disease that was caused by smoking is over and we can move on because, if we don't do more, tens of millions of Americans will die prematurely over the next few decades.

REHMIsn't it true that thousands of young people are just beginning to smoke every single day?

MCAFEEYes. Although we have seen steady, very slow progress in declines in tobacco use, there are still one in four high school seniors and one in three young adults are current smokers.

MCAFEEWe're also seeing in terms of new trends and increasing number of youth and young adults who are using multiple types of tobacco products of particular concern is an increase in the use of cigars, especially flavored cigars, cheaper cigars because they're taxed at a lower rate and cigars that mimic cigarettes that are technically labeled as cigars for pricing and so that they're not regulated but that functionally act like cigarettes.

REHMOK. I want to ask you about the use of electronic cigarettes. Is that on the rise?

MCAFEEYes, it is. We did a study recently that found that just between the year 2000 and 2011, we saw an increased awareness, doubling with 6 percent of all adults and about 21 percent of current adult smokers ever used e-cigarettes, and they went from 40 to 60 percent being aware. And this is true across the board, but it's especially true among smokers and former smokers where we've seen a big uptick.

REHMAnd tell me whether there's any evidence whatsoever from the public health community regarding electronic cigarettes and whether they are in fact safer than tobacco products.

MCAFEEWell, there are several different ways that we're thinking about this, and we think it's an incredibly important question. And as we think about it, we need to focus on the harm that's caused by cigarette smoking and ways to get smokers to quit and prevent non-smokers from starting. And the challenge is that we don't yet know how e-cigarettes are going to completely fit into that. Will the availability of the cigarette alternative that does deliver nicotine without also delivering harmful byproducts of combustion, could this play a beneficial role in reducing tobacco-related death and disease?

MCAFEEThis would be especially true if a large number of smokers successfully switch completely to e-cigarettes either permanently or as a transition phase to nicotine abstinence. But the other alternative is that the availability of e-cigarettes could result in harm by increasing the initiation of cigarette use among youth and young adults or by delaying quitting among smokers...

REHMI see.

MCAFEE...who, rather than switching, engage in dual use, which currently looks like that's the majority situation...

REHMSo...

MCAFEE...whether people are using it in secondhand smoke situations where it's hard to smoke cigarettes...

REHMSure.

MCAFEE...or -- and where we see ex-smokers think, hey, well, maybe I could go back to e-cigarettes. But that rekindles their nicotine addiction, and then they start actually smoking cigarettes themselves.

REHMAll right. So as a public health official dealing with tobacco and tobacco products, would you like to see regulation of electronic cigarettes?

MCAFEEWell, I think the challenge right now is, you know, there are several hundred manufacturers of e-cigarettes and in the studies that have been done looking at constituents of what's in them, there's incredible variety both between the different brands that are manufactured but also there's incredible variety even in the same electronic cigarette over time. And there's no way to predict that because one product has a characteristic today that, you know, next month it will have the same characteristics.

MCAFEESo I think it's going to be very important to have both uniformity, but there are also other issues that again in terms of maximizing benefit and minimizing harm, it's going to be very important that marketing promotion, distribution and sale be controlled in a manner in which they will not become appealing to use. Ideally, we would see marketing that would focus on permanent and complete replacement in current smokers rather than this kind of situational substitution...

REHMAll right.

MCAFEE...where they're being encouraged to use them in situations where they can't smoke. And then all of this, however, it's probably the most important thing as to what how e-cigarettes will play out somewhat paradoxically maybe less associated with e-cigarettes themselves and more with what we as a society continue to do and do more strongly around traditional burned cigarettes.

REHMAll right. Dr. Tim McAfee, he's director of the Office of Smoking and Health with the Centers for Disease Control. If you can stay on the line with us, Dr. McAfee, I'm going to turn to Mitch Zeller of the Food and Drug Administration. Mitch, more people than ever are saying all smoking should be illegal.

MR. MITCH ZELLERThere are people who are saying that. Congress has spoken, though, when it comes to the regulation of tobacco products. It remains a legal product, but now, finally the Food and Drug Administration is in the business of regulating products that meet the definition of a tobacco product under a standard of do it in a way that is appropriate for the protection of the public health.

REHMDo e-cigarettes or these electronic cigarettes fall into your domain?

ZELLERWell, there was litigation a couple of years ago, and the courts ruled that as long as an electronic cigarette does not make a cessation or therapeutic claim which would leave it to be regulated as a drug or a medical device by FDA, as long as they don't make claims like that, then the only way they can be regulated by FDA is as a tobacco product, and that's because the nicotine in e-cigarettes is derived from tobacco. And FDA has announced its intention to regulate e-cigarettes as tobacco products. We haven't done it yet, but those are in the plans.

REHMHow soon do you think that may come about?

ZELLERWe are getting very close to being able to announce an expansion of authority over all products that meet the definition of a tobacco product.

REHMAll right. And turning to you, Mitch Felberbaum, the smoking bans around the increase in perhaps smaller communities around the country?

MR. MICHAEL FELBERBAUMThere's been certainly a movement toward of smoking bans both public and private around the country. Some of them have taken place on a statewide basis. Some of them have taken place, you know, from town to town. But there are certainly an increase in that in that trend.

REHMAnd, Dr. Thomas Glynn, do you envision a day when all smoking will be banned?

DR. THOMAS GLYNNI certainly can envision it, and I hope it's during my lifetime. You know, I go back in this a long way, and I remember Surgeon General Koop in the 1980s giving out more of these buttons that said SFS 2000, smoke free society 2000. We hoped to reach that then. But we're at, you know, as Tim mentioned, we're kind of at a crossroads right now, and there's enormous opportunity. We're talking about some of that this morning. So is there a time? I think we can start talking about the so-called endgame perhaps in some of the Western societies certainly.

REHMDr. Thomas Glynn, he's director of cancer science and trends for the American Cancer Society. Here in the studio, Mitch Zeller, he's director of Center for Tobacco Products at the Food and Drug Administration, and reporter Michael Felberbaum, he covers the tobacco industry for The Associated Press, and on the line with us is Dr. Tim McAfee, he's with the Centers for Disease Control and Prevention. Short break. We'll be right back.

REHMAnd welcome back. We're talking about smoking in this hour, the efforts not only in communities and states around the country to ban most forms of tobacco use. And we now get to the question of e-cigarettes -- electronic cigarettes. And I'm wondering, Michael Felberbaum, if you can explain just how they work.

FELBERBAUMSure. Electronic cigarettes are -- in general, are battery-powered devices. Some of them are made of plastic. Some of them are metal. And they have a chamber that heats a liquid nicotine solution with flavors of mostly, you know, tobacco flavoring, menthol flavoring and other flavors. And they create a vapor that the user would inhale.

REHMSo it goes down into the lungs that vapor.

FELBERBAUMWell, I guess it depends on how strongly they draw and if they want to inhale that. But it would be used in the same way as a traditional cigarette. That's the idea.

REHMDr. Glynn, I had a guest here in the studio the other day. And, of course, we have no smoking in this building. It's a smoke-free building. But I walked in to the studio and there he was smoking an electronic cigarette. And I wondered -- I mean, this was a big entertainer, who was clearly sort of nervous about being here, I think, which is why he continued to smoke throughout the hour. I did not ask him to put the cigarette down. Should I have?

GLYNNGood question, and it's something that certainly the airline, for instance, have been very concerned about. For instance, if someone lights up an e-cigarette on a plane, is that something that they can be asked to stop? And the airlines have done it in different ways. Some are allowing it, some not. Same thing if you're sitting in a theater or if you're sitting in a restaurant. We've become in this society very used to not having any kind of smoke around us.

GLYNNAnd although the e-cigarettes do give off a vapor that is not the same as cigarette smoke -- it doesn't have the number of chemicals as Mitch said -- it's still -- there is still concern as Tim said as well. And one of the big issues that we can deal -- one of the ways we can deal with this is through FDA regulation because it will enable us to be able to make some judgment. Research is also continuing on indeed whether the vapor coming from the e-cigarettes have any danger or not. And I don't know...

REHMNow, it was interesting, Mitch Zeller, because I could not smell a thing.

ZELLERWell, the thing that's the most interesting about the e-cigarette is we look at individual-level risk. What is the risk to, let's say, a current smoker, who would otherwise be unable or unwilling to quit if that person completely substituted all of their conventional cigarettes for an e-cigarette? That's individual-level risk. But policy is going to be made here at the population level because then there's population-level harm. Who is actually using these products, and how are they being used? Tim talked about this earlier.

ZELLERAre current smokers going to be less inclined to quit and more likely to engage in what we call duly use of both the combustible version and the electronic version? Are kids going to start using e-cigarettes? These are the kinds of questions that we have that ultimately comes down to behavior. And right now, we have far more questions than answers.

REHMMichael, what are the challenges facing the FDA in regulating nicotine?

FELBERBAUMIn regulating nicotine, in general, certainly, the challenges come into place where the FDA has two separate centers that regulate -- that could potentially regulate a nicotine product depending on whether they want to make a cessation claim to stop smoking, to help people stop smoking or if they just want to be regulated as a tobacco product. So there are certainly two different avenues there.

REHMAnd what about the Congress? To what extent does the Congress get into all of this?

FELBERBAUMWell, I mean, in terms of what they've said, they've given the FDA the authority to regulate tobacco products. And I think Mitch could probably speak to exactly what the law says better than I can.

REHMMitch.

ZELLERWhat's really interesting about the nicotine question is there's this old adage: People smoke for the nicotine, but they die from the tar. It's not the nicotine that is causing all of the premature death and disease. It's for -- it's combustible cigarettes and the 7,000 other chemicals that are in smoke. So FDA has an opportunity to look at a comprehensive nicotine regulatory policy if, ultimately, it's all the other compounds in tobacco smoke that are killing people and causing disease and not the nicotine.

REHMDr. Glynn, who is smoking e-cigarettes?

GLYNNAgain, good question. As Mitch said, we have more questions than answers right now with e-cigarettes. But certainly, it looks like it is current smokers who are using them to perhaps try and stop or, as Tim said, to use them when you're not able to smoke regular cigarettes. And the big question for us is, are they going to be using the e-cigarettes as a way of continuing to smoke regular cigarettes, or will they use them to help stop?

GLYNNAnd that -- if they do use them to help stop, we've made a great public health advance. If they're using them continue cigarette smoking, then we've lost something. So we're really at a very, very important juncture with devices like the e-cigarettes.

REHMDr. McAfee, how do you see that?

MCAFEEWell, I generally agree. Again, the most important thing that Mitch Zeller emphasized and Dr. Glynn is that we got to do something in this country about the fact that 40 million people are continuing to smoke cigarettes and over 1,000 kids a day are getting addicted.

MCAFEEWe just completed a couple of studies that were published in the New England Journal of Medicine earlier this year that hundreds of thousands of smokers, former smokers and non-smokers, and found that even now in the 21st century, if you smoke, you are losing over a decade of life expectancy on average and that this is -- we now know, which we didn't know 20 years ago, we know that this is just as true for women as it is for men, and it's not just killing senior citizens, you know, who are dying at 70 instead of 80.

MCAFEEIt's the number one killer of people -- preventable killer of people in middle age. So there's an urgent need to accelerate what would have been a very pretty steady but very gradual declines that we've seen in youth initiation and adults smoking rate. And we're trying to do this in the context of over $8 billion a year, $1 million an hour that's spent every day marketing cigarettes.

REHMWow.

MCAFEESo we have to think about how e-cigarettes will play in this context.

REHMSure.

MCAFEEAnd again, we think that e-cigarettes are much more likely to play a beneficial role if we continue our efforts and enhance them to flip over from the more laissez-faire approach that we're having towards burn cigarettes.

REHMOK. Now, let me, Mitch Zeller, quote a little bit from a Forbes magazine article dated March 28 of this year, the question, "Are e-cigarettes really 'smoking cessation' devices? Legally, no, but many people see them as just that. If you compare usage of e-cigarettes with that of regulated smoking cessation methods, you find 8 percent of adults who smoke cigarettes in the last 12 months used these devices to try to kick the habit, second only to cold turkey, 11 percent of adult smokers, and higher than percentage of patches, 6 percent, pills, 5 percent, gum, 4 percent."

ZELLERThe challenge is that when it comes to FDA-approved medications to help smokers quit, they've been regulated under a standard of safety and efficacy. There's clinical trial evidence that they work and that they are safe. And there is promise with e-cigarettes. But to date, the evidence is anecdotal. And there are advocates who believe from their own personal experiences that only the e-cigarette enabled them to get off of a conventional combustible cigarette.

ZELLERFDA is a regulatory agency, and it needs to see clinical trial evidence that if it's going to be marketed as a cessation product that there is the right kind of scientific evidence to prove it.

REHMAll right. And joining us by phone from Scottsdale, Ariz., is Craig Weiss. He's president and CEO of NJOY, makers of electronic cigarettes. Thanks for joining us, sir.

MR. CRAIG WEISSThank you, Diane.

REHMCraig, do you believe that electronic cigarettes should be regulated?

WEISSYes. We've been very much in favor of reasonable regulation by the FDA. I think it's very important to answer the many questions that were asked in this call. Customers should know and consumers should know what it is that they're buying. They should know what ingredients are in these products, and they should know that they're being manufactured in a proper and efficacious way, and that the ingredients in there are not toxic.

WEISSThey should have certain knowledge. And NJOY has been very committed to leading the effort on this front. And while we're not currently regulated, of course, we expect to be. And so we've undergone significant laboratory testing of our products, including, for example, HPHC, which stands for harmful and potentially harmful constituents.

WEISSThis is a test that's mandated and required by the FDA of combustion cigarettes companies and tests for 20 toxic chemicals that are found in combustion cigarettes. We've got the results of that, which we're very pleased with and are currently expecting those to be published in a peer reviewed scientific journal in the next few months. So those things -- we've also, in fact, conducted our first clinical trial which has been accepted and peer reviewed in the American Journal of Health Behavior.

REHMOK. Let me ask you, you used the word reasonable. What does the word reasonable mean from your perspective?

WEISSSo it means several things. First of all, it means regulation should not make it more onerous to buy an electronic cigarette which all of the emerging scientific data supports is a far less toxic product than the combustion cigarette. It should not be more difficult to buy an electronic cigarette for a consumer than it is to freely buy a combustion cigarette whose toxic causes are very well-known.

WEISSIt should also require the testing that I've talked about to confirm what's, you know, in this product, so ingredient listings, reasonable manufacturing practices. So to the point that I think it was Dr. McAfee made earlier, people know from one batch to the next that you're getting the exact same thing as previously. And I think it should be -- clearly, we support no access to minors. We only market our product to adult-committed smokers.

WEISSWe have no interest in non-smokers or youth. We support every law that bans the sale of electronic cigarettes to minors. So preventing youth access is critical. We're the only independent electronic cigarette company to be members of the We Card Program, the national age verification program. So things of that sort that will, you know, provide consumers with knowledge. And if you're making cessation or health claims, then you should regulate it as a drug.

REHMAll right. And you're listening to "The Diane Rehm Show." Michael Felberbaum of the Associated Press has a question.

FELBERBAUMYeah. Craig, you know, we've heard you speak now about, you know, about reasonable regulation and as far as the product standards. Can -- where do you see electronic cigarettes and in terms of how they should be marketed? Do you feel like they should be marketed any differently than regular tobacco products?

WEISSI do, and I think the marketing is a critical point because it's important that smokers are made aware of the fact that there is an alternative to them that's a reasonable alternative. And, you know, Nicorette, for example, advertises broadly, certainly well beyond what cigarettes can do, including sporting events.

WEISSI think the critical elements of any kind of advertising restrictions are what were discussed earlier, which is that the proper protection should be put in place so that no one's advertising to children, no one's advertising these products in a way that they haven't been approved for by the FDA. So, for example, if they're making cessation or therapeutic claims, then they need to be approved as a drug.

WEISSBut at the end of the day, you have an epidemic in this country of over 400,000 Americans dying every year from tobacco-related illness. It's basically a 9/11 every three days. And you have a public health epidemic. And so the ability to make smokers aware of what these devices are. Even though many smokers say they know "what an electronic cigarette is," they don't really understand that it can be something that is -- resembles a cigarette, that's as satisfying to them potentially as a cigarette.

REHMAnd on that point, I want to ask Dr. Glynn. Is there any indication that these electronic cigarettes themselves can become addictive?

GLYNNWell, certainly they deliver nicotine, and nicotine is an addictive substance. But I'm not sure that's as great a concern as the overall health issue dealing with e-cigarettes because, as Mitch pointed out, nicotine is not the killer in cigarette smoke. You know, 70 percent of people in -- of smokers in the U.S., -- that's about 30 million people -- just don't want to stop smoking. That's -- and 50 percent try every year.

GLYNNSo the really big issue is can e-cigarettes help accelerate that? And that's where the big question is right now. Most of what we have is anecdotal information. So we need -- that's why we need really solid information. And they help people stop 'cause we have 30 -- over 30 million people who, every day, get up and say, I want to stop smoking.

REHMMitch.

ZELLERThe public health question, Diane, is who is using these products, and how are they being used? If the products are being marketed -- and here's the public health concern. If the products are being marketed to current smokers to be used in situations where they can't light up, then the public health concern is that a product that still might be less harmful at the individual level will wind up serving as a bridge to get a current smoker from their last cigarette to their next cigarette.

ZELLERSo marketing matters, and ultimately the behavior matters. If there is complete substitution, that's one thing. If it's making a current smoker concerned about their health, less motivated, less inclined to quit, that's another matter.

REHMBut what about my health when somebody is using an electronic cigarette?

ZELLERAnd the answer is we don't know. It's on the long list of questions that we have.

REHMAnd how much time is it going to take to know that?

ZELLERThere are a lot of studies underway on those kinds of questions. I think in general, I think experts more vested in the toxicology and the chemistry would say, you're at greater peril exposed to secondhand smoke from a conventional combustible cigarette. But we still have these questions about exposure to non-users from e-cigarettes.

REHMAll right. Mitch Zeller of the FDA. And, Craig Weiss, I want to thank you for joining us. Craig is CEO of NJOY, makers of electronic cigarettes. Thanks for being with us.

WEISSThank you.

REHMAnd we have a short break coming up. When we come back, your calls, questions. Stay with us.

REHMAnd welcome back. Time to open the phones first to Detroit, Mich. Hi there, Phil, and congratulations.

PHILThanks, Diane. Yeah, after 16 years of smoking, I'll celebrate one year of not smoking this week.

REHMGood for you.

PHILI just had two quick questions. The first one was, does my body have the ability to repair the damage that I caused of 16 years of smoking?

REHMOK. Let me ask you a couple of questions. How long did you smoke?

PHILI smoked for 16 years.

REHMSixteen years. And how much did you smoke?

PHILProbably, on average, a pack a day, and I'm now 32 years old.

REHMOK. Dr. Glynn.

GLYNNGreat decision and great questions. How long and how much are the two determinants as to how quickly you can repair. And the answer is, Phil, you can repair quite quickly. Your risk of heart disease is dropping every day. And, in fact, by the time you're about a year out, your risk of a heart attack is going to drop by half.

GLYNNAnd after about five years, you will be back to close to being that of a non-smoker. Lung cancer is going to take a little bit longer, but because you stopped so early in life, it's -- your risk is going to be quite low over time. So, basically, you made a wonderful decision, and your body is going to repair itself.

REHMLet me ask you. Did you quit cold turkey, Phil, or did you use the e-cigarette?

PHILWell, for about two years, I tried to quit. And I tried almost every method out there including acupuncture or -- and -- I was hypnotized once, too, and that didn't really work. But I finally used a drug called Chantix, and that helped me quit. Also, the fact that I want to start a family and don't want my kids exposed to cigarettes was also a big factor.

REHMGood for you and congratulations. What about Chantix, Mitch Zeller?

ZELLERChantix is an FDA-approved medication. It does not have any nicotine in it. But it's a safe and effective medication.

REHMWhat is it?

ZELLERIt is a chemical compound called varenicline, that, in the hands of someone like Phil who sounds extremely motivated to want to become tobacco free, can help smokers do exactly that.

REHMTaken in what form?

ZELLERIt's a pill.

REHMOK. All right. Congrats, Phil. Let's go to Brooke in Evansville, Ill. You're on the air.

BROOKEHi, Diane. Thanks for taking my call.

REHMSure.

BROOKEAnd I'm actually from Indiana. Sorry.

REHMI'm sorry. What did I say?

BROOKENo. Illinois, but it's perfectly fine.

REHMSorry.

BROOKEI'm still close, so it's all right.

REHMOK.

BROOKEI just wanted to make a comment because I actually work part time at a liquor store, which is right next to a store that specifically only sell e-cigarettes. They sell the kind, you know, where you drip the vapor into the chamber, and you take a hit off of it. And I just noticed -- I actually date a man who's been smoking for 20 years. And he tried the e-cigarette. And I'm all for him not smoking them anymore.

BROOKEHe said it just made him -- it didn't taste like tobacco, so he craved the cigarette more. We see people at the store. It opens at 10 o'clock. Normally, if you drive by about 9:30, you'll -- there's already a parking lot full, and there's a line of people outside the door waiting to get in to the e-cigarette store.

REHMWow.

BROOKEIt's highly addictive. This past weekend, the e-cigarette store did about three times as much in credit card sales as the liquor store did.

REHMThat's fascinating. Dr. Zeller.

ZELLERI think the interesting thing about the marketplace for e-cigarettes is consumers seem to be speaking with their pocketbooks. And that's why in this calendar year, it's expected that e-cigarette sales are going to exceed the sales of nicotine replacement therapy, the gum, the patch and the lozenge. And so there's something going on here.

ZELLERAnd one of the signals is that current smokers certainly seemed to be open to getting their nicotine in alternative ways. And that takes us to the potential benefits of electronic cigarettes if there's no combustion, if you're not getting the 7,000 chemicals. But again, it comes back to who is using them and how are they being used. But these stories of people lining up before the store opens...

REHMWow.

ZELLER...and the anecdotal stories that are coming in about how e-cigarettes have helped individual smokers become tobacco free need to be built into this equation because there are benefits and there are risks.

REHMI think there are other things that need to come into the equation. Here's an email from Rick in Orlando, Fla., who says, "I contracted bladder cancer second only to lung cancer as a result of lifelong smoking. I began smoking electronic cigarettes about one year ago. I've had nine procedures to remove tumors from my bladder. My last surgery four months ago found fewer tumors. My last checkup showed no tumors." Dr. McAfee, do you want to weigh in on that?

MCAFEEWell, I'm not quite sure what the question is. It's admirable...

REHMMore about a statement regarding bladder tumors as well as lung cancer.

MCAFEEOh, I'm not sure it would be number two after lung cancer, but it certainly is on the list of cancers that are known to be associated with smoking. So, again, it's very unfortunate. One of the things that we've been trying to do at CDC is we've been running a national mass media campaign, tips from former smokers where we try to make these harms that are caused by smoking more real to the American people, which is actually what smokers told us they wanted.

MCAFEEThousands of smokers that we interviewed said that one of the reasons it's hard to quit smoking is that the harms are aren't as real as the immediate benefits that people feel from smoking which relieves their withdrawal symptoms.

MCAFEESo I think this is a very -- these kinds of stories about, hey, you know, this really happened to me, I didn't really think it was real, but, you know, for every person who dies from a smoking-related death, there are 20 people that continue to live with serious -- at least one, if not more -- serious smoking-related diseases that cause a horrible toll of disability and suffering on people.

REHMDr. Glynn.

GLYNNYeah. Since I'm with the American Cancer Society, I'm obligated to point out that cigarette smoke causes about 15 kinds of cancer. But I think it's also important for people to understand that it's not just cancer, and it's certainly not just lung cancer, but it's heart disease and lung disease and exacerbating the effects of asthma and diabetes. So it's -- unfortunately, cigarette smoke is a non-specific killer. It kills with cancer and many other diseases as well.

REHMAll right. To Syracuse, N.Y. Hi, Jerry.

JERRYOh, good afternoon. Well, excuse me, good morning. I am also -- I'm sitting here waiting to see my urologist, would you believe it? I had bladder cancer also.

REHMOh, I'm so sorry.

JERRYOh, it's from cigarette smoke, but it was a long time ago. I have been going for my annuals for -- since forever. But anyway, what I wanted to say was I was at a function. There was open food in a room. A group of people were smoking these smokeless cigarettes but a lot of vapor, and I asked them to stop because you could transmit disease such as TB. We don't know what the heck is going on with this. You know, I'm not saying that there's a study that proves it, but I was offended by...

REHMWell, as someone who has experienced the worst that cigarette smoking can present, I blame you not. Dr. Glynn, what's your thinking about this? Just as Mitch Zeller said earlier, are we likely to see these e-cigarettes on planes, in restaurants, in other places where cigarette smoke is banned?

GLYNNWell, I think one thing, public opinion is going to help determine that as to whether, in fact, we are going to continue to have a smoke-free society. There is a bill in the California legislature right now which would put e-cigarettes in the same position as regular cigarettes. If you can't -- if you can't smoke a regular cigarette somewhere, you can't use the e-cigarette.

GLYNNNow, as Mitch pointed out, I think Tim mentioned as well, the vapor from the e-cigarette is certainly -- it must be less dangerous than cigarette smoke. It just could not have the same number of chemicals. So we're not talking about the same level by any means of danger, but it does not mean that it's harmless. And that's what we need to do more research on and where FDA regulation will help.

REHMMitch.

ZELLERYeah, let's come back to basics here, and Tim has made this point repeatedly. Cigarette smoking remains the leading cause of preventable death and disease in this country today. It's shocking with everything that we know about the harms associated with cigarette smoking. And even more distressing is that children and adolescents remain the replacement customers for the addicted adult smokers who die or quit every day. The good news is fewer kids are taking up the habit. But over 300,000 kids a year become regular smokers.

ZELLERThey've made the progression from experimentation to regular smoking, and they're on that horrible trajectory to addiction, disease and premature death. FDA is trying to do its job. We're investing and enforcing youth access restrictions so that retailers don't illegally sell to kids. And we're going to be launching a public education campaign at the end of the calendar year to reach at-risk, vulnerable 12 to 17-year-olds and -- with messages that they will understand. But shockingly, kids remain the replacement customers for the addicted adults...

REHMAll right.

ZELLER...smokers who die and quit.

REHMTwo email questions here, one about Chantix. Dr. Glynn, here's an email from Carol that says, "Chantix is linked to serious side effects, which should be mentioned, as well as its success in helping people kick the habit."

GLYNNWell, certainly, there, you know, we have seven FDA-approved medications. Five of them are nicotine replacement products. One is Zyban, and the other is Chantix. And Chantix, there is no doubt, as Mitch said, it has been helpful in helping people stop. There is also a caution about it that it can cause people to have, for instance, suicidal ideation. So we need to be very careful, as with any drug, in how they're used. Now, Chantix and Zyban and the inhaler are all prescription medications...

REHMI see.

GLYNN...which mean that if you're using it, you're under the care of your physician, and both of you need to be very careful. But I do emphasize that this have been helpful in helping people stop. And as Mitch said, shockingly, we still have 40-some million people smoking. And anything we can do to help them stop, as we've heard from some of the listeners, is going to be good for public health and good for the population.

REHMAll right. And another email question for you, Mitch, "Are there findings that menthol cigarettes could be more addictive than non-flavored cigarettes?"

ZELLERFDA just released some actions within the last week or so on menthol, including release of a preliminary scientific evaluation where we concluded -- but we've put this out for public comment -- that there is a concern with menthol that it can mask the harshness otherwise associated with the smoke going down.

REHMBecause it's cooler.

ZELLERBecause of the cooling effect.

REHMYeah.

ZELLERAnd there certainly seems to be a disproportionate number of kids who initiate, who starts smoking with menthol cigarettes. It's why we've committed to doing a public education campaign that's going to talk to kids in ways that they will understand about the harms of menthol cigarettes.

REHMAnd you're listening to "The Diane Rehm Show." And at this moment, it's time for my confession that I smoked for 10 years, from the time I was 15 until I was 25, when my husband said to me, I cannot stand the smell of cigarettes on you in your hair, in your clothes, on your body. I tell that story because I do believe that personal fragrance and standing next to people who smoke, who reek of cigarette smoke can be highly offensive. Mitch Zeller.

ZELLERBut let's not forget the smoker in the equation. They have become addicted. And the overwhelming majority of smokers wished they never started and wished that they could stop.

REHMAnd I quit cold turkey and went on a diet at the same time.

ZELLERAnd more power to you, but so many smokers try and fail that way. We really need to be emphatic with those who remained smoking today.

REHMIs there any indication that smoking is more addictive today than it was 20 years ago?

ZELLERThere are some suggestions and the evidence about the design of the cigarette, but I don't believe that it's been proven.

REHMIt hasn't been proven?

ZELLERNo.

REHMHow come?

ZELLERWe know all we need to know about how addictive cigarettes are without the relative comparison, are they more addictive today? They are powerfully addictive regardless of what we would say compare to the cigarette 20 years ago. The cigarette is deliberately designed to create and sustain addiction.

REHMExactly. All right. And finally, to Fairfax, Va. Sandra, you're on the air.

SANDRAHi. Thank you for taking my call. Can you hear me?

REHMSure.

SANDRAOK. My husband and I are renting a condo in Fairfax County. And last summer, we struggled with a resident who was smoking on her balcony below us, and it was funneling in to our apartment through our sliding glass balcony doors. And I had a lot of compassion for her. I understand addiction. And my mother and my sister are both smokers.

SANDRASo I tried to work with her about when this could happen, when, you know, we could have our windows open, and it just didn't work. And I tried to get the condo -- the HOA people involved. And they basically said that she has all the rights, and I have none. And I was just wondering if there was anything that I could do to advocate for myself and others.

REHMSure, sure. I understand. Dr. Glynn.

GLYNNYeah. Sandra's dilemma is really important one in public health law right now. It's being considered in a number of courts. And working through the homeowners association is certainly one option. You know, secondhand smoke kills more than 40,000 Americans every year. And it is a serious health issue. It's between heart disease and lung cancer. So Sandra has that on her side that this is a public health issue.

GLYNNIt's not simply an annoyance issue, which it certainly can be. And there is clear evidence that secondhand smoke seeps from one unit to another, no question, and that's been measured. So she can go to the homeowners association and beyond with solid data, not just this is annoying but data that this is a health issue and not simply one of annoyance.

REHMAnd that's got to be the last word from Dr. Thomas Glynn, director of cancer science and trends for the American Cancer Society. Dr. Tim McAfee is with the Centers for Disease Control and Prevention. Michael Felberbaum covers the tobacco industry for the Associated Press. Mitch Zeller is with the FDA. I thank you all. Let's hope this conversation helps some people. Thanks for listening. I'm Diane Rehm.