Hands Off Tobacco: 10th Grade Curriculum

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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.

Š2004, 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

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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

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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

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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 use—lung cancer, heart disease, oral cancer, strokes and so forth—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.

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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%

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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,

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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


Self-Esteem and Self-Concept


Friends and Peers


Decision Making

Grade Level
















5-3 5-4

7-3 7-4





Media and Other Influences to Use Tobacco

5-3 5-4

7-6 7-7



Resisting Influences to Use Tobacco







Health Effects of Tobacco Use


6-1 6-2

6-3 6-4


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














10-6 10-7

11-5 11-6


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

Teacher’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 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/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


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


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



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,


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


to look older,


more mature, cooler W

to be rebellious

L102_CoolGuy L102_Rebel


to fit in


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?


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




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


Look closely at the Kool display and packaging for their “Soundtrack of the Streets� promotion. Who is the target of this appeal? What about the Stars packaging, with their flavored cigarettes?





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






Page 10.2.6

Lesson 10-2:

Why Tobacco?

Procedures: (continued) The tobacco companies have also used “stealth� marketing techniques, producing lifestyle magazines and using them as advertising vehicles. Who do you think these magazines appeal to?

L102_AlecBaldwin L102_AllWoman



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














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.



Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org

Then ask students where the idea that “smoking is cool” comes from.

Source: www.trinketsandtrash.org

What about the idea that smoking is relaxing?



Source: www.trinketsandtrash.org

Or that smoking is romantic? Notice the effort to appeal to Spanish-language communities in this advertisement.

Source: www.trinketsandtrash.org

Page 10.2.8

Lesson 10-2:

Why Tobacco?

Procedures: (continued) What about the notion of smoking as being “manly” and “masculine”? How do you think these types of images will influence how teenaged boys will think about smoking? L102_VSlimsAppeal05

What is behind the s marketing of Virginia Slims Cigarettes, using the “You’ve come a long way, baby” tagline? Who is this advertising aimed at? How might it influence how young women think about smoking?


Why do you think some brands of cigarettes are marketed as “men’s” brands, while others are marketed as “women’s brands?” Aren’t cigarettes pretty much all the same?



Facilitate a group discussion of target marketing. Ask students about the places they've seen tobacco promoted: W

You saw an ad for cigarettes on a car racer's outfit. Who watches car races? Who do you think they are trying to reach? How does car


Valuable Resource: One interesting exercise may be to engage your students in “ad busting”—that is, to reveal the reality behind tobacco advertisements. An excellent outline for this exercise can be found at: www.cdc.gov/tobacco/sgr/sgr4kids/adbust.htm

racing affect your perception of smoking, or the type of person who smokes? W

You noticed a cigarette ad on a skimpy tank top. Who would wear that tank top? What does having an attractive or sexy person wearing tobacco brand names say about smoking?


An airplane flew over the beach with a cigarette logo on the side. Who is at the beach? You were at a sporting event, and saw a tobacco banner advertisement hanging on the wall. Who attends these sporting events?

Page 10.2.9

Lesson 10-2:

Why Tobacco?

Procedures: (continued) 10.

Ask the students to think about whether these advertisements and marketing efforts reach Deaf young people? What is it about the advertisements that makes them effective? What characteristics make them difficult for young Deaf people to interpret or understand?


Explain to students that tobacco companies are legally forbidden from advertising directly to young people, but that they go to great lengths to show tobacco in ways that are very appealing to the young.

Ask students: Why is the teen market so attractive for tobacco companies? What are some of the ways companies might be able to make their advertising campaigns attractive to young people without actually showing young people in the advertisements? Make sure that the discussion covers the following points: W

Teens are one of the most powerful groups of consumers in the country; they tend to spend any money they have rather than save it as many older people do.


Teenagers will start to use a product, become loyal to it, and buy it for many years to come.


Tobacco companies make money by getting people addicted to their product. Younger smokers get "hooked" on cigarettes, and replace older smokers who die from smoking.


Teenagers influence other teens (peer pressure). If you wear a tobacco company's shirt, you are providing free advertising for the company to all of your friends.


What about advertisements showing young adults smoking and having fun? What about the use of cartoon characters such as Joe Camel?

Journal Have you ever bought something that you have been pressured to buy? What was it? Why did you feel pressured to buy it? How did you feel about this situation?

Page 10.2.10

Lesson 10-3

To Smoke or Not: It’s Your Decision! Introduction: The first two lessons in this unit explored many of the forces that encourage (or discourage) the use of tobacco. In the face of these forces, however, the individual still makes a decision to use or abstain from tobacco. This lesson teaches an explicit set of steps that students can use to analyze decisions and the consequences of choosing among different decisional choices, including the decision to use tobacco.

Lesson Objectives: By the end of Lesson 10-3, students will: W

Identify the different factors (self-esteem, friends, parents, peers, marketing) that influence the decision to use tobacco or not


Use the D.A.R.E. Decision Making Process to analyze how decisions are made in light of these different factors


Understand some of the ways in which they can influence others’ decision-making

Materials: W

D.A.R.E. Decision-Making Worksheet

Key Terms: D.A.R.E. Decision-Making Process: A series of steps taught to youth to help them define important decisions and analyze the options and consequences involved in each decisional choice. The components of the D.A.R.E. process are as follows:

decision making: the processes used in making a choice, especially with regard to behavioral choices.

(D) define the decision: What is the decision to be made? What are the issues? Do you understand them? (A) assess: What options are being considered for the decision? What are the consequences of each of the different options, for yourself as well as others around you? (R) respond: Choose which option is the safest for you, or has the most favorable impact. (E) evaluate: How good was the decision that was made? What were the impacts?

Page 10.3.1

Lesson 10-3:

To Smoke or Not: It’s Your Decision!

Procedures: 1.

Review the factors discussed in Lesson 10-2 that contribute to the decision to smoke. Some of these include curiosity or boredom; lack of knowledge about smoking; friends’ behavior; family environment; to relieve stress or depression; to look older, more mature, cooler or to fit in; to be rebellious. Point out that sometimes these factors can help kids decide not to smoke; for example, family members may be opposed to smoking; friends may discourage rather than encourage smoking. Or, students may decide not to

Teacher’s Note:

smoke because they know all about the dangers of smoking. In addition, there may be other forces discouraging smoking: local

Some good examples of how these factors exert both a “push” and a “pull” with respect to tobacco use can be found in Lesson 8-3, Friends, Peers and Others and Tobacco Use.

ordinances prohibiting smoking in public places, restaurants and bars; school regulations forbidding smoking on campus; the high cost of cigarettes; and so on. Nevertheless, young people still make the decision to try to smoke.


How can we make better decisions? Review with students the D.A.R.E. Decision Making Process. Point out that the D.A.R.E. process encourages us to think carefully about the different aspects of making a decision-from defining what our actual choices are and why the decision is important, to identifying the consequences of our possible decisions. If we understand how friends, peers, family and others influence our decisions, we can more clearly identify our choices, assess their consequences,

Teacher’s Note: If your class has never covered the D.A.R.E. decision-making process before, you may need to take some time to review the steps with your students. The model can be found in Lesson 7-3, which uses the decision-making model of the Drug Abuse Resistance Education (D.A.R.E.) program, the pioneer prevention effort established in 1983. Given the widespread use of D.A.R.E. programming in the elementary grades, there is a significant likelihood that your students will have been previously exposed to the D.A.R.E. decision-making model. If not, the concepts underlying the model are relatively straightforward and are reviewed in Lesson 7-3.

and make wise decisions.


Use the following situation and the D.A.R.E. Decision Making worksheet to demonstrate how the process can be applied. W

Jane is a good student. Her teachers like her very much. Lately, she has felt distressed because she is not getting the grades she would like. She is curious about cigarettes. Smoking looks like fun. Over the past few weeks, several of her friends have taken to sharing cigarettes after school. They’ve asked Jane if she would like to join them, but she knows the school has strict rules against smoking. Still, she sees kids her age at the mall smoking, and she thinks that maybe she'd like to try smoking just out of curiosity. Her smoking friends have also told her that cigarettes help them to relax.

Page 10.3.2

Lesson 10-3: To

Smoke or Not: It’s Your Decision!

Procedures: (continued) Jane’s mother has always told her that smoking is a nasty habit, and she has other friends who think that smoking is "yucky." Jane knows from class that smoking can cause health problems, but she thinks that not much will happen to her if she just tries smoking once or twice. Ask students to use the D.A.R.E. Decision Making Process worksheet to analyze the types of choices Jane faces, and the types of consequences she might face with whatever choices she makes.





Discuss with your students the way other students might have influenced Jane’s decision to smoke, both positively and negatively. Ask your students if they feel they can influence the decision-making of others: sisters or brothers, parents, friends, etc. Students should describe how they influence others and the way the feel about this responsibility.

Homework You are invited to a party where some of your classmates and some older kids are present. As everyone stands around talking, some people light a cigarette. They look cool and relaxed and very grown up. You are offered a cigarette. You have never smoked, and you know your parents don’t want you to start. Your closest friends find smoking “yucky,” but they are not at the party. What would you do? Complete the D.A.R.E. Decision-Making worksheet to explain your decision.

Page 10.3.3

Lesson 10-3 Homework: D.A.R.E. Decision-Making Process

Name __________________________________

Decisions, Decisions! The D.A.R.E. Decision-Making Process Worksheet

Instructions: Making decisions can be easier if you have a plan. Use this worksheet to decide how you would act if you were in the following situation. Once you’ve completed the worksheet, think about important decisions you’ve had to make, and how you would think about them now. You are invited to a party where some of your classmates and some older kids are present. As everyone stands around talking, some people light a cigarette. They look cool and relaxed and very grown up. You are offered a cigarette. You have never smoked, and you know your parents don’t want you to start. Your closest friends find smoking “yucky,” but they are not at the party. What would you do? Complete the D.A.R.E. Decision-Making worksheet to explain your decision.

Fill out the D.A.R.E. steps on the following page.

Lesson 10-3 Worksheet: D.A.R.E. Decision-Making Process

Name __________________________________

Decisions, Decisions! The D.A.R.E. Decision-Making Process Worksheet

Instructions: Making decisions can be easier if you have a plan. Use this worksheet to help Jane make some decisions about using tobacco. Once you’ve completed the worksheet, think about important decisions you’ve had to make, and how you would think about them now. Jane is a good student. Her teachers like her very much. She is also on the school basketball team, although she is not one of the starting five. Lately, she has felt distressed because she is not getting the grades she would like. She is curious about cigarettes. Smoking looks kind of fun. Over the past few weeks, several of her friends have taken to sharing cigarettes after school. They’ve asked Jane if she would like to join them, but she knows the school has strict rules against smoking. Still, she sees kids her age at the mall smoking, and she thinks that maybe she’d like to try smoking just out of curiosity. Her smoking friends have also told her that cigarettes help them to relax. Jane’s mother has always told her that smoking is a nasty habit, and she has other friends who think that smoking is “yucky.” Jane knows from class that smoking can cause health problems, but she thinks that not much will happen to her if she just tries smoking once or twice.

Fill out the D.A.R.E. steps on the following page.




Lesson 10-4

The Consequences of Tobacco Use Introduction: In this lesson, students are introduced to the health and other impacts of tobacco use. These are divided into the classic long-term health effects (damage to the body’s respiratory and cardiovascular systems) as well as the short-term effects that are more likely to be relevant to young people. The concept of addiction is introduced, and will be explored in greater depth in Lesson 10-5.

Lesson Objectives: By the end of Lesson 10-4, students will: W

Identify the undesirable health and other consequences of tobacco use


Counter the myths that often characterize youth tobacco use


Understand the addiction cycle

Materials: W

Coffee stirrers (small, hollow straws) for an emphysema demonstration


The ABCs of Smoking Pamphlets 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 Handout (also on CD under “WebPages” folder


Tobacco advertising samples (provided on CD)


The Big Dipper video

Key Terms: health consequences: the physiological results, both immediate and long-term, of tobacco use

smokeless tobacco: chew, chewing tobacco and other tobacco products that are consumed orally, but not smoked.

social consequences: the results of tobacco use that pertain to relationships with others; compliance with school and community laws and regulations; economic impact; and other non-health considerations.

warning labels: messages on tobacco products or advertisements that are designed to discourage use of the product by explaining the health impact of using tobacco products.

Page 10.4.1

Lesson 10-4: The

Consequences of Tobacco Use

Procedures: 1.

Teacher’s Note:

Some long-term health consequences of tobacco use. Ask your class to list some of the most important health consequences of tobacco use. Students will probably list the most obvious, which are the long-term consequences of smoking and tobacco use: Respiratory system: Describe briefly the function of the lungs: with every breath, oxygen is extracted from the air

Some of the most frequently cited health consequences of tobacco use are discussed in Lessons 7-5, 8-6 and 9-4. These include the health effects on the respiratory system and lung function, and the resulting diseases of emphysema and lung cancer; the effects on the cardiovascular system, including atherosclerosis, heart disease and stroke; as well as more immediate effects on endurance, lung growth, and other health impacts. Students should be prompted to raise these health consequences at a minimum. This lesson also includes several participatory demonstrations of some of these health consequences. If your students have not done these in a prior lesson, they can be performed here.

and transferred to the bloodstream, which carries the oxygen to every cell in the body. At the same time, carbon dioxide, a waste product, is extracted from the blood and exhaled from the lungs. This gas exchange takes place in little air sacs called alveoli. Inhaled air also carries dirt, germs and other contaminants into the lungs. To clean these particles from the lungs, the lungs produce mucus, a thick fluid, which traps these foreign particles. This mixture of mucus and particles is then moved out of the lungs by little hair-like structures, called cilia, that line the lungs and airways, and that move back and forth to push the mucus out of the lungs. Whenever you cough or clear your throat, you are actually clearing some of this contaminantladen mucus out of your body. What does smoking do to the lungs? First, the smoke damages the cilia that moves mucus out of the lungs, making it more likely that germs, dirt and other contaminants (together with the mucus) will get trapped in the lungs. The more and the longer you smoke, the greater the damage done to these cells until they lose almost all of their ability to clean the lungs. The result is often “smoker's cough,” the hack-

Teacher’s Note: If your students have previously completed the 8th grade unit of this curriculum, they may have already studied the health and social consequences of tobacco use. If so, you may choose to present an abbreviated version of the material presented here.

Valuable Resource: Other facts and figures regarding smoking and young people can be found at: http://tobaccofreekids.org/research/ factsheets/index.php

Check This Out!: A wonderful interactive animated presentation of the effects of tobacco on different organ systems in the body can be found at: http://www.cdc.gov/tobacco/sgr/ sgr_2004/sgranimation/flash/ index.html

ing, mucus-laden cough that long-time smokers often experience, especially on awakening in the morning. If the lungs and airways become inflamed and clogged with mucus, this can lead to chronic bronchitis, making it difficult to breathe.

Page 10.4.2

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued)

Teacher’s Note:

Second, the smoke itself contains many harmful chemicals and contaminants that can damage the lungs. These chemicals are often referred to collectively as tars. Use the Mechanical Smoker to demonstrate the accumulation of tars in the lungs. Tar is like a thick, dark and sticky film that coats the inside of the lungs. Contact with the chemicals can cause damage to the lung tissue, eventually resulting in lung cancer, a disease that causes the

The chemical soup that makes up tobacco smoke (and tobacco juice) is discussed in greater detail in Lesson 9-4. If your students have not received this information previously, you may want to present it here, using the What’s In Cigarette Smoke? handout and the materials supplied with this curriculum.

destruction of healthy lung tissue. Smoking is the number one cause of lung cancer, and lung cancer


is one of the leading causes of death in the United

Purpose: To demonstrate what it feels like to have emphysema.

States. More than 85% of people who get lung cancer die within five years. The more you smoke and the longer you smoke, the greater your chances of getting lung cancer. This risk is especially high for those who started smoking when they were young. Smoking also damages the alveoli, the little air sacs

Materials: Coffee stirrers (hollow) or very small straws Procedure: Have students place a coffee stirrer in their mouths. Explain that for the next two minutes, they can breathe ONLY through the coffee stirrer. After students have recovered, repeat the exercise, but this time ask students to walk around the room and try to talk with each other, again without inhaling anything except through the straw.

where gas exchange in the lungs takes place. This damage means that your lungs become much less able to perform the gas exchange that brings oxygen into your body. In some people, this damage goes on to become a disease called emphysema, where the lungs have lost most of their ability to absorb oxygen. In addition, smoking causes the airways (the lungs and the tubes leading to them) to overreact to

Explain: This is the way it feels ALL THE TIME if you have emphysema. No matter how hard you breathe, your body cannot get the oxygen it needs. Have students note how much worse it felt if they had to move around. Point out that any exertion—even just walking around—becomes very difficult for a person with emphysema.

harmful substances, causing them to tighten up ("constrict"), and leading to wheezing and shortness of breath. This can be especially serious for those people who already suffer from asthma.

Note that the disease is progressive—that is, it gets worse and worse over time—and has no cure. The disease is almost always fatal, but not before a long period of wasting and fatigue.

All of these physical changes impair the function of the lungs. Other Cancers Smoking is not only linked to cancer of the lungs, but cancer in other parts of the body as well. Cancer is actually several different diseases affecting different parts of the body, but having one characteristic in common—cancer cells reproduce in a wild and uncontrolled fashion, and crowd out and destroy healthy cells in the process.


Page 10.4.3

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued) A healthy lung normally has a smooth surface. Compare the healthy lung with this diseased lung of a smoker. This lung shows lung cancer, the grayish-white bumps on the lung.



Lung cancer is the most common cause of cancer death in both men and women. One of the reasons is that by the time it is discovered, the cancer has spread to different organs and tissues in the body. Smoking is the number one cause of lung cancer.


Chemicals from tobacco eventually end up in the urine, which then collects in the bladder. The bladder is then bathed in these cancer-causing chemicals, which can cause bladder cancer.

Oral cancers include those of the tongue, mouth, cheek and lips. One of the most important causes of oral cancer is tobacco, both smoked and chewed. Here, a sore on the tongue is cancer which, if not removed, may spread to other tissues.



Because the liver filters the body’s blood, it is a common site for cancer to spread. Smoking is the cause of laryngeal cancer, or cancer of the voicebox which is located in your throat.



Page 10.4.4

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued) Cigarette smoking is the single most preventable cause of cancer. Cigarette smoke is known to contain at least 60 substances that can cause cancer in the body. Many of these substances are produced when tobacco is burned (and then inhaled into the body), but some of these substances are also present in unburned tobacco (which is why smokeless, or chewing, tobacco also causes cancer.)

Teacher’s Note: You may want to mention to your students that they can also be exposed to these chemicals through secondhand smoke (environmental tobacco smoke) from someone else’s smoking. This is discussed in Lesson 9-4.

Smoking and smokeless tobacco have been linked to cancer throughout the body, including cancers of the mouth, nose, throat, esophagus, salivary glands, bladder, kidney, pancreas, colon, rectum, cervix and vulva in women, the penis in men. It is also possibly linked to cancer of the stomach, prostate gland, and certain skin and blood cancers. How does this happen? When you use tobacco, either by smoking it or chewing it, your body absorbs (through the lungs, mouth, throat and eye tissues, and the skin) the chemicals that cause cancer. These chemicals then circulate in the bloodstream throughout the body. Cardiovascular Diseases

One User’s Story: If your students are not yet familiar with the story of Sean Marsee, you can present it here. The actual story illustrates the tragic consequences of chewing tobacco for one young man. The story can be found at: http://whyquit.com/whyquit/ SeanMarsee.html The story can also be found on the accompanying CD (in the “WebPages” folder, titled “Sean Marsee’s Message”). You might want to consider reviewing this story as a class exercise, or having students read it as part of a homework or journal exercise.

Smoking can also damage your heart and arteries. Your heart is responsible for pumping blood throughout your body. This blood is 1.

pumped through the lungs to pick up oxygen, and then


pumped through a network of arteries, or tubes, that carry oxygenated blood to every cell in the body; and then


through veins, that return the blood (now carrying carbon dioxide wastes) back to the lungs, where the carbon dioxide waste is exchanged for fresh oxygen.

How does smoking damage this system? 1.

Smoking causes atherosclerosis, a gradual clogging


and narrowing of the arteries that carry freshly oxygenated blood to the body's tissues and organs. If the arteries that supply the heart with oxygen become narrowed and clogged, the heart tissue can become damaged or destroyed, leading to a heart attack.

Page 10.4.5

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued) 2.

Smoking also increases blood pressure, or the amount of force the heart needs to exert to pump blood through the body. High blood pressure can also damage the heart and arteries.


The resulting damage to the arteries that supply the heart may also lead to more gradual destruction of heart tissue, leading to a disease called congestive heart failure, where the heart is no longer fully able to pump blood.


The damage to other arteries in the body, particularly those that supply the brain with oxygen, can also lead to strokes, in which narrowing or a clog in the arteries stops the blood flow to certain areas in the brain. The resulting lack of oxygen


causes these brain tissues to die, often leading to paralysis, loss of function (speech, walking, motor skills, etc.) and death. Smoking can also damage the skin, from the outside (direct exposure to cigarette smoke or tobacco juice and their harmful chemicals) and the inside (through damage to the blood vessels that supply the skin with oxygen and nutrients. When skin cells are exposed to smoke, and are unable to receive the oxygen and nutrients they need, one result is wrinkling. You can see this particularly in the lines around smokers’ mouths and eyes. In addition, the skin’s normal repair functions are affected, meaning that wounds—cuts and other skin injuries—heal much more slowly. These are just SOME of the effects of smoking on the body. Smoking also affects the body’s bones, leading to weaker bones more prone to breakage in old age; is linked to cataracts in the eye that can lead to blindness; can damage one’s sense of taste and smell; can interfere with the body’s normal immune function, making a person more susceptible to colds and disease; etc.


Immediate Health Effects of Tobacco Use Tobacco use not only has long-term health consequences. It also has immediate health effects. W

Smoking interferes with the normal growth and development of the lungs as young people grow. If you smoke in your teens, chances are you are preventing your lungs from growing to their full potential.


Smoking causes more phlegm production and coughing, and other respiratory symptoms such as shortness of breath.

Page 10.4.6

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued) W

Smoking hurts physical fitness, especially endurance.


Smoking may make you more susceptible to colds and minor illnesses, meaning that young people who smoke tend to be less healthy than those who do not.


Smokeless, or chewing, tobacco can lead to mouth sores and gum disease, even at an early age.

Perhaps most important about this faulty belief (that a person can just smoke for a little while and cause no long-term health damage) is that most people who smoke "for a little while" end up addicted and smoking for many many years.


Social Consequences of Smoking Ask your students if anyone can think of any reasons—other than harmful health impacts—that would discourage people from smoking. Prompt your students using some of the following examples: bad breath, burn holes in clothing, yellow teeth, harming others (secondhand smoke), causing fires, upsetting parents or friends, "grossing out" others, punishment for breaking "no smoking" laws or regulations, financial cost of smoking, etc. Compile answers into categories such as the following: consequences concerning how one appears to others (bad breath, dirty, smelly, etc.); those concerning relationships with others (parents, friends, etc.); those concerning rules and regulations; those concerning financial considerations (the costs of smoking). Also, as the health consequences of tobacco use have become better known, more and more people in our society and elsewhere have come to recognize these dangers and have decided to actively fight against smoking. There are increasing numbers of rules about where one can and cannot use tobacco products. Smoking is now prohibited in many workplaces—including schools, hospitals, airplanes, and public buildings. In some places it is difficult for smokers to get jobs because their smoking would expose other people to harm through the smoke from their cigarettes, cigars and pipes.


Do these health and social consequences prevent young people from using tobacco products?

Teacher’s Note: You may want to mention to your students that they can also be exposed to the chemicals in tobacco smoke through secondhand smoke (the smoke from someone else’s burning cigarette). This is discussed in Lesson 9-4.

Sadly, very often the answer is “no.” Many of the health effects of tobacco use take a long time to develop. They are primarily problems of middle and older age. Young people don’t think about what

Page 10.4.7

Lesson 10-4:

The Consequences of Tobacco Use

Procedures: (continued) can occur later in their lives. Consequently, they don’t really think that these longterm consequences have anything to do with them. Moreover, young people do not often think about the immediate health and social consequences of tobacco use, until after they’ve begun to smoke or use smokeless tobacco. Often children and teenagers who start to smoke think that they will smoke for just a little while and then quit. They believe that they can quit any time they want. Even if they recognize the health and other consequences of tobacco use they believe that they will not be smoking long enough to experience these problems. Indeed, surveys have found that many young people—7 out of every 10 who have started to smoke—want to quit. Young people begin to experience the immediate health and social problems of tobacco use, often very soon after they start to smoke or chew tobacco. They may begin to think about the long-term problems that can occur, about how they are being manipulated to smoke, and may worry about the money they are spending to buy cigarettes. But when they try to quit, they often find that they are “hooked”—that it is difficult to stop. It may be difficult for them to resist peer and other pressures to smoke that got them started in the first place. Most important, they run into a characteristic of tobacco use that makes it difficult to quit—that tobacco use is highly addictive.

Homework: Pass out the story of 19 year-old Sean Marsee. Have students write about their reaction to the story. If you consider this assignment as too disturbing for your students, you may opt to use this story as an in-class exercise.

Page 10.4.8

Lesson 10-4

What’s in Tobacco Smoke?

What’s in Tobacco Smoke? Cancer Causing Agents Nitrosamines Crysenes Cadmium Benzi (a)pyrene Polonium Nickel P.A.H.s Dibenz Acidine B-Naphthylamine Urethane N. Nitrosonomicotine Toluidine

Metals Aluminum Zinc Magnesium Mercury Gold Silicon Silver Titanium Lead Copper

Acetone Nail polish remover

Acetic Acid Vinegar

Ammonia Floor and toilet cleaner

Arsenic Insecticides and poisons

Butane Cigarette lighter fluid

Cadmium Rechargeable batteries

Carbon Monoxide

Car exhause fumes






Body tissue preservative


Lighter fluid

Hydrogen Cyanide

Gas chamber poison


Swamp gas


Rocket fuel


Moth balls



Nitrous Oxide Phenols Disinfectants Candle wax Solvents

Source of information: American Lung Association

Nineteen Year Old Sean Marsee's Tobacco Message

Talihina High School's most outstanding athlete, Sean Marsee had won 28 track medals in the 400 meter relay while running the anchor leg. His classmates honored him with a walnut plaque. After a ten month battle with rapidly spreading cancer that started on his tongue, Sean Marsee died at age 19.

A smokeless tobacco user since age 12, Sean refused to believe his mother's warnings that tobacco was hazardous, smoke or no smoke.

It was early on February 25th. Sean Marsee smiled a tired smile at his sister, pointed his index finger skyward, and an hour later, at age 19, Sean

Marsee was dead. Just ten months earlier, Sean, an 18 year-old high school senior and star of the school track team, was just a weekend away from competing in the state track finals, and just a month away from graduation. It was then that Sean opened his mouth and showed his mother an ugly sore on his tongue. His mother, a registered nurse, took one look and felt her heart sink. A user of smokeless chewing tobacco and snuff since age 12, rarely was Sean without a dip. Living from nicotine fix to nicotine fix, he went through a can of snuff every day and a half. When Sean's mother finally discovered his secret she hit the roof. She tried explaining just how hazardous that tobacco was for him, smoke or no smoke, but Sean Sean Marsee before the final battle. refused to believe her. He argued that other boys on the track team were dipping. He argued that his coach knew and didn't seem to care. He argued that high profile sports stars were using and marketing smokeless tobacco. How could it be dangerous, he pleaded. In the end, his mother simply dropped the subject. But now, an angry red spot with a hard white core, about the size of a half-dollar, was being worn by his tongue. "I'm sorry, Sean," said Dr. Carl Hook, the throat specialist. "It doesn't look good. We'll have to do a biopsy." Sean was stunned. Aside from his addiction to nicotine, he didn't drink, he didn't smoke and he took excellent care of his body; watching his diet, lifting weights and running five miles a day, six months a year. Now this. How could it be? "But I didn't know snuff could be that bad for you," Sean said. "I'm afraid we'll have to remove that part of your tongue, Sean," Dr. Hook said. The high school senior was silent. "Can I still run in the state track meet this weekend?" he finally asked. "And graduate next month?" Dr. Hook nodded. On May 16th, Dr. Hook performed the operation. More of Sean's tongue had to be removed than was anticipated. Worse yet, the biopsy results were back and the tumor tested positive for cancer. Arrangements were made for Sean to see a radiation therapist, but before therapy began, a newly swollen lymph node was found in Sean's neck. It was an ominous sign that the cancer had spread. Radical neck surgery had now become necessary. Dr. Hood gently recommend to Sean that he undergo the severest option: removing the lower jaw on the right side, as well as all lymph nodes, muscles and blood vessels except for his artery. There might be some sinking, he explained, but the chin would support the general planes of the face. His mother began to cry. Sean was being asked to approve his own mutilation. This was a teenager who was so concerned about his appearance that he'd even swallow his dip rather than be caught spitting tobacco juice. They sat is silence for ten minutes. Then, dimly, she heard him say, "Not the jawbone. Don't take the jawbone." "Okay, Sean, " Dr. Hook said softly. "But the rest; that's the least we should do." On June 20th Sean underwent his second surgery. It lasted eight hours.

At school, 150 students and teachers assembled in June to honor their most outstanding athlete. Sean could not be there to receive their award. His Coach and his assistant came to Sean's home to present their gift, a walnut plaque. They tried not to stare at the huge scar that ran like a railroad track from their star performer's earlobe to his breastbone. Smiling crookedly out of the other side of his mouth, Sean thanked them. With five weeks of healing and radiation therapy behind him, in August Sean greeted Dr. Hood with enthusiasm, plainly happy to be alive. Miraculously, Sean had snapped back. He really believes his superb physical condition is going to lick it, Dr. Hook thought. Let's hope he's going to win this race too. But in October Sean started having headaches. A CAT scan showed twin tentacles of fresh malignancy, one snaking down his back, the other curling under the base of his brain. In November, Sean underwent surgery for the third time. It was the jawbone operation he had feared - and more. After 10 hours on the operating room table, he had four huge drains coming from a foot long crescent wound, a breathing tube sticking out of a hole in his throat, a feeding tube through his nose, and two tubes in his arm veins. Sean looked at his mother as if to say, "My God, Mom, I didn't know it was going to hurt like this." The Marsees brought Sean home for Christmas. Even then, he remained optimistic until that day in January when he found new lumps in the left side of his cheek. His mother answered the phone when the hospital called with the results of the biopsy. Sean knew the news was bad by her silent tears as she listened. When she hung up, he was in her arms, and for the first time since the awful nightmare started, grit-tough Sean Marsee began to sob. After a few minutes, he straightened and said, "Don't worry. I'm going to be fine." Like the winning runner he was, he still had faith in his finishing kick. One day Sean confessed to his mother that he still craved his snuff. "I catch myself thinking," he said, "I'll just reach over and have a dip." Then he added that he wished he could visit the high-school locker room to show the athletes "what you look like when you use it." His appearance, he knew would be persuasive. A classmate who had come to see him fainted dead away. Shortly before Sean's death he told his mother that there must be a reason that God decided not to save him. Sean's mother believes that Sean's legacy is in having his story spread and hopefully "keeping other kids from dying." When Sean became unable to speak, a friend asked him if their was anything he wanted to share with other young athletes. With pencil in hand Sean wrote, "Don't dip snuff." On the morning of February 25th, Sean Marsee, age nineteen, exhaled his last breath.

Compiled using photos, facts and extensive quotations from an October 1985 Reader's Digest article by Jack Fincher, entitled "Sean Marsee's Smokeless Death," located at pages 107 through 112. Compiled by John R. Polito, Founder WhyQuit.com, June 2000

Youth Nicotine Addiction Warning Signs

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Last Updated on October 8, 2002 by John R. Polito

Lesson 10-5

Hooked! The Process of Addiction Introduction:

This lesson expands on the concept of addiction, and explains the mechanism of the addiction cycle. The lesson emphasizes the relative quickness with which addiction can occur; and the importance of prevention (that is, avoiding any tobacco use at all) because of the difficulty of quitting once an addiction has formed.

Lesson Objectives: By the end of Lesson 10-5, students will: W

Plan Ahead!

Describe early tobacco use as a strong

This lesson calls for having a guest speaker who can give a first-person narrative of how difficult it is to quit smoking. To find such a person, contact your local American Lung Association or American Cancer Society to see if they can suggest a volunteer to speak to your class. Such volunteers might include smokers who have tried (and failed) to quit, or former smokers who have successfully quit.

predictor of prolonged addiction W

Review the following concepts: addiction, cessation, and withdrawal


Identify reasons that people quit smoking


Define the term relapse

Materials: W

I Don't Want to Use Tobacco Pictionary Cards


One Addict’s Story: Bryan Curtis Handout (also on CD in the “WebPages” folder)


Graphic: The Addiction Cycle


Reasons for Avoiding or Quitting Tobacco Use Worksheet

Key Terms: addiction: Extreme physiological and psychological dependence on a substance such as tobacco, alcohol or other drug, that has progressed beyond voluntary control. People who are addicted often feel sick when they stop using this substance. cessation: In terms of tobacco use, the process of stopping all tobacco use, particularly after one has already become addicted.

relapse: In terms of tobacco, starting to smoke or chew tobacco again after an attempt at quitting has been made; to take up tobacco use again after a period of abstinence. withdrawal: The range of unpleasant physiological and emotional reactions of the body in response to withholding a drug (such as nicotine in tobacco products) that the body has become addicted to.

Page 10.5.1

Lesson 10-5: Hooked!

The Process of Addiction

Procedures: 1.

Ask students to define the terms addiction and withdrawal.


Ask your students:

Teacher’s Note: If your class has not learned these terms in a prior unit (e.g., Lesson 9-5 in the 9th grade curriculum) review the following procedures as necessary. If your class has covered these concepts, skip to Activity 5.

What is addiction, and how does it happen? Explain to students that people often use the word “addiction” in a very general way. They’ll say, “I’m addicted to pizza,” or “I’m addicted to that television show,” referring to any behavior someone might find pleasurable and doing excessively. However, when it comes to behaviors such as tobacco use or drug use, “addiction” means something very different. With true addiction, the following things happen: W

The substance produces a pleasant feeling.


Over time, you need to use more and more of the substance to obtain this pleasant feeling.


If you stop using the substance, you will feel unpleasant feelings called withdrawal symptoms. You will feel better only if you can use more of the substance.


You will continue to use this substance to pursue this pleasant feeling and avoid feeling bad, even if you know the substance is harming your body.


Show the graphic of the Addiction Cycle. In tobacco, the drug nicotine is the substance that causes addiction to smoking and other tobacco use. Nicotine is found in all tobacco products: cigarettes, cigars, pipe tobacco, smokeless (chewing) tobacco, bidis, kretek, etc. Let’s examine the addiction cycle: that is, how a young person like you can quickly become addicted to tobacco. Pleasant feelings Smoking a cigarette may cause some initial dizziness or nausea as a person becomes accustomed to inhaling smoke. But it also produces a pleasant sensation almost immediately. This sensation is caused by nicotine. Within seconds of inhaling tobacco smoke (or placing a plug of smokeless tobacco in the mouth), nicotine is absorbed into the bloodstream where it quickly travels to the brain. Here, the nicotine causes chemical changes in the brain that produce the pleasant sensation. This pleasant feeling wears off quickly, and the smoker must inhale more smoke to experience that pleasant feeling again. The desire for these sequences of little nicotine “hits” is what encourages more regular use.

Page 10.5.2

Lesson 10-5:

Procedures: (continued)


So you smoke another cigarette. And the cycle starts over again.

Hooked! The Process of Addiction


Within seconds of inhaling, nicotine speeds its way to your brain.



Over time, your brain becomes accustomed to nicotine stimulation. Once this happens, you experience unpleasant withdrawal symptoms if your nicotine craving is not satisfied.

4 Your brain starts to crave

another “hit� of nicotine— telling you to smoke another cigarette.

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


But as soon as you stop smoking, this stimulation wears off as the nicotine level in your body falls. L87_AddictionCycle

The need to use more and more As a person starts to use tobacco (and nicotine) regularly, their brain and body become less sensitive to the pleasurable effects of nicotine. This is called building up tolerance, and means that the smoker or smokeless tobacco user needs to smoke (or chew) more, and more often, in order to receive the same pleasurable sensations as he did before. Withdrawal symptoms As the body becomes accustomed to nicotine, body and brain cells become dependent on the nicotine in tobacco. While nicotine may produce pleasurable sensations in the body, withholding nicotine starts to cause a number of unpleasant sensations, which range from mild to severe: W

Feeling restless


Feeling irritable, moody or tense




Headaches or dizziness


Sweating and unsteadiness


Nausea or physical illness

Page 10.5.3

Lesson 10-5:

Hooked! The Process of Addiction

Procedures: (continued) These physical symptoms are known as withdrawal symptoms. Withdrawal can be a very uncomfortable feeling, and is the reason why most people find it so difficult to quit smoking after becoming addicted to nicotine. To relieve these withdrawal symptoms, the smoker or tobacco user must smoke another cigarette, or place another plug of smokeless tobacco in their mouth. Hooked! Addiction can happen very quickly, especially in young people. Some teenagers start experiencing withdrawal symptoms, even if they feel they are just “playing around” and smoking a few cigarettes a week! When a person is dependent on nicotine, they feel that they don't have a choice about using tobacco anymore. They feel they must use tobacco. They must plan where they go and what they do so that they will be able to use the drug nicotine. It is like carrying a ball and chain. Addiction creates a feeling of need—a craving-in your body and your brain. People who are addicted to nicotine in tobacco will continue to smoke, even if they know they are doing great harm to their health. This is why you often hear smokers say, “I know I should quit. But I can’t.”


Most people who experiment with, and begin to casually use, tobacco, plan to quit when they get older. But most people find it very difficult to quit once they've become addicted. Research shows that nicotine is as addictive as cocaine and heroin. Ask students to think about what this means.


Why is preventing tobacco use so important? Review with your students some of the reasons why young people try smoking (from Lesson 10-2): W

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


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


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


family environment: My parents smoke; My siblings smoke.


relieve stress or depression: I found out that when I was feeling anxious, stressed or depressed, a cigarette helped calm me down or helped make me feel better;


to look older, more mature, cooler; to fit in


to be rebellious

Page 10.5.4

Lesson 10-5:

Hooked! The Process of Addiction

Procedures: (continued) Ask your students: W

Teacher’s Note:

These are some of the most common reasons for why young people start to smoke. But what about someone your age who already smokes regularly? What do you think are some of the most common reasons for why kids continue to smoke or use other tobacco products?

Students may volunteer a number of different answers, including those on the previous page. But make sure that one important answer—addiction— is mentioned. “I smoke because I can’t quit.”

If none of your students mentions addiction, present the following fact. W

When researchers talk to young people who smoke regularly, more than 7 out of 10 say they wish they’d never started smoking. So why do they continue to smoke?

Emphasize that the list of reasons why people-including young people-continue to use tobacco products is different than the list of reasons why they started using tobacco in the first place. Any list of reasons for continuing tobacco use MUST have ADDICTION at the very top. Help students to recognize that prevention—never starting to use tobacco products in the first place—is very important because of the addictive nature of nicotine at all ages. Remind students that many young people believe that if they just smoke a little, they will not become hooked. Yet once a person starts smoking, it’s difficult to continue smoking “just a little.” Smoking “just a little” can quickly lead to “smoking a lot” and addiction.


What are some of the reasons why people should quit smoking, or avoid smoking in the first place? Have the class play the I Don't Want to Smoke Pictionary game. Divide the class into two groups. Using Pictionary cards, have the teams play accordingly: W

One person from Team A is chosen to select a card and read it silently. If he or she does not understand the card, the

One User’s Story: Another tragic story of the difficulty of quitting smoking can be found at: http://whyquit.com/whyquit/BryanLeeCurtis.html The story can also be found on the accompanying CD (in the “WebPages” folder, titled “Smokin Kills: Bryan’s message”). You may want to use this story as a class exercise, or a homework or journal exercise. Make sure you ask students to pay attention not only to Bryan’s smoking, but also to that of his family members, who find it difficult to stop, even in the face of Bryan’s illness.

teacher can explain it. W

The person will draw the reason for quitting or avoiding smoking on the board. Team A has 45 seconds to correctly guess the reason. If they are successful, they will receive 5 points.


If Team A cannot guess the picture within the allotted time, Team B gets a chance to guess the answer for 3 points.

Page 10.5.5

Lesson 10-5:

Hooked! The Process of Addiction

Procedures: (continued)



Team B draws and guesses.


For bonus points, teams can come up with more ideas.

Explain to students that while some people quit smoking and or chewing tobacco successfully the first time, others cannot quit and begin smoking again. This is called relapse. Some smokers quit and relapse many times before they successfully quit forever. Some people never quit. Have the class discuss the following statement: “Death is the cure for smoking.”


Guest Speaker: The purpose of the guest speaker is to provide a first-person narrative of the difficulties of quitting an addictive behavior such as smoking. Contact the local branch of the American Cancer Society, the American Lung Association, the American Heart Association, or other similar agency for assistance in identifying a smoker or ex-smoker who has attempted to quit smoking and experienced relapse. If possible, the Guest Speaker should be deaf to facilitate communication with the class. Invite the Guest Speaker to come to class and discuss the factors involved in the decision to quit smoking, the process of quitting, and the circumstances of his or her relapse.

Homework: Ask students to complete the Reasons for Quitting or Avoiding Smoking worksheet, to list reasons why people should quit smoking if they smoke, or why they should avoid smoking in the first place if they've never tried before. Encourage your students to add their own circles to the worksheet if they have ideas that are not already listed.

Journal: Have you ever made changes in your life that you considered an improvement, and then fallen back into your old habits—for example, lost weight and gained it back, or improved your grades and then failed again? Describe what happened and how it made you feel. Alternative Journal Question: Some people have sued cigarette companies because they smoked and got cancer or emphysema. These people feel that the cigarette companies are responsible for their disease. What do you think about this? Who is responsible if a smoker gets sick from smoking?

Page 10.5.6

Lesson 10-5 Graphic: The Addiction Cycle

The Addiction Cycle 6

So you smoke another cigarette. And the cycle starts over again.


Within seconds of inhaling, nicotine speeds its way to your brain.


Over time, your brain becomes accustomed to nicotine stimulation. Once this happens, you experience unpleasant withdrawal symptoms if your nicotine craving is not satisfied.


Your brain starts to crave another “hit” of nicotine— telling you to smoke another cigarette.


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


But as soon as you stop smoking, this stimulation wears off as the nicotine level in your body falls.

Smoking Kills

"He Wanted You to Know"

On the day of Bryan's death, June 3, wife Bobbie and son Bryan keep a bedside vigil. The recent photo of father and son is on the bed. [Times photo: V. Jane Windsor]

by Sue Landry

Bryan Curtis started smoking at 13, never thinking that 20 years later it would kill him and leave a wife and children alone. In his last weeks, he set out with a message for young people.

ST. PETERSBURG -- Cigarette smoke hangs in the air in the room where Bryan Lee Curtis lies dying of lung cancer. His head, bald from chemotherapy, lolls on a pillow. The bones of his cheeks and shoulders protrude under taut skin. His eyes are open, but he can no longer respond to his mother or his wife, Bobbie, who married him in a makeshift ceremony in this room three weeks ago after doctors said

there was no hope. In Bryan's emaciated hands, Bobbie has propped a photograph taken just two months ago. It shows a muscular and seemingly healthy Bryan holding his 2-year-old son, Bryan Jr. In the picture, he is 33. Bryan Lee Curtis, then 33, holds son Bryan He turned 34 on May 10. Jr., 2, in this March 29 photo. Curtis would die about two months later.

[Photo: Curtis


A pack of cigarettes and a lighter sit on a table near Bryan's bed in his mother's living room. Even though tobacco caused the cancer now eating through his lungs and liver, Bryan smoked until a week ago, when it became impossible. Across the room, a 20-year-old nephew crushes out a cigarette in a large glass ashtray where the butt joins a dozen others. Bobbie Curtis says she'll try to stop after the funeral, but right now, it's just too difficult. Same for Bryan's mother, Louise Curtis. "I just can't do it now," she says, although she hopes maybe she can after the funeral. Bryan knew how hard it is to quit. But when he learned he would die because of his habit, he thought maybe he could persuade at least a few kids not to pick up that first cigarette. Maybe if they could see his sunken cheeks, how hard it was becoming to breathe, his shriveled body, it might scare them enough. So a man whose life was otherwise unremarkable set out in the last few weeks of his life with a mission.

*** Bryan started when he was just 13, building up to more than two packs a day. He talked about quitting from time to time, but never seriously tried. Plenty of time for that, he figured. Older people got cancer. Not people in their 30s, not people who worked in construction, as a roofer, as a mechanic. He had no health insurance. But he was more worried about his mother, 57, who had smoked since she was 25. "He would say, "Mom, don't worry about me. Worry about yourself. I'm healthy,' " Louise Curtis remembers. "You think this would happen later, when you're 60 or 70 years old, not when you're his age." He knew, only a few days after he went to the hospital on April 2 with severe abdominal pain, how wrong he had been. He had oat cell lung cancer that had spread to his liver. He probably had not had it long. Also called small cell lung cancer, it's an aggressive killer that usually claims the lives of its victims within a few months. While it seems unusual to the Curtis family, Dr. Jeffrey Paonessa, Bryan's oncologist, said he is seeing more lung cancer in young adults. "We've seen lung cancer earlier and earlier because people are starting to smoke earlier and earlier," Paonessa said. Chemotherapy sometimes slows the process, but had little

effect in Bryan's case, he said. Bryan also knew, a few days after the diagnosis, that he wanted somehow to try to save at least one kid from the same fate. He sat down and talked with Bryan Jr. and his 9-yearold daughter, Amber, who already had been caught once with a cigarette. But he wanted to do more. Somehow, he had to get his story out. When he still had some strength to leave the house, kids would stare. "They'd come up and look at him because he looked so strange," Louise Curtis said. "He'd look at them and say, "This is what happens to you when you smoke.' "The kids would say, "Oh, man. I can't believe it,' " Louise Curtis said. In the last few weeks, Bryan's mother has been the agent for his mission to accomplish some good with the tragedy. She has called newspapers and radio and television stations, seeking someone willing to tell her son's story, willing to help give him the one thing he wanted before he died. Bryan never got to tell his story to the public. He spoke for the last time an hour before a visit from a Times reporter and photographer. "I'm too skinny. I can't fight anymore," he whispered to his mother at 9 a.m. June 3. He died that day at 11:56 a.m., just nine weeks after the diagnosis. Bryan Lee Curtis Sr. was buried at Memorial Park Cemetery in St. Petersburg on June 8, a rare cloudy day that threatened rain. At the funeral service at nearby Blount, Curry and Roel Funeral Home, Bryan's casket was open and 50 friends and relatives could see the devastating effects of the cancer. Addiction is more powerful. As the graveside ritual ended, a handful of relatives backed away from the gathering, pulled out packs of cigarettes and lit up.

Originally Published on June 15, 1999 in the St. Petersburg Times Posted at www.WhyQuit.com on July 15, 1999

January 23, 2001 - "It's almost been 2 years now. We set and watch home movies of us. His son is missing him too. Christmas was the worst. He had to go outside and show his dad what he got for Christmas. That really tore me up." Bobbie Jo Curtis

February 28, 2002 - Bobbie indicates that Bryan's mother was able to quit smoking following her son's death. Bryan Jr. will turn six on August 23, 2002, at which time he will have been fatherless for more than half his life. Email Bobbie and Bryan Jr.

Have you met Noni? Have you heard 19 year old Sean's message ... ... or from those lucky enough to survive the worst scare of their life! Why do two million middle-aged smokers smoke themselves to death each year? Will you be one of them? Knowledge is power!

WhyQuit.Com | About Us | Contact Us | Link to Us | What's New?

Last Updated on August 10, 2003 byJohn R. Polito

Lesson 10-5: Pictionary Game

“I Don’t Want to Use Tobacco” An Anti-Tobacco Pictionary Game

“My friend has been smoking cigarettes again, and his breath smells really bad.”

“Basketball and smoking don’t mix.”

“Food smells and tastes much better if you don’t smoke.”

“Kissing a smoker is like licking an ashtray.”

“My girlfriend thinks it’s sexy when I spit out tobacco juice.”

“Smoking makes me look cool— yellow teeth, brown fingers, and holes in my clothes!”

“Cigarettes or: movie tickets; a new book; video games; new clothes”

“I want to be a good role model for my younger brother and sister.”

Lesson 10-5: Pictionary Game

“I Don’t Want to Use Tobacco” An Anti-Tobacco Pictionary Game - Page Two

“I wonder why my friends all get up and leave whenever I light up a cigarette?”

“Yes, smoking makes you look older—it causes your skin to wrinkle.”

“Coach told me if I smoke, I’m off the team.”

“My parents would kill me if they caught me smoking.”

A fool says, “I smoke everyday because I want to. I can quit anytime I want!”

“Smoking hurts your endurance.”

“Your smoke makes me choke!”

“If you smoke while you’re pregnant, you can hurt your unborn child.”

Lesson 10-5 Worksheet: Reasons for Avoiding or Quitting Smoking

Name __________________________________

Reasons for Avoiding or Quitting Tobacco Use Family


___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Money

Instructions: Provide reasons why you should avoid or quit tobacco use.

Health ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Other ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

Lesson 10-6

Convincing Others Not to Smoke Introduction: This lesson introduces students to the world of social action,

especially the tobacco control movement that has arisen in response to the large amount of information now available about the dangers of smoking, the hazards of secondhand smoke exposure, and the lengths to which tobacco companies have gone to keep this information from public view. The marketing strategies of tobacco companies have also been an impetus for social action, particularly for young people.

Lesson Objectives: By the end of Lesson 10-6, students will: W

Investigate a smoking prevention program


Contact community-based voluntary organizations to collect prevention, cessation and other anti-tobacco information directed to youth.


Access information and resources on the web. This can include, for example the Tobacco Free Kids website (www.tobaccofreekids.org), the

Plan Ahead! This lesson asks students to access community-based 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 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. Samples of anti-tobacco educational materials can also be obtained free of charge from:

Truth campaign (www.thetruth.com), the


American Legacy Foundation (www.americanlegacy.org), and Canada's anti-tobacco website (www.infotobacco.com). W

Discuss why the government would require cigarette companies to put a warning label on their product.


Write "BE SMART, DON'T START" letters aimed at younger students


Teacher’s Note: You may want to start this lesson by reviewing statistics about the proportion of young people in different grades who have tried smoking. This information is presented in Lesson 8-5.

Organize a "BE SMART, DON'T START" campaign at school.

Materials: W

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 (U.S., Canada and Brazil)


Journeyworks, Inc. Pamphlet: 10 Best Reasons Not to Smoke While You’re Pregnant

Page 10.6.1

Lesson 10-6:

Convincing Others Not to Smoke

Procedures: 1.

Ask students to think about what messages would help young people and adults on campus to be more resistant to smoking or to help them quit. Students should think about the kinds of components an effective program would have.


Ask students to use the internet to contact the American Cancer Society, the American Lung Association, TobaccoFreeKids and other organizations listed above, to obtain information and materials they might be able to use to promote an anti-tobacco program on campus.


Review the anti-tobacco advertisements provided and any materials that were collected by students. Gather the class around a table and lay out the anti-tobacco materials . Ask the students to group them by the educational approaches used, e.g., those that address the health impacts of tobacco use; those that address the cosmetic aspects (makes your clothes, hair, breath smell bad, etc.); those that address some of the other physiological impacts of smoking (eg., the link to impotence in males); those that address tobacco executives, tobacco marketing, and the profit motives in pushing tobacco; etc. Ask the students to discuss the relative merits of each of these approaches: W

Do you think this is a good way to get kids to not smoke?


Why do you think this approach would work? What about for Deaf youth?


Are the messages clear and understandable for Deaf youth?


Do you think that telling young people about the health effects of tobacco use really "works" to discourage this use?


What kind of messages do you think work best?

Some anti-tobacco messages focus on the health effects of smoking.



Page 10.6.2

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued)




s These ads also touch on the health impacts of tobacco use.





Page 10.6.3

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued) These advertisements focus on the harmful ingredients in tobacco products, cigarette smoke and secondhand smoke.


“Many bug sprays contain nicotine. All cigarettes do.”


“The same formaldehyde that preserves dead frogs is found in cigarettes.”


“Cyanide is the deadly ingredient in rat poison. And just one of the many in cigarettes.”



s L106_SmokeFree02

These advertisements focus on the people who are affected by secondhand smoke exposure.


Page 10.6.4

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued)


These advertisements poke fun at the notion that smoking is cool and attractive.





Page 10.6.5

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued)







These advertisements rely on celebrity endorsement of being smoke-free.


Page 10.6.6

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued)





These anti-tobacco advertisements take direct aim at the tobacco industry and their marketing and advertising practices.

Provide each student with an empty cigarette package. Discuss with your students who the Surgeon General is, and what the various warning labels say. List these warnings on the board. Ask your students to identify who is targeted by each of the Surgeon General's warnings.



Discuss with your students the reasons that the government would require warning labels on cigarette packs. Provide your students with a brief accounting of how these labels came to be placed on cigarette packages. Ask your students the following: W

Do you think these warnings are effective? How about for young people like yourselves?


When you look at the packages from Canada, what differences do you notice from those of the United States? Do you think the explicit pictures of diseased lungs, oral cancer, and such would dissuade young people like yourselves from starting to smoke? Why or why not?


Do you think the warnings on cigarette packages from the United States should be stronger? In what ways?

Page 10.6.7

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued)





Cigarette warning labels required on tobacco products sold in Brazil





Cigarette warning labels required on tobacco products sold in Canada

Page 10.6.8

Lesson 10-6: Convincing

Others Not to Smoke

Procedures: (continued) 6.

If the students could design warning labels that would appeal to Deaf youth like themselves, what would those labels look like? Divide the class into groups and ask them to prepare a health alert message to put on cigarette packages and other tobacco products, into pamphlets, in videos, or on posters. Ask students to think about how they would appeal specifically to Deaf young people like themselves. Would they use the same message in each of these places? Why or why not? Have the students present their messages to the class.


Using the 10 Best Reasons Not To Smoke While You're Pregnant pamphlet by Journeyworks Publishing Inc., internet and library resources, have students identify the harmful effects that smoking has on the unborn child. List these on the board.


Review with the class the current Surgeon General's warning labels that refer to pregnancy and smoking. Have them discuss the following: W

Do you think this message is powerful?


Compare this label with those required by other countries. Do you think the existing labels required by the U.S. government for pregnant women are strong enough, or should they be stronger? Why or why not?


Explain to students that they are going to undertake a project to influence younger students to NOT smoke. W

They will start a program called BE SMART, DON'T START.


They will each write a letter to a younger student.


The purpose of the letter is to convince the younger student NOT to smoke. The letters should include information about the effects of smoking on the body, decision-making, and refusal skills.


Teacher’s Note This project can be undertaken as an imaginary one, or you may think about implementing this to target students in the lower grades.

Students can then work in groups to design a poster for the BE SMART, DON'T START project.

Journal: Think about the materials you have reviewed. If you were in charge of providing an anti-tobacco program for your school, what would you do? Why?

Page 10.6.9

Lesson 10-7

No Smoking Allowed! Anti-Tobacco Regulations Introduction:

This lesson introduces students to laws and policies that limit smoking in various locations. These grew out of the grassroots Non-Smokers’ Rights movement.

Lesson Objectives: By the end of Lesson 10-7, students will: W

Be aware of some of the rules governing smoking in their community.


Research their community’s laws about public and workplace smoking using the internet and other sources.

Materials: W

The Facts About Smoking in Public Places Worksheet

Key Terms: Non-Smokers' Rights: Non-smokers have sought to achieve smoke-free places where people are not exposed to secondhand smoke. By mobilizing political support through education and legislation, this movement has produced laws and policies which prevent smoking in many places such as schools, government buildings and workplaces.

Data Resource: It is useful to be familiar with the ordinances governing smoking and tobacco use in your local community. Your community’s ordinances may be listed on sites such as the following: www.no-smoke.org/lists.html In addition, some state and local governments and other private agencies maintain state-specific lists, such as the following for New Jersey: www.njgasp.org Additional information by state can be found using the American Lung Association’s database on stateby-state tobacco control legislation at: http://slati.lungusa.org/about.asp Many states and local departments of health also have special offices concerned with tobacco control. In California, this office is housed in the Tobacco Control Section of the California Department of Health Services: www.dhs.ca.gov/ps/cdic/ccb/tcs/Index.htm In New Jersey, the state-level office is the Comprehensive Tobacco Control Program of the New Jersey Department of Health and Senior Services: www.state.nj.us/health/as/ctcp/ By doing some preliminary research into appropriate agencies in your community, you can provide your students with a valuable starting point for their research.

Page 10.7.1

Lesson 10-7:

No Smoking Allowed!

Procedures: 1.

Explain to students that in recent years, many communities and states have established rules about where people can and cannot smoke.


Develop with your students a list of voluntary organizations, and state and local government agencies, that can provide them with information about smoking control, and rules and regulations regarding tobacco control in their community and state. Start with the websites listed in Data Resources above.


Distribute the Fact Finding form to students. The class will work together to learn the answers to the questions on the form. You can divide the questions among your students or investigate each one as a class.


Students will share information so that each student has a complete and accurate form.


Ask your students to identify who makes these rules in these places?


Facilitate a class discussion about the student's opinions of these restrictions on smoking. Do students support the restrictions? Why or why not?


Discuss some of the other ways besides legislating smoke-free areas that governments have sought to control smoking: W

Media campaigns: Anti-tobacco advertising


Bans on tobacco advertising on television in particular; and more recently, striking agreements with tobacco companies to bar advertising from billboards, public transit, magazines with a large youth readership, etc.


Taxation of tobacco products: Governments require taxes on the sale of tobacco products. What effect does raising (or lowering) these taxes have on the price of cigarettes? How might this affect smoking rates?


Controls on the sale of tobacco products: Governments have sought to exert more control over how and where tobacco products can be sold. These include the proximity of sales outlets to schools and other areas where young people congregate; enforcing minimum age requirements for the sale of tobacco products; outlawing the sale of cigarettes in vending machines; etc.


Requirements for health warnings on all tobacco packaging and advertising.

Page 10.7.2

Lesson 10-7:

No Smoking Allowed!

Procedures: (continued) Journal: Do you think that restrictions on smoking areas help people to quit smoking? Why or why not?

Page 10.7.3

Lesson 10-7 Worksheet: The Facts About Smoking in Public Places

Name __________________________________

The Facts About Smoking in Public Places Instructions: Do any of the following places allow smoking? Who makes the rules in each of these places? Use the internet, telephone, library, interviews with local, state and national officials, contacts with voluntary agencies, and any other means available to you to find out the following information. Be sure to write your source of information for each item.

Allows Smoking? Location Schools Restaurants Shopping Malls 7-11 Stores Movie Theatres Basketball Arena Baseball Stadium Bowling Alleys Grocery Stores Office Buildings Hospitals College Campuses Government offices (such as the Post Office or City Hall) Airplanes and Airports Parks and Beaches



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