Hands Off Tobacco: 11th 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

11th Grade Lessons:

Needed Materials and Preparations Lesson 11-1

* Worksheet: Road to Improvement (transparency and handouts) Blank index cards

Lesson 11-2

* Worksheet: D.A.R.E. Decision-Making Process (transparency and handouts) * Decision cards

Lesson 11-3

* The ABCs of Smoking booklet and transparencies * Mechanical Smoker * Anti-tobacco warnings for tobacco packaging Balloon for each student * Coffee stirrers (small, hollow straws) for an emphysema demonstration A wristwatch or clock with a second hand 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 11-4

* Graphic: The Addiction Cycle * Matching Game Cards

Lesson 11-5

* Prevention posters or advertisements related to smoking, alcohol and other drugs, drunk driving, and other health behaviors * Tobacco advertisements * Anti-tobacco materials and advertisements

Lesson 11-6

* Worksheet: The Costs of Smoking * Worksheet: Tobacco Sales * Map of State Cigarette Tax Rates Handout * Tobacco Taxation Fact Sheet Handout * Journeyworks, Inc. pamphlet: Tobacco and Money: What Does Smoking Really Cost?

Lesson 11-7

* Tobacco Advertisements * Postcards from the American Cancer Society

* 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.

11th Grade Lessons Materials List

Lesson 11-1

Developing a Self-Improvement Plan Introduction: This lesson examines the value of making a plan when trying to change a behavior. It explores the importance of taking into account barriers that emerge and need to be addressed and triggers that result in going back to old behaviors.

Lesson Objectives: By the end of Lesson 11-1, students should be able to: W

Define concepts of self-esteem and self-image


Identify an area of self-improvement they would like to undertake


Make an action plan for this self-improvement


Identify situations and other triggers that may impede their progress


Strategize ways to deal with these triggers


Identify people who will help or hinder their progress, and explain why

Materials: W

Road to Improvement Worksheet (transparency and handouts)


Blank index cards

Key Terms: action plan: a detailed sequence of steps one plans to take to achieve a desired outcome. barrier: something that keeps people from acting on their plans in the ways that they would like. self-esteem: one’s sense of confidence and satisfaction in oneself; self-respect.

self-improvement: taking action to make ourselves better. social support: help from one’s friends or family members that can be crucial for changing health behavior such as quitting smoking. trigger: something that can cause people to go back to an old behavior they are trying to change.

Page 11.1.1

Lesson 11-1:

Developing a Self-Improvement Plan

Procedures: 1.

Ask students to identify one aspect of themselves that they would like to improve upon. This might include a change such as, for example, doing better in school, losing weight, becoming more outgoing, getting into better physical shape, or stopping smoking.


Ask students to visualize what things will look like or feel like if they make this change. How would life be different? Would there be an impact on relationships? school performance? financial status? appearance?


Teacher’s Note: Key starting points in the curriculum for each grade level are the concepts of self-esteem and self-image. We start with these ideas because they are critical to how people act and behave, to how others respond and react, and to how these reactions and responses are perceived. Your students may have covered these concepts in earlier grades. If not, you may want to draw on the materials in lessons 7-1, 8-1, 9-1 or 10-1 as appropriate, in discussing these issues with your class.

Distribute the Road to Improvement worksheet. Explain to students that any time there is something to be done, it is good to have an action plan. An action plan describes the steps that need to be taken to achieve a goal. It can help a person anticipate the steps they will need to take, and identify any difficulties they may encounter in pursuing their goal. Have your students consider what some of these difficulties might be. These might include situations people find themselves in. The behavior of friends, peers and other people can often make it difficult to keep to a plan. W

If you are trying to lose weight, friends who ask you to go with them to buy french fries and a milkshake every day after school may make it hard for you to stick with a weight loss plan.


If you are a smoker trying to quit, friends who continue to offer you cigarettes, or who smoke in front of you, may make it hard for you to avoid


smoking yourself. How you feel about yourself can also influence your actions and behaviors. W

If you are trying to improve your study habits, feelings of stress, tiredness, boredom, hunger, sadness, or loneliness may lead you to put your books down, or keep you from doing your work. L111_Friendsmoke


If you are trying to lose weight, but one day feel particularly depressed because of a hard day at school, you might decide to treat yourself to a large bowl of ice cream to help yourself feel better.

Page 11.1.2

Lesson 11-1: Developing

a Self-Improvement Plan

Procedures: (continued) People, situations or self-concepts can be barriers that keep people from acting on their plans in the ways they would like. They can also be triggers that cause people to go back to the old behaviors they are trying to change. If a person learns to identify their barriers and triggers, they can plan for how they will react to them to keep from straying from their plans.


Describe the following to your class: John is a school mate who wants to get better grades. What steps can you identify that would help John achieve this goal? What people might help him? What situations might hinder him? How might John’s self-concept create difficulties for him? How can John deal with these barriers and triggers? Work with your class to complete an action plan using the Road to Improvement Worksheet transparency. This should include listing steps that will help John achieve his goal and the barriers and triggers that he might encounter.


Give students class time to identify an area of improvement and to complete the Road to Improvement worksheet for a change they would like to make in their own life. Invite your students to share their action plan with the class. Ask the class to provide

Teacher’s Note: Sharing the plans should be voluntary, and students should be advised of this.

additional ideas to enhance each student's action plans. List on the board the Barriers and Triggers that students

Teacher’s Note:



Distribute blank index cards. Ask your students to write down the goal they identified. Ask them to then list several of the triggers that they might encounter on the card along with strategies for resisting these triggers. Explain to your students that these strategies become part of their action plan. Your students can tape the card to the mirror in their room or carry it in their pocket.

Discuss with your class that social support for achieving the goals of an action plan can be very helpful. However, friends, peers and others who care about a person do not always provide this help and support. Sometimes, they can create barriers and provide unwelcome triggers. “Smoking buddies,” “ice cream buddies,” “buddies who share play time but not work time activities,” and others can feel unhappy and betrayed when changes are made in behaviors they have been a part of. They can sometimes try to sabotage these changes, which can create problems.

Journal: If you were a smoker, why do you think your “smoking buddies” might not want you to stop smoking?

Teacher’s Note: Completion of the cards could also be a homework assignment.

Page 11.1.3

Lesson 11-1 Worksheet: Road to Improvement

Name __________________________________

The Road to Improvement! My Goal:

More steps to help me reach my goal: Possible barriers to these steps:

Possible barriers to these steps:

More steps to help me reach my goal:

Steps to help me reach my goal:

Lesson 11-2

It’s Your Decision: You Decide! Introduction: This lesson discusses factors that influence the decisions people make. It also examines the decision making process. Students will review and practice the D.A.R.E. decision making process.

Lesson Objectives: By the end of Lesson 11-2, students should be able to: W

Discuss factors that help them make important decisions such as whether or not to smoke


Identify which factors have the greatest influence on the decisions they make and why

Materials: W

D.A.R.E. Decision-Making Process Worksheet (transparency and handouts)


Decision cards

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: (D) define the decision: What is the decision to be made? What are the issues? Do you understand them?

decision factors: things that can influence decision-making, such as opinions of peers, friends, or family members. family values: beliefs and standards held by family members. short and long-term goals: things one strives to achieve.

(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 11.2.1

Lesson 11-2:

It’s Your Decision: You Decide!

Procedures: 1.

Divide the class into pairs of students. Give each pair of students an envelope containing a Decision Card, and a Decision Making worksheet. On each card, one of the following decisions to be made will be written: W

Should I try out for the swim team?


Should I smoke?


Should I shave my head if I go to Gallaudet University as other freshman do?


Should I have sexual intercourse?


Should I gossip about my classmate?


Should I borrow my friend’s GameBoy without asking?


Should I go to college?


Should I go to a college with many Deaf students? With mainly hearing students?


Teacher’s Note: Explain the elements of the D.A.R.E. Decision Making Process Model using the transparency. Explain that rather than only making a final decision, the model calls for identifying and listing the factors to be taken into account when making decisions. This includes assessing consequences for each choice that could be made. Discuss with your students what they are thinking about when they have to make a decision.

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, and is based on 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, it is very likely 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.


What do I want?


Will the decision affect my health or safety?


What would my friends say?


Do I have any similar past experiences?


What might my parents say or do?


What do I know about the effects that this decision might have?


How would it affect other areas of my life?


Will this decision affect my short or long term goals?


What else might you consider in making this decision?

Page 11.2.2

Lesson 11-2: It’s

Your Decision: You Decide!

Procedures: (continued) Discuss with your class how family values, friend's values, older kids, future goals, past experience, or product advertisements can influence decisions.


As a class exercise, use the following example to review the D.A.R.E. Decision Making Process: I want to use my mom's car. She is not home, and although I do not have permission to use the car, I have the car keys. Should I use my mom's car without asking for permission?


Ask students to use the same process to address the decisions on their Decision Cards. Ask them to list on their worksheet the factors that would influence their decisions and to assess the consequences of the choices they made.


When each pair has completed their worksheets, ask the class to discuss the factors identified by their classmates and other possible influences that could be taken into account. Ask your students to think about the factors that seemed to influence them more than

Teacher’s Note: Review lesson 9-2 for a discussion of peers, friends and the influence process.

others. For example, did they always worry about what their friends think? Do they ever consider their future goals? Ask your students why they think some decisions are easier to make than others. Discuss with them the difference between peers and friends. In what kinds of decisions do these people play a part? How do peer influence and peer pressure occur?


Explain to students that it is important to be aware of why they make the choices they do.


Is the decision to use tobacco products different from or the same as the decision to use other substances such as hard drugs or alcohol? In what ways? Things to consider are the legality of the drug for minors and adults, the impact of the drug when used, the health effects, the addiction, product marketing, and the roles of peers and friends.

Teacher’s Note: You may also want to consider other frequently mentioned reasons for starting to use tobacco products (See Lesson 8-5). These include stress relief, getting an energy boost or having fun. To what extent do these reasons apply to using tobacco, hard drugs and alcohol?

Journal: Who is the person who most influences me in my decision-making and why?

Page 11.2.3

Lesson 11-2 Decision Cards

Decision Cards Should I try out for the swim team?

Should I smoke?

Should I shave my head if I go to Gallaudet University as other freshman do?

Should I have sexual intercourse?

Should I gossip about my classmate?

Should I borrow my friend’s GameBoy without asking?

Should I go to college?

Should I tell a teacher about my friend smoking marijuana behind the gym after school?

Lesson 11-2 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 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. “I want to use my mom's car. She is not home, and although I do not have permission to use the car, I have the car keys. Should I use my mom's car without asking for permission?”

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 11-3

Health Impacts of Smoking Introduction: This lesson reviews and demonstrates the health impacts of smoking and gives students the opportunity to consider the effects of tobacco use at all ages. If a guest speaker is invited, students can experience a personal story of these health effects. Cigarette warning labels are discussed and students can evaluate to what extent they are adequate.

Lesson Objectives: By the end of Lesson 11-3, students should be able to: W

Explain that smoking can cause various illnesses including emphysema, heart disease and lung cancer


Interview a person who has emphysema or heart disease or a respiratory therapist to discuss illnesses related to smoking


Evaluate warning labels and how they have changed over time

Materials: W

The ABC’s of Smoking Booklets and Transparencies


Mechanical Smoker


Balloon for each student


Coffee Stirrers (hollow straw type)


A wristwatch or clock with a second hand


Tobacco package warning labels (provided on CD)

Plan Ahead! Contact the American Lung Association, the American Cancer Society, or your local Health Department or hospital to arrange for a guest speaker to talk about the health effects of tobacco use. Ask for a signing speaker. If one is not available, ask the school principal to arrange for an interpreter. Prior to the arrival of the guest speaker, find out if they are willing to be videotaped so their presentation can be used in the future.

Key Terms: cancer: a term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body. chemotherapy: treatment that involves administering medicines that kill cancer cells, sometimes with severe side effects such as nausea, hair loss, and weakening. coronary heart disease: a condition in which the arteries that supply the heart with blood (and oxygen) narrow from an accumulation of plaque (atherosclerosis), causing a decrease in blood flow to the heart.

emphysema: a chronic disease in which the lungs lose their ability to absorb oxygen. A primary cause is smoking, while air pollution, environmental or occupational hazards, and genetic factors may also play a role in this disease. heart attack: also called myocardial infarction; damage to the heart muscle due to insufficient blood supply and lack of oxygen. lung capacity: the amount of air one can hold in one’s lungs. radiation: the use of high-energy radiation from x-rays, neutrons, and other sources to kill cancer cells and shrink tumors. Radiation therapy affects cancer cells in a targeted area.

Page 11.3.1

Lesson 11-3:

Procedures: 1.

Tell your students that tobacco use, especially smoking, increases morbidity (sickness) and mortality (death). In fact, tobacco use is the #1 preventable cause of death and disease in

Teacher’s Note: Some of the most important health effects of tobacco use have been described in prior lessons (see 8-6, 94, 10-4 and the introduction to the curriculum). If your students have already had these prior lessons, you may be able to move quickly through the material presented in this lesson. If not, a careful and detailed discussion of the material presented here is appropriate.

the United States.


What is smoking, and how does it affect your health?

Valuable Resource: Additional sources of excellent information about the health effects of tobacco use can be found online at: http://www.cdc.gov/tobacco/sgr/ sgr4kids/sgrmenu.htm

Use the Mechanical Smoker machine to show the mechanics of smoking, and to

http://tobaccofreekids.org/research/ factsheets/index.php

demonstrate the build-up of smoking residue on the lungs. Point out the residue on the

Check This Out!:

inside of the machine, and explain how inhaling cigarette smoke into the lungs leaves this residue behind. This residue contains chemicals, including tar and nicotine that cause both

A wonderful interactive animated presentation of the effects of tobacco on different organ systems in the body can be found at:

health effects AND addiction.


Health Impacts of Smoking

Pass out balloons to all students. Each student

http://www.cdc.gov/tobacco/sgr/ sgr_2004/sgranimation/flash/ index.html

should take as deep a breath as possible, blow as much air as possible into the balloon (one breath only) and then tie them. Explain to the class that their lungs held this air before the balloon did. Every person's lungs have a different lung capacity. Notice the different size of the balloons in the room. There is a good chance that students who are athletes will have bigger balloons (i.e., were able to expel more air into the balloon) than non-athletes, and that non-smokers will have bigger balloons than smokers. Explain to students that certain things can increase or decrease lung capacity. Ask students to discuss what they


think these may be. If students do not mention smoking, explain that smoking decreases lung capacity. It also significantly increases a person's risk for lung-damaging diseases such as emphysema and lung cancer.


Ask the class if anyone knows what emphysema is. Explain that emphysema is a disease that destroys the lungs' ability to absorb oxygen. What does this mean? Explain to your students that emphysema is a disease process

Teacher’s Note: An effective demonstration of what it feels like to have emphysema is presented on the next page. If your students have not tried this exercise in a previous grade, you can use it to great effect here.

in which smoking can play a major role. The smoke irritates the

Page 11.3.2

Lesson 11-3: Health

Impacts of Smoking

Procedures: (continued) tissues of the lung, and over time leads to a breakdown in the lungs' alveoli sacs, where oxygen from the air in the lungs is taken into the bloodstream. When the alveoli sacs are destroyed, the body cannot extract the oxygen from the air in the lungs. Emphysema makes it very difficult to breathe. There is no cure for emphysema. It is a progressive disease that just gets worse, and is usually fatal.


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

Emphysema is only one of the diseases that can result from smoking. Smoking can also cause cancer. Tobacco smoke contains many different chemicals, some of which can cause damage to the genetic information contained in the body's cells. In the lung, this damage can lead to lung cancer. Lung cancer is the uncontrolled growth of abnormal cells in one or both of the lungs. While normal lung tissue cells reproduce and

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.

develop into healthy lung tissue, these abnormal cells reproduce rapidly and never grow into normal lung tissue. Cancer cells (tumors) then form and disrupt the lung, making it difficult for the

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.

lungs to function properly.

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.


Page 11.3.3

Lesson 11-3: Health

Impacts of Smoking

Procedures: (continued) What does emphysema look like? Compare the healthy lung on the previous page with the lung from a person with emphysema at left. Chemicals from tobacco eventually end up in the urine, which then collects in the bladder. The bladder is then bathed in these cancercausing chemicals, which can cause bladder cancer. L113_emphysema L113_BladderCancer

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. L113_OralCancer



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. Smoking can lead to high blood pressure, which in turn can cause a stroke, or bleeding in the brain. The damage that strokes can do is clear in this specimen at right.

L113_Stroke L113_Larynx

Page 11.3.4

Lesson 11-3: Health

Impacts of Smoking

Procedures: (continued) The same chemicals that damage lung cells can also cause damaging cellular changes in other organs of the body, leading to other cancers in organs and tissues such as the mouth and nasal passages, esophagus, cervix, pancreas, bladder, and others. Cancer can often be treated. However, cancer treatment—chemotherapy, radiation therapy, and other treatments—can have severe side effects, including nausea, hair loss, diarrhea, weakening, and extreme weight loss. Moreover, chemotherapy is not always successful.


Smoking can also contribute to heart disease. The chemical called tar in tobacco narrows the arteries that carry oxygenated blood to the body, meaning that the heart must pump harder and faster to do its job. Over many years, this can damage the heart. The heart itself also suffers from the body's reduced ability to oxygenate its blood. This damage can lead to heart failure, or a heart attack. Because smoking narrows the arteries supplying blood, it increases the chance that a person will experience a stroke, or a blockage of blood to the brain. When a stroke happens, portions of the brain are deprived of oxygen and suffer damage. (See the illustration on the previous page.) This damage can be mild or severe, and can result in paralysis and even death. Ask students if anyone they know has ever suffered from any of these conditions.


Have your students consider the warning messages that smokers receive when it comes to these consequences of smoking. W

Point out that the United States was the first country in the world to introduce health warning. The first warning label on cigarettes came about in 1965. The message said

Teacher’s Note:


No additional warning labels were allowed. W

In 1969, the message was changed to read


All of these labels used on cigarettes in the United States represented a compromise between the government and the tobacco industry. Other countries such as Canada, Australia, Brazil and countries in the European Union have implemented stronger labels with bold print, large font and hard hitting pictures and package inserts. See the following examples and use them with your students for a discussion on how warning labels might be designed to be more effective.

No additional warning labels were allowed.

Page 11.3.5

Lesson 11-3: Health

Impacts of Smoking

Procedures: (continued) W

In 1984, the messages were changed again. Now, 4 rotating messages were included :


No additional warning labels were allowed on cigarettes. W

In 1986, a law was passed to put three rotating warning labels on smokeless tobacco.




Ask what your students think about these changes. Do they think that the labels that are now on cigarettes are strong enough to discourage people—especially young people—from smoking? Why do they think the laws prevented other messages? Have your students consider how the United States might make messages stronger. Have them review some of the warning labels from other countries. Remind your students as they consider this question that “a picture is worth a thousand words.”

Homework: Ask your students to go on an internet “Tobacco Facts Scavenger Hunt” to collect information on the consequences of tobacco use. They can collect specific facts and statistics about the impact of tobacco use in the United States and elsewhere. These could include facts on short- and long-term health consequences, and the social and economic costs of tobacco use to individuals and the society. Students can work in teams. Every student should come up with at least 20 facts. This exercise could be a team competition.

Page 11.3.6

Lesson 11-3: Health

Impacts of Smoking

Procedures: (continued)




Cigarette warning labels required on tobacco products sold in Brazil





Cigarette warning labels required on tobacco products sold in Canada

Journal: What will you remember about the guest speaker and why? OR In addition to health effects of smoking, what are some social effects of smoking?

Page 11.3.7

Lesson 11-4

The Addiction Cycle Introduction: This lesson explains in detail the phases of the addiction cycle. It also discusses different ways to quit smoking.

Lesson Objectives: By the end of Lesson 11-4, students should be able to: W

Define the terms addiction, withdrawal, addiction cycle and cessation


Discuss reasons people quit smoking


Define relapse


Identify reasons people might relapse


List cessation strategies

Materials: W

Graphic: The Addiction Cycle


Matching Game Cards

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. addiction cycle: The sequence of steps that spiral into addiction, involving the gradual development of physical dependence, along with the growing importance of withdrawal symptoms, in encouraging and reinforcing continued tobacco use.

craving: An intense and prolonged desire; for those addicted to nicotine, it is usually manifested as an intense desire for cigarettes or other tobacco product. 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 that the body has become addicted to.

cessation: In terms of tobacco use, the process of stopping all tobacco use, particularly after one has already become addicted.

Page 11.4.1

Lesson 11-4:

Procedures: 1.

Ask your students if anyone can define the term addiction. For example, one teenager has described it as “Addiction is needing to smoke first thing in the morning, not just when you are bored or hanging out with your friends.” 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

The Addiction Cycle

Teacher’s Note: Review findings from the scavenger hunt homework from the prior lesson. That is, use these facts to emphasize the consequences of tobacco use. Although many people, including many smokers, know these facts, they still cannot quit. Use this review to introduce the concept of addiction.

Teacher’s Note: The addiction cycle has been described in detail in grade 9-5 and 10-5. If students have been exposed to this information in prior grade levels, the information presented here can be reviewed briefly.

substance to obtain this pleasant feeling. W

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.


Use the graphic of the Addiction Cycle to guide the following discussion: W

Nicotine is an addictive substance that is found in all tobacco products: cigarettes, cigars, pipe tobacco and chewing tobacco. Research shows that nicotine is as addictive as heroin and cocaine. If a person is addicted to nicotine, their body craves it.


Most people start using tobacco when they are young. The addiction process starts with experimentation. When a person first uses tobacco, he or she may feel dizzy and nauseous, and the smoking can sometimes cause the smoker to feel sick.


If the person continues to “try” smoking, these initial physical reactions may subside as the body becomes accustomed to inhaling smoke. At this time, the smoker may begin to have feelings of mild pleasure and relaxation with the act of smoking. This is due to the nicotine that is in tobacco. Nicotine reaches the brain within 10-20 seconds from the start of a puff. It releases chemicals in the brain that affect mood and performance.

Page 11.4.2

Lesson 11-4:

The Addiction Cycle

Procedures: (continued)

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.


Because nicotine affects the pleasure center of the brain, it can suppress appetite, improve performance and memory and reduce anxiety and tension. W

These physical responses of pleasure and relaxation may lead a person to more regular use. However, the brain and body also become less sensitive to the pleasurable effects of nicotine. This means that the smoker needs to smoke more, and more often, in order to receive the same pleasurable sensations.


These are the first steps to addiction/dependency. This is the process by which your body and brain cells become dependent on the nicotine in tobacco. While providing nicotine may cause pleasurable sensations in the body, withholding nicotine starts to cause a number of unpleasant sensations


These physical symptoms are known as withdrawal. 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. Most withdrawal symptoms are very strong 24-48 hours after cessation of tobacco. For most people, they gradually start going away over several weeks. Some

Page 11.4.3

Lesson 11-4: The

Addiction Cycle

Procedures: (continued) symptoms, such as eating more than usual, weight gain, and craving cigarettes (particularly in stressful situations) may go on longer. W

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. If the body becomes dependent on a drug, the person experiences a range of discomforts if deprived of the drug.


Most people who experiment with, and begin to casually use, tobacco, plan to quit when they get older. But most people are unable to quit once they've become addicted.


Page 11.4.4

Lesson 11-4:

The Addiction Cycle

Procedures: (continued) 3.

Ask students to describe the symptoms of withdrawal. As they mention symptoms, write them on the board. Ask students how a person experiencing these symptoms might deal with them. Use the following list for guidance: W

Feeling irritable, moody, or tense—try to relax, take a walk


Headaches or dizziness—sit or lie down and close your eyes


Feeling restless—walk, exercise or do a hobby


Insomnia—avoid caffeine, do relaxation exercises


Upset stomach or constipation—drink lots of water, eat more fruits and whole grains

Teacher’s Note: The key concept here is to have students understand the difficulties of stopping smoking and therefore the value of never starting in the first place.


Coughing—drink water, juice, warm tea (decaf)


Drowsiness or fatigue—get fresh air, take a nap


Difficulty concentrating—take a break, get some exercise


Increased appetite—drink water, eat healthy snacks, exercise


Dry mouth or sore throat, gums and tongue—drink water, suck on ice

Point out to students that when a person stops smoking, he has to cope with the physical changes associated with nicotine withdrawal, AND he also has to learn new ways to cope with stressful situations, that do not include smoking a cigarette.


People stop smoking either all at once (cold turkey) or more gradually (tapering or cutting down until you stop entirely). There are different strategies that people use to quit: W

Support Group: Join other people who also want to quit using the drug. Group members can support and encourage each other, understand each other's feelings, and provide assistance with withdrawal symptoms.


Counseling: A professional counselor can help a person who wants to quit by helping them talk about their feelings, stress, or how to cope with withdrawal symptoms and other aspects of the quitting process. Counselors may also use other methods to help people quit smoking such as biofeedback, relaxation exercises and hypnosis. Physicians and other health providers can also offer counseling face-to-face or by telephone (hotline).


Nicotine Replacement Therapy (NRT): Some people use The Patch, Nicotine Gum, Nicotine Nasal Spray, or Nicotine Inhalers to help them stop smoking. NRT is a way for people to still get small doses of nicotine without smoking or using smokeless tobacco. Each day they use less and less until

Page 11.4.5

Lesson 11-4:

The Addiction Cycle

Procedures: (continued) their body does not feel cravings or withdrawal anymore. Some of these NRT products are available over the counter for people who are 18 or older. Physicians can prescribe NRT for minors. W

Medication: Some people get a medication from the doctor called an antidepressant. The anti-depressant drug helps the brain get used to living without nicotine again. These drugs require a prescription.

Ask your students if they think that NRT or anti-depressants are appropriate for younger smokers who want to quit. Do the benefits outweigh any possible risks?


Explain to your students some of the changes that occur in the body when someone quits smoking: W

within 20 minutes of quitting: k Blood pressure drops to normal. k Pulse rate drops to normal.


within 8 hours of quitting: k Carbon monoxide level in the blood drops to normal.


24 hours after quitting: k Chance of heart attack decreases.


48 hours after quitting: k Improved sense of smell and taste.


72 hours after quitting: k Lung capacity increases. k Breathing becomes easier.


Two weeks to three months after quitting: k Lung function increases. k Circulation improves.


One to nine months after quitting: k Body's overall energy level increases. k Coughing, sinus congestion, fatigue, and shortness of breath all decrease. k Cilia regain normal function in lungs, increasing ability to handle mucus, clean the lungs, and reduce infection.


Ten years after quitting: k Lung cancer death rate is half that of a continuing smoker.

Page 11.4.6

Lesson 11-4:

The Addiction Cycle

Procedures: (continued) k The chance of developing cancer in other parts of the body, including the mouth, throat, esophagus, bladder, kidney and pancreas, also decreases.


Review with students the meanings of new terms by having the class match the term to its definition on the Matching Game Cards.


Discuss with your students the advantages and disadvantages of cessation. Be sure to include health, social and economic considerations. Review with your students the difference between prevention and cessation.

Journal: Do you know anyone who has ever quit smoking? What methods did they use to try to stop smoking? Which methods worked for them? What do you think is the most effective way to quit and why?

Page 11.4.7

Lesson 11-4 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.

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.


Lesson 11-4 Matching Game

Matching Game Cards Nicotine

An addictive substance (nicotine)

Addiction Cycle

1) Experimentation 2) Regular Use 3) Dependency/Addiction (The Addiction Cycle)


The feeling of needing something very badly (craving)


Unpleasant physical and psychological feelings that occur when you stop using a drug to which you’ve become addicted. (withdrawal)

Smoking Cessation


Quit smoking (smoking cessation)

Go back to using a drug such as tobacco after you’ve already tried to quit. (relapse)

Tapering Use

Quitting by using less and less of a drug each day. (tapering use)

Cold Turkey

To quit using a drug or substance abruptly, without ever touching it again. (cold turkey)

Nicotine Replacements

The patch, nicotine gum, nicotine inhalers (nicotine replacements)


Helping someone to quit smoking by talking, biofeedback, relaxation, hypnosis. (counseling)


Medicine prescribed by a doctor to help a person quit smoking. (anti-depressant)

Nicotine withdrawal symptoms

Moodiness, anxiety, increased appetite, stomach aches, nausea, insomnia, inability to focus (nicotine withdrawal symptoms)

Reasons to Quit Smoking

Health, pregnancy, money, family, friends (reasons to quit smoking)

Lesson 11-5

Promoting Healthy Decisions Introduction: This lesson introduces students to the concept of marketing. It examines how products such as tobacco are promoted. It also talks about campaigns to promote healthy decisions such as, for example, tobacco counter-advertising campaigns. The goal of this lesson is to have students think about the many ways in which the tobacco industry seeks to manipulate young people to start smoking, and what those concerned about this problem have tried to do to limit the industry's influence.

Lesson Objectives: By the end of Lesson 11-5, students should be able to: W

Recognize tobacco marketing strategies


Identify strategies used in campaigns to promote healthy decisions, such as the decision not to smoke.


Use marketing techniques to create an anti-tobacco advertising campaign for teens

Materials: W

Prevention posters or advertisements related to smoking, alcohol and other drugs, drunk driving, and other health behaviors


Tobacco advertising samples (provided on CD)


Anti-tobacco materials and advertising samples (provided on CD)

Key Terms: advertising campaign: when a business or group tries to sell an idea or product to a group of people. Advertising campaigns use different strategies to sell depending on the group they want to convince or target.

marketing: the steps a business or group takes to convince others to buy a product or believe an idea. This usually involves emphasizing positive things about the product or idea, for example, that smoking is fun, relaxing and cool.

counter-advertising: when a group or organization tries to lessen the impact of an advertising campaign by presenting other information. For example, governemnt health agencies try to show the negative health and social impacts of smoking to counter the tobacco industry’s ads that portray smoking as glamorous and fun.

Page 11.5.1

Lesson 11-5: Promoting

Healthy Decisions

Procedures: 1.

Display the health promotion posters supplied with the lesson materials. Ask students to identify what message each poster is trying to convey. The class should make a single statement of the message of the poster and tape it below the poster. For example, for an ad about drunk drivers, the message might read: "Don't drink and drive because it can kill you or others."


Ask your students to identify any other campaigns that they have seen that target health or other social issues. Examples might include: W

Partnership for a Drug Free America (Alcohol and other drugs)


The More You Know Series (parenting, literacy, prejudice, child abuse and other topics) (www.nbc.com/footer/tmyk/)


Take a Bite Out of Crime (McGruff the Crime Dog) (www.mcgruff.org)


The Truth Campaign (www.thetruth.com)

What do these campaigns involve beside the kind of print ads the class has been examining? These might include for example TV ads, newspaper stories and billboards.


Now ask your students specifically to think about the marketing campaigns of the tobacco industry. Ask students to identify in what ways tobacco companies spend money to promote their product. Use the images on the following pages to prompt discussions. Possible answers include: W

magazine ads


point-of-purchase displays (advertising placed right where you would normally buy a product; for example, tobacco ads near the cash register where you would buy cigarettes.)


sports event sponsorships


entertainment and cultural sponsorships


product placements in movies

Ask your students what appeals to them, if anything, in these ads. Is it the message? Is it the use of movie stars? Are the messages clear? Do they think the ads can be successful in getting people to think about their behaviors? Change their behaviors?


s Everyone has probably seen traditional advertising by tobacco companies, such as this Marlboro Cigarettes magazine advertisement. Why do you think the makers of Marlboros chose this particular image? Who would it appeal to?

Page 11.5.2

Lesson 11-5:

Promoting Healthy Decisions

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... L115_CamelCoupons




...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 11.5.3

Lesson 11-5:

Promoting Healthy Decisions

Procedures: (continued) Tobacco dollars are also used to hire celebrities to promote products. Why do tobacco companies want to use movie stars and models in portraying their products?


L115_AlecBaldwin L115_DemiMoore

The tobacco companies have also used “stealth� marketing techniques, sponsoring sporting events and producing lifestyle magazines and using them as advertising vehicles. Who do you think a women’s tennis match would appeal to? What about lifestyle magazines?

L115_PenelopeCruz L115_Navratilova


Free gifts with the purchase of cigarettes were an important marketing tool for tobacco companies. This practice has since been voluntarily restricted by the tobacco companies under the terms of the Master Settlement Agreement, although they still offer sales-linked coupons that are redeemable for a range of clothing, gadgets and other goods.



Page 11.5.4

Lesson 11-5:

Promoting Healthy Decisions

Procedures: (continued) 4.

Explain to your students that the 1998 Master Settlement Agreement was designed to limit tobacco marketing to young people. Have your students consider the following facts: W

The major cigarette companies now spend more than $11.22 billion per year (or more than $30.7 million every day) to promote their products.


Cigarette company spending to market their products increased by more than 67% from 1998 to 2001.


Magazine ads for each of the three most popular youth brands (Marlboro, Newport, and Camel) reached more than 80% of young people in the United States an average of 17 times in 2000.


Cigarette advertising in magazines with high youth readership actually increased by 33% after the Master Settlement Agreement, in which the tobacco companies agreed not to market to kids.


After tobacco billboards were banned by the Master Settlement Agreement the cigarette companies increased their advertising and promotions in and around retail outlets, such as convenience stores.

Ask students why tobacco companies make such an effort and spend so much money to promote their products. Possible answers include: W

to sell more product


to replenish the pool of smokers by replacing those who quit or die.

Who are these "replacement smokers?" Point out to your students that almost 90% of all regular smokers begin smoking at or before age 18, and once they start it is very hard to quit. This makes young people, such as your students, an important target for the tobacco industry. Do your students agree with this? Ask your students if they think that tobacco marketing really influences young people. Have your students consider the following research findings: W

Kids are more than twice as likely as adults to recall tobacco advertising.


Teens are more likely to be influenced to smoke by cigarette advertising than they are by peer pressure.


Adolescents who own a tobacco promotional item and who can name a cigarette brand whose advertising attracted their attention are twice as likely to become established smokers than those who do neither.

Page 11.5.5

Lesson 11-5:

Promoting Healthy Decisions

Procedures: (continued) Ask your students how they feel about being manipulated by these big tobacco companies!


Explain to students that while tobacco companies spend a great amount of money on advertising to sell cigarettes,

Teacher’s Note: You and your students can find more facts about tobacco marketing at: www.tobaccofreekids.org/factsheets

the government and various other organizations also make a tremendous effort to prevent people from smoking. These agencies support research and anti-tobacco programs, and the government has passed laws as part of anti-tobacco campaigns. Ask students what type of anti-tobacco marketing and strategies they have seen. Possible answers include: W

ads on television


the Truth Campaign posters


“No smoking� signs


school-based educational efforts




magazine ads


laws that prohibit smoking in the workplace, in public buildings, in public spaces, restaurants, bars


internet sites

Ask students why the government and other organizations are so concerned about preventing smoking. Possible answers include: W

the costs of treating smoking-related diseases


the social and economic costs of illness (missed days from work or school)


the social burdens of addiction and illness


the costs to society in terms of higher insurance rates


fire-related economic costs L115_ButtsGross

Anti-tobacco ads have sometimes used humor to attack smoking, as in these ads here.


Page 11.5.6

Lesson 11-5:

Promoting Healthy Decisions

Procedures: (continued)


“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 Look how these billboards are using the “glamour of smoking” as portrayed in tobacco advertisements, and L115_Scent turning the message around to point out why smoking is a bad idea... ...while carrying the “masculinity” of the Marlboro Man to its natural conclusion if one takes up smoking.



Page 11.5.7

Lesson 11-5:

Promoting Healthy Decisions

Procedures: (continued)

L115_TableforOne L115_BlewAway



Some anti-tobacco advertising portrays directly the deadly consequences of tobacco use.


Others borrow the technique of celebrity appeal to promote both tobacco use prevention and cessation.


L115_Smoking Is Ugly


Page 11.5.8

Lesson 11-5:

Procedures: (continued) 6.

Divide the class into groups of four students. Have the groups design an anti-tobacco campaign. Have each group consider the type of strategies they would choose to influence young people not to smoke. Review the appeal strategies used by marketers that were introduced in Lesson 9-3: W

Fun and Pleasure




Adventure and Excitement












Free Stuff!

Ask each group to choose the appeal strategy(ies) they will use. Ask each group to come up with an ad slogan or idea that would be suitable for a television advertisement or a poster. Have them consider, in particular, how to appeal to other deaf youth like themselves. Have these ideas ready by the next class.

Promoting Healthy Decisions

Teacher’s Note: This is a good point at which to introduce the fact that the government has had ambiguous policies towards the tobacco industry. On the one hand, the government has sought to control tobacco in many ways. For example:

W Supports research to better understand the health consequences of tobacco use, how to prevent such use, and how to help people stop smoking

W Provides education about the dangers of tobacco use

W Requires the placement of labels on cigarettes and other tobacco products

W Passes laws establishing "smoke free" public places On the other hand, there are many ways the government has failed to do all it could to control tobacco. For example, the government:

W Provides subsidies to tobacco farmers to keep them in business

W Has failed to place even stricter labeling and advertising requirements on the tobacco industry

W Has for many decades failed to identify tobacco

and nicotine as drugs, and therefore subject them to regulation as drugs

W Has failed to vigorously enforce laws about tobacco sales to minors

W Has failed to support international efforts to control tobacco advertising and sales, especially by American tobacco companies.

Consider why federal, state, and local government has not always taken stronger actions. Note the economic and political power of the tobacco industry.

Teacher’s Note: This activity can be expanded over several lessons. Students can design a more detailed plan—such as developing a script for a commercial. Students can also implement a campaign in school if time allows and if a video camera or other equipment is available. This might include introducing the concepts in the first session; allowing students to discuss and refine their ideas with their classmates in the second session; and then allowing perhaps a week or more to actually develop a finished product.

Journal: Which of the appeal strategies you talked about in class are most important for you and your friends? Why do you think that is so?

Page 11.5.9

Lesson 11-6

Controlling Access to Tobacco by Minors Introduction: This lesson explores some of the laws and policies that have been implemented to discourage young people from smoking. Your students should be able to recognize the relationship between these types of laws and individual behavior.

Lesson Objectives: By the end of Lesson 11-6, students should be able to: W

Understand the restrictions on the sale of tobacco to minors


Research the penalties for vendors who sell tobacco to minors


Calculate the economic costs of smoking to individuals


Understand public policy issues such as taxation as they relate to tobacco use

Materials: W

Internet access


Costs of Smoking Worksheet


Tobacco Sales Worksheet


Map of State Cigarette Tax Rates Handout


Tobacco Taxation Fact Sheet Handout (See L12_WebPages Folder)


Tobacco and Money: What Does Smoking Really Cost? Journeyworks pamphlet

Key Terms: minor: legal term for a young person, usually under 18 years of age. penalties: punishment. sting operation: In law enforcement a sting operation is an operation designed to catch a person committing a crime, by means of deception. For example, a teenager working with law enforcement might try to purchase tobacco from a store to identify store keepers that are not complying with laws limiting sales to minors. vendors: someone who exchanges goods or services for money.

Page 11.6.1

Lesson 11-6: Controlling

Access to Tobacco by Minors

Procedures: 1.

Pass out the Tobacco Sales Worksheet, and write the following questions on the board:



Is it legal to sell tobacco to a minor?


Is there a penalty for selling tobacco to a minor? What is the penalty?


Are the rules and penalties the same in all states?


What do cigarettes cost per pack?


What does chewing tobacco cost?


What taxes are charged per pack of cigarettes?


Divide the class into teams. Have your students find the answers to these questions for their community and state by: L116_SeeID


Calling or visiting a store that sells cigarettes

Teacher’s Note:

(make sure the students ask to see a store manager and explain that they are doing a class exercise) W

Researching online


Going to the library

Warn your students that their answers may vary, depending on where they find the information. For

The internet can be useful to your students in completing the worksheet. Much of the information can be found through a Google search (for example, searching for “tobacco tax rates new jersey”), or by visiting some of the web sites listed below. The Tobacco Free Kids site is particularly good. It has a series of “factsheets” which cover a number of the issues listed above in Procedure #1. Sites:

example, the price of a pack of cigarettes will vary considerably by brand, store, or whether they are


purchased online.




Assign an additional State to each team. Is the legal age to buy cigarettes the same in every state?

www.cdc.gov/tobacco www.cdc.gov/tobacco/tips4youth.htm www.cdc.gov/HealthyYouth/tobacco/ index.htm

Is the cost of a pack of cigarettes the same in every state? Have your students compare their notes to see if the rules are consistent across all states. Ask students why states and communities might differ in their policies towards taxation and L116_Misty

regulation of sales to minors.

Page 11.6.2

Lesson 11-6: Controlling

Access to Tobacco by Minors

Procedures: (continued) 4.

Explain to your students that in some communities, young people and police officers have conducted sting operations to identify vendors who sell tobacco products to minors, or people who are too young to legally purchase those products. Do you think this is a good idea? Will it prevent people from selling to minors? Do

Teacher’s Note: Under no circumstances should students attempt sting operations on their own. These must be conducted in conjunction with the local police.

you think it will prevent minors from smoking?


Distribute the Cost of Smoking Worksheet. Ask your students about the tax amounts they uncovered in their search in their own community and other states. If necessary use the handout Map of State Cigarette Tax Rates if students have not been able to locate materials on their own. Explain how the taxes can raise the price of cigarettes. What does this mean for young people


trying to buy cigarettes? (Answer: it makes them more expensive, and therefore more difficult to buy.) What else determines the price of a cigarette? Ask your students to report what they found out about the cost of cigarettes and chewing tobacco in local stores. Explain

Teacher’s Note: Students should consider that people who are addicted to tobacco will often give up other things to pay for cigarettes.

to students that smokers who are addicted to smoking often find they must smoke from half a pack (10 cigarettes) to more than two packs (40 cigarettes) per day. Ask your students to calculate, using the worksheet, how much a smoker would spend on cigarettes every year if they smoked half a pack; one pack; or two packs per day. How much will they have spent after five years? Ask your students to list some of the things they could buy with these amounts of money.

Teacher’s Note: Your students may want to explore the price of cigarettes in different countries on the internet. For example try http://ash.org or try a google search using keywords such as “cigarette prices international.”

Ask your students if they think this cost has an impact on whether or not people-especially young people-smoke. Why? Why not?


Ask your students to compare the cost of cigarettes in local stores and those sold on the internet. How difficult do your students think it would be to purchase cigarettes online? What are the difficulties in controlling internet sales to underage teens? Do people pay taxes when they buy cigarettes on the internet?


Ask how governments use these taxes as instruments of public policy. How do tobacco taxes and the cost of cigarettes in the United States compare to those in other countries? Use the Tobacco Taxation Fact Sheet Handout.

Page 11.6.3

Lesson 11-6:

Controlling Access to Tobacco by Minors

Procedures: (continued) Journal: What do you think is the best way to prevent stores from selling cigarettes and chewing tobacco to minors? Give reasons for your answer.

Page 11.6.4

Lesson 11-6 Worksheet: Tobacco Sales

Name __________________________________

Tobacco Sales Instructions: Complete the following chart regarding tobacco sales and young people, and the cost of cigarettes. You can find answers by conducting Google searches on the internet, visiting some of the web sites mentioned in class, or by visiting stores and finding out how much packages of cigarettes cost. Caution: If you ask store owners about policies regarding selling tobacco or cigarettes to minors, please be sure to inform them that you are conducting this as part of a class exercise.



Is it legal to sell tobacco to a minor?

Is there a penalty for selling tobacco to a minor? What is the penalty?

Are the rules and penalties the same in all states?

Cost per pack: What do cigarettes cost per pack?

What does chewing tobacco cost?

What taxes are charged per pack of cigarettes?

Cost per carton of 10 packs:

Source of Your Answer (If a website, list the URL)

Lesson 11-6: Tobacco Tax Map

Tax Rates by State The numbers below show the amount of tax each state adds to a package of cigarettes. Which states are highest? Which are lowest?


National Center For Chronic Disease Prevention and Health Promotion

TIPS Home | What's New | Mission | Fact Sheets | Site Map | Contact Us

Tobacco Taxation • Overview • Publications Catalog • Surgeon General's Reports • Research, Data, and Reports • How To Quit • Educational Materials • New Citations • Tobacco Control Program Guidelines & Data • Celebrities Against Smoking • Sports Initiatives • Campaigns & Events • Smoking and Health Database • Related Links

Fact Sheet Substantial scientific evidence shows that higher cigarette prices result in lower overall cigarette consumption. Most studies indicate that a 10% increase in price will reduce overall cigarette consumption by 3% to 5%. Youth, minorities, and low-income smokers are two to three times more likely to quit or smoke less than other smokers in response to price increases. Increases in cigarette excise taxes are an effective policy tool in deterring smoking initiation among youth, prompting smoking cessation among adults, and reducing the average cigarette consumption among continuing smokers. Despite the proven effects of increasing both the price of cigarettes and tobacco excise taxes, the average price and excise tax on cigarettes in the United States is well below those of most other industrialized nations. Higher cigarette prices will not simply reduce average cigarette consumption but also will reduce overall smoking prevalence. Higher prices will result in more smokers deciding to quit and fewer young people opting to begin smoking. Studies of smokeless tobacco products suggest that increasing their prices would reduce the prevalence of smokeless tobacco use as well.

Global Cigarette Prices and Taxes in U.S.Dollars,1999 Country

Tax as % Tax Price Tax Price


86% 5.64



82% 4.47



80% 1.88



76% 3.82



76% 3.03



75% 3.35



75% 2.65



75% 1.94



74% 2.33



73% 1.75



73% 14.19 1.63

Netherlands 72% 2.37



71% 2.58



70% 3.70



60% 3.26



55% 1.41



41% 1.92



11% 0.34


Source: Non-Smokers’ Rights Association web site. * 1:(Highest-New Foundland) 2:(Lowest-Ontario) 3:(Highest-Alaska) 4:(Lowest-Kentucky)

Taxes on smokeless tobacco products are much * Links to non-Federal organizations are provided solely lower than taxes on cigarettes, particularly at as a service to our users. Links the federal level. Research suggests that do not constitute an increases in cigarette excise taxes, while endorsement of any organization by CDC or the Federal reducing cigarette smoking, may have contributed to greater use of smokeless tobacco Government, and none should be inferred. The CDC is not products. Some public health advocates and responsible for the content of others have therefore called for the equalization the individual organization Web pages found at this link. of taxes on tobacco. Healthy People 2010 calls for state and federal

taxes to increase to an average of $2 for both cigarettes and smokeless tobacco products by the year 2010. The importance of tobacco to the U.S. economy has been overstated. Judicious policies combined with higher tobacco taxes and stronger prevention policies can help foster economic diversification in tobacco-producing areas. Privacy Policy | Accessibility TIPS Home | What's New | About Us | Site Map | Contact Us CDC Home | Search | Health Topics A-Z

This page last reviewed May 14, 2004 United States 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

Lesson 11-7

Saying “No” to Tobacco Introduction: This lesson draws together many of the themes developed in the prior lessons. It reviews aspects of communication and how to say "no" effectively to friends and peers when it comes to tobacco use. It reviews some of the ways in which the tobacco industry promotes its products, and develops the theme that young people can resist these forces.

Lesson Objectives: By the end of Lesson 11-7, students should be able to: W

Use refusal skill strategies


Recognize the many marketing strategies of the tobacco industry.


Write a message to the tobacco industry

Materials: W

Tobacco advertising samples (provided on CD).


Postcards from the American Cancer Society

Key Terms: refusal skills: tools which one can use against friend or peer pressure to do something that one finds undesirable, unsafe, or wrong. refusal strategies: ways of expressing refusal, divided here into three major types: passive, aggressive and assertive. Passive: refusal in a non-confrontational manner without actually saying “No.” Tends to be non-committal (“Um...maybe”), and often involves leaving an issue unresolved. Aggressive: refusal expressed by using confrontational strategies. Assertive: Refusal in a firm, clear, but non-threatening manner.

Page 11.7.1

Lesson 11-7:

Saying “No” to Tobacco

Procedures: 1.

Ask students to think about all of the "pushes" and "pulls" to behave in one way or another. Discuss with them that, ultimately, it is up to each person to be responsible for his or her own behavior, for finding ways to make good decisions and to carry them out. This is not always easy to do. Ask your students: Have any of you ever been in a situation where someone has asked you to do something that you thought might be wrong, illegal, dangerous, or disappointing to your parents or friends? What kind of situa-

Teacher’s Note:

tions do you think you might encounter where you might find yourself struggling to say no? List student responses.


Be prepared to provide some examples or add to the list created by the students.

Explain to your students: One of the difficult things for anyone to do is to say "No" when they don't really want to do something. How difficult do you think it would be to say no to the following situations? W

your best friend invites you to join her after school to smoke


a group of people you'd like to get to know invites you to someone's home because their parents are gone and everyone will be drinking beer


your boyfriend asks you to have sex


your friends are cutting school and want you to join them


your parents aren't home, and your friend tells you to take the family car out for a spin without permission


you are shopping with your friends, and one of them dares the others in the group to shoplift something


Explain to students that there are different ways to respond to pressure to do something that they don't want to do. These can be classified as passive, aggressive, and assertive. Explain that sometimes we feel pressure from friends or peers to do something we don’t want to do, or think that we shouldn’t do. Tell your students that refusing to go along with others—

Teacher’s Note: This discussion on resistance strategies is also presented in Lessons 8-4 of the 8th grade and 9-2 of the 9th grade curriculum. If your students have already covered this material, review briefly the different types of resistance strategies students can use when confronted with pressure to do something they don't want to do.

including people whose ideas and opinions are important to us—can be difficult to do, but that it helps if they know specific ways to say “No!”—resistance strategies.

Page 11.7.2

Lesson 11-7:

Saying “No” to Tobacco

Procedures: (continued) Remind your students that ultimately they are responsible for the decisions they make, no matter how they are pressured by others. In making these decisions, it can be helpful to go through the steps of the D.A.R.E. Decision-Making Process.


Discuss the different types of resistance that people use. Sometimes these are referred to as passive, aggressive and assertive resistance strategies. What do these terms mean?

Example #1: Passive Resistance W

Your friends ask you to join them behind the gym to smoke cigarettes.


What are the common ways you might resist this request? (e.g., I ignore my friends’ invitation; I shrug my shoulders; I say, ‘Maybe next time.”; I giggle and then look away.) Explain that when we use these methods, we are using passive resistance. We avoid confrontation by being neither agreeing or disagreeing, walking away, or ignoring the issue.

Teacher’s Note:

Ask your students: What other types of situations can you think of where you've used passive resistance? What are some of the advantages of passive

Advantages might include avoiding conflict; disadvantages might include not resolving the problem, or not making your decision clear to others.

resistance? What are some of the disadvantages?

Example #2: Aggressive Resistance Some strategies can be termed aggressive resistance. These usually involve a more confrontational tone, such as taking a cigarette that someone has offered you and crushing it in your hands, saying, “Get that stuff out of my face!” L117_Aggressive

Ask your students: What other situations can you think of where someone might use aggressive resistance? What are some of the advantages and disadvantages of

Teacher’s Note: Advantages might include being clear and forcefully direct; disadvantages might include sparking a fight or argument, or causing bad feelings.

aggressive resistance? L117_Assertive

Example #3: Assertive Resistance A third resistance strategy is sometimes called assertive resistance. Assertive resistance usually involves making your resistance known in a direct but non-

Page 11.7.3

Lesson 11-7:

Saying “No” to Tobacco

Procedures: (continued) confrontational manner. For example, “No thanks, I don’t smoke,” or “Let’s NOT get into your parents’ liquor cabinet—why don’t we find something else to do instead?”

Ask your students:

Teacher’s Note:

What other situations can you think of where someone might use assertive resistance? What are the advantages and disadvantages of assertive resistance?


Advantages might include being direct; disadvantages might include causing bad feelings.

Ask your students: What can you do if a friend or group of friends wants you to do something—such as smoke a cigarette, try marijuana, have sex, get drunk—that we are afraid to do, or don't think we should do? It can be hard to stand up to them and say “No,” even when you want to. Different situations may require different strategies. Here are some techniques you can use to say “No.” Have your students examine the following techniques. How well do they think they would work in different situations?

1. Be Direct 2. Change the Subject L117_Refusal01


3. Think of a Clever Response


4. Make a Joke


Page 11.7.4

Lesson 11-7:

Saying “No� to Tobacco

Procedures: (continued) 5. Blame an Adult

6. Avoid the Situation or Walk Away




Point out to your students that there are also pressures that come from beyond immediate friends and people we know. Students need to be aware of these forces and able to respond appropriately to them. Use the social and cultural messages conveyed by the tobacco industry to illustrate this point. Review what some of the images that are used in tobacco advertisements convey. What desires do these advertisements for cigarettes appeal to? What experiences and self-images do these advertisements want us to associate with tobacco use?




How does advertising reinforce the notions of smoking as a relaxing pleasure?



Page 11.7.5

Lesson 11-7:

Saying “No” to Tobacco

Procedures: (continued) What do these advertisements say to us about smoking and our sense of femininity and masculinity?






s Or our sense of the exotic, romantic and fun?


Before the harmful health effects of tobacco were widely publicized, tobacco companies sought to allay smokers’ health concerns with advertisements featuring medical personnel, and others describing cigarettes that were “mild” and free of “irritation.”


Many of these ads were produced in the 1940s and 1950s. Do you think tobacco companies could produce advertisements like these today? Why or why not? What do you think of these ads?



Page 11.7.6

Lesson 11-7:

Saying “No� to Tobacco

Procedures: (continued) These advertisements are also from the 1940s and 1950s. To whom do you think these ads appeal? Do you think you would see ads like thes today? Why or why not?

L117_FatherSon1945 L117_MotherChild

Note that the industry uses many other strategies to promote their products and their industry. These include, for example, funding sport, cultural, educational, and community events and activities that people value (see examples in Lesson 11-5)


Pass out the postcards from the American Cancer Society. Ask students to write a message about not smoking either to a friend or to a tobacco company. Have each of the students present their message to the class.

Teacher’s Note: In instances when you feel that the message is appropriate, have students identify the mailing address and send the cards. See if anyone responds!

Journal: Think about the ways to respond to pressure from others. Which is the most effective for you and why? OR What are the ways in which the tobacco industry tries to gain acceptance in our society?

Page 11.7.7

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