Hands Off Tobacco: 12th Grade Curriculum by Heather Holmes

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

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

California School for the Deaf, Fremont

Barbara A. Berman, PH.D.

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

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

Recruitment, Retention and Communications Core UCLA Jonsson Comprehensive Cancer Center

PDF processed with CutePDF evaluation edition www.CutePDF.com

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

ÂŠ2004, 2007 University of California, Los Angeles

Introduction for Teachers

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

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

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

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

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

Introduction for Teachers

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

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

Is tobacco use addicting for children and teenagers?

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

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

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

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

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

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

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

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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

Introduction for Teachers

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

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

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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

5th

Self-Esteem and Self-Concept

5-1

Friends and Peers

5-2

Decision Making

Grade Level

7th

8th

9th

10th

11th

12th

7-1

8-1

9-1

10-1

11-1

12-1

7-2

8-2

9-2

5-3 5-4

7-3 7-4

8-3

10-3

11-2

12-2

Media and Other Inﬂuences to Use Tobacco

5-3 5-4

7-6 7-7

8-5

9-3

Resisting Inﬂuences to Use Tobacco

5-5

8-4

9-7

8-6

9-4

8-7

Health Effects of Tobacco Use

6th

6-1 6-2

6-3 6-4

Addiction

Anti-Tobacco Efforts and Social Action

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

7-5

10-2

12-5

11-7

12-6

10-4

11-3

12-3

9-5

10-5

11-4

12-4

9-6

10-6 10-7

11-5 11-6

12-7

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

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

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

Introduction 13

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

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

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

Introduction 14

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

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

Introduction 15

Introduction for Teachers

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

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

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

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

Introduction 16

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

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

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

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

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

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

Introduction 17

Additional Resources for Teachers

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

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

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

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

Healthy Schools Healthy Youth!

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

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

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

Resources 18

Additional Resources for Teachers

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

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

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

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

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

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

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

✷ Advocating for changes in government policies to reduce tobacco use

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

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

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

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

Resources 19

Additional Resources for Teachers

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

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

✷ The Truth® Campaign www.thetruth.com

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

✷ Streetheory®

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

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

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

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

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

Resources 20

Additional Resources for Teachers

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

Monitoring the Future

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

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

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

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

✷

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

✷

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

✷

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

✷

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

✷

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

✷

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

Resources 21

12th Grade Lessons:

Needed Materials and Preparations Lesson 12-1

Five large poster boards * Poster Headers Index cards Colored Markers Tape

Lesson 12-2

Copies of the daily newspaper for each student

Lesson 12-3

* The ABCs of Smoking booklet and transparencies

Lesson 12-4

* Worksheet: Interviewer with a Smoker * One User's Story: Sean Marsee * One Addict's Story: Bryan Lee Curtis * Graphic: The Addiction Cycle 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 12-5

* American Cancer Society Teens Kick Ash! Program Guide * Graphics: Industry Quotes (PowerPoint slides on CD) * Postcards from the American Cancer Society

Lesson 12-6

* Graphic: Prescription for Success * Word Search

Lesson 12-7

* Internet or Phone Access * Web Addresses * Anti-tobacco materials Additional anti-tobacco materials can be collected by students prior to this lesson * Anti-tobacco warnings for tobacco packaging

* 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.

12th Grade Lessons Materials List

Lesson 12-1

What Does It Mean To Be Healthy? Introduction: This lesson explores the concepts of health and wellness. It encourages students to consider the relationship between health and self-esteem, and the ways in which our decisions are shaped by our sense of wellness. In turn, it examines how self-esteem and our sense of wellness shape the choices and decisions we make. Materials regarding decision making and the D.A.R.E. Model, introduced at earlier grade levels, can be integrated into this discussion.

Lesson Objectives: By the end of Lesson 12-1, students should be able to: W

Identify what is important to them and what they value

Understand the dimensions of health and wellness—physical, social, emotional, intellectual and spiritual wellness

Consider how people act to enhance their sense of wellness

Describe the ways in which wellness influences and is influenced by self-esteem

Materials: W

5 large poster boards, with one aspect of wellness written or taped on each

Poster Headers (provided)

Index cards (five per student)

Colored Markers

Tape

Key Terms: health: the state of being sound, whole, or well. From the root word “heal.” The World Health Organization (WHO) defines health as complete physical, mental and social well-being and not merely the absence of disease or infirmity. self-esteem: one’s sense of confidence and satisfaction in oneself; self-respect.

Page 12.1.1

Lesson 12-1:

What Does It Mean To Be Healthy?

Procedures: 1.

Pass out five index cards to each student. Ask them to think about five things that are most important in their lives. This can include, for example, people, abilities, aspirations. Ask students to write one of these on each card. Collect the cards for later use in the lesson.

Write the word “health” on the board. Begin a discussion by asking your students to define this concept. Discuss with your students that physical health is more than the absence of disease, illness, or being in good shape, and that health and wellness involves more than physical health. It has social, emotional, intellectual and spiritual dimensions, as well. To explore this with your students, pose the following types of questions for class discussion: W

What if someone is very smart and gets very good grades in school but has no friends? What if he has no family that he loves, or that loves him? What if he is anti-social and hates being around other people? Is he still healthy?

What about the person who has nothing physically wrong with her, but is always lonely and depressed? Or who is angry all the time? Is she still healthy?

What about people who look great—perfect bodies, perfect skin, white teeth, nice hair, beautiful faces, with no diseases—but all they do is go to the gym and exercise? Their main concern is how they look in the mirror. They don't care about the people around them, or how anyone else is doing. Is this person healthy?

Write the definition of “health” on the board. Explain to your students that when we talk about “health” we include not only physical health, but also social, emotional, intellectual and spiritual health as well. “Health” is an overall state of “well-being.” Explain to your students that “being healthy” involves making

“Health” The state of being sound, whole, or well. Complete physical, mental and social well-being, and not merely the absence of disease or infirmity.

choices and decisions each day that promote not just physical health, but social, emotional, intellectual and spiritual health as well.

Display the five poster boards with a dimension of health written on each in five different locations in the classroom. Use the Poster Headers—physical, social, emotional, intellectual, spiritual—that are provided.

Page 12.1.2

Lesson 12-1:

What Does It Mean To Be Healthy?

Procedures: (continued) 4.

Divide the class into five teams. Give each team a different color marker. Have the teams go from one poster to the next listing activities or behaviors which people do to enhance or develop that area of wellness. Remind your students that they should read the list already on the poster before adding their ideas, so that no ideas are duplicated.

When each group has contributed to each poster, discuss the ideas that were listed. Use the concepts included on the poster headers to encourage contributions from the class. Collect the cards that your students filled out at the beginning of class. Read each card and ask the class what areas of “health” are reflected on the card. When the group decides the appropriate area, tape the card to the poster. Write duplicate cards if needed, in order to tape the card to all of the areas where it belongs. This can be helpful in encouraging students to consider that the things we value relate to many aspects of our lives. For example:

Basketball (physical and or social health)

Good grades (intellectual health)

Having good friends (social health)

Feeling that my life has meaning (spiritual health)

Getting involved with a service club (social health, spiritual health)

Feeling satisfied with myself and what I can do (emotional health)

Aiming for college (intellectual, social health)

Ask your students to consider the kinds of actions that can hurt their chances of achieving each of these kinds of health. If your students do not mention risk-taking behaviors—such as unsafe sex, drug use, drinking and driving or tobacco use—you can do so as you move to each poster. How do the decisions to take part in these behaviors affect each aspect of health? Ask your students to consider that the decisions we make and our actions can have positive implications for some aspects of health, but can be hurtful in other ways. For example, how might tobacco use hurt physical health, but make a young person seem “cool” or more socially acceptable?

Teacher’s Note: This is a good point at which to discuss the complexity of choices—how they can hurt and help—and thus why making decisions and choices can be difficult to do. You may want to discuss the D.A.R.E. Decision Making Process as a tool that can help in making good decisions. Given the widespread use of D.A.R.E. programming in the elementary grades, it is likely that your students will have been previously exposed to the D.A.R.E. Model. If not, the concepts underlying the model are relatively straightforward and are reviewed in Lesson 7-3.

Page 12.1.3

Lesson 12-1:

What Does It Mean To Be Healthy?

Procedures: (continued) 7.

Begin a discussion of “self-image” and “self-esteem” by asking the following: What is self-esteem? What do we mean when we say someone has high self-esteem? Low self-esteem? Does your self-esteem change according to your surroundings, for example, when you are with your Deaf friends, or when you are with hearing friends? When you are here on campus, or when you are at the local mall? Does your self-esteem affect the way you behave? Ask the class how the broad definition of health they have just discussed relates to self-esteem. Explain that poor health— physical, social, emotional, intellectual, or spiritual—is linked to

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.

low self-esteem. Ask students to brainstorm ways that low/high self-esteem can affect: Relationships: If you feel bad about your abilities, intelligence, or appearance, how do you think that might affect your relationships with your family? Deaf friends? Hearing friends? Other peers? Boyfriend or girlfriend? How would things be different if you thought highly of your abilities, social skills, intelligence, or appearance? Choices: How might the way you feel about yourself affect your decisions in trying new activities? Making friends? Working? Joining a sports team or school club? Using drugs, tobacco or alcohol? What differences do you think high self-esteem and low self-esteem make in these choices?

Explore with your students the kinds of challenges relating to self-esteem and health that Deaf young people may face. Are these issues the same as those facing other adolescents? Are they different? How can your students deal with these challenges?

Journal: How does your sense of health—or lack of health—affect your self-esteem? The decisions you make? Which areas of your health do you most focus on? How do you promote your overall health in each of the five areas? What areas do you feel you need to develop further?

Page 12.1.4

Lesson 12-1 Poster Headers

Poster Headers

Physical Wellness Care of the body; keeping fit; good grooming, cleanliness and diet.

Social Wellness

Getting along with others; working or playing well in a group; making and keeping friends and communicating effectively.

Lesson 12-1 Poster Headers

Poster Headers

Intellectual Wellness

Developing your intelligence throughout your life by trying new things and continuing to learn and understand new ideas.

Emotional Wellness

Liking and accepting yourself; giving and getting support from others when needed; being able to express emotions in a healthy way.

Lesson 12-1 Poster Headers

Poster Headers

Spiritual Wellness Feeling connected with the world, family, friends, other people or a higher power.

Lesson 12-2

Making Healthy Decisions Introduction: This lesson extends the discussion of decision-making, and explores some of the forces that play a role in the decisions we make. We focus on the influence of people in our immediate environment—family, friends, peers. This will serve as a starting point for the discussion in future lessons of broader cultural forces that influence our lives.

Lesson Objectives: By the end of Lesson 12-2, students should be able to: W

Recognize the various types of decisions they make every day, and their shortand long-term implications

Consider the role of family, friends and peers in the decisions they make

Examine decisions that young people make in their daily actions

Assess the decisions that people “in the news” make—what shapes their decisions and what are the implications of these decisions?

Materials: W

Copies of the daily newspaper for each student

Key Terms: D.A.R.E. Decision-Making Process: A series of steps that help youths define important decisions and analyze the options and consequences involved in choices. 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? (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?

peer influence: the indirect force that peers exert in shaping one's opinions, perceptions, desires and behavior. peer pressure: the more direct force that friends and peers often use to shape one's opinions, perceptions, desires and actions.

Page 12.2.1

Lesson 12-2:

Making Healthy Decisions

Procedures: 1.

Ask your students what they consider to be the important decisions they have to make. Encourage your students to include some of the new decisions they will need to think about and make now that they are seniors in high school. List these on the board. For example: W

Going to college

Using alcohol and other drugs

How nice you are to others

Clothing you wear

How much you exercise

How much you study

Getting a job

How much sleep you get

How often you take time for yourself

Who you date

Who your friends are

How well you behave

Discuss the choices that are available for each of these decisions. Consider with your students the

Teacher’s Note

consequences of their decisions. Encourage your students to particularly weigh the effects that their choices have on their sense of health, referring to the five aspects of health identified in Lesson 12-1 and listed on the posters in the room, and on their self-

You may want to explore with your class that people have different decisions to make in life, and that decisions that are important often change as we go through life.

esteem.

Ask your students to think about how they make decisions. What do they take into account? Do they always think about their actions in advance, at all? Why? Why not? What is the danger of making decisions without some thought as to the consequences— short and long term—of their actions?

Teacher’s Note This is an opportunity to have students think about how many decisions they and other people make, even very important decisions, without reflecting on the implications of these actions. Remind your students of the value of considering the implications of action, whether or not they choose to use a "formal" model such as D.A.R.E. Such a model is only a starting point for the strategies they themselves can develop for making thoughtful choices. If you feel that you need to review the D.A.R.E. Decision-Making Process with your students, you can find a detailed discussion of the process in lesson 7.3.

Page 12.2.2

Lesson 12-2: Making

Healthy Decisions

Procedures: (continued) Sometimes it is easier to consider the decision process when we look at the lives of others. Discuss one or more of the following examples with your students: W

Kelly and Kim are best friends. The two girls always study together, buy the same clothes and feel that they are like sisters. The girls are on the swim team together and both try to take care of their bodies. Both girls are invited to a party. Kelly really likes a boy name Jake. Jake offers the girls a beer. What do you think will happen and why? What aspects of health are reflected in this dilemma? What are the consequences of the possible actions?

Jose and Kevin are brothers. Jose is in 11th grade and Kevin is in 9th grade. Last year their grandmother died of lung cancer from smoking. The boys both promised their mom that they would never smoke. One day, Kevin sees his brother smoking with friends after school. What do you think will happen? Why? What aspects of health are reflected in this dilemma? What are the consequences of the possible actions?

Nancy and Bernard are dating. Bernard is 18 and Nancy is 16. Nancy really loves Bernard but she is not ready to have sex with him. Bernard pressures her often. Nancy knows that if she becomes sexually active and her mom finds out, her mom will be hurt and disappointed. Bernard tells Nancy that if she does not have sex with him, he will find another girlfriend. What do you think will happen? Why? What aspects of health are reflected in this dilemma? What are the consequences of the possible actions?

Randy goes to church every Sunday with his grandfather. They are very active in their church community. Randy is a great soccer player and he would like to join the team. All of the kids on the team are pressuring him to join. Soccer practice is every Sunday. If he joins the soccer team, he will miss church. What do you think will happen? Why? What aspects of health are reflected in this dilemma? What are the consequences of the possible actions?

Candace has been smoking but she wants to quit. All of her friends smoke. Her friends think that she should quit if she wants to, but none of the others wants to stop smoking. Many of her friends tease her when they smoke and she doesn't. When she is with her friends and they are smoking she feels a strong temptation to smoke. What do you think will happen and why? What aspects of health are reflected in this dilemma? What are the consequences of the possible actions?

Returning to the list of decisions students have to make (Procedure 1), discuss with your students what considerationsâ&#x20AC;&#x201D;and what peopleâ&#x20AC;&#x201D;are likely to influ-

Page 12.2.3

Lesson 12-2: Making

Healthy Decisions

Procedures: (continued) ence their decisions and choices. You may want to select only a few of the decisions listed to facilitate a more in-depth discussion. What influences are most important in each decision? What influences are less important? Why? Is this the same for all decisions? Discuss with your students the multiple pressures and influences in their immediate environment - the role of friends, peers, parents, and teachers in the decisions they make. Remind your students that the behavior of others can help us achieve our goals but can also serve as barriers. Also, when we try to change our ways, the actions of others can serve as triggers and encourage us to return to old behaviors, as well.

Teacherâ&#x20AC;&#x2122;s Note: Peer influence and peer pressure have been discussed in more detail in lessons 8-2 and 9-2. If your students have not been exposed to these lessons, you may want to review these important influences on decision making. Specific resistance strategies that students can learn to use are also covered in depth in Lesson 11-7. If your students have not previously been exposed to these strategies, you may want to review them briefly here.

Have your students consider the influence people can have when it comes to use of illegal drugs. Who would be likely to support a decision to use drugs? Who would support a decision NOT to use drugs? Who might help someone trying to stop using drugs? Who would not really care at all? What would happen if you decided not to smoke cigarettes but your friend pressured you to just try a cigarette out of curiosity? What effect does it have if young people see celebrities they admire who are smoking, or coaches or athletes they respect who are using smokeless tobacco? Remind your students to consider that it is not always what people say, but often what people do, that influences behavior.

Distribute copies of the daily newspaper to each member of the class. Have your students go through the newspaper, picking out people in the news who have made important decisions that effect their own lives

Teacherâ&#x20AC;&#x2122;s Note: Encourage selection of wellknown public figures that have made decisions with some farreaching consequences.

and the lives of others. These can be decisions that your students think are wise - or foolish. Each represents an important starting point for discussion. Discuss with the class what areas of health the person seems to value, based on the newspaper article. Does it seem that there are areas of health that are being ignored? What shaped their behavior? How does their behavior affect the lives of others? Do their actions and decisions seem to reflect

Teacherâ&#x20AC;&#x2122;s Note: This can be a class or homework assignment. If used as a homework assignment, students can be asked to further research the life of the person and to find out more about their choices and decisions and what has shaped the path of their lives.

careful thought and consideration?

Page 12.2.4

Lesson 12-2: Making

Healthy Decisions

Procedures: (continued) As an alternative, you can go through the paper and make selections of individuals whom you think are important for your students to consider.

Journal: Who are the people who influence you the most? Is this influence positive or negative for you? Why?

Page 12.2.5

Lesson 12-3

How Tobacco Affects Your Body Introduction: The next three lessons address the question of why people do not always make good decisions. These three lessons focus on these issues in the context of tobacco use. In lesson 12-3 we build on and extend the discussion in Lesson 12-2 that considers the role of friends, peers and family. In this lesson we consider another theme - that what we know has an effect on the decisions we make. It also considers barriers to knowledge, why we are not always receptive to information about the consequences of behaviors. Each of the next three lessons may take more than one session to complete.

Lesson Objectives: By the end of Lesson 12-3, students should be able to: W

Recognize that we sometimes make poor decisions because we don't know or consider the consequences of our actions

Recognize the consequences of tobacco use and the reasons why young people don't always pay attention to them

Materials: W

The ABCs of Smoking Pamphlet

Key Terms: health consequences: the physiological results, both immediate and long-term, of tobacco use passive smoking: Inhaling secondhand smoke from someone else's smoking, or from their lit cigarette, cigar or pipe.

Page 12.3.1

Lesson 12-3:

How Tobacco Affects Your Body

Procedures: 1.

Remind your students that in the last lesson they began to consider how decisions are made. Sometimes we do not make wise decisions. Sometimes we do not take actions that allow us to achieve the goals of good health. In Lesson 12-2 we discussed some of the types of influences that shape the decisions that we make. We considered the role of parents, peers, friends— people we know. Another reason why we make the decisions we make has to do with the information and knowledge we have—what we know and what we don't know. Ask your students to consider this with respect to risk-taking behavior such as tobacco use. Introduce to your students the following important facts about tobacco: W

Tobacco is the most preventable cause of death in our nation

Tobacco use is responsible for nearly one in five deaths in the United States - an estimated 440,000 deaths each year

About 4.9 million smoking-related, premature deaths occurred throughout the world in the year 2000

About half of all Americans who continue to smoke will die from their cigarette smoking addiction

Smoking causes approximately $157.7 billion in health-related economic costs each year. This includes adult mortality related productivity costs, adult medical expenditures, and medical expenditures for newborns.

Refer to the following list of organs and body parts below.

Teacher’s Note

Mouth, Teeth, and Throat

Lungs

Eyes and Ears

Skin and Hair

Muscles and Joints

Heart

Other organs such as the bladder, kidney, pancreas, stomach

Reproductive organs and pregnancy outcomes

A detailed discussion of the health effects of smoking is covered in Lesson 11-3, and includes participatory demonstrations that can show these impacts to students. If your students have not been exposed previously to the 11th grade curriculum, you may want to review that material here.

Assign each organ or body part to a student or small group. Have each student prepare a report to present to the class on the health effects of tobacco use—and exposure to the tobacco use of others—on their assigned organ or body part.

Page 12.3.2

Lesson 12-3: How

Procedures: (continued) Encourage your students to find and present images of the health effects, if possible. The following are additional facts that may be of use to you: W

Mouth: Smoking and chewing tobacco can cause cancer of the soft tissues of the mouth; delays healing of mouth injuries; causes bad breath; results in loss of ability to taste; and causes mouth sores.

Teeth: Smoking can lead to an increase in periodontal and gum disease in smokers. Smokers experience greater teeth loss, and slower healing of any injuries to the mouth and gums. Smoking also stains the teeth.

Throat: Smoking is a well-known link to throat cancer that may result in removal of the voice box (larynx) that allows people to speak.

Lungs: Approximately 90% of all lung cancers result from smoking. Lung cancer is the number one cancer killer of Americans. The chemicals in cigarette smoke alter the genetic information in cells, leading to the creation of cancerous cells that begin to multiply rapidly. These cells crowd out and displace the healthy cells, but carry out none of the healthy cells'

Tobacco Affects Your Body Teacher’s Note

In 2004 the Surgeon General's Report provided an update of the health consequences of tobacco use. This comprehensive account can be found at: www.hhs.gov/surgeongeneral/library/ smokingconsequences/ This site also provides a link to a wonderful interactive animated presentation of the effects of tobacco on different organ systems in the body: http://www.cdc.gov/tobacco/sgr/ sgr_2004/sgranimation/flash/index.html Tobacco Free Kids is another excellent online source of information. It provides Fact Sheets on the consequences of tobacco use that would be helpful to your students: http://tobaccofreekids.org/research/ factsheets/index.php The American Council on Science and Health has also produced an excellent guide to the health consequences of smoking, titled Cigarettes: What the Warning Label Doesn’t Tell You—Information Tobacco Companies Don’t Want Teens to Know About the Dangers of Smoking. The book was written for young people (with the help of young people) and is available for viewing online at: http://www.acsh.org/publications/ pubID.188/pub_detail.asp

functions. W

Bladder: Smoking may increase risk for bladder cancer up to 2.5 times that of non-smokers (250%); the risks may be even higher for women. The chemicals in tobacco smoke may result in toxic changes to bladder cells, causing them to become cancerous.

Kidney: Smoking increases risk of renal cell (kidney) cancer by 30% to 100% according to the American Cancer Society. As a result of smoking, the arteries that feed into the kidney may become blocked or narrowed, leading to kidney failure.

Pancreas: Smoking increases risk for pancreatic cancer, especially among long time smokers.

Brain: Smoking lowers the amount of blood circulating in the brain, starving it of oxygen. By narrowing the arteries that supply the brain, smoking also cuts off the flow of oxygen-rich blood to the brain. Higher blood pressure may lead to strokes (bleeding in the brain) or aneurisms (weakening in

Page 12.3.3

Lesson 12-3: How

Tobacco Affects Your Body

Procedures: (continued) the walls of the blood vessels in the brain that can lead to pressure on the surrounding brain tissue, or rupture leading to severe bleeding in the brain). W

Eyes: Smokers develop cataracts, or a clouding of the lens in the eye, much earlier and at a higher rate than non-smokers. Cataracts can eventually lead to blindness. Smoking also leads to higher rates of macular degeneration (cellular degeneration of the light-sensing cells at the rear of the eye); all of these are the likely result of decreased flow of oxygenated blood to the eye tissues, and can result in blindness.

Skin: smoking results in premature wrinkling of the skin. Possible mechanisms include decreasing blood flow to the skin, and promoting the destruction of collagen, which gives skin its elasticity. Smoking may also be linked to increased susceptibility to skin cancer. Wounds heal more slowly.

Reproductive organs: Smoking in males is linked to impotence, or the inability to maintain an erection for sex. This is thought to be due mainly to reduced blood flow and oxygenation of tissues. For pregnant women, smoking is not only harmful to the health of the mother, but to the well being of the fetus, as well. Smoking and exposure to secondhand smoke among pregnant women is a major cause of spontaneous abortions, stillbirths, and sudden infant death syndrome (SIDS) after birth. Smoking and exposure to secondhand smoke during pregnancy also directly increases the risk of many other conditions such as, for example, birth and delivery problems, growth retardation and low birth weight, childhood leukemia, cleft pallets and lips. Exposure to secondhand smoke can also increase other health problems for babies and young children.

Heart: Smoking damages the arteries that supply the heart with oxygen; narrows the arteries, causing blood pressure to rise, and making the heart work harder; and these can result in heart failure.

After hearing the presentations of the health effects of smoking, ask students to identify social and economic effects of this behavior. Ask students to consider the following questions: W

Will smoking make someone more popular? What do guys think of girls who smoke? What to girls think of guys who smoke? Would students rather kiss a smoker or a non-smoker?

What are some of the economic costs of smoking?

Do you think that smokers are more likely to engage in other risk behaviors? Why or why not?

Do you think that people who start smoking have high or

Teacherâ&#x20AC;&#x2122;s Note The social and economic consequences of tobacco use have been described in prior lessons (see 9-4, 10-4 and in the introduction to the curriculum). If your students have not been exposed to these lessons, a more detailed discussion of these social and economic consequences of tobacco use may be appropriate.

low self-esteem? Why?

Page 12.3.4

Lesson 12-3: How

Tobacco Affects Your Body

Procedures: (continued) 4.

Now that the class has discussed the effect of smoking on health, and the social and the economic consequences of smoking, explore why, in light of these consequences, young people start to smoke. Have your students consider that young people may not always know the consequences of smoking. Some adolescents may have heard about these facts on TV, from magazines, in school or on the Internet, but they may still experiment—and find themselves hooked. Why is this? This discussion may include the following points: W

Many of the health effects of tobacco use take a long time to develop. They are primarily problems of middle and older age. Young people don't think about what can occur later in their lives, or that these problems can have anything to do with them.

Young people do not often think about the immediate health and social consequences of tobacco use that can occur.

Often children and teenagers who start to smoke think that they will smoke for just a little while and then quit. They believe that they can quit any time that they want. Even if they recognize the health and other consequences of tobacco use, they believe that they will not be smoking long enough to experience these problems.

Indeed, surveys have found that many young people—7 out of every 10 who have started to smoke—want to quit. Young people begin to experience the immediate health and social problems of tobacco use, often very soon after they start to smoke or chew tobacco. They may begin to think about the long-term problems that can occur, about how they are being manipulated to smoke, and may worry about the money they are spending to buy cigarettes. But when they try to quit, they often find that they are “hooked”—that it is difficult to stop. It may be difficult for them to resist peer and other pressures to smoke that got them started in the first place. Most important, they run into a characteristic of tobacco use that makes it difficult to quit—that tobacco use is highly addictive.

Homework: Have your students work on their presentations in class and also as a homework assignment.

Journal: Imagine that you have been a smoker for many years. There will have been significant damage to many different parts of your body. Based on what you have learned how would this damage affect your activities of daily life?

Page 12.3.5

Lesson 12-4

Understanding the Danger of Addiction Introduction: This lesson continues the examination of influences on decisions in Lessons 12-1 (the role of self-concept and values), 12-2 (the role of friends, peers, family and other people close to us), and 12-3 (the role of knowledge and its limitations). In this lesson your students will examine another factor: addiction, and the significant role it assumes in decision-making.

Lesson Objectives: By the end of Lesson 12-4, students should be able to: W

Recognize the addictive properties of tobacco and why this makes cessation difficult.

Conduct an interview (either in-class as a group or on a one-to-one basis) with a smoker or former smoker.

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

Materials: W

Interview with a Smoker Worksheet.

One Userâ&#x20AC;&#x2122;s Story: Sean Marsee Handout (also provided on CD)

One Addictâ&#x20AC;&#x2122;s Story: Bryan Curtis Handout (also provided on CD)

Graphic: The Addiction Cycle

Key Terms: addiction: Extreme physiological and psychological dependence on a substance such as tobacco, alcohol or other drug, that has progressed beyond voluntary control. People who are addicted often feel sick when they stop using this substance. cessation: In terms of tobacco use, the process of stopping tobacco use, particularly after one has already become addicted. relapse: In terms of tobacco, starting to smoke or chew tobacco again after an attempt at quitting has been made; to take up tobacco use again after a period of abstinence.

Page 12.4.1

Lesson 12-4: Understanding

the Danger of Addiction

Procedures: 1.

Review with your students some of the reasons why young people begin to smoke or use tobacco. W

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

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

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

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

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

to look older, more mature, cooler

to be rebellious

to fit in

But what actually happens when someone starts to smoke? Why shouldn’t a person be able to smoke for just a little while and then quit? What’s the harm? Explain the following: W

When a person smokes or chews tobacco, one of the many chemicals they are taking into their bodies is nicotine. 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.

When a person tries tobacco out of curiosity, or to fit in with friends, or to look cool, he or she is said to be “experimenting” with tobacco use. The first time a person uses tobacco, he or she may feel dizzy and sick.

If the person continues to “experiment” with 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.

These physical responses of pleasure and relaxation may lead a person to more regular use. Rather than “experimenting” with tobacco out of curiosity, the person is now smoking because it makes him or her feel better. This is the point at which “experimental” smoking becomes “occasional” or “regular” use.

Page 12.4.2

Lesson 12-4:

Understanding the Danger of Addiction

Procedures: (continued) 3.

So where does addiction come in? Ask your students if anyone can define the term addiction. What is addiction, and how does it happen? Explain to students that people often use the word “addiction” in a very general way. They’ll say, “I’m addicted to pizza,” or

Teacher’s Note: If your class has not covered the topic of addiction in a prior unit (e.g., Lesson 11-4 in the 11th grade curriculum), the concept is discussed again here. If your class has already been exposed to these concepts, you may wish to review them briefly before going to Procedure 3.

“I’m addicted to that television show,” referring to any behavior someone might find pleasurable and doing excessively. However, when it comes to behaviors such as tobacco use or drug use, “addiction” means something very different. With true addiction, the following things happen: W

The substance produces a pleasant feeling.

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

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

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

Examine the addiction cycle: that is, how a young person can quickly become addicted to tobacco. Pleasant feelings Smoking a cigarette or chewing tobacco may cause some initial dizziness or nausea the first time a person uses tobacco. But it also produces a pleasant sensation almost immediately. This sensation is caused by nicotine. Within seconds of inhaling tobacco smoke (or placing a plug of smokeless tobacco in the mouth), nicotine is absorbed into the bloodstream where it quickly travels to the brain. Here, the nicotine causes chemical changes in the brain that produce the pleasant sensation. This pleasant feeling wears off quickly, and the smoker must inhale more smoke to experience that pleasant feeling again. The desire for these sequences of little nicotine “hits” is what encourages more regular use. The need to use more and more As a person starts to use tobacco (and nicotine) regularly, their brain and body become less sensitive to the pleasurable effects of nicotine. This is called building up tolerance, and means that the smoker or smokeless tobacco user needs to smoke (or chew) more, and more often, in order to receive the same pleasurable sensations as he did before.

Page 12.4.3

L124_FirstTime

Lesson 12-4:

Understanding the Danger of Addiction

Procedures: (continued) Withdrawal symptoms As the body becomes accustomed to nicotine, body and brain cells become dependent on the nicotine in tobacco. While nicotine may produce pleasurable sensations in the body, withholding nicotine starts to cause a number of unpleasant sensations, which range from mild to severe: W

Feeling restless

Feeling irritable, moody or tense

Insomnia

Headaches or dizziness

Sweating and unsteadiness

Nausea or physical illness

These physical symptoms are known as withdrawal symptoms. Withdrawal can be a very uncomfortable feeling, and is the reason why most people find it so difficult to quit smoking after becoming addicted to nicotine. To relieve these withdrawal symptoms, the smoker or tobacco user must smoke another cigarette, or place another plug of smokeless tobacco in their mouth. Hooked! Addiction can happen very quickly, especially in young people. Some teenagers start experiencing withdrawal symptoms, even if they feel they are just “playing around” and smoking a few cigarettes a week! When a person is dependent on nicotine, they feel that they don't have a choice about using tobacco anymore. They feel they must use tobacco. They must plan where they go and what they do so that they will be able to use the drug nicotine. It is like carrying a ball and chain. Addiction creates a feeling of need—a craving-in your body and your brain. People who are addicted to nicotine in tobacco will continue to smoke, even if they know they are doing great harm to their health. This is why you often hear smokers say, “I know I should quit. But I can’t.” Most young 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 12.4.4

Lesson 12-4:

6 So you smoke another

Procedures: (continued)

cigarette. And the cycle starts over again.

Understanding the Danger of Addiction

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

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

4 Your brain starts to crave

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

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

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

L114_AddictionCycle

Ask your students: Why is it so important to talk to young people your age about smoking and tobacco use? W

Most people who smoke started when they were young. Almost all say they started smoking regularly before the age of 18.

Ask your students: How many of you know someone your age who has tried smoking? The Facts:

L124_12thGrade; Source: Monitoring the Future, 2004

The numbers are only slightly lower for Deaf youths. In a survey of over 200 Deaf high school students in California, 45%, or nearly half, have tried smoking at least once.

Page 12.4.5

Lesson 12-4:

Understanding the Danger of Addiction

Procedures: (continued) W

Most smokers wish they had never tried smoking.

Ask your students: How many times have you heard someone your age say, “I don’t really smoke—just every so often with friends, or at parties.” The Facts: More than one out of every three young people who ever try smoking a cigarette become regular, daily smokers before leaving high school. About 22% of all high school students—more than one out of every five— currently smokes.

L124_Statistics; Source: Monitoring the Future, 2004

Most young people who try smoking think they’ll be able to stop whenever they want.

Ask your students: How many times have you heard someone your age say, “Smoking is no big deal. I can quit later anytime I want.” The Facts: If you ask a high school student who smokes every day if they think they will still be smoking in five years, almost all of them say “no.” But if you talk to them again when they are adults, most will

L124_Boasting

still be smoking. W

Most smokers have a hard time quitting because nicotine is very addictive.

Ask your students: How many of you know a smoker who has tried to quit, but failed? The Facts: By high school, nearly three out of every four regular smokers have already tried to quit smoking, and failed.

Addiction Stories: Two stories illustrating the tragic consequences of tobacco addiction can be found at: http://whyquit.com/whyquit/BryanLeeCurtis.html and http://whyquit.com/whyquit/SeanMarsee.html The stories can also be found on the accompanying CD (in the “WebPages” folder). You may want to use these stories as a class exercise, or a homework or journal exercise.

Page 12.4.6

Lesson 12-4:

Understanding the Danger of Addiction

Procedures: (continued)

L124_Cartoon

Guest Speaker: The purpose of the guest speaker is to provide a first-person narrative of the difficulties of quitting an addictive behavior such as smoking. Contact the local branch of the American Cancer Society, the American Lung Association, the American Heart Association, or other similar agency for assistance in identifying a smoker or ex-smoker who has attempted to quit smoking and experienced relapse. If possible, the Guest Speaker should be deaf to facilitate communication with the class. Invite the Guest Speaker to come to class and discuss the factors involved in the decision to quit smoking, the process of quitting, and the circumstances of his or her relapse. To prepare for the speaker's presentation, have the class prepare some questions that they would like the speaker to answer, including topics they would like to discuss. You can draw on the Interview with a Smoker (Lesson 7-6) as a starting point.

Page 12.4.7

Lesson 12-4:

Understanding the Danger of Addiction

Procedures: (continued) Questions might include: W

When did they start to smoke?

Why did they start to smoke? Who were they with? Where did they get the cigarettes or other tobacco products?

What illnesses or other negative effects have they experienced relating to their tobacco use?

Did their parents smoke? close friends?

For current smokers…. W

Have they ever tried to quit?

How many times?

What methods did they use?

Do they want to quit? Why? What stops them?

For former smokers…. W

When did they quit (at what age)?

For how long did they smoke before quitting?

What methods did they use to quit?

How many times did they quit before they succeeded?

Why did they quit?

Do they think they will go back to tobacco use?

Journal:

Teacher’s Note: As an alternative to a group interview with a guest speaker, you can have your students identify and conduct an interview with an individual former or current smoker as a homework assignment. Students should check with you before conducting the interview to be certain that no one person—such as a member of the school staff or faculty—is being burdened to conduct more than one interview. Several of your students can work together outside of class to complete this assignment.

What did you learn through the Interview with a Smoker that you did not know before? OR What did you learn about the difference between reasons for smoking initiation and the reasons for regular smoking that you did not know before?

Page 12.4.8

Lesson 12-4 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.

L114_AddictionCycle

Lesson 12-4 Worksheet: Interview with a Smoker

Name __________________________________

Interview with a Smoker Instructions: The purpose of this assignment is to see what smokers themselves think about smoking, and to find out the circumstances of their starting to smoke.

When and how did you start smoking? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Do you consider yourself to be addicted to smoking? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

How long have you smoked? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

How did you first start smoking? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Did you think you would become a regular smoker when you started? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Lesson 12-4 Worksheet: Interview with a Smoker

Interview with a Smoker 6.

Have you ever tried to quit smoking? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

If so, why did you try to quit? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

How did you try to quit? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

What did it feel like when you tried? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

10.

If not, do you think you will ever try to quit? When? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

11.

What would you say to someone who wants to try smoking? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Nineteen Year Old Sean Marsee's Tobacco Message

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

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

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

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

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

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

Youth Nicotine Addiction Warning Signs

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

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

Smoking Kills

"He Wanted You to Know"

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

by Sue Landry

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

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

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

[Photo: Curtis

Family]

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

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

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

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

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

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

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

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

Last Updated on August 10, 2003 byJohn R. Polito

Lesson 12-5

Understanding Manipulation by the Tobacco Industry Introduction: In this lesson, we explore other forces and factors that shape the decisions we make. This lesson provides students with the opportunity to consider the many marketing strategies of the tobacco industry that influence people in ways they don't often recognize or think about.

Lesson Objectives: By the end of Lesson 12-5, students should: W

Recognize the diverse promotion strategies used by the tobacco industry and the ways in which these influence individual behavior

Understand the worldwide influence of the tobacco industry

Identify ways in which they can voice their views

Conduct one or more activities described in the American Cancer Society (ACS) Teens Kick Ash! program guide.

Materials: W

American Cancer Society Teens Kick Ash! Program Guide

Industry Quotes (See the folder L12_PowerPoint on the CD)

Postcards from the American Cancer Society

Key Terms:

Developing nations: Developing nations are in general countries that have not achieved a significant degree of industrialization and which have a low standard of living. Manipulation: Conscious strategies to shape othersâ&#x20AC;&#x2122; perceptions of a product or idea through marketing efforts.

World Health Organization: Headquartered in Geneva, Switzerland, the World Health Organization (WHO) is an agency of the United Nations, acting as a coordinating authority on international public health issues. WHO takes a negative stance towards tobacco.

Social action: Actions taken by citizens to express their opinions and to try to bring about change in ways that can improve society.

Page 12.5.1

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: 1.

Ask your students to recall the kinds of influences that shape decisions, such as the decision to use tobacco products that you have been discussing during the past several lessons. Remind your students of pressures and influences that they may not recall. List these on the board. These should include: W

Self concept and self-esteem: Our sense of health and what we value

The influence of those who are close to us : Our friends, family, peers, teachers

Our knowledge: What we know, what we believe, and what we think is important

Explore with your students what is missing from this list. Introduce to your students the importance of forces and factors outside of their immediate circle of friends, family and peers. The major force here is the tobacco industry, and the efforts it makes to encourage tobacco use in this country and around the world.

Teacherâ&#x20AC;&#x2122;s Note:

When we think about the influence of the tobacco industry, we often focus on the marketing efforts of tobacco companies to sell their products. This is an extremely important aspect of tobacco industry activities. It involves advertising, but also other types of marketing, such as sponsorship of cultural, social and sporting events. Ask students to examine some of the different

Your students may have already been exposed to this aspect of tobacco industry activities. It may be worthwhile, however, to consider again some of the images, which the tobacco industry presents to the public, the messages behind these images, and, in particular, their influence on the behavior of young people.

ways tobacco companies advertise their products. Some people have said that such tobacco advertising should be banned because of the harmful effects of smoking and tobacco use. In the past, tobacco companies have answered, saying their product is legalâ&#x20AC;&#x201D;why shouldnâ&#x20AC;&#x2122;t they be allowed to advertise it? What do your students think? L125_JoeCamel L125_MarlboroAd

Everyone has probably seen traditional advertising by tobacco companies, such as these Camel and Marlboro cigarettes magazine advertisements. Why do you think the tobacco makers chose these particular images for their advertisements? Whom would they appeal to?

Page 12.5.2

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

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?

L125_InStoreAd

A great deal is also spent on special promotions, such as these mailed dollar-off coupons, giveaways, and purchase points that can be redeemed for other merchandise... L125_KoolRadio

L125_CamelPinups

L125_CapriAd

L125_Giveaway

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

L125_NewportCoupon

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

L125_CamelGolf

L125_KoolDisplay

L125_StarsCollage

L125_SalemSlideBox

Page 12.5.3

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

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

L125_MarlboroRacing L125_Navratilova

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

L125_CamelCalendar L125_CamelCards

L125_CamelToy

L125_KoolToys

L125_MarlboroBag

L125_CamelShirt

L125_CamelCup

Page 12.5.4

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

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

L125_AlecBaldwin L125_AllWoman

L125_KoolMag

Teacher’s Note: This next section asks students to take a more detailed look at tobacco industry activities, and is probably ideal for the most advanced of your students. There is a wealth of information, including previously secret tobacco industry documents, that show the lengths to which the tobacco industry has gone to encourage tobacco use in this country. One valuable source is the document Trust Us - We're the Tobacco Industry. This booklet was prepared by the Campaign for Tobacco-Free Kids (USA) and Action on Smoking and Health (UK), and is available online at: http://www.ash.org.uk/html/conduct/ html/trustus.html

A copy is also available in the folder PDFFiles in the 12th Grade Lesson unit on the accompanying CD (titled TrustUs.pdf) Another valuable starting point on the Internet is the website of Americans for Nonsmokers' Rights. Industry activities are discussed at: http://www.no-smoke.org/shenanigans.html. Finally, the Tobacco-Free Kids web site maintains numerous informative factsheets that can be used by students for supplemental information: www.tobaccofreekids.org/research/factsheets

Tobacco companies have long argued their right to market and advertise tobacco, a legal product. Encourage your students to consider this argument in light of the following: Tobacco companies denied for many years that smoking and tobacco use were related to lung cancer and other diseases. Yet their own advertising showed their awareness of the health effects of tobacco use, even before scientific research began to show that smoking in fact caused many health problems, disease and death.

Page 12.5.5

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: (continued) 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.”

L125_Doctor1940

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?

L125_Doctor1946

These advertisements suggest that tobacco companies long ago were concerned about perceptions that smoking might be harming the body. Marketing cigarettes that were “less harsh” was a way to let smokers feel that they were doing less harm to their health.

L125_CamelWayne

L125_CamelNoRegret

Later, as scientific evidence became overwhelming, tobacco companies began to admit the health hazards of smoking—but used it to advertise and sell cigarettes that they claimed—incorrectly— to be “safer” than regular cigarettes!

L125_CamelAthlete1935

L125_NewCig

L125_LowToxAdvance L125_OmniAd

Page 12.5.6

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: (continued)

Teacher’s Note:

Tobacco companies denied in public for many years that nicotine was addictive.

The following tobacco industry quotes are available on PowerPoint slides. See the folder “L12_PowerPoint” in the 12th grade lessons file.

But their own internal documents show they knew all along that nicotine was addictive. More important, they knew that to keep selling cigarettes, they had to keep smokers addicted. Have your students examine the following quotes from industry documents, and cited in Trust Us—We’re the Tobacco Industry. Notice the dates of the quotes. What do your students think? “Nicotine is addictive. We are, then, in the business of selling nicotine— an addictive drug effective in the release of stress mechanisms.”

Brown & Williamson (makers of Kool, Pall Mall, Lucky Strikes, and many other cigarette brands), 1963

“We have, then, as our first premise, that the primary motivation for smoking is to obtain the pharmacological effect of nicotine.” Phillip Morris (makers of Marlboro, Virginia Slims, Benson & Hedges and many other cigarette brands), 1969

Tobacco companies recognized that if they reduced nicotine in their products, they would lose customers: “If nicotine [is the most important part] of smoking, and if we...move toward reduction or elimination of nicotine in our products, then we shall eventually liquidate our business. If we intend to remain in business and our business is the manufacture and sale of dosage forms of nicotine, then at some point we must make a stand.” R.J. Reynolds (makers of Camel, Winston, Salem and many other cigarette brands), undated

So publicly, the tobacco companies denied that nicotine (and smoking) were addictive. “The definition of addiction is wide and varied. People are addicted to the Internet. Others are addicted to shopping, sex, tea, and coffee. The line I would take is that tobacco isn’t addictive but habit forming.” Tobacco Institute, 1998

“I do not believe that nicotine is addictive.” Thomas Sandefur, Brown & Williamson, in testimony before Congress, 1994

For many years, tobacco companies publicly insisted that they oppose youth smoking, and that they do not market to children. Yet their own internal documents say otherwise: “...the base of our business is the high school student.” Lorillard (makers of Kent, Newport, True and many other cigarette brands), 1978

“...the 14-18 year old group is an increasing segment of the smoking population. R.J.R. must soon establish a successful new brand in this market if our position in the industry is to be maintained over the long term.” R.J. Reynolds (makers of Camel, Winston, Salem and many other cigarette brands), undated

Page 12.5.7

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: (continued) “The first cigarette is a noxious experience to the [beginner]. To account for the fact that the beginning smoker will tolerate the unpleasantness we must invoke a psychological motive. Smoking a cigarette for the beginner is a symbolic act. I am no longer my mother’s child, I’m tough, I am an adventurer, I’m not square. Whatever the individual intent, the act of smoking remains a symbolic declaration of personal identity...As the force from the psychological symbolism subsides, the pharmacological effect [addiction] takes over to sustain the habit.” Phillip Morris (makers of Marlboro, Virginia Slims, Benson & Hedges and many other cigarette brands), 1969

So how did the tobacco industry appeal to youth? Show again the advertising samples, as well as these additional samples below:

L125_CamelAviator

L125_CamelMotocross

L125_CamelLights

L125_koolbattle

L125_CamelPool

Page 12.5.8

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: (continued) 4.

Students do not always realize that the industry itself has been aware of the ways in which it has misled the public about its products or its actions. Reading about this “in the industry's own words” can help students understand this.

Ask students: W

How do you feel about these quotes? What do they make you feel about the tobacco industry?

How do you feel when tobacco companies show smoking as a pleasurable, exciting, relaxing, and “cool” activity?

How do you feel when you learn that tobacco companies have fought for decades against the research that shows nicotine is addictive; or that smoking and tobacco use causes cancer?

How do you feel when you learn that the tobacco companies actively seek to hook young smokers, in part by using cartoon figures, or rugged young men, or beautiful young women in their advertising, or by advertising in magazines read by young people?

Do you still think smoking is “cool,” “glamorous,” or “sexy?”

Consider with your students that these influences do not just occur in the United States but occur worldwide. And remind your students that when the promotion of tobacco products occurs in developing nations, people—including young people—in these countries begin to smoke and to experience the cycle of addiction, which makes it hard to quit. When this occurs, these nations,which have many other health, social and economic problems, must then also deal with the consequences of tobacco use. Facts: W

Tobacco use is increasing world wide, and particularly in the developing nations of the world. There are currently more than 1.1 billion smokers in the world. If current trends continue, this number will increase to 1.6 billion by 2025.

The World Bank estimates that “every day, worldwide, there are between 82,000 and 99,000 young people starting to smoke and risking rapid addiction to nicotine.”

Discuss what these numbers mean for tobacco company sales and profits.

Page 12.5.9

Lesson 12-5:

Understanding Manipulation by the Tobacco Industry

Procedures: (continued) 7.

Discuss with your students the concept of “social action”—that citizens can take responsible actions to express their opinions and to try to bring about change in ways that can improve society. Look through the American Cancer Society (ACS) Guide, Teens Kick Ash! Discuss these activities with your class. Your students can select one or more projects to work on as a group project. Projects can be completed in class, as group activities, or as homework assignments.

Journal: How does it make you feel to realize how the tobacco industry manipulates young people? OR Do other industries try to do what the tobacco industry does? Why? Why not? Has the tobacco industry influenced your behavior? If so, how? If not, why not?

Page 12.5.10

Lesson 12-6

Understanding Tobacco Use Prevention and Cessation Introduction: This lesson introduces “data” about tobacco use and interest in quitting among young people. This lesson also explores the concept of cessation. It encourages students to think about how difficult it is to stop smoking. Some of your students may be using tobacco and may want to quit - now or sometime in the future. Or they may want to help a friend stop smoking or using smokeless tobacco. In this lesson they can discuss some “tips” for making this happen.

Lesson Objectives: By the end of Lesson 12-6, students should: W

Consider how many young people, including young Deaf people, are smoking cigarettes, and want to quit

Understand the meaning of “cessation” and how it is different from prevention

Identify some of the steps they can take to help smokers—themselves or others—stop smoking

Materials: W

Graphic: Prescription for Success

Word Search

Key Terms: prevention: to keep something from happening. For example, by not starting to smoke, one will not get addicted to tobacco and will not experience the many health, social and financial consequences of using tobacco. smoking cessation: To stop smoking after one has become addicted.

Page 12.6.1

Lesson 12-6:

Understanding Tobacco Use Prevention and Cessation

Procedures: 1.

Ask your students the following questions about their peers: W

How many young people your age do you think have EVER tried smoking, even just one or two puffs?

How many young people your age do you think have smoked at least once in the last 30 days?

How many young people your age do you think smoke every day?

How many young people your age do you think smoke at least half a pack of cigarettes (10+) per day?

Write the studentsâ&#x20AC;&#x2122; answers on the board. Then show the following statistics:

L126_12thGrade; Source: Monitoring the Future, 2004

L126_30Day; Source: Monitoring the Future, 2004

L126_DailyUse; Source: Monitoring the Future, 2004

Page 12.6.2

Lesson 12-6: Understanding

Tobacco Use Prevention and Cessation

Procedures: (continued)

L126_HalfPack; Source: Monitoring the Future, 2004

What about for Deaf youth? The numbers are similar for Deaf youth, according to a recent survey of Deaf high school and college students in California. W

45%, or nearly half, of the Deaf high school students had tried smoking at least once.

For the college students, that number rose to 65%.

Compare your students’ estimates with the figures given above. If their estimates were higher, explain that young people often overestimate the number of people who smoke, perhaps thinking that smoking is a more common behavior than it really is. Some people may be encouraged to try smoking if they believe that, “everyone else is doing it.” If your student's estimates were lower, explain that tobacco use and smoking are important problems for young people, especially for your students’ age group. Explain to your students that they are at an age of very high risk for becoming

Teacher’s Note: It is important for students to understand that smoking is a serious problem for young people their age. They should be familiar with the implications of the statistical figures presented above—in particular, that about 1 in 3 teens who ever tries even just one puff of tobacco goes on to become a daily smoker. The lesson: Don’t start. At the same time, it is important to counter the notion that “everyone smokes.” Research shows that young people who overestimate the number of their peers who smoke are more likely to start smoking themselves. While it is important to use the statistics to point out the seriousness of the tobacco use problem, it is also important to emphasize that the vast majority of young people—85% or more—are not regular (daily) smokers.

addicted to tobacco use.

Well, if smoking is so bad, all you have to do is quit. How hard can that be? Pretty hard. Among young people under age 18 who smoke regularly, more than half say they want to quit. In fact, 58% say they’ve tried to quit in the past year but failed. They failed because of the power of addiction. A survey of Deaf high school and college students in California found 42 current smokers. Of these smokers, 25 said they wanted to quit, and 31 had actually tried to quit. Yet all of them are still smoking! Quitting smoking is not easy. What’s easiest is to not start smoking in the first place.

Page 12.6.3

Lesson 12-6: Understanding

Tobacco Use Prevention and Cessation

Procedures: (continued) 3.

While it is very difficult to stop, it is certainly not impossible. In fact, about half of all people who have ever smoked are now former smokers. They quit. It often took more than one "try" and it was certainly not easy for most of these people. But they accomplished this important goal for good health.

Have your students create a list of steps that can be taken to stop smoking. In making the list ask your students to put themselves in the shoes of a smoker. What would be important to them? What would harm their changes for success? Encourage your students to think about cessation even though they might not be smokers themselves. W

Help your friend think about situations to avoid "high risk" situations where they often smoke. Help your friend avoid these situations that "trigger" smoking.

Don't smoke in front of a person who is trying to quit or offer them cigarettes.

Help your friend keep busy so they keep their mind off smoking.

Tell them that they are doing a good job - and that

Teacher’s Note: There are many youth-oriented quitting (“smoking cessation”) programs that are available online. A good example is that available through the Centers for Disease Control at: www.cdc.gov/tobacco/quit/IQuit.pdf The document is also available in the PDF Files folder in the 12th Grade Lessons Folder on the accompanying CD. It is likely, however, that most of your students will not be smokers, although they may have already experimented with tobacco. This activity is designed to suggest ways to “help a friend” who may be trying to quit. As appropriate, you can remind your students that if they are tobacco users themselves, they can think about how to use the following ideas. You may also wish to discuss this privately with individual students.

they can do it. W

Quitting is easier if done with a friend. Encourage your friend to find a quitting buddy. If you smoke, you can be that buddy. Even on weekends quitting buddies can support each other via e-mail, pager, or phone calls.

Understand that someone who is quitting smoking may be moody or irritable during withdrawal.

If a friend who is trying to quit tells you that they are thinking of smoking, remind them of their success up until now and of all the reasons they decided to quit.

If a buddy goes back to smoking help them think of this as a slip - not as a permanent relapse. What can they learn from the experience? How can they avoid it in the future?

Remind them of the benefits to quitting - health, appearance, smell better, money saved, family and friends who want them to be healthy.

Remind them that cravings don't last forever. They usually last for a few minutes and then go away. Most people get over their withdrawal symptoms in a few weeks.

Page 12.6.4

Lesson 12-6: Understanding

Tobacco Use Prevention and Cessation

Procedures: (continued) W

There is help out there.

Get support from a group or a cessation program.

Encourage your friend to call their family doctor for advice and counseling.

Teacherâ&#x20AC;&#x2122;s Note: To find more resources about conducting a cessation program for young people, contact your local or state health department, American Cancer Society at 1(800)ACS-2345 or 1(800) 277-2345, or the American Lung Association at 1(800) LUNG-USA to get more information.

Homework: Distribute the Tobacco Word Search. Have your students complete the search. Remind them that they need to not only find the words, but explain their importance in preventing tobacco use.

Journal: Think about a current goal that you have. What can people do to help you? What might others do that will hinder you? Should schools offer a "cessation program" for students who want to stop smoking? Why? Why not?

Page 12.6.5

Lesson 12-6 Handout: Helping Someone You Know Quit Smoking

Helping Someone You Know Quit Smoking A Prescription for Success

From the Desk of a Friend

Prescription:

Lesson 12-7

The Anti-Tobacco Movement Introduction: This lesson introduces students to the tobacco control movement.

The effort to prevent tobacco use developed in response to the growing awareness of the dangers of smoking and secondhand smoke exposure. The tobacco control movement was also a response to the activities of the tobacco industryâ&#x20AC;&#x201D;the efforts of tobacco companies to keep information about the health hazards and danger of addiction from public view and to recruit new smokers.

Lesson Objectives: Plan Ahead!

By the end of Lesson 12-7, students will: W

Investigate a smoking prevention program

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

Access information and resources on the web. This can include, for example the Tobacco Free

This lesson asks students to access community-based resources to assess existing anti-tobacco efforts, and to consider how they might design a similar effort to reach the Deaf. Many of these resources are available online, and we have provided web page addresses that can serve as starting points. If appropriate, you may wish to assign certain web sites to groups of students to explore and present to the class, or the searching can be done as a class exercise. Samples of anti-tobacco educational materials can also be obtained free of charge from:

Kids website (www.tobaccofreekids.org), the

www.journeyworks.com

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

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

Consider the steps that citizens can take to influence the marketing, sales and use of tobacco products, in their own communities and beyond.

Materials: W

Internet or Phone Access

Web Addresses

Anti-tobacco materials (collected by students from voluntary organizations and the state and local health departments)

Anti-tobacco warnings for tobacco packaging (U.S., Canada and Brazil)

Page 12.7.1

Lesson 12-7:

The Anti-Tobacco Movement

Procedures: 1.

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

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

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

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

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

Are the messages clear and understandable for young Deaf people?

Do you think that telling young people about the health effects of tobacco

L127_DebVoicebox

use really "works" to discourage this use? W

What kind of messages do you think work best?

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

L127_Insides

Page 12.7.2

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued)

L127_EKG

L127_Fingernails

L127_ChemotherapyScares

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

L127_Limp

L127_MindIfISmoke

L127_BlewAway

L127_ChronicCoffin

Page 12.7.3

Lesson 12-7: The

Anti-Tobacco Movement

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

L127_BugSpray

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

L127_Frog

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

L127_RatPoison

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

L127_SmokeFree

L127_HighChair

s L127_SmokeFree02

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

L127_DaddysEyes

Page 12.7.4

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued)

L127_ButtsGross

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

L127_UtterFool

L127_GoodLooks

L127_BrookeShields

L127_ChewingMales

Page 12.7.5

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued)

L127_ChristyBeauty

L127_tonyhawks

L127_ChristysLungs

L127_ImproveGame

L127_JackieChan

L127_Boyz2Men

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

L127_Sosa

Page 12.7.6

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued)

L127_SweetProducts

L127_CoverUp

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

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

L127_RealMarlboro

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

L127_WarningLabel01

In a compromise struck between the federal government and the tobacco industry, no additional warning labels were allowed. This meant that if individual states wanted

Teacherâ&#x20AC;&#x2122;s Note: All of these labels used on cigarettes in the United States represented a compromise between the government and the tobacco industry, which first sought to avoid labeling, and then fought to limit the wording on the labels. Other countries such as Canada, Australia, Brazil and countries in the European Union have implemented stronger labels with bold print, large font, declarative statements, 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, and the governmentâ&#x20AC;&#x2122;s role in countering the marketing of tobacco.

to put different warning messages on the tobacco products sold within their state borders, they would not be allowed to do so.

Page 12.7.7

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued) W

In 1969, the message was changed to read

L127_WarningLabel02

Again, no additional warning labels were allowed. W

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

L127_SGLabels

As before, no additional warning labels were allowed on cigarettes. W

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

L127_Smokeless01

L127_Smokeless03

L127_Smokeless02

Ask your students the following: W

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

Show your class the examples of warning labels from Canada and Brazil. Ask your students: W

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

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

Page 12.7.8

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued)

L127_Canada03

L127_Canada05

L127_Canada07

L127_Canada04

Cigarette warning labels required on tobacco products sold in Canada

L127_Brazil01

L127_Brazil04

L127_Brazil03

Cigarette warning labels required on tobacco products sold in Brazil

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

Page 12.7.9

Lesson 12-7: The

Anti-Tobacco Movement

Procedures: (continued) 7.

Explain to students that various groups are responsible for the anti-tobacco materials reviewed above. Some of these are listed below. Have students discuss why these agencies and organizations might be concerned with preventing or reducing tobacco use. W

Government Agencies These include local and state health departments, and agencies such as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health.

Teacher’s Note

Voluntary Agencies These include non-profit, non-governmental agencies such as the American Heart Association, the American Lung Association, the American Cancer Society.

Professional Organizations These include groups such as the American Medical Association, and the American Dental Association.

International Organizations, such as the World Health Organization

As a class or homework exercise, you may want to assign groups of students to research each of the following organizations online. They can present information about the organizations, what they do regarding tobacco control, and why they are concerned about the issues of tobacco use and smoking.

Other “grassroots” organizations These include groups such as the Campaign for Smoke Free Kids (www.tobaccofreekids.org), the Truth Campaign (www.thetruth.com), Americans for Non-Smokers’ Rights (www.no-smoke.org), Why Quit (www.whyquit.com).

Ask your students to think about what the government has done to limit tobacco use. Explain that governments not only pass laws (for example, that restrict smoking in workplaces, or that control the sale of tobacco to youth), they also support research and public health education (for example, through advertisements, or setting school health curricula). They can also set tax policies (e.g., place a tax on tobacco products) that can discourage tobacco use by making tobacco products more expensive.

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

Page 12.7.10