Hands Off Tobacco: 10th Grade Curriculum by Heather Holmes

Hands Off Tobacco! An Anti-Tobacco Program for Deaf Youth Cynthia B. Sternfeld, ED.S., LPC Susan M. Barnabei, B.S. Karan Kriger, B.S. Marie H. Katzenbach School for the Deaf

Debra S. Guthmann, ED.D. Frank Lester, M.S.W.

California School for the Deaf, Fremont

Barbara A. Berman, PH.D.

Division of Cancer Prevention and Control Research UCLA School of Public Health and Jonsson Comprehensive Cancer Center

Annette E. Maxwell, DR.P.H. Glenn C. Wong, M.P.H.

Recruitment, Retention and Communications Core UCLA Jonsson Comprehensive Cancer Center

PDF processed with CutePDF evaluation edition www.CutePDF.com

Hands Off Tobacco! An Anti-Tobacco Program for Deaf Youth This curriculum was developed through funding from TRDRP, the Tobacco Related Diseases Research Program, University of California (Grants # 10GT-3101, 12HT-3201, Barbara A. Berman, Ph.D., Principal Investigator, UCLA; Debra S. Guthmann, Ed.D., Principal Investigator, California School for the Deaf, Fremont). We wish to express our deep appreciation to the faculty, staff, students and their parents at the California School for the Deaf, Fremont (Fremont, California), the Marie H. Katzenbach School for the Deaf (Trenton, New Jersey), the California School for the Deaf, Riverside (Riverside, California), and the Minnesota State Academy for the Deaf (Faribault, Minnesota) for their participation in this study. We also thank Linda Oberg, M.S., M.A.; members of our Expert Curriculum Review Panel (Sook Hee Choi, M.A., Chriz DallyJohnson, M.A., Janet Dickinson, Ph.D., Thomas Holcomb, Ph.D., Nancy Moser, LCSW, Katherine A. Sandberg, B.S., CCDCR, and Mary Skyer) for their help in the formative stages of curriculum development; Mr. Jon Levy and the faculty, staff and students of the Orange County Department of Education Regional Deaf and Hard-of-Hearing Program, University High School, Irvine, California; and Heidi B. Kleiger, B.S., Lauren Maucere, B.S., and our colleagues at the Greater Los Angeles Agency on Deafness (GLAD), Los Angeles, California, for their help and support in this program of research. Images used for analysis, critique and description throughout this curriculum were obtained primarily from the website www. trinketsandtrash.org. Additional sources of materials include the American Lung Association and the website www.WhyQuit.com.

ÂŠ2004, 2007 University of California, Los Angeles

Introduction for Teachers

Hands Off Tobacco! An Anti-Tobacco Program for Deaf Youth

IGARETTE SMOKING is the single most preventable cause of death and disease in our society. It is responsible for approximately one in five deaths—over 440,000 deaths each year— in the United States. This is more than the number of people killed by AIDS, alcohol, motor vehicle accidents, homicide, illegal drugs and suicide, combined. Nearly half of all Americans who continue to smoke will die from a smoking-related disease. Across the globe, smoking accounts for approximately 4.2 million deaths annually, and this number is growing. By 2025 it is estimated that seven million people throughout the world will die from tobacco use each year.*

Is tobacco use a problem for young people? Yes, absolutely. More than 90% of all adult smokers begin to smoke while they are children or teenagers. In the United States alone, more than 4,000 young people under the age of 18 smoke their first cigarette each day, and 2,000 others go on to become regular, daily, smokers. That's more than 730,000 new underage daily smokers each year. More than a third of all youngsters who ever try smoking a cigarette become regular, daily smokers by the time they leave high school. About 4.5 million youth under the age of 18 are current smokers. Monitoring the Future, an annual series of nationwide surveys conducted by the University of Michigan Institute for Social Research among 8th, 10th and 12th grade students, reports that cigarette use has been falling among American adolescents since the mid-1990s. But the rate of decline is slowing, and there is growing concern that these gains may be near an end. And even with these gains, which simply offset the dramatic * Trends and patterns change very quickly. We therefore

choose to provide only limited data in presenting this curriculum. The Campaign for Tobacco-Free Kids Web site (www.tobaccofreekids.org), the annual Monitoring the Future report (www.monitoringthefuture.org or http://drugabuse.gov), and the Youth Tobacco Survey are only a few of the many places on-line where there is easy access to current information regarding changing patterns of tobacco use among children and teenagers.

increases in teen smoking in the first half of the 1990s, it is important to note that a quarter of young people —nearly one out of every four— are actively smoking by the time they leave high school. Furthermore, some young people who are not smoking in high school will begin after they graduate, and others who are not daily smokers in high school will become daily smokers after they leave school. Initiation and development of tobacco use among children and teenagers involves a process that starts with attitude formation about smoking, proceeds through trial and experimentation, and all too often ends in regular use. We also know that several factors place children and adolescents at risk for starting tobacco use and becoming an addicted smoker. These include: W Behavioral risk factors for tobacco use: Poor school performance, low aspirations for future success, school absences, and school dropout. Other behavioral factors include risk-taking and rebelliousness, coupled with a lack of skills to resist influences to use tobacco, alcohol or drugs. W Environmental factors: If family members or close friends smoke; and if tobacco products are readily accessible. Advertising and promotion are an important aspect of the environment, shaping young people's views of the utility of smoking and other tobacco use. So too are community-level factors such as the extent to which sales to minors are restricted, the cost of tobacco products, and restrictions on smoking in public places. These factors influence not only access to tobacco products, but also the perceived acceptability of tobacco use. W Personal risk factors: These include aspects of a young person's interaction with the social environment. Smoking is most likely among youngsters with low self esteem; who believe that tobacco use has a valuable social function; who Introduction 1

Introduction for Teachers

believe that "everyone else smokes;" and who are susceptible to peer pressure to smoke. Personality factors such as depression, helplessness, aggression, pessimism, and limited ability to conceptualize the future have also been found to predict smoking among young people. Children from lower income families are also at greater risk for smoking than other young people. Although these characters increase the risk of tobacco use, the fact is that smoking initiation occurs among young people across all behavioral, environmental and personality characteristics. To understand why young people continue to smoke once they have started, we need to take into account the very real danger of addiction.

results in relapse when a quit attempt is made. Once they begin, many smokers—young and old—find themselves caught up in a cycle of addiction that makes quitting very difficult. How does the Addiction Cycle work? While much has still to be learned about the process of nicotine addiction, including the role of genetics in this process, much has already been learned (See Figure 1).

Is tobacco use addicting for children and teenagers?

W Nicotine is one of more than 4,000 chemicals found in the smoke from tobacco products such as cigarettes, cigars and pipes, and in smokeless tobacco products such as snuff and chewing tobacco. Nicotine is absorbed through the skin and mucosal lining of the mouth and nose or by inhalation in the lungs. It enters the blood stream and travels throughout the body.

Certainly. In fact, not only do most adult smokers report that they started smoking as children or teens-most also report that they were addicted by the time they left high school. This is why reaching out to young people now about avoiding tobacco use is so critical. Tobacco use and addiction happen very quickly.

W Immediately after exposure to nicotine, there is a “kick” caused in part by the drug's stimulation of the adrenal gland which discharges epinephrine—adrenaline. The rush of adrenaline stimulates the body and causes a sudden release of glucose, an increasing blood pressure, respiration, and heart rate.

What do we mean by “addiction?” Addiction is characterized by compulsive drug-seeking and use, even when the user knows the dangers involved. Tobacco certainly fits this description. Most smokers identify tobacco as harmful and indicate that they would like to quit. Nearly 35 million smokers make a serious attempt to stop smoking every year. But less than 7% of those who try to quit on their own stay off cigarettes for more than a year. Most relapse-that is, they go back to smoking in a few days after trying to quit.

W Depending on how it is taken, nicotine can reach peak levels in the bloodstream and brain very quickly. A cigarette, for example, is a highly engineered, efficient drug-delivery system. The inhaled smoke from a cigarette carries nicotine deep into the lungs where it is quickly absorbed into the blood and carried to the heart and the brain. It reaches the brain within about ten seconds of inhaling.

The desire to quit is not just expressed by adults. Once children and teenagers begin to smoke, they commonly believe that they can quit whenever they choose. The truth is that quitting, even for a young person, is difficult to do. While some young smokers are able to quit before leaving high school, nearly three out of every four regular smokers in high school have already tried to quit but failed. The most important reason for this is that tobacco products contain nicotine, a chemical as highly addictive as cocaine and heroin. And addiction to tobacco products can occur very quickly. Children and teenagers who try to quit find that they experience the withdrawal symptoms that adults experience, and this frequently

W Once in the brain, nicotine stimulates the release of the neurotransmitter dopamine. Dopamine is involved in regulating feelings of pleasure, and creates a “reward pathway” that encourages continued nicotine intake by the tobacco user. Nicotine also has an impact on other brain chemicals that affect mood and performance, including acetylcholine (arousal, cognitive enhancement), norepinephrine (arousal, appetite suppression), vasopressin (memory improvement), serotonin (mood modulation, appetite suppression) and beta-endorphins (reduction of anxiety and tension). W Research indicates that other chemicals in tobacco may also play a role in the addiction

Introduction 2

Introduction for Teachers Figure 1: The Addiction Cycle

So the person smokes another cigarette. And the cycle starts over again.

Within seconds of inhaling, nicotine speeds its way to the smoker’s brain.

Over time, the brain becomes accustomed to nicotine stimulation. Once this happens, the smoker experiences unpleasant withdrawal symptoms if the nicotine craving is not satisfied.

4 The smoker’s brain starts to crave another “hit” of nicotine—which prompts the person to smoke another cigarette.

process by decreasing levels of an enzyme that break down dopamine, thereby inhibiting the body's ability to block the increase of dopamine. W After the initial “hit” of nicotine in the brain, its concentration in the blood begins to fall rapidly. Nicotine is eliminated from the body primarily by the liver. In about 30 minutes the body has cleaned out much of the nicotine. Without nicotine to provide the pleasure stimulus in the brain, a smoker then begins to feel tired, jittery and depressed. These feelings are symptoms of withdrawal, and trigger a craving for another dose of nicotine by smoking another cigarette, or chewing on another plug of smokeless tobacco. Tobacco users continue to smoke or chew throughout the day to maintain the drug's pleasurable effects and prevent unpleasant withdrawal symptoms. W With repeated smoking during the day, nicotine levels accumulate, plateau through the day, and then gradually fall overnight. Many smokers describe the first cigarette of the day as the most pleasurable because of the relief it gives to withdrawal symptoms they experience upon waking in the morning.

In the brain, nicotine causes the release of a chemical called dopamine which stimulates feelings of pleasure and relaxes you.

But as soon as the person stops smoking, this stimulation wears off as the nicotine level in the body falls.

A typical smoker takes about 10 puffs on a cigarette during the five minutes that a cigarette is lit. A smoker that smokes a pack of cigarettes a day—20 cigarettes—gets 200 “hits” of nicotine to the brain each day. W As the nervous system adapts to nicotine, smokers tend to develop a tolerance to the chemical. This causes tobacco users to smoke or chew more over time to achieve the same nicotine “hit.” W When people try to quit they frequently experience withdrawal: irritability, difficulty in concentrating, sleep disturbance, increased appetite, depression, and fatigue. These feelings usually last for a few days or weeks. But they can last longer. They can be mild or severe. They frequently result in relapse to tobacco use. W Behavioral and psychological aspects of addiction are also very important and can contribute to the craving for a cigarette. For some smokers, the feel, smell and sight of a cigarette, and the behaviors associated with obtaining, handling, lighting and smoking cigarettes are associated with the Introduction

Introduction for Teachers

pleasurable effects of smoking. Smokers come to associate these behaviors with a reduction in stress. Given the difficulties in stopping smoking once someone is addicted, it becomes clear why prevention—finding ways to encourage people to never start smoking in the first place—is so important. And because most smoking begins in childhood and adolescence, the importance of prevention among young people is clear. But prevention is difficult to achieve. What makes tobacco use prevention such a difficult task? Prevention is difficult because the act of tobacco use—smoking cigarettes, cigars, and other tobacco products, or chewing smokeless tobacco—has been linked to social meanings and utilities, apart from its physiological effects, that make tobacco use attractive. The act of smoking or chewing tobacco is associated with independence, toughness, rebellion, camaraderie, sophistication, relaxation and fun. Tobacco use is perceived as being “cool.” How did tobacco use come to have these social meanings? Most of this is the result of the tremendous marketing effort put forth by the sellers of tobacco products. First, they developed innovative strategies for marketing tobacco, pioneering the use of brand names and packaging to segment markets (cigarettes for men versus those for women; for tough men versus the sophisticated individual; and those for the young). Perhaps more important, they promoted tobacco use as not only normal and acceptable, but as a desirable practice as well.

had already linked the rise in tobacco use with an equally dramatic increase in lung cancer and other diseases. Spurred on by these research findings, the government, voluntary agencies and others began to disseminate information about the health effects of tobacco use. The government also began to make efforts to control the marketing and sale of tobacco products. These efforts led to a greater awareness of the health risks of smoking and to declines in smoking rates since the peak years in the 1960s. This took place first for men, and then later—and more gradually—for women. Still, the significant fact is that nearly a quarter of the adult American population, or about one in four adults in the United States, smokes cigarettes. And despite what is known and continues to be discovered about the health consequences of tobacco use, the tobacco industry remains a powerful economic and political force, both in the United States and around the world. Over one billion men and 250 million women in the world are daily smokers-consuming 15 billion cigarettes every day-and the ranks are growing every day. Today the tobacco industry spends upward of $11.5 billion dollars annually on marketing in the U.S.-about $31 million dollars each day. Some of the most familiar images in marketing—the Marlboro Man, Joe Camel, and beautiful Virginia Slims models to name a few— are linked to tobacco products. And marketing is only one of the many ways in which the tobacco industry has sought to gain and retain acceptance for its products and for this industry in the United States and elsewhere.

In the early decades of the 20th century, tobacco use was linked to manliness, success, athleticism and more through carefully crafted marketing strategies. As a result, before World War I, tobacco use was primarily a male behavior. Recognizing that few women smoked, tobacco companies in the 1920s and 1930s began to market tobacco products to women by linking smoking to thinness, emancipation, independence, youth, fun and beauty.

When it comes to young people, the tobacco industry has always denied that it markets its product to children and teenagers. But the industry's own internal documents reveal that young people have long been viewed as an important segment of the tobacco market. Children and teenagers are susceptible to tobacco messages and images, teenagers are more likely than adults to recall tobacco advertising, and a far greater proportion of young smokers buy the top three brands of cigarettes—those most heavily advertised—than do adults.

The aggressive promotion of tobacco use—especially cigarette smoking—as a socially acceptable and desirable behavior resulted in a dramatic increase in tobacco use in the 20th century, to where more than half of all adult men and a third of adult women in the U.S. were smokers by the 1960s. By this time, however, scientific research

While Camel cigarettes no longer uses Joe Camel in its advertising, we can learn a great deal from this highly successful campaign. While this campaign was taking place, a study of product logo recognition of three-to-six-year-olds revealed that over 90% of the six-year-olds correctly matched the cartoon Camel with cigarettes. Between 1989

Introduction 4

Introduction for Teachers

and 1993 the amount spent on Joe Camel went from $27 million to $43 million. This led to a 50% increase in Camel's share of the youth market. It had no impact at all on the company's adult market share. We often think of peer influences and adult role models as key to understanding tobacco use. And without doubt, these are critical factors we need to take into account. But the social and cultural environment also has a direct impact on the behavior of young people, and plays an important role in shaping the behavior of peers and adults. Cigarettes and other tobacco products have come to have an important place not only in adult culture, but in youth culture, as well. What are the health and other consequences of smoking? Condemnation of tobacco dates back for centuries. Prior to the 20th century opposition to tobacco use was often on moral and religious grounds. Health concerns were voiced. But they did not emerge as the most significant argument until the 20th century, when physicians and researchers began to report the health consequences of this behavior. In 1964, in response to growing calls for action, a landmark report was published, Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service. This, the first Report of the Surgeon General regarding tobacco, documented what was then medically known: smoking was a cause of cancers of the lung and larynx (voice box) in men and chronic bronchitis in both men and women. Extensive research into the health effects of smoking continued, from that time until the present, and the understanding of tobacco's role in disease and death has grown. The Surgeon General’s Report and others have carefully documented many of these issues—the addictive nature of nicotine, the health consequences of secondhand smoke exposure, the implications of smokeless tobacco use—and more. In 2004, on the 40th anniversary of the first Surgeon General's Report, a new report, The Health Consequences of Smoking: A Report of the Surgeon General, was published. In that report the conclusion is drawn that smoking harms nearly every organ of the body, and that “smoking remains the leading cause of preventable death and has negative health impacts on people at all stages of life. It harms unborn babies, infants, children, adolescents, adults and seniors.”

W Smoking causes cancer and accounts for at least 30% of all cancer deaths. Tobacco smoke contains at least 60 cancer causing substances. Lung cancer is the leading cause of cancer death in men and women, and smoking causes about 90% of lung cancer deaths in men and almost 80% in women. Smoking is also a known cause of cancer of the oral cavity, larynx (voice box), pharynx, esophagus, bladder, pancreas, kidney, blood (leukemia) stomach, pancreas and cervix. W Smoking is a cause of coronary heart disease, the leading cause of death in the United States. A smoker is four times more likely to die from coronary heart disease than a nonsmoker; 21% of all coronary heart disease deaths in the U.S. each year are attributed to smoking. W Smoking causes respiratory diseases. It is a known to cause more than 90% of deaths from chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis; male and female smokers increase their risk of death from these diseases by nearly 10 times. Smoking causes chronic coughing and is linked to pneumonia. Smokers are more susceptible to influenza (the flu) and are more likely to experience severe symptoms when they get the flu. W Smoking causes strokes, the third leading cause of death in the United States, and circulatory deficiencies which can contribute to infection and tissue death, particularly for parts of the body like hands and feet that are distant from the heart. It is also known to contribute to aortic aneurysm, a dangerous weakening and ballooning of the major artery near the stomach. W Research has linked smoking to rheumatoid arthritis, hearing loss, vision problems (such as cataracts), facial wrinkling, gum disease (periodontitis), reduced bone density among postmenopausal women, hip fractures and osteoporosis, diabetes, and to making diabetes worse for those who have this disease. It can reduce the effectiveness of medicines used to treat, for example, diabetes, ulcers, sleeplessness and pain. Smokers who get immunizations such as flu vaccine and hepatitis B vaccine are not as well protected against the disease as are nonsmokers. Smokers have a lower survival rate after surgery compared to that for nonsmokers because of damage to Introduction 5

Introduction for Teachers

the body's host defenses, delayed wound healing, and reduced immune response. Smokers tend to have more ulcers than non-smokers, and smoking keeps ulcers from healing. Smoking affects the sense of smell and smokers are more likely than non-smokers to snore. W Women who smoke and take birth control pills run an increased risk of stroke. Women who smoke are at increased risk for infertility. Smoking during pregnancy can cause health problems for both mothers and babies, such as pregnancy complications, premature birth, low birth weight infants, stillbirths, and Sudden Infant Death Syndrome (SIDS). Smoking by fathers prior to conception may have health consequences for their offsprings as well, even when the mother does not smoke. Children exposed to secondhand smoke after birth are at a greater risk of childhood wheezing, respiratory tract infections, of getting or worsening asthma, of chronic respiratory symptoms such as colds, coughs, sore throats, stuffy noses, and middle ear infections, of poorer lung function, increased heart rate, complications after surgery and higher blood levels of lead, a toxic metal. W Smoking has been linked to erectile dysfunction in men. W Adults exposed to secondhand smoke increase their risk of heart disease morbidity and mortality, lung cancer, eye and nasal irritation, pneumonia and other respiratory infections. W Socioeconomically, the costs of smoking are high. The financial costs of smoking-related diseases are borne by society in the form of higher health insurance costs and greater health care expenditures, especially in the public, taxpayer-financed health care system. The economic costs include lost productivity in the workplace due to smoking-related illness and premature death. These costs are staggering. It is estimated in the United States that smoking costs $75 billion in direct medical expenses and $82 billion in lost productivity every year. And there are the additional costs of dealing with the more than 140,000 smoking-related fires in the U.S. each year.

But what do these health impacts mean to young people? Research has clearly shown that the earlier young people begin to smoke, the greater their risk of developing smoking-related diseases in adulthood. However, the primary difficulty in communicating these health effects to young people is that many of the most graphic consequences of tobacco useâ&#x20AC;&#x201D;lung cancer, heart disease, oral cancer, strokes and so forthâ&#x20AC;&#x201D;are far off in the future and beyond the horizon as far as an adolescent is concerned. In a youth-oriented anti-tobacco curriculum, it is important to emphasize both the immediate health and social consequences of tobacco use. What are the immediate health consequences of tobacco use for young people? W First, a young person's lung function is immediately impaired, and the effects are consistent with early signs of obstructive airway disease. What does this mean? Some lung tissue damage occurs, diminishing the ability of the lungs to take in oxygen. This damage gets progressively worse the more one smokes. Not surprisingly, young people who smoke are less physically active, perform more poorly at all levels of physical exertion, improve more slowly with training, and have poorer endurance overall than non-smokers. W Smoking slows the normal development and growth of a young person's lungs. This means that young people who take up smoking while their bodies are still growing may be permanently stunting their lung capacity. This has been shown to be especially the case for girls who take up smoking. W Smoking contributes to the onset of asthma, and can greatly aggravate an existing asthma condition. W High school seniors who smoke rate their overall health more poorly than do nonsmokers. They are more likely than non-smokers to report experiencing cough with blood or phlegm, shortness of breath when not exercising, and wheezing and gasping. Young smokers are more likely to suffer exercise-related injuries than their non-smoking peers, and heal more slowly from injuries. Over time, smoking causes premature wrinkling of skin.

Introduction 6

Introduction for Teachers

W There is evidence that smoking is sometimes a first step towards other substance use. Young people age 12-17 who smoke are more than 11 times as likely to use illicit drugs and 16 times as likely to drink heavily as young people who do not smoke. W But the damage is not confined to tobacco that is smoked. Smokeless (chewing) tobacco causes mouth sores and gum disease, even at a young age. Oral and nasopharyngeal cancers are less commonly seen, but can also occur at young ages. Both smoking and smokeless tobacco lead to bad breath, yellowed teeth, stained fingers, dulled taste buds, and a dulled sense of smell. W Of course, the most insidious impact of youth smoking is that those who start smoking at a younger age are more likely than later starters to develop a long-term addiction to tobacco. The younger a person starts, the greater the difficulty in quitting tobacco at a later age. Smoking also has social and economic consequences for young people. W Some of the effects on personal grooming— bad breath, yellowed teeth, and discolored fingers—have already been mentioned. Add to this list the smoky odor in hair and clothing, and burn holes in clothing. Smoking may change social relationships with others, including family, girlfriends or boyfriends, non-smoking friends, teachers, employers, athletic teams and other social groups. There are a host of social consequences related to the act of smoking itself, such as getting punished for breaking school rules, being asked to step outside of restaurants, or getting cited for smoking in a public place. Many of these social consequences may be more immediate, and therefore more important to young people, than the long-term health consequences of tobacco use. W Economically, smoking is an expensive activity. As a daily habit, smoking or chewing tobacco represents a high opportunity cost for young people. At anywhere between $3 and $5 per pack of cigarettes, smoking represents a great deal of foregone savings or purchases of other goods, entertainment or services.

What efforts have been made to change the acceptance of tobacco in our culture? What can we do in the future? The rising prominence of tobacco use in this and other countries has been accompanied by movements that seek to control or restrict this behavior. Some of these earliest movements were based on “moral” or “hygienic” concerns. By the mid 20th century, the anti-tobacco effort began to crystallize around the increasing scientific awareness of the health consequences of smoking. This growing awareness provided the impetus for new antitobacco efforts by government, as well as voluntary agencies such as the American Lung Association, the American Cancer Society and the American Heart Association. Today, these groups, together with a host of academic, educational, professional, legal, private and grassroots organizations play a significant role in the struggles to prevent tobacco use; educate the public; regulate tobacco distribution, sales and marketing; demand moral and financial accountability from tobacco companies for the costs of smoking; fight for non-smokers rights to smoke-free air; craft ordinances to limit smoking in public places; examine the marketing practices of tobacco companies worldwide; shed light on the political strategies of this industry; and conduct all of the other activities that have become hallmarks of the international anti-tobacco movement. The anti-tobacco movement has become a significant force for change. Its efforts have contributed to a reduction in tobacco use in our country and other industrialized nations, and steps are being taken to ensure international cooperation in tobacco control efforts. The World Health Organization's (WHO) Framework Convention for Tobacco Control, is a pioneering example of such cooperation. It provides a framework for nations to work, and work together, to contain the rapidly spreading tobacco epidemic. What has been learned to date suggests that no single approach can, alone, solve the tobacco control problem. Diverse approaches are needed, and comprehensive programs that include multiple strategies seem to have the greatest impact. Economic approaches, such as increasing the cost of cigarettes, are seen as key to tobacco control. Research indicates that for every increase of 10%

Introduction 7

Introduction for Teachers

1964 Surgeon General’s Report Broadcast advertising ban

U.S. entry into WWII

Number of cigarettes

U.S. entry into WWI

1998 Master Settlement Agreement Fairness Doctrine requires free time for antitobacco ads

First modern reports link smoking and cancer Great Depression

Federal cigarette tax doubles

Non-Smokers’ Rights Movement begins

Year Figure 2. Adult per capita cigarette consumption and major smoking and health events, United States, 1900-1999

in the cost of cigarettes there is a decline of about 4% in tobacco use, and that this impact is greatest among young people. Increasing the tax on tobacco products is one way to increase their cost. However, the average price of cigarettes and the average cigarette excise tax in this country are well below those in most other industrialized countries. The taxes on smokeless tobacco products are well below those on cigarettes. Other economic approaches relate to efforts to reduce the supply of cigarettes, such as by removing price supports, ensuring that our trade policies discourage—not encourage—the exporting of tobacco products to other countries, and by establishing and enforcing laws that prevent the smuggling of cigarettes. Efforts to limit tobacco industry advertising and promotion have been attempted since the 1960s. In 1965, general health warnings were placed on cigarette packages. While seen at the time as an important step forward, placement of these weak messages in fact prevented any further federal, state or local requirements for health messages. The enactment of the Comprehensive Smoking Education Act of 1984 (Public Law 98-474) required four rotating warnings on cigarette packages, but failed to adopt other Federal Trade Communication (FTC) recommendations for stronger messages on packages. Far stronger messages, including visual images, have been enacted in other nations, such as Canada and Brazil.

In another attempt to control advertising, successful court action in 1969 invoked the Fairness Doctrine to require broadcast media to air antitobacco advertising (at no charge) to counter the paid tobacco advertising on television and radio. Evidence suggests that the anti-tobacco advertisements had considerable impact on the public's view of cigarettes that alarmed the industry. In 1971, the tobacco industry agreed to a ban on the advertising of tobacco products on broadcast media, in part because the legislation also eliminated the Fairness Doctrine requirement that led to the airing of anti-tobacco messages. Although this agreement was hailed as an important step forward for tobacco control, evidence suggests that it did little to reduce the advertising and marketing efforts of tobacco companies. Tobacco companies dramatically increased their print and “point of purchase” advertising; placement of tobacco products in movies; the use of promotional logo and brand name items; sponsorship of cultural, sports, and other events; as well as political contributions to seek less restrictive legislation on tobacco production, sales and marketing activities. The growing body of evidence about the health effects of environmental tobacco smoke exposure for children and adults has led to widespread clean indoor air regulation since the 1970s. Grassroots action by non-smokers has played a vital role in the passage of laws, policies and rules that,

Introduction 8

Introduction for Teachers

today, limit—and in many instances entirely eliminate—smoking and exposure to ambient smoke in many settings. These include government offices, public places, eating (and drinking) establishments, work sites, military establishments, and domestic and many international airline flights. Anti-tobacco activists continue work towards increasing this regulation in indoor and outdoor settings, and in encouraging smokers to make their homes and cars “smoke free.” Restricting the access of minors to tobacco products has widespread approval. All states prohibit sales or distribution of tobacco to minors, and recent advances have limited where vending machines selling cigarettes can be placed, to reduce the likelihood that they will be used by children or teenagers. However, it is not clear that young people have difficulty in obtaining tobacco products, and efforts continue to be made to ensure that local ordinances are in place and vigorously enforced. Significant steps have been taken to help people manage their nicotine addiction. These have included developing and disseminating self-help materials, and strategies that can be used by physicians, nurses, dentists, and other health care providers to assist their patients in quitting. Strides have been made in developing effective pharmacologic interventions, such as, for example, nicotine replacement products. Past and current efforts have also focused on developing products that result in “harm reduction” for tobacco users who do not quit. Encouraging cessation is an important element of prevention. As smokers and other tobacco users quit, the health and other consequences of tobacco use decline. As more and more people enter the ranks of those who don't smoke or use smokeless tobacco, acceptance of tobacco use in the community begins to decline, as well. Norms begin to change. Since the 1950s, people have been suing the tobacco companies, using several different private litigation strategies. In 1998 a Master Settlement Agreement was negotiated by the tobacco industry with 46 states and the District of Columbia, five commonwealths and territories. (The four remaining states had already successfully sued the industry.) In exchange for relief from some types of litigation, the tobacco companies paid a large sum of money, and agreed to change aspects of its past practices, such as placement of tobacco products in movies and advertising targeting young people. The tobacco companies were also

required to fund the American Legacy Foundation which has pursued tobacco prevention via its Truth campaign, support of research, and other activities. The hope that states would use funds they received in the Settlement to further support anti-tobacco programming has not, for the most part, been realized. It is not clear how dramatically tobacco industry activities have changed. Litigation continues to the present. Finally, the anti-tobacco movement has sought to “get the word out”—to educate the public not only about the health and other consequences of tobacco use, but also about the activities of the tobacco industry. Learning about the industry from its own internal documents, made available from industry “insiders” and through litigation, has been an important part of this process. Mass media campaigns have played an important role, as well. The goal of changing adult culture, norms and behavior has been central to these and other tobacco control efforts. So too has working with children to prevent the uptake of tobacco use in the first place. And, as is so often the case when it comes to children, this has brought anti-tobacco activists and researchers to the school-house door. What efforts have been made to bring tobacco prevention to schools? School-based efforts to encourage young people not to smoke began in the 1960s. The earliest programs were based on an Information-Deficit Model. These programs assumed that young people did not know or fully understand the dangers of smoking, and if they did, they would choose not to smoke. Unfortunately, these programs, which were geared to providing information about the health consequences of tobacco use, did not work. They failed to consider the complex link between knowledge and behavior, that young people would not consider health consequences that might occur sometime in the future as relevant to their lives, the role of environmental and individual forces and factors in tobacco use, and the role of addiction. To address the limitations of this approach, during the 1970s researchers shifted their focus to developing and testing programs based on an Affective Education Model. These programs reflected the observation that the use of cigarettes was associated with negative or antisocial patterns of adolescent behavior. Educators concluded that these patterns—and in turn behaviors such as smoking—

Introduction 9

Introduction for Teachers reflected reduced levels of perceived self-worth and poor attitudes toward family, school and community. Affective Education Model prevention programs focused on clarifying values, building self-esteem and a sense of self-worth, and teaching general skills such as assertiveness, communication, and problem solving. While these programs did not work either—indeed, in some instances the concern was that they even generated interest in the behaviors they were attempting to discourage—one positive outcome was that researchers began to pay more attention to exploring why young people smoke. They also recognized that no program would work without addressing the underlying reasons for this behavior. A third approach to prevention, known as the Social influences Resistance Model, evolved in the 1980s. These programs drew on previous efforts and on the unfolding understanding of the complex issues involved in tobacco use by young people, while focus on recognizing, managing, and resisting the social influences that encourage tobacco use. These programs emphasize not only the impact of factors in the immediate environment—the role of peers and friends, siblings and parents—but also the influence of the wider community and culture, including the mass media and tobacco industry marketing. It is also considered important that students develop an understanding of the norms regarding tobacco use—that most people, including most young people, don’t smoke regularly and that smoking is increasingly looked upon negatively by many people of all ages. Insight into the addiction process, the short and long-term consequences of tobacco use, and the process of cessation are often included. Anti-tobacco education continues to be a “work in progress.” While we continue to do research and to learn, we know that: ✷

✷

The peak years for ﬁrst trying to smoke are the sixth and seventh grades, between the ages of 11 and 12, with a considerable number of young people starting earlier. Therefore, prevention programs in school need to be initiated in middle school or even earlier) and should be continued throughout the high school years. Beginning in high school is too late. The effectiveness of programs is dose related. A greater number of educational contacts over a longer period of time yield larger and more enduring smoking prevention effects.

✷

School programs are more effective when they are part of a broader, community strategy, when mass media elements are included, and when family members are involved.

✷

While some kinds of information may not be useful in tobacco prevention—such as a focus on long term health consequences using scare tactics—information about the tobacco industry’s inﬂuence and about secondhand smoke exposure seems to be important to young people.

✷

The impact of social inﬂuence programs does not seem to be reduced when these programs include more than tobacco—for example, when these programs seek to address other substance use behaviors often linked in the behavioral development of young people.

✷

Various personnel—staff, students—have successfully delivered these programs. These programs have been successful in urban, suburban and rural schools serving diverse populations.

✷

For school programming to be effective it needs to include tobacco-free policies involving faculty, staff, and students and relating to all school facilities, property, vehicles and events.

✷

Special programs—guest speakers, special events—cannot be substituted for repeated, intensive, focused classroom programming.

Can self-esteem, the ability to make healthful decisions, the skills needed to resist peer and other pressures be taught? Can they be taught in a few sessions in a tobacco-related curriculum? Is the school the best place to convey these important lessons? These are not easy questions and we do not minimize the challenges. But evidence suggests that intensive, sustained school-based programming can make a difference. Why tailor a program to Deaf/Hard-of-Hearing youth? We have sought to develop a tobacco prevention curriculum for Deaf children and adolescents that can help to ensure that these youngsters grow up to be “smoke free.” Our program incorporates what is today known regarding effective anti-tobacco

Introduction 10

Introduction for Teachers education. It is the first-ever effort of its kind to provide Deaf youth with a comprehensive tobacco-prevention program that is tailored to their cultural and linguistic needs. We developed this program because we are committed to the belief that the ongoing effort to reduce and eliminate tobacco use among young people needs to reach all youngsters.

place in some Deaf/Hard-of-Hearing educational settings. We recognize that tobacco use is only one of many extremely important health issues that need to be included, where possible, in what is an already full academic curriculum. To address this issue we have sought to take steps to organize our curriculum in ways that can facilitate its usefulness and place a minimal burden on the school staff.

We also believe that Deaf youngsters are at risk for tobacco use. We know that children and adolescents that struggle with issues of social acceptance and self-esteem, who experience communication barriers, and who face difficulties when it comes to school performance, are at great risk for tobacco use and other risk taking behavior. We recognize that Deaf youth often face these and other challenges. Data regarding tobacco use among Deaf youngsters is sparse. But in a survey we conducted among over 400 Deaf/Hard-ofHearing high school and college students in California, we found that there is considerable experimentation with cigarette smoking in this population. Among the 226 high school participants in our study, 45% reported ever having smoked cigarettes. The rate was 65% among the 241 college students we interviewed. Anecdotal reports from educators, community agencies, and health care providers confirm that tobacco use is a problem among Deaf/Hard-of-Hearing youngsters.

How is our curriculum organized?

In seeking to craft our program we have called on the expertise of educators with long experience in Deaf education and in curriculum building for this population, as well as on researchers in the field of tobacco prevention and control.

However, we also recognize that these are overarching themes and the way they are approached should vary for students of different ages. In recognizing that material should not simply be repeated from year to year we therefore propose a variety of examples and different projects and activities. We also make recommendations in each module that can assist faculty in choosing themes and topics for classroom discussions and activities that make best sense in diverse settings, and, in particular, where student requirements vary, even at a single grade level.

We have adopted a Social Influences Resistance Model approach to the particular needs of this student population, ensuring that all aspects of the program are appropriate and meaningful for Deaf youth, with varying needs, at each grade level. We have sought to utilize many visual aids and illustrations. We have emphasized hands-on activities. In some instances we have included a greater focus on “information”—for example the health consequences of tobacco use—than would likely be provided to hearing youth. We do this because experts in education for this population have emphasized to us that Deaf/Hard-of-Hearing youth may lack access to this information through the incidental health communication that reaches hearing young people via mass media and in the doctors office. This focus on the health implications of tobacco use is certainly not a substitute for other key elements of the program. We utilize the D.A.R.E. resistance framework because of its

We have established basic themes which we address at every grade level. These include: Self-esteem and self-concept The influence of friends and peers Decision-making The influence of tobacco industry marketing The health effects of tobacco use The addiction cycle Anti-tobacco efforts and social action We take the approach of returning to these themes at each grade level. We do so because we believe that these are basic issues that deserve to be revisited throughout the middle and senior high school years. We also recognize that students may not be exposed to six years of programming and thus “depending” on prior introduction of material in previous years would not be appropriate.

We have had as a guiding principal the view that this curriculum can be utilized—in whole or part—in a range of educational environments. It can be implemented in residential programming, in a classroom in a Deaf school, or in a mainstream setting. There are modules that can be used in teaching math, science, social studies and other subjects. They can be utilized in a self-contained classroom or as part of a school-wide effort. Elements of the program—or the program as a whole—can be introduced on a “stand alone” basis. Or tobacco prevention can be incorporated into educational programming that targets Introduction 11

Introduction for Teachers

How the Lessons are Organized Topic

5th

Self-Esteem and Self-Concept

5-1

Friends and Peers

5-2

Decision Making

Grade Level

7th

8th

9th

10th

11th

12th

7-1

8-1

9-1

10-1

11-1

12-1

7-2

8-2

9-2

5-3 5-4

7-3 7-4

8-3

10-3

11-2

12-2

Media and Other Inﬂuences to Use Tobacco

5-3 5-4

7-6 7-7

8-5

9-3

Resisting Inﬂuences to Use Tobacco

5-5

8-4

9-7

8-6

9-4

8-7

Health Effects of Tobacco Use

6th

6-1 6-2

6-3 6-4

Addiction

Anti-Tobacco Efforts and Social Action

diverse risk taking behaviors that are of critical importance to young people today and that are certainly of concern among educators of Deaf youth—other substance use, AIDS education, safe sex and more. We have sought to create a “user friendly” tobacco prevention curriculum that teachers can integrate into their work without having to do additional research or to search for other materials. The curriculum for each grade level has a cover sheet that lists needed materials and preparations for each lesson. Using the curriculum will require some advance planning. For example, you may need to contact a speaker or arrange for equipment. Most

7-5

10-2

12-5

11-7

12-6

10-4

11-3

12-3

9-5

10-5

11-4

12-4

9-6

10-6 10-7

11-5 11-6

12-7

materials and all the worksheets for the students are provided on the accompanying CD, but you may have to make copies or transparencies, or adapt materials for use with technologies such as the SmartBoard. All of the images used throughout are also included on the CD as digital ﬁles, and can be inserted into documents or PowerPoint slides as needed. Homework assignments may also be completed as classroom activities. To minimize the burden on faculty we have not included detailed references to the extensive body of tobacco-related research that serves as the framework for this program. However, we realize that teachers may seek more information, or may want to direct students to the resources available in this ﬁeld. With this in Introduction 12

Introduction for Teachers mind we have provided a brief list of references as a starting point. We would be pleased to provide additional references, citations, and materials. Please contact us at: Debra S. Guthmann, Ed.D. California School for the Deaf, Fremont dguthmann@csdf-cde.ca.gov (510) 794-3684 Barbara Berman, Ph.D. Division of Cancer Prevention and Control Research UCLA School of Public Health and Jonsson Comprehensive Cancer Center bberman@ucla.edu (310) 794-9283 A Word about Smoking Cessation It used to be thought that smoking cessation was only an adult issue. We now know better. Many young people who start to smoke want to quit, but ﬁnd that they have become addicted tobacco users and that it is hard to stop. Important strides have been made in identifying cessation strategies that are effective among young people. Dissemination—getting these programs to the teenagers that need them—is a challenge that needs to be faced. Providing school-based cessation programming for these children and teenagers is one of the critically important ways in which this can be done. While we introduce cessation in Lesson 12-6, provision of a cessation program is beyond the scope of this prevention curriculum. We encourage educators and health care providers serving Deaf and Hard-of-Hearing youth to recognize the importance of such programming, and to seek ways to provide this vital service for their students. Contacting local and State Health Departments and

the Centers for Disease Control and Prevention (CDC) is one way to begin. So too is contacting local chapters of voluntary agencies such as the American Cancer Society, the American Heart Association, and the American Lung Association. For example, the ALA currently has two evaluated cessation programs for young people—NOT-ONTOBACCO® and Tobacco-Free-Teens® that can be adapted for use among Deaf/Hard-of-Hearing students. Evaluation of the Curriculum We developed and evaluated our curriculum through a research project funded by the State of California Tobacco-Related Diseases Research Program. As part of this research effort we asked a group of skilled teachers of Deaf/Hard-of-Hearing young people to help us draft the curriculum. We then asked educators at two Schools for the Deaf to adopt our curriculum, put it to use, adapt the content as necessary, and to share with us their experiences. We asked these teachers to help us understand if the program was useful, what parts of the curriculum “made sense” in the setting in which they teach, and what advice they would give to other educators seeking to use this as a learning tool. What did we learn? Our curriculum received praise. Over 75% of the faculty evaluating speciﬁc elements of the program rated both the content of the curriculum and suggested classroom activities as “excellent.” Over 80% described the ease of use, appropriateness for grade level, and appropriateness for deaf youth as “excellent.” Other comments regarding speciﬁc aspects of the curriculum are on the pages that follow.

Introduction 13

Introduction for Teachers The curriculum provided useful tools, and was well-organized and well laid-out for demonstrating the concepts of tobacco use and prevention. “There is plenty in the curriculum. Nothing needs to be added. The content is good…” “Curriculum was WOW, very beneﬁcial!” “I was dazzled by the curriculum, the color, [and] the pictures. It is very user friendly.” “It’s easy to follow and easy to use.” “The [curriculum] allowed for great ﬂexibility for me to go to different grade levels to get information and activities that I needed.”

The emphasis on graphic and visual elements was seen as very valuable. “The graphics provided for this lesson are great! I’ve used them all.” (10-2) “This lesson is one of my favorites. It is very visually ‘impactive’ with a lot of good graphics.” (10-4) “Pictures are worth a thousand words…this generated discussion.” (11-3) “The picture and articles with information were powerful and students were responsive to them.” (12-3) “Students loved the pictures.” (12-5) “Visual activities worked for both high and low functioning students.”

Speciﬁc lessons and content elements were described as particularly valuable and appropriate for the students. “Advertisements were good visuals for both higher level class as well as lower level classes.” (9-3) “(I) used the journal idea to create class discussion.” (7-7) “The stat(istics) help to make points.” (7-7) “Students really liked the interview process.” (12-4) “Kids with good language skills really enjoyed the “Lights, Camera, Action” activity.” (8-3) “Students liked the role play.” (8-3) “The students really enjoyed refusal skills roulette.” (8-4) “Tobacco ads on CD were very helpful. They loved interviewing the staff.” (8-5) “The class can beneﬁt from this content.” (9-1) “They liked the inventory list and ‘What’s My Line.’”(9-1) “Vocabulary words were helpful. (The) DARE worksheet was good. Not everyone remembers DARE. (I) had to review (it).” (11-2)

Introduction 14

Introduction for Teachers The teachers who used the curriculum felt that it did a good job of conveying the risks of tobacco use, the activities of the tobacco industry, and other important tobacco-related issues – of teaching the subject matter. “Students talked about family member smoking in home or car, and asked what to do about the situation. Good lesson to introduce myths of smoking, and how smoking is often viewed by young people.” (7-4) “The notion of (the) ‘smoking is cool’ activity is great. It made students think what the advertisement is trying to portray.” (7-7) “Students were surprised at the variety of tobacco products. They would not have recognized them.” (8-5) “Students enjoyed making anti-smoking advertisements.” (They) made antismoking advertisements that we thought Deaf might like.” (9-7) “The graphic of (the) addiction cycle in this lesson was a great asset to have. I liked the list of withdrawal symptoms. It was good to repeat the point of why young people start smoking.” (10-5) “Excellent coverage on how tobacco can affect many parts of the body.” (12-3) “It was helpful to break down the topic on addiction such as cycle, withdrawal, etc.” (12-4) “Students related to quitting smoking and the activity trying to quit. They were also interested in ﬁnding info from school and surveying our own students.” (12-6) “Students don’t often get to see anti-tobacco messages, so this is a good time and place to show them the messages.” (12-7)

The curriculum was praised for the ways in which it generated good discussions and created learning opportunities in areas well beyond tobacco education. “This is an excellent starter topic, and helps students see their own strengths.” (7-1) “(The lesson) helped students consider ‘sensitive issues’, e.g., family smoking and what students can do (about it)” (7-4) (7-6) “The information on the addiction cycle was used in another situation, especially about drugs. The lessons are worthwhile to repeat for each grade level.” “Teachers used the curriculum as a jumping off point for the more meaty discussions.” “Students liked to share their life-experience stories.” “Also useful were problem-solving discussions to talk about how to deal with difficult issues faced by students. i.e., what to do when you are ‘stuck’ with parents who smoke in the house.” “Lots of sharing and reflecting…Reflection is a big part of retention and education. Reflection is the top of the educational pyramid. If they can reflect and share opinions that is the top.” “(This lesson) elicits good discussion among those with good communication skills.” “Discussing different consequences… helped students to get the big picture and see the future.” (8-6) “We had a good discussion on friendship.” (7-2) “My lower level class discussions were less productive but still got the point.” (10-1)

Introduction 15

Introduction for Teachers

We also received some constructive criticism and were informed of way that educators enhanced or could enhance the curriculum. Changes were made or suggested to maximize the value of the planned activities: “I used other sources and added what I needed.” “Emphasis could be made on refusal skills because tobacco could be a gateway to other risky behavior.” In a number of instances homework and individual assignments were done together as a classroom activity. “Instead of doing the warning label worksheet (designed as an individual activity), we did the activity as a whole class. Students would come up with ideas of how warning labels should be.” (7-5) “Students designed their own warning label to place on cigarette boxes.”

To ensure non-threatening content and student safety… “Rather than ask students about their own characteristics, “I think I’d like to hand out inventories/”What’s My Line” that are ﬁlled in (for) a ﬁctional person and (which can then) generate a discussion on how this person can improve selfesteem.” (9-1)

To enhance communication… “(It is) difﬁcult to express in written form. (I) did it through the air.” (8-2) “I made a Power Point (presentation for the lesson).” (8-2). “used the journal idea to create class discussion.” (8-3). “needed to explain the sarcasm behind the pictures.” (9-7) “A Power Point presentation was developed for each lesson making the class more visually impacting. That helped [keep] the students’ attention. Some students like to see the information in English, which was presented on the screen.” (Praised the lesson but added) “I used Microsoft Galley Clib of ﬁsh and hook to illustrate my point of getting hooked and addiction…” (10-5). “(I) want to try digital camera to generate images of emotion and have students generate (through pictures) things that make them feel this way.“ (9-1) One teacher put together pictures of different physical systems (respiratory, nervous, skeleton, muscular, etc.) and showed how smoking may have affected each system. The values of cigarettes in the 1980’s were not used because students could not relate to that period of time. So, the teacher obtained a catalog from Toys R Us and had the students compare the current value

of cigarettes to different products from that store. It was suggested that experiential speakers be invited to take part and to discuss ways to stop smoking. Teachers sharing their own experiences would also be helpful. Teachers need to capitalize on other technologies such as the board maker and V-Com’s CD’s with signs in .gif and .mov formats.

Introduction 16

Introduction for Teachers To maximize the value of lessons for students at varying skill levels… “Levels of function were sometimes low so I used various grade levels in the curriculum and made modifications.” “For 9th grade, many of the kids can’t read so I used various grade levels in the curriculum and signed information in ASL.” “Facts are easier to teach to children with learning difficulties than abstract concepts such as feelings and self-esteem.” “Students could not initiate/identify each tool. I role played each with the word as a demonstration…(and) only show two tools at a time. (I) let them pick one.” (9-1) “Homework…(was) appropriate for advanced students.” (11-1) “Matching, scrabble words, word search, and spelling worksheets are best for special needs.” (11-3) “Replace some definitions with …pictures.” (11-4) “I had to bring everything down a few levels to help them understand.”

Reﬂecting on the 8th grade curriculum she taught, one teacher indicated that “it may be better to do the self-esteem [and other early lessons] after the content lessons. The content lessons were more of a “hook” for the students.” Also, the suggestion was

made that the self-esteem and decision making lessons be embedded into the other content lessons, that counselors be invited to co-teach and help out with the self esteem lessons, and that self-esteem be included as an important theme in all levels.

Educators expressed that effectiveness relies on preparing in advance and sharing successful adaptations with colleagues … “The curriculum should allow for and communicate that teacher discretion is the key in terms of content and order of presentation.” “The goal for next year is to break the lessons down more, and do different lessons in different classrooms. Some of the lessons may be appropriate in reading class, i.e. media. Some of the lessons on different body systems may be well taken in biology/science class.”

We will further evaluate the impact of our program through survey data collected among students and faculty, including faculty plans for providing tobacco education programming in the future. This information will be published in the research literature and communicated to educators serving Deaf/Hard-ofHearing youth.

We welcome comments from educators who adopt this curriculum. Please contact Dr. Debra S. Guthmann at: Dguthmann@csdf-cde.ca.gov for more information about where to obtain a copy of this curriculum at no cost. We thank you for your help and support in this effort!

Introduction 17

Additional Resources for Teachers

Additional Resources: You can use the following resources to obtain additional information about the issues of tobacco use prevention and youth. They can also be ideal sources for students who are interested in conducting additional research, or who may want to become involved in the anti-tobacco movement in their school or community.

The Centers for Disease Control and Prevention The Centers for Disease Control and Prevention is the lead federal agency for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States. The CDC maintains the following resources for educators and students:

Tobacco Information and Prevention Source (TIPS) www.cdc.gov/tobacco/index.htm

An excellent resource for tobacco-related information that is ideal for educators and students.

Healthy Schools Healthy Youth!

http://www.cdc.gov/HealthyYouth/index.htm A resource for schools and educators that presents the latest information on school-based health education for youth.

Local Voluntary Organizations The following are all nationwide, community-based voluntary organizations that, as one part of their overall mission, engage in tobacco-related research, education, patient service and advocacy. All maintain local community offices that can be valuable resources in providing printed materials, or access to networks of volunteers who can present educational programs for schools and community groups. They can also make referrals to community-based programs addressing such issues as smoking cessation. Access the organizations, and find your local community office, at the following online addresses: The American Cancer Society at www.cancer.org The American Heart Association at www.americanheart.org The American Lung Association at www.lungusa.org

Local and State Departments of Health Contact your local and State Health Department to identify who is responsible for tobacco-related education. Most departments of health maintain websites that can be accessed through on-line search engines such as Google at www.google.com.

Resources 18

Additional Resources for Teachers

Reports of the Surgeon General www.cdc.gov/tobacco/sgr/index.htm

These are excellent, detailed reports on a number of issues relating to tobacco use. In the curriculum we have referred to the following speciﬁc reports, but all of these reports are of great value as well. They are all available at the web address above.

✷ U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Ofﬁce on Smoking and Health, 2004.

✷ U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Ofﬁce on Smoking and Health, 2000.

✷ U.S. Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Ofﬁce on Smoking and Health, 1994.

Non-Proﬁt Advocacy Organizations Many of the following organizations were established to achieve speciﬁc anti-tobacco-related goals, including:

✷ Providing public education about the dangers and societal costs of tobacco use

✷ Advocating for changes in government policies to reduce tobacco use

✷ Exposing activities of the tobacco industry in marketing and extending the sale of tobacco products

✷ Encouraging social action to control and reduce tobacco use ✷ Providing resources for smoking cessation Campaign for Tobacco-Free Kids® www.tobaccofreekids.org

The Campaign for Tobacco-Free Kids is a private, non-proﬁt organization committed to protecting children from tobacco addiction and secondhand smoke.

www.WhyQuit.com WhyQuit is an online forum devoted to providing support for nicotine dependency cessation, and youth dependency prevention.

Resources 19

Additional Resources for Teachers

Non-Proﬁt Advocacy Organizations (continued) The American Legacy Foundation www.americanlegacy.org

The American Legacy Foundation a national, independent public health foundation that develops national programs to address the health effects of tobacco use through grants, technical training and assistance, youth activism, strategic partnerships, counter-marketing and grass roots marketing campaigns, public relations, and community outreach to populations disproportionately affected by the toll of tobacco. The foundation sponsors the following major activities:

✷ The Truth® Campaign www.thetruth.com

The Truth Campaign is a major national tobacco youth prevention and education effort that uses advertising, grassroots and promotional events, and the interactive Web site (www.thetruth.com) to give teens the facts about tobacco use and tobacco marketing and encourage them to get involved in the effort to inform their peers.

✷ Streetheory®

www.streetheory.com Streettheory is a national effort to assist and facilitate the work of the statebased youth activism programs. The web site (www.streetheory.org) provides a central reference tool and repository for youth activists and their ideas for prevention and education.

✷ Circle of Friends: Uniting to be Smoke-Free ww.join-the-circle.org

This program is a national grassroots social movement to support for women struggling to quit smoking, and to highlight the toll of tobacco-related disease on American women, their families and communities.

Americans for Nonsmokers’ Rights www.no-smoke.org

Americans for Nonsmokers’ Rights is the leading national lobbying organization dedicated to nonsmokers’ rights, taking on the tobacco industry at all levels of government to protect nonsmokers from secondhand smoke and youth from tobacco addiction. Their web site (www.no-smoke.org) provides a wealth of information about the dangers of secondhand smoke, and serves as a resource for advocacy efforts to reduce tobacco use and secondhand smoke exposure. The organization also includes the American Nonsmokers’ Rights Foundation, an educational nonproﬁt organization that creates comprehensive programs for school-age youth on issues of smoking prevention and their right to breathe smoke-free air.

Resources 20

Additional Resources for Teachers

Facts and Figures A number of organizations regularly compile statistics on youth tobacco use and make these available to the public on a recurring basis. Other resources include one-time publications whose presentation of information and data are unique and valuable contributions to the discussion on tobacco use and youth.

Monitoring the Future

www.monitoringthefuture.org Monitoring the Future is an ongoing study of the behaviors, attitudes, and values of American secondary school students, college students, and young adults. Each year, a total of some 50,000 8th, 10th and 12th grade students are surveyed (12th graders since 1975, and 8th and 10th graders since 1991.) In addition, annual follow-up questionnaires are mailed to a sample of each graduating class for a number of years after their initial participation. The study is housed in the University of Michigan’s Institute for Social Research, and the research data are made available on their web site (www.monitoringthefuture.org).

The Youth Behavioral Risk Factor Surveillance System www.cdc.gov/HealthyYouth/yrbs/index.htm

The YRBSS was developed in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth and adults in the United States. These behaviors, often established during childhood and early adolescence, include tobacco use, unhealthy dietary behaviors, inadequate physical activity, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases, and unintentional injuries and violence. The youth survey data are available online at www.cdc.gov/healthyyouth/yrbs/index.htm. ✷

Berman BA, Eckhardt EA, Kleiger HB et al. Developing a tobacco survey for Deaf youth. American Annals of the Deaf, 2000; 145(3):245-55)

✷

Campaign for Tobacco-Free Kids. Trust Us, We’re the Tobacco Industry. 2001. Available online at: www.tobaccofreekids.org/campaign/global/framework/docs/TrustUs.pdf

✷

Glantz SA. Tobacco: Biology and Politics. Health EDCO. 1992.

✷

Kluger R. Ashes to Ashes: America’s Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris. New York: Random House, 1996.

✷

Lynch BS, Bonnie RJ., Editors. Growing Up Tobacco Free. Institute of Medicine. National Academy Press, Washington, D.C. 1994.

✷

McKay J, Eriksen M. The Tobacco Atlas. Geneva: World Health Organization. 2002.

✷

Meister K, Bowman KC, Ross GL, et al. (Ed.) Cigarettes: What the Warning Label Doesn’t Tell You. Information Tobacco Companies Don’t Want Teens to Know About the Dangers of Smoking. New York: American Council on Science and Health. 2003. The title can be read or downloaded from the following site: www.acsh.org/publications/pubID.188/pub_detail.asp

Resources 21

10th Grade Lessons:

Needed Materials and Preparations Lesson 10-1

* Worksheet: What Do I Admire?

Lesson 10-2

* Tobacco advertising samples (provided on CD)

Lesson 10-3

* Worksheet: D.A.R.E. Decision-Making Process

Lesson 10-4

* Coffee stirrers (small, hollow straws) for an emphysema demonstration * The ABCs of Smoking Pamphlet and Transparencies * Mechanical Smoker * Journeyworks, Inc. pamphlets: How Tobacco Affects Your Body A Teen's Guide to Facts About Tobacco Smokeless Tobacco: Spit it Out! * What's in Cigarette Smoke? Partial list of chemicals in tobacco * One User's Story: Sean Marsee * Tobacco advertising samples (provided on CD) * The Big Dipper video

Lesson 10-5

* I Don't Want to Use Tobacco Pictionary Cards * One Addict's Story: Bryan Lee Curtis * Graphic: the Addiction Cycle * Worksheet: Reasons for Avoiding or Quitting Tobacco Use Contact your local chapter of the American Cancer Society or the American Lung Association if you need a guest speaker who is a smoker or former smoker.

Lesson 10-6

Internet or Phone Access * Web Addresses Anti-tobacco materials (collected by students from voluntary organizations and the state and local departments of health) * Anti-tobacco warnings for tobacco packaging (Pictures provided) * Journeyworks, Inc. pamphlet: 10 Best Reasons Not to Smoke While You're pregnant

Lesson 10-7

* Worksheet: The Facts About Smoking in Public Places

* These materials are included in the supply kit that accompanies

this curriculum, or in the case of handouts and worksheets, as PDF files on the accompanying CD. The PDF format should allow you to print the files directly from computer to printer, or you can print a single copy and make duplicates for your class.

10th Grade Lessons Materials List

Lesson 10-1

Self-Esteem: How Does It Shape Our Choices? Introduction: This lesson introduces students to the concepts of self-esteem and self-concept, and their link to behaviors and choices. Together with Lesson 10-2, which examines friends and peer relationships, this material provides students with basic tools for analyzing and making decisions, including those concerning tobacco use.

Lesson Objectives: By the end of Lesson 10-1, students will: W

Define the concepts of self-image and selfesteem

Understand how self-esteem may impact how they relate to different emotional states, such as stress or depression

Understand how self-esteem and self-concept often color the behavioral choices we make

See how they can use their understanding of self-esteem to make better decisions

Identify ways in which they can enhance their self-esteem

Plan Ahead! Lesson 10-6 asks students to access communitybased resources to assess existing anti-tobacco efforts, and to consider how they might design a similar effort to reach the Deaf. Many of these resources are available online, and we have provided web page addresses (see Lesson 10-6) that can serve as starting points. If appropriate, you may wish to assign certain web sites to groups of students to explore and present to the class, or the searching can be done as a class exercise. This contact should begin as early as possible to allow students to collect various anti-tobacco education materials. These should be available to students by the time they reach Lesson 10-6.

Materials: W

What Do I Admire? Worksheet

Key Terms: self-esteem: belief in one's worth; self respect; the value you place on yourself.

Page 10.1.1

Lesson 10-1: Self-Esteem:

How Does It Shape Our Choices?

Procedures: 1.

Initiate a discussion of self-esteem by asking the following: W

What is self-esteem? What do we mean by someone having high selfesteem? Low self-esteem? What are the characteristics of someone who has high self-esteem? Low self-esteem?

Ask students: W

Does your self-esteem change according to your surroundings, e.g., when you are with your Deaf friends, or when you are with hearing friends? When you are here on campus, or when you are at the local shopping mall? Do you think you behave differently in these situations? In what ways?

In what ways do you think self-esteem is related to how someone acts when confronted with: k Making new Deaf friends k Making new hearing friends k Meeting Deaf people for the first time k Meeting hearing people for the first time k Dealing with bullying or teasing

Teacherâ&#x20AC;&#x2122;s Note: You can pose these situations at the left in terms of a person who has high self-esteem and then one who has low selfesteem.

k Joining a school club k Going to a party where people are smoking and drinking k Being asked by friends to smoke a joint/marijuana cigarette k Being asked by friends to help them buy cigarettes

Make sure that students understand that self-esteem can be important in shaping people's responses to the above situations. Point out how higher self-esteem can sometimes be a protective mechanism, helping people to deal with stress or depression, or to avoid potentially harmful behaviors such as drinking, smoking or taking drugs.

Ask students: W

Are there instances where too much self-esteem may get one in trouble? For example, what if someone thinks they are invincible, or that their own opinions are always the best ones? What about people who are overly selfcentered or selfish?

Page 10.1.2

Lesson 10-1:

Self-Esteem: How Does It Shape Our Choices?

Procedures: (continued) 4.

Distribute the What Do I Admire? worksheet. Lead students through the exercise. From the list below (and on the worksheet), have students choose the seven qualities that they most admire in people their age: ____ Intelligent/Smart ____ Attractive/good-looking ____ Athletic/strong/good at sports ____ Artistic/talented/creative ____ Leader/someone that others look up to ____ Popular ____ Friendly/likeable ____ Kind/caring/sensitive/considerate of othersâ&#x20AC;&#x2122; feelings ____ Good sense of humor ____ Fun to be around ____ Has nice things/has money to spend ____ Doesn't worry about what others say ____ Tough/doesn't let others push them around ____ Respects teachers/parents ____ Dresses well/nice clothes/nice appearance ____ Calm and steady personality ____ Wacky and crazy ____ Not afraid to try new things ____ Knows what they want ____ Relaxed and easy-going Have students write these seven items in the appropriate spaces on the worksheet. Explain that these characteristics are ones we would most likely want to see in ourselves. Have the students rate on the accompanying scales the extent to which they think these traits apply to themselves. Explain to the students that their ratings are a quick picture of how they see themselves against a list of characteristics that they admire. Identifying differences between their current behaviors and thinking and the characteristics they think are ideal can be a start toward making positive changes. For example: W

I would like to be smarter and get better grades in school. 1. I can seek out more help from my classmates; communicate better with my teachers; or change my study habits so that I have more time to study. These choices would move me farther to the right on my scale, and closer to my ideal.

Page 10.1.3

Lesson 10-1:

Self-Esteem: How Does It Shape Our Choices?

Procedures: (continued) 2.

I could choose to be a little less critical about my academic performance. Perhaps I can recognize that although I struggle a bit in math, I actually do pretty well in science or art. Recognizing these strong points can help me to feel better about my overall academic performance.

Homework: For each of the items on their lists, have students draft a plan or set of goals for resolving the difference between how they see themselves and what they consider ideal; the way they would like to be.

Page 10.1.4

Lesson 10-1 Worksheet: What Do I Admire?

Name __________________________________

What Do I Admire? Step One:

From the following list, mark with an the seven characteristics or traits that you most admire in other people your age.

___ Intelligent, smart ___ Attractive, good-looking ___ Athletic, strong, good at sports ___ Artistic, talented, creative ___ Leader, someone that others look up to ___ Popular, well-liked by others ___ Friendly ___ Kind and caring, sensitive, considerate of others’ feelings ___ Good sense of humor ___ Fun to be around ___ Has nice things, has money to spend ___ Doesn’t worry about what others say ___ Tough, doesn’t let others push them around ___ Respects teachers and parents ___ Dresses well, wears nice clothes, has a nice appearance ___ Calm and steady personality ___ Exciting and energetic personality ___ Not afraid to try new things ___ Knows what they want, a go-getter ___ Relaxed and easy-going

Lesson 10-1 Worksheet: What Do I Admire?

What Do I Admire? Step Two: Write your seven items from the previous page into the spaces below. Mark on the accompanying scale how well each characteristic describes yourself.

Characteristic or Trait #1

Characteristic or Trait #2

Characteristic or Trait #3

Characteristic or Trait #4

Characteristic or Trait #5

Characteristic or Trait #6

Characteristic or Trait #7

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

This characteristic doesn’t describe me at all

This characteristic describes me well

Lesson 10-2

Why Tobacco? Introduction: This lesson asks students to examine many of the reasons why young people try smoking, including those directed at social relationships (friend and peer pressure) and affective changes (to deal with depression, boredom, or spur excitement); and the role of advertising and marketing in influencing how young people view smoking.

Lesson Objectives: By the end of Lesson 10-2, students will: W

Identify factors that encourage young Deaf people to use tobacco: self-esteem issues (including the desires to "look cool," "appear more mature," etc.); peer pressure (including the need to "fit in"); stress and depression; marketing efforts of tobacco companies; media images.

Recognize tobacco marketing strategies and their appeal

Materials: W

Tobacco advertising samples (provided on CD)

Key Terms: media: TV, radio, newspapers and other forms of mass communication restrictions: Laws and rules limiting a particular behavior billboards: Large outdoor signs used in advertising target marketing: Marketing that is geared to a particular group; for example, youth or a particular ethnic group

Page 10.2.1

Lesson 10-2: Why

Tobacco?

Procedures: 1.

Ask students to list all of the possible reasons they can think of that young people decide to smoke. Write these reasons on the board. These might include: W

curiosity or boredom: What is smoking all about? What is it like?

lack of knowledge about smoking: I didn't know smoking can harm my body, I didn't think I'd become addicted. W

L102_curious

friends' behavior: My friends were trying smoking, and I just went along. L102_FriendsDoIt

L102_Ignorance

family environment: My mom and dad both smoke, and my grandparents too.

relieve stress or depression: I found out that when I was feeling anxious,

L102_FamilySmokes

stressed or depressed, a cigarette helped calm me down or helped make me feel better.

to look older,

L102_Relax

more mature, cooler W

to be rebellious

L102_CoolGuy L102_Rebel

to fit in

L102_FitIn

Page 10.2.2

Lesson 10-2:

Why Tobacco?

Procedures: (continued) 2.

Examine friends' behavior. Ask the class to what extent they believe the behavior of their friends affects their own behaviors.

Ask students: W

Do you tend to think similarly to your friends? In what ways? Do you think you tend to make similar choices, for example, with respect to they type of clothing you wear, the music you

Teacher’s Note: Peer influence and peer pressure have been discussed in prior lessons 8-2 and 9-2. If your students have not been exposed to these lessons, you may want to review these important influences on tobacco use in this lesson.

listen to, and other choices you make? Do you think you tend to choose to behave in similar ways to how your friends behave? Point out that with respect to smoking, young people are much more likely to start smoking if their five best friends smoke.

Ask students: W

Why do you think this is so? When it comes to your own group of friends, how easy do you think it would be to resist smoking if your friends all smoked? Would you feel funny asking them not to smoke? What if your friends wanted to try smoking? How would you react? What would you say? How do you think you could avoid smoking in such a situation?

Teacher’s Note: Point out to your students how their own attitudes towards tobacco use may be profoundly shaped by what they see: W if their parents smoke to reduce stress; W if they smoke to relax or enjoy a meal; W if they smoke to be sociable or have fun; OR: W if they’ve seen a parent ill from smoking; W if their parents’ smoking makes the home smell bad; W if there are arguments in the home about smoking, etc.

Examine family environment. Ask the class how many students have family members-parents, grandparents, siblings, other relatives-who smoke. Explain that research has also shown that those who grow up with family members who smoke are more likely to become smokers themselves than those who grow up in non-smoking families.

Ask students: W

Why do you think this is so? How do you think it would affect your own attitudes towards smoking if someone in your family smoked? Might growing up in a smoking household discourage smoking?

Teacher’s Note: Examine relief of stress or depression: Young people often see smoking as a way to deal with stress or depression. This leads some young people to overlook the harmful effects of smoking.

Point out that while tobacco use may provide some relief of the symptoms of stress or depression (e.g., may make one temporarily feel better), it does little to address the underlying reasons why one feels depressed or stressed.

Page 10.2.3

Lesson 10-2:

Why Tobacco?

Procedures: (continued) Ask students: W

How effective do you think smoking is as a way to deal with stress or depression? What alternate ways can you use to deal with stress and depression? (Physical exercise, a hobby, meeting new people, etc.)

How many of you have friends or family members who smoke to deal with stress? How well do you think it works?

Examine to look cool, more mature. Explain that teens sometimes believe that smoking will improve their image; that smoking can make them appear more mature or “cool.”

Ask students: W

Think of the teens you know who smoke. Do they seem more mature or attractive to you? How many of you think that smoking is attractive? How many would like to date someone who smokes? Marry someone who smokes? Live with someone who smokes? How many of you have been near someone who smokes? How does it make that person smell? What about their breath? Teeth? Fingers?

Given how most people think about smokers and smoking, why do we still continue to see smoking as “glamorous,” “cool,” or “mature?” Write on the board: $11,2000,000,000 (11.2 billion dollars). Explain to students that cigarette companies spent this amount in 2001 to try to get people to smoke. Ask students why the tobacco companies spend such huge sums on advertising. W

To sell more cigarettes

To replace smokers who die each year

To get young people to start buying cigarettes so that they will become life-long customers.

What do they spend this money on? Everyone has probably seen traditional advertising by tobacco companies, such as this Camel Cigarettes magazine advertisement. Why do you think the makers of Camels chose this particular image? Who would it appeal to? L102_JoeCamel

Page 10.2.4

Lesson 10-2:

Why Tobacco?

Procedures: (continued) Tobacco advertising dollars are also used for in-store displays. How many of you have seen displays like these at corner grocery and liquor stores?

L102_InStoreAd

A great deal is also spent on special promotions, such as these mailed dollar-off coupons, giveaways, and purchase points that can be redeemed for other merchandise... L102_KoolRadio

L102_CamelPinups

L102_CapriAd

L102_Giveaway

...as well as on special promotional packaging for their products.

L102_NewportCoupon

Look closely at the Kool display and packaging for their â&#x20AC;&#x153;Soundtrack of the Streetsâ&#x20AC;? promotion. Who is the target of this appeal? What about the Stars packaging, with their flavored cigarettes?

L102_CamelGolf

L102_KoolDisplay

L102_StarsCollage

L102_SalemSlideBox

Page 10.2.5

Lesson 10-2:

Why Tobacco?

Procedures: (continued) Tobacco advertising dollars have also been used to sponsor sporting events, such as the Virgina Slims Tennis Championships, or Formula One racing...

L102_MarlboroRacing L102_Navratilova

...and for a host of promotional items including t-shirts, sports bags, toys, calendars, playing cards, and a multitude of other goods.

L102_CamelCalendar L102_CamelCards

L102_CamelToy

L102_KoolToys

L102_MarlboroBag

L102_CamelShirt

L102_CamelCup

Page 10.2.6

Lesson 10-2:

Why Tobacco?

Procedures: (continued) The tobacco companies have also used â&#x20AC;&#x153;stealthâ&#x20AC;? marketing techniques, producing lifestyle magazines and using them as advertising vehicles. Who do you think these magazines appeal to?

L102_AlecBaldwin L102_AllWoman

L102_KoolMag

Use the visual resources here and those from Lesson 9-3 to review with students the strategies used by companies to sell tobacco to teens. Make sure the students cover the following points:

Fun & Pleasure

Good health

Adventure/Excitement

Money/Fame/Power

Beauty

Acceptance/Popularity

Romance

Brains/Intelligence/Wisdom

Free stuff!

Ask students to identify which of these strategies they are most vulnerable to and why. Ask if any of these approaches are particularly appealing to Deaf young people. Why?

Page 10.2.7

Lesson 10-2:

Why Tobacco?

Procedures: (continued) What kinds of situations do these cigarette advertisements depict? When students see these ads, what kind of ideas to they start to have about smoking? Do you think these advertisements might influence young people’s expectations for smoking? Ask your students to come up with adjectives to describe these scenes: for example, fun, excitement, friendship, exotic.

L102_NewportFun

L102_CamelCasbah