Hands Off Tobacco: 9th Grade Curriculum

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

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

California School for the Deaf, Fremont

Barbara A. Berman, PH.D.

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

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

Recruitment, Retention and Communications Core UCLA Jonsson Comprehensive Cancer Center

PDF processed with CutePDF evaluation edition www.CutePDF.com

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

Š2004, 2007 University of California, Los Angeles

Introduction for Teachers

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


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

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

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

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

Introduction for Teachers

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

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

Is tobacco use addicting for children and teenagers?

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

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

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

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

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

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

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

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Introduction for Teachers Figure 1: The Addiction Cycle


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


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


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

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

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


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


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

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


Introduction for Teachers

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

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

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

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

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

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

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

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

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

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

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

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

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1964 Surgeon General’s Report Broadcast advertising ban

U.S. entry into WWII

Number of cigarettes

U.S. entry into WWI

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

First modern reports link smoking and cancer Great Depression

Federal cigarette tax doubles

Non-Smokers’ Rights Movement begins

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

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

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

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

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

Introduction 9

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

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

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

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

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

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

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

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

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

Introduction 10

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

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

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

How is our curriculum organized?

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

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

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

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

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

Introduction for Teachers

How the Lessons are Organized Topic


Self-Esteem and Self-Concept


Friends and Peers


Decision Making

Grade Level
















5-3 5-4

7-3 7-4





Media and Other Influences to Use Tobacco

5-3 5-4

7-6 7-7



Resisting Influences to Use Tobacco







Health Effects of Tobacco Use


6-1 6-2

6-3 6-4


Anti-Tobacco Efforts and Social Action

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














10-6 10-7

11-5 11-6


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

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

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

Introduction 13

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

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

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

Introduction 14

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

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

Introduction 15

Introduction for Teachers

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

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

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

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

Introduction 16

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

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

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

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

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

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

Introduction 17

Additional Resources for Teachers

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

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

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

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

Healthy Schools Healthy Youth!

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

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

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

Resources 18

Additional Resources for Teachers

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

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

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

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

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

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

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

✷ Advocating for changes in government policies to reduce tobacco use

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

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

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

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

Resources 19

Additional Resources for Teachers

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

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

✷ The Truth® Campaign www.thetruth.com

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

✷ Streetheory®

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

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

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

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

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

Resources 20

Additional Resources for Teachers

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

Monitoring the Future

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

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

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

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

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

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

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

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

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

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

Resources 21

9th Grade Lessons:

Needed Materials and Preparations Lesson 9-1

* Worksheet: Self-Esteem Inventory * Worksheet: What's My Line

Lesson 9-2

Tool Box (labels for cards are provided)

Lesson 9-3

8 shoe boxes with Shoe Box Labels (labels are provided) Magazines appealing to different audiences (at least one for each student) * Tobacco advertising samples (provided on CD) * Anti-tobacco advertising samples (provided on CD) * Worksheet: I Spy Tobacco!

Lesson 9-4

* Nail polish remover, batteries, ant poison, picture of preserved animal, ammonia, mothballs, picture of car with exhaust coming out of the tail pipe, picture of prison death row cell * Chemical labels * What's in Tobacco Smoke? (partial list of chemicals in tobacco) * Worksheet: Your Smoke Makes Me Choke * One User's Story: Sean Marsee * Journeyworks Publishing Pamphlets: Secondhand Smoke: Protect Your Air Environmental Tobacco Smoke: What It Is and What You Can Do About It Secondhand Smoke Is Not Healthy for Living Things

Lesson 9-5

* One Addict's Story: Bryan Curtis * Graphic: The Addiction Cycle

Lesson 9-6 Lesson 9-7

School smoking policy in student or faculty handbook (if available) * Anti-tobacco advertising samples (provided on CD) Stationery for letters

* 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.

9th Grade Lessons Materials List

Lesson 9-1

Self-Esteem: How Do You See Yourself? Introduction: This lesson introduces students to the concept of self-esteem and how it relates to relationships and behavior. The point is to make students aware of how their own perceptions of who they are as individuals can affect the ways they behave both around and towards others. This theme is expanded upon in Lesson 9-2, which looks at how students respond to friend and peer influences.

Lesson Objectives: By the end of Lesson 9-1, students will: W

Gain awareness of how self-esteem can work for or against them


Identify areas of self esteem that are high or low


Develop strategies to increase their self-esteem

Materials: W

Self-Esteem Inventory Worksheet


What's My Line Worksheet

Key Terms: competence: having the necessary abilities or qualities to do things, perform tasks, or get along with others.


self-esteem: belief in one’s worth; self respect; the value you place on yourself. self-image: the inner picture that one has of him- or herself; the concept one has of one’s competence, worth, attractiveness, intelligence and other characteristics and traits. Self-image is also often referred to as self-concept. worth: the value one places on one’s accomplishments, abilities, and relationships with others.

Page 9.1.1

Lesson 9-1:

Self-Esteem: How Do You See Yourself?

Procedures: 1.

Write the following definitions on the board and facilitate a discussion to ensure that students understand the terms: Self-Image: The whole inner picture that you have of yourself; what you think of your abilities, worth, attractiveness, intelligence, and other aspects of yourself. This is also sometimes described as self-concept. Self-Esteem: belief in one's worth; self respect; the L91_SelfEsteem1

value you place on yourself.


Initiate 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 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, 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? L91_FeelBad


Pass out the Self-Esteem Inventory and ask students to

Teacher’s Note:

complete the form. Tell students that there are no right

You will be asking students to refer to these worksheets in Lesson 9-2.

or wrong answers.

Page 9.1.2

Lesson 9-1: Self-Esteem:

How Do You See Yourself?

Procedures: (continued) 5.

Ask students to look over their inventories. Discuss how greater counts of “false” answers may indicate low self-esteem. Lead a discussion about factors that help to boost or lower self-esteem. Ask the class to brainstorm ways that teenagers can increase their self esteem.


Ask your students to complete the What’s My Line? worksheet in class or for homework. Explain that most people mark themselves somewhere between the two extremes listed for each line. However, they may “lean” more toward one side or the other (e.g., “I tend to be more sloppy than neat, although I’m not a total slob.”). Facilitate a discussion about the students’ ratings. Looking over your worksheets, where do you usually place yourselves? Are there any areas in which you've placed yourselves at the extreme ends? Are there any of these areas that you would like to change?

Journal: If you could change one thing about yourself, what would it be and why?

Page 9.1.3

Lesson 9-1 Worksheet: What’s My Line?

Name __________________________________

What’s My Line? Each line below is about you! Put an "X" where you fit on each line. Total Slob! My room is a mess!

Total Slob!



Neat Freak! My room is always neat!

Neat Freak!

My room is a mess!

My room is always neat!

Hot Temper!

Cool Head

I get angry easily

I rarely get angry



I am really good at sports!

I’m not very good at sports



I always feel positive

I always feel like things are bad



I like to make decisions and have others follow

I prefer to let others make decisions


Secret Keeper

I love to spread stories about others!

I never talk about other people’s business

Grudge Holder


I can stay angry at others for a long time

I am able to forgive people

Lesson 9-2

Assessing Peer Pressure Strategies Introduction:

This lesson explores how peer pressure occurs and ways in which such pressure can be resisted. Students are taken through exercises in trying to pressure others into engaging in behaviors such as smoking; and in considering the various types of resistance strategies that might be employed to counter this pressure. The link between self-esteem and the ability to resist peer pressure is also reviewed.

Lesson Objectives: By the end of Lesson 9-2, students will be able to: W

Identify the Tools of Fools (direct orders, insults, harassment, exclusion), strategies used by people to pressure others into certain actions or behaviors.

Materials: W

Tool Box (box with cards, each card imprinted with one of the Tools for Fools Strategies)

Key Terms: harassment: Constant badgering or annoyance aimed at persuading someone to do something they otherwise might not want to do. refusal skills: tools which one can use against friend or peer pressure to do something that one finds undesirable, unsafe, or wrong. refusal strategies: ways of expressing refusal, divided here into three major types: passive, aggressive and assertive.


For Review: peer influence: the indirect force that peers exert in shaping one's opinions, perceptions, desires and behavior. (See Lesson 8-2) peer pressure: the more direct force that friends and peers often use to shape one's opinions, perceptions, desires and actions. (See Lesson 8-2)

Passive: refusal in a non-confrontational manner without actually saying “No.” Tends to be non-committal (“Um...maybe”), and often involves leaving an issue unresolved. Aggressive: refusal expressed by using confrontational strategies. Assertive: Refusal in a firm, clear, but non-threatening manner.

Page 9.2.1

Lesson 9-2:

Assessing Peer Pressure Strategies

Procedures: 1.

Use the following questions to start a discussion about peer pressure: W

What is peer pressure?


When can peer pressure be a negative force? (Use examples to prompt: when you feel L92_Decisions03

pressured to do something you don't want to do; smoking, drugs and alcohol use; dangerous driving; etc.) W


Is peer pressure always something negative? When do you think peer pressure can be something positive? (Use examples to prompt: doing well in school; not acting out in class; working as a member of a team).


Who exerts peer pressure? Is it different when it comes from your friends than when it comes from other kids your age that you may not know? In what ways? Do you think you feel more peer pressure from other Deaf kids, or more from hearing kids?


How can you tell the difference between positive peer pressure and negative peer pressure?



Think about the times you have felt pressured to do something you didn't want to do. How did others make you feel that pressure?


Think about the times you've pressured others to do something. How did you do it? What techniques did you use?


Introduce Tools of Fools. Write on the board the strategies that people use to try to pressure someone. For each tool, talk about the words or signs that people use, including more subtle non-verbal body language: W

Direct Order (“Do It!”)


Insults, including name calling and mean gestures (“What are you, a baby?)


Harassment, including threats (Bothering someone repeatedly to try to convince them.)


Exclusion, including making a person feel left out. (“Everyone's doing it except you!”)


Non-verbal or other physical cues, such as: rolling eyes or not giving eye contact; ignoring you; turning their backs to you; talking about a person behind their back; etc.

Page 9.2.2

Lesson 9-2: Assessing

Peer Pressure Strategies

Procedures: (continued) W

Guilt, such as making people feel bad if they don't go along, as a way of getting them to do something they otherwise might not do. (“Oh forget it, if you don't want to go, I'll just go by myself!”)

Ask students, “Which of these Tools for Fools have you experienced? From whom? Do you think that your being Deaf makes you more vulnerable to such Tools? Less vulnerable? Why?”


Ask students to think about the Tools for Fools that are being used in each of the following situations: W

Why don't you smoke cigarettes with us, are you scared?


Want some pot? C'mon, it won't hurt you. No one will find out. You'll just feel a little relaxed, that's all.


Come on, no one will know if we have sex, don't you love me?


I have some beer in my backpack, meet me after school to drink it. Everyone else will be there.


I found some ecstasy in my sister's room, let's try it. Oh, but I forgot— your mommy would get mad at you. Never mind.


Hey, be a pal and keep these cigarettes in your locker for me until after school, OK?


Explain that sometimes we feel pressure from friends or peers to do something we don’t want to do, or think that we shouldn’t do. Tell your students that refusing to go along with others—including people whose ideas and opinions are important to us—can be difficult to do, but that it helps if they know specific ways to say “No!”—resistance strategies. Remind your students that ultimately they are responsible for the decisions they make, no matter how they are pressured by others. In making these decisions, it can be helpful to go through the steps of the D.A.R.E. Decision-Making Process.


Teacher’s Note: This discussion on resistance strategies is presented in Lesson 8-4 of the 8th grade curriculum. If your students have already covered this material, review briefly the different types of resistance strategies students can use when confronted with pressure to do something they don’t want to do. Otherwise, that material is covered here as well. If your class has never covered the D.A.R.E. decision-making process before, you may need to take some time to review the steps with your students. The model can be found in Lesson 7-3, which uses the decision-making process of the Drug Abuse Resistance Education (D.A.R.E.) program, the pioneer prevention effort established in 1983.

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

Page 9.2.3

Lesson 9-2: Assessing

Peer Pressure Strategies

Procedures: (continued) Example #1: Passive Resistance W

Your friends ask you to join them behind the gym to smoke cigarettes. What are the common ways you might resist this request? (e.g., I ignore my friends’ invitation; I shrug my shoulders; I say, ‘Maybe next time.”; I giggle and then look away.) L92_Passive

Explain that when we use these methods, we are using passive resistance. We avoid confrontation by being neither agreeing or disagreeing, walking away, or ignoring the issue.

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

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

passive resistance? What are some of the disadvantages?

Example #2: Aggressive Resistance Some strategies can be termed aggressive resistance. These usually involve a more confrontational tone, such as taking a cigarette that someone has offered you and crushing it in your hands, saying, “Get that stuff out of my face!” L92_Aggressive

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

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

aggressive resistance?

Example #3: Assertive Resistance


A third resistance strategy is sometimes called assertive resistance. Assertive resistance usually involves making your resistance known in a direct but nonconfrontational manner. For example, “No thanks, I don’t smoke,” or “Let’s NOT get into your parents’ liquor cabinet—why don’t we find something else to do instead?”

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

Teacher’s Note: Advantages might include being direct; disadvantages might include causing bad feelings.

disadvantages of assertive resistance?

Page 9.2.4

Lesson 9-2: Assessing

Peer Pressure Strategies

Procedures: (continued) 6.

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

1. Be Direct 2. Change the Subject L92_Refusal01


3. Think of a Clever Response


4. Make a Joke


5. Blame an Adult

6. Avoid the Situation or Walk Away

L92_Refusal05 L92_Refusal06

Page 9.2.5

Lesson 9-2: Assessing

Peer Pressure Strategies

Procedures: (continued) 7.

Divide the class into two teams. Team A will select a Tools for Fools Card from the Tool Box and will show that strategy. For example, the team picks the Insult card and says, “You are such a wimp if you don’t try smoking!” Team B must decide which Tool is being used and then decide which of the refusal strategies will work best for that situation and role play it back.


Discuss the following points with the class: W

Which of the Tools was the hardest for you to respond to? Which one caused you to feel the most pressure?


Which refusal strategy worked the best for you?


Practicing refusal skills and knowing what type peer pressure affects you the most will be helpful.


Ask students to practice these refusal skills through out their day whenever possible to become more skilled.


Have students review their homework from Lesson 9-1 (What's My Line?). Ask your students how the ways they see themselves might make them more susceptible, or less susceptible, to pressure from others.

Journal: What type of peer pressure makes you feel the worst? Why? What type of peer pressure is the hardest for you to respond to? Why?

Page 9.2.6

Lesson 9-2 Tools for Fools

Name __________________________________

Tools for Fools Labels Direct Order “Do It!”

Insults Name-calling, teasing, making fun of someone


Making Someone Feel Left Out



bothering someone repeatedly to try to convince them, includes threats

Eye-rolling, mean gestures, dirty looks, etc.

Making someone feel guilty if they don’t go along

Lesson 9-3

Evaluating Media Messages Introduction:

The lesson asks students to examine the impact of advertising and marketing on their decision-making, particularly when it comes to evaluating behavioral choices regarding the use of tobacco. Students review the various types of messages and appeals that are made and the various strategies used to deliver these messages. Students are then asked to consider the effectiveness and appeal of these messages for Deaf youth, and how these messages can be effectively countered with the marketing of anti-tobacco messages.

Lesson Objectives: By the end of Lesson 9-3, students will be able to: W

Identify how marketing strategies target teens.


Identify ways in which marketing influences young people's decision-making.


Identify ways in which marketing strategies might be successful (or unsuccessful) in reaching Deaf teens.


Identify more effective ways to reach Deaf teens with anti-tobacco programming.

Materials: W

8 shoe-boxes - with Shoe Box Labels


Magazines appealing to different audiences (at least one for each student)


Tobacco advertising samples (provided on CD)


Anti-tobacco advertising samples (provided on CD)


I Spy Tobacco! Worksheet

Prepare: W

Collect various magazines that appeal to different audiences (for example, business, women, teens, news, sports, health and fitness, beauty, hobbies, music, skateboarding, etc.). This lesson's exercises will work best if students can view a variety of magazines for diverse audiences. It is best if you start assembling this collection as early as possible, or ask your students to bring in different types of magazines over the preceding month or so.


Ask students to look through magazines and newspapers for advertisements, including tobacco ads, and to bring those they find to class.

Key Terms: advertising: one of the major tools of marketing, usually through media such as magazines, television, billboards, etc. manipulation: Conscious strategies to shape others’ perceptions of a product or idea through marketing efforts.

marketing: persuasion to buy a product or accept an idea by presenting it in a favorable light that shows its advantages or attractions; advertising.

Page 9.3.1

Lesson 9-3:

Evaluating Media Messages

Procedures: 1.

Review some of the factors that encourage smoking that were covered in Lesson 9-2, including peer pressure. Ask your students to review some of the ways they can resist the pressure to smoke or use tobacco.


Explain to your students that when people are asked why they started smoking, they often give the following answers: W

curiosity or boredom


to relieve stress or depression


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


to be rebellious; to have fun

And yet, when scientists talk to young people, they actually find that most teenagers don’t think smoking is cool. In fact, W

67% of teenagers say that seeing someone smoke turns them off.


65% say that they strongly dislike being around smokers.


86% would rather date people who don’t smoke.

Even teenagers who smoke don’t think that smoking is so cool. More than half want to quit, and 70% wish they had never started smoking in the first place.


Ask your students: W

Where does the idea that smoking is cool, fun, exciting and rebellious come from? Maybe because that is how smoking is portrayed in cigarette advertising. Can advertising really be that powerful?


Begin a discussion of products students like to buy—shoes, soda, clothing, electronic goods and the like. Ask students to identify the “best” or “coolest” shoes, bags, skateboards, gadgets, clothing and so forth.

Ask your students: W

Why do you choose a particular brand of shoe, or type of soda? What do you think about products such as Nike shoes, or Red Bull, especially compared to similar products?

Ask students how they know about these products, and why they think they are the best. L93_ConsumerGoods

Page 9.3.2

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) Explain that most of the items we think are “best” or “coolest” are often items that are advertised by celebrities or people we admire, or that appeal to our desires. Advertisements and “marketers” try to convince us that if we buy a particular product, we will look better, feel better, have more fun, be more relaxed, or any number of other positive results. This is someL93_BeautyAd

times referred to as manipulation. W

Do you think this manipulation is conscious on the part of advertisers? Why or why not?


Using magazines geared to several different audiences (teens, women's magazines, popular music, cars, skating, home


design, personal finance), ask students to tear out at least ten advertisements. Ask them to write on the back of each one the name of the magazine in which the advertisement was found. Distribute the advertisements around the class and ask students to analyze them.

Ask your students: W

What is the product being advertised? What is the advertisement telling us about the product? What is the advertisement trying to tell us if we use the product?

Explain to students that companies want us to buy their product so that they can make money. If a company can successfully get people to buy their product, the company will make money.


Ask students to identify aspects of commercials from TV that appeal to teens. For example: W

Nike—Just Do It! Shows strength and power


Gatorade—Shows strength, power, speed, slick like water, cool


Acne medicine—Beauty, building one’s confidence

Ask students for other examples.

Page 9.3.3

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) 7.

Ask your students: W

How do commercials influence how you think about the products?

Explain that companies try to tell us that if we use their product, it will bring us the things we want. They try to convince us that their product will give us:



Fun and Pleasure


Good Health


Adventure and Excitement


Money, Fame or Power


Beauty and Popularity




Brains, Intelligence and Wisdom


Free Stuff!!

Cut out the Shoe Box Labels, and glue each one to a shoe box. Ask students to sort the ads into the appropriate shoe boxes. Discuss how the ads differ by magazine type, and why. Talk about the importance of the audience: W

What type of advertisements would you expect to find in a teen magazine? How about a gaming magazine? A personal finance magazine?

Ask students to identify the things that they would like most from the above list. Which do they think is most important? How would these appeals play to people with different levels of self-esteem?


Distribute to the class copies of tobacco advertisements and ask the students to classify them into the categories above. What are the messages in these advertisements? What audiences are targeted in these tobacco advertisements? Ask them if it is clear (visually) what product the advertisements are selling, and how. Refer to some of the older advertisements, particularly those featuring tobacco recommendations by doctors, and those featuring parents and children.

Teacher’s Note: As part of the 1998 Tobacco Master Settlement Agreement that was reached between major tobacco companies and 46 states, the tobacco industry agreed to a number of new restrictions on tobacco advertising (joining the ban on television advertisements for tobacco products). Included in these restrictions are bans on the use of cartoons in advertising or packaging for tobacco products; elimination of most outdoor advertising, including billboards, and signs and placards in arenas, stadiums, shopping malls, and on transit (e.g., buses and trains); and bans on the sale or distribution of apparel and merchandise with brand name logos (although tobacco companies continue to give away free merchandise in exchange for “points” or “coupons” earned with each purchase of cigarettes.) The Master Settlement Agreement also bans payments to promote tobacco products in movies, on television shows, in videos and videogames, and other entertainment. Tobacco companies are also prohibited from brand name sponsorship of events with a significant youth audience (football, basketball, baseball, hockey and soccer). Students should be encouraged to think about how marketing to young people might still be occurring, even in the face of these prohibitions. You can read more about this at: http://caag.state.ca.us/tobacco/resources/ msasumm.htm

Page 9.3.4

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) What desires do these advertisements for cigarettes appeal to? What experiences and self-images do these advertisements want us to associate with tobacco use?




What do these advertisements want to say to us about smoking and our sense of femininity and masculinity? L93_VSlims01

Or our sense of the exotic, romantic and fun? L93_Ad04




Page 9.3.5

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) Why do you think tobacco companies want to show celebrities smoking? Why are these images important to tobacco marketers? What do you think of these ads?


L93_AlecBaldwin L93_DemiMoore



Celebrities are useful even if they are not directly promoting the use of tobacco. By using stars such as Martina Navratilova in their sponsorship of sporting events (since restricted under the terms of the Master Settlement Agreement), or by using celebrities such as Penelope Cruz in producing “lifestyle” magazines (along with many tobacco ads inside) for home delivery, tobacco companies can reach out to audiences they might not reach otherwise. Who would be excited about the Virginia Slims Tennis Championships? Who might read “Flair” magazine?

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




Page 9.3.6

Lesson 9-3:

Evaluating Media Messages

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 touting cigarettes that were “mild” and free of “irritation.” Many of these ads were produced in the 1940s and 1950s. Do you think tobacco companies could produce advertisements like these today? Why or why not? What do you think of these ads?



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

L93_FatherSon1945 L93_MotherChild

Page 9.3.7

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) 10.

Ask your class if anyone has ever seen anti-tobacco advertising. Explain that government agencies and other groups are countering tobacco companies’ advertisements with their own anti-tobacco advertisements. W

What messages are these advertisements trying to convey? Are they effective or convincing? Do you think these advertisements are convincing for Deaf youth? What kind of advertisement do you think YOU could design to reach other Deaf kids?


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



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

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


s Look how these billboards are using the “glamour of smoking” as portrayed in tobacco advertisements, and L93_Scent turning the message around to point out why smoking is a bad idea... ...while carrying the “masculinity” of the Marlboro Man to its natural conclusion if one takes up smoking.



Page 9.3.8

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued)

L93_TableforOne L93_BlewAway



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


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


L93_Smoking Is Ugly


Page 9.3.9

Lesson 9-3:

Evaluating Media Messages

Procedures: (continued) Homework: Distribute the I Spy Tobacco! Worksheet. W

Have students record, while they watch television over the next week, every situation in which they see smoking or tobacco use of any kind. Ask them to write down the name of the show, and briefly describe the circum-

Teacher’s Note: Use the examples of tobacco advertising above to review the objectives of the homework assignment with your students.

stances on the worksheet. Remind your students to include comedies, movies, newscasts, or even anti-smoking messages. Also, ask them to notice if they see tobacco advertisements when watching sporting events on television, such as tennis matches, automobile racing, baseball games, and other tobacco-sponsored sports. W

Have students, over the course of the next week, note every instance of tobacco advertising that they can find or see. Record the location of these advertisements on the worksheet. Instruct students to look for such advertising, not just in the usual places (e.g., in magazines), but also on clothing, hats, at the beach, at sporting events, and so forth.


If students see a movie, have them record any instances of smoking they see. Have the students record who is smoking, and a brief description of the circumstances.

Journal: Companies give away hats and shirts that bear the picture or name of the product they sell. They do this as a form of advertising, because they know that when people wear these items, they are helping to promote awareness of the companies’ products. What are your thoughts on tobacco companies engaging in this type of marketing?

Page 9.3.10

Lesson 9-3 Worksheet: I Spy Tobacco!

Name __________________________________

I Spy Tobacco! Instructions: 1.

As you watch television this week, or if you see a movie, record every instance in which you see smoking or tobacco use of any kind. Write down the name of the show or movie and briefly describe the situation (Who was smoking? Why?).


As you walk about over the next week, note every instance of tobacco advertising you can see, including signs in stores, ads in magazines, on clothing, at the beach—keep a sharp eye out! Record the details below.

TV Show, Movie, or Place You Saw Smoking or Tobacco Advertisement

Describe the Situation

Lesson 9-4

So What’s So Bad About Tobacco? Introduction:

Students are presented with a graphic presentation of the different types of chemicals found in tobacco and cigarette smoke. These chemicals are then linked to the various health effects of tobacco use (both smoked and smokeless) on the respiratory and cardiovascular systems of the body, as well as on other tissues and organ systems. Students are also introduced to the hazards of secondhand smoke.

Lesson Objectives: By the end of Lesson 9-4, students will be able to: W

Identify the types of tobacco use


List some chemicals in tobacco


Identify damaging effects of tobacco use


Identify the dangers of secondhand smoke

Materials: W

Nail polish remover




Ant poison


Picture of a preserved animal






Picture of car with exhaust coming out of the tail pipe


Picture of prison death row cell


Chemical Labels


What’s in Tobacco Smoke? Partial list of chemicals in tobacco


Your Smoke Makes Me Choke Worksheet


One User’s Story: Sean Marsee Handout (also on CD in the “WebPages” folder)


Journeyworks Publishing pamphlets: Secondhand Smoke: Protect Your Air Environmental Tobacco Smoke: What It Is and What You Can Do About It Secondhand Smoke Is Not Healthy for Living Things

Key Terms: inhale: to draw air into the lungs, along with any chemicals, dirt, germs, and other particles that may be floating in the air passive smoking: Inhaling secondhand smoke from someone else's smoking, or from their lit cigarette, cigar or pipe.

secondhand smoke: Secondhand smoke is the exhaled smoke from the lungs of a smoker, as well as the smoke that disperses from a lit cigarette, cigar or pipe. It is also commonly referred to as environmental tobacco smoke, or ETS.

Page 9.4.1

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: 1.

Have the above-listed items on a table in the front of the room. Ask students to name the items and if they know, what they are used for. Ask students what would happen if they ingested the items they see on the table.


Place the appropriate label (See Chemical Labels) on each of the items. Explain that the word on the label is one of the poisonous chemicals found in the item. Explain that each of these chemicals is also contained in cigarette smoke. Tobacco contains more than 4,000 chemicals that enter the body either through smoking or chewing tobacco products.


Explain that these are just some of the poisons that enter the body through tobacco use. When tobacco is burned (as in a cigarette), these chemicals enter the body through the smoke. Similarly, if tobacco is chewed (as in smokeless tobacco), many of these chemicals are absorbed into the body through the tissues of the mouth and throat. Distribute the comprehensive list of chemicals in tobacco.


Teacher’s Note: Write the words Health Consequences on the board. Explain that over the past 50 years, scientists have shown that the components of tobacco—the chemicals found in tobacco and in the smoke when tobacco is burned—can harm the body in very serious ways. Ask your class if they can list some of the most important health consequences of tobacco use. Classify the responses into the following categories:


Effects on the respiratory system: The most common way people use tobacco is to burn it and inhale the resulting smoke, either from a cigarette, cigar, pipe, bidi, kretek, or waterpipe (hookah). This smoke causes a great deal of damage to the tissues of the respiratory system: that is, the lungs and airways leading to them. When a person inhales, their lungs fill with air containing oxygen. The lungs have tiny air sacs, called alveoli, where the oxygen is absorbed into the blood and exchanged with carbon dioxide, a waste product of the body that is exhaled as the per-

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

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

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

son breathes out. This process is called gas exchange, and is

Page 9.4.2

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) the primary function of the lungs. The oxygen absorbed by the blood in the lungs is then carried to the heart, and all other tissues and organs of the body. When you inhale, the inside of your lungs and airways are exposed to air, including any germs, dust, dirt particles and other objects floating in the air. To clean away these foreign particles, your lungs and airways secrete mucus, which traps the particles. Little hair-like structures called cilia that line the airways move in a sweeping motion to push this mucus out of the lungs. This mucus, with its trapped particles, can then be coughed, spit,


or otherwise passed out of the body. So what does smoking do? Tobacco smoke slows the motion of the cilia, making it more difficult to move mucus out of the lungs and airways. This makes it more likely likely that germs, dirt and other contaminants (together with the mucus) will get trapped in the lungs. The more and the longer you smoke, the greater the damage done to the cilia, until they lose almost all of their ability to clean the lungs. The result is often “smoker’s cough,” the hacking, mucus-laden cough that long-time smokers often experience, especially on awakening in the morning. If the lungs and airways become inflamed and clogged with mucus, this can lead to chronic bronchitis, making it difficult to breathe. When a person smokes, the tobacco smoke is inhaled into the lungs, where the smoke leaves behind a sticky residue called tar. Contact with this residue can damage the lungs, and over time may result in diseases such as lung cancer.

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

Source: The ABC’s of Smoking


Source: The ABC’s of Smoking


Page 9.4.3

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) The smoke also damages also damages the alveoli, the little air sacs where gas exchange in the lungs takes place. This damage means that your lungs become much less able to perform the gas exchange that brings oxygen into your body. In some people, this damage progresses to become a disease called emphysema, where the alveoli (air sacs) have been damaged to the point where oxygen can no longer be absorbed into the bloodstream. Smoking also causes the airways (the lungs and the tubes leading to them) to overreact to harmful substances, causing them to tighten up (“constrict”), and leading to wheezing and shortness of breath. This can be especially serious for those people who already suffer from asthma. L94_emphysema

s What does emphysema look like? Compare the healthy lung on the previous page with the lung from a person with emphysema above.

L94_HeartDetail L94_Stroke



Effects on the circulatory system: The chemicals found in tobacco have many effects on the body's circulatory system. Smoking encourages a process call atherosclerosis, or narrowing of the arteries and blood vessels. This reduces the flow of blood and oxygen to important organs, including the brain and heart. Over time, this narrowing can lead to a heart attack

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

(if the heart tissue is deprived of the oxygen it needs to keep beating), or a stroke (caused by a blockage of a blood vessel in the brain or neck, leading to tissue damage or death in the brain.)

Page 9.4.4

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) 7.

Mouth and throat tissues: The chemicals that cause damage to lung tissues can also damage tissue in the mouth, leading to gum disease, mouth sores and tooth loss. These chemicals can also lead to cancer of the mouth and throat.



Tobacco use can lead to gum ulcers as in this picture here. Eventually, this tissue damage can lead to oral cancer, such as that featured in the anti-tobacco advertisement at right: L94_OralCancer


Other organ systems: Over the long term, smoking has also been linked to cancer of the bladder, kidney, pancreas and other important organs in the body.


What about smokeless (chewing) tobacco products? Since these aren’t burned and smoked, doesn’t that make them safe? Explain to your students that these products also contain harmful chemicals that can cause diseases such as oral cancer. Many young people believe that these types of tobacco are safe because they are not smoked, but this is an incorrect belief.


Social consequences of smoking: Ask your students

One User’s Story: If your students are not already familiar with the story of Sean Marsee, his experience with the use of smokeless tobacco can be found at: http://whyquit.com/whyquit/SeanMarsee.html The story can also be found on the accompanying CD (in the “WebPages” folder, titled “Sean Marsee’s Message”). You might want to consider reviewing this story as a class exercise, or having students read it as part of a homework or journal exercise.

if anyone can think of any reasons—other than harmful health impacts—that would discourage people from smoking. Possible prompts include: Personal appearance/grooming: e.g., bad breath, yellow teeth, discolored fingers, holes in clothing. Relationships with others: e.g., upsetting parents, disappointing teachers, putting off friends.

Page 9.4.5

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) Rules and regulations: e.g., getting punished for breaking school rules, being asked to step outside restaurants, getting cited or ticketed in public places for violating no-smoking regulations. As the health consequences of tobacco use have become better known, more and more people in our society and elsewhere have come to recognize these dangers and have decided to actively fight against smoking. There are increasing numbers of rules about where one can and cannot use tobacco products. Smoking is now prohibited in many workplaces—including schools, hospitals, airplanes, and public buildings. Financial considerations: How much does smoking cost?


Explain that one of the difficult things about educating young people about tobacco is that many of the health impacts seem to be so far off into the future that they don't seem to matter. However, there are some immediate health impacts, even for youths. What are these? W

Cigarette smoking during adolescence appears to reduce the rate of lung growth, and hence the maximum level of lung function that can be achieved.


Young smokers are much more likely to experience shortness of breath, coughing spells, phlegm production, wheezing, and overall diminished physical health. Often young smokers have more difficulty exercising because they have a hard time getting enough oxygen when they breathe hard.


Young smokers are less physically fit than their non-smoking peers.


Smoking can contribute to the onset of asthma, or can severely aggravate an existing asthma condition.


Chewing tobacco can lead to mouth sores and gum disease, even at a young age.


Both smoking and chewing tobacco can lead to bad breath, yellowed teeth, stained fingers, dulled taste buds, and a dulled sense of smell.


One unseen impact is that young people who start smoking at a younger age are more likely than later starters to develop a long-term addiction to tobacco. If you start smoking at a younger age, chances are you will have a much more difficult time quitting tobacco use later on, than someone who begins smoking at a later age.

Page 9.4.6

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) 12.

Ask the class if anyone can define the term secondhand smoke. Write other terms for secondhand smoke on the board: passive smoking, environmental tobacco smoke (ETS). Explain that secondhand smoke is the smoke that a person breathes in from someone else's cigarette or other tobacco product that produces smoke, such as cigars, pipes, bidis, clove cigarettes, or kretek. Explain that not only does a smoker inhale the chemicals on the table, but so does anyone who inhales the secondhand smoke. Secondhand smoke contains at least 60 carcinogens (chemicals that are known to cause cancer). A person exposed to this smoke absorbs these carcinogens just as a smoker does.


Ask students if they have ever been exposed to secondhand smoke. Explain that secondhand smoke can harm nonsmokers. Distribute the Secondhand Smoke pamphlet by Journeyworks Publishing and identify the health risks. Exposure to secondhand smoke: W

increases your risk of lung and nasal sinus cancer, even if you yourself do not smoke


causes burning eyes, nasal congestion and wheezing


increases the prevalence of ear infections, especially in young children


increases the risk of bronchitis, pneumonia and other respiratory tract infections, especially in chilL94_PassiveSmoking

dren W

is associated with reduced lung function


increases the risk of heart disease in people who are not smokers


is linked to SIDS, or Sudden Infant Death Syndrome, that affects newborn babies


leads to smaller birthweight babies for women exposed to secondhand smoke during their pregnancies


Have the wrappers from four packs of cigarettes on a table. W

Ask students to look carefully at the packs to find something exactly the same on each pack—the Surgeon General’s Warning.


Ask students: Who is the Surgeon General? Answer: The Surgeon General is a doctor who is appointed every four years by the President, and serves as the top symbol of the nation’s commitment to protecting and improving the people’s health.

Page 9.4.7

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued) W

In 1964, the Surgeon General released a landmark report that focused attention on the dangers to health posed by tobacco and smoking. This report was one of the main forces behind the government’s efforts to begin labeling tobacco packaging with Surgeon General’s warnings:


Explain that the government requires a warning on all packs of cigarettes because of the danger involved with smoking. Ask students if they think these warnings are useful? Do they think people read them? Do they think these warnings are effective for young people their age? Why or why not? What messages do they think would work better? Are there any messages they can think of that could be aimed specifically at Deaf people? Should they warn about other diseases or consequences of smoking?



Examine the warning labels that are produced by Canada and Brazil. Ask your students: Do you think these are more powerful labels? Why or why not? Do you think they would be more effective at persuading people not to smoke? Which country’s labels would be best for the Deaf in your opinion?




Cigarette warning labels required on tobacco products sold in Brazil

Page 9.4.8

Lesson 9-4:

So What’s So Bad About Tobacco?

Procedures: (continued)





Cigarette warning labels required on tobacco products sold in Canada

Homework Ask students to use the Your Smoke Makes Me Choke worksheet to create a cartoon related to the issue of secondhand smoke.

Page 9.4.9

Lesson 9-4

What’s in Tobacco Smoke?

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

Metals Aluminum Zinc Magnesium Mercury Gold Silicon Silver Titanium Lead Copper

Acetone Nail polish remover

Acetic Acid Vinegar

Ammonia Floor and toilet cleaner

Arsenic Insecticides and poisons

Butane Cigarette lighter fluid

Cadmium Rechargeable batteries

Carbon Monoxide

Car exhause fumes






Body tissue preservative


Lighter fluid

Hydrogen Cyanide

Gas chamber poison


Swamp gas


Rocket fuel


Moth balls



Nitrous Oxide Phenols Disinfectants Candle wax Solvents

Source of information: American Lung Association

Lesson 9-4 Chemical Labels

Chemical Labels Cadmium Cadmium is a toxic metal. It is used in many manufacturing processes, and is used to make products such as household batteries. It is known to cause cancer in the lung and prostate; and can cause kidney damage and bone disease.

It is found in cigarette smoke.

Ammonia Ammonia is a common chemical that is used to make fertilizer, textiles, plastics, explosives, and liquid household cleaning products. Ammonia irritates the skin, eyes, nose, throat and lungs, and in large doses can cause severe burns.

It is found in cigarette smoke.

Acetone Acetone is a chemical used to make plastics, fibers, drugs and other chemicals. One common use is as a solvent to dissolve other substances, as in nail polish. Exposure can cause eye and lung irritation, and dizziness. Exposure to large amounts can cause unconsciousness or coma.

It is found in cigarette smoke.

Arsenic Arsenic is a naturally-occurring chemical that is used to make ant poison. Arsenic can irritate your throat and lungs, cause nausea and vomiting, damage blood vessels, lead to abnormal heart rhythm and lower your red and white blood cell count. It can increase the risk of cancer of the lungs, skin, bladder, liver, kidney and prostate.

It is found in cigarette smoke.



Formaldehyde is a chemical that is used as a preservative, and is used as an embalming fluid (to preserve dead tissue). Low levels can irritate the eyes, nose, throat and skin. Formaldehyde has been shown to cause nose cancer in animals, and scientists believe it will also be shown to be a human carcinogen.

Naphthalene is commonly found in the home in moth balls and other insect repellents. It is also used to make plastics and toilet deodorant blocks. Exposure to naphthalene can damage or destroy red blood cells. In animal studies, longterm exposure to this chemical caused nasal and lung inflammation, and lung and nasal tumors.

It is found in cigarette smoke.

It is found in cigarette smoke.

Carbon Monoxide (CO)


CO is a colorless gas, and is the major component of car exhaust. At low doses, CO can cause fatigue, and chest pains in people with heart disease. At higher doses, it causes impaired vision and coordination, headaches, confusion and nausea. In high concentrations it is fatal, causing death by interfering with oxygen intake.

It is found in cigarette smoke.

Cyanide is an extremely poisonous chemical that in low levels can cause breathing difficulty, heart pains, vomiting, blood changes, and headaches. High levels harm the brain and heart, and cause coma and death. Smoking cigarettes is a major source of exposure to cyanide.

It is found in cigarette smoke. Source of information: Agency for Toxic Substances and Disease Registry, U.S. Centers for Disease Control

Lesson 9-4 Worksheet: Your Smoke Makes Me Choke!

Name __________________________________

Your Smoke Makes Me Choke! Instructions: Use the space below to draw a cartoon expressing your views about secondhand smoke.

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

Lesson 9-5

Hooked! What Is It to Be Addicted? Introduction:

This lesson covers the concept of addiction, and the role of nicotine in causing addiction to tobacco. Students are introduced to the mechanism of nicotine addiction and its self-reinforcing nature (the Addiction Cycle), to dispel many young people's’ misconceptions about their ability to avoid tobacco addiction.

Lesson Objectives: By the end of Lesson 9-5, students will be able to: W

Define addiction


Identify nicotine as the addictive substance in tobacco


Understand the difference between smoking prevention and cessation.


Identify aspects of withdrawal


Interview an adult who has quit smoking


Compare information gained in interviews to aspects of addiction and withdrawal learned in class

Materials: W

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


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. craving: An intense and prolonged desire; for those addicted to nicotine, it is usually manifested as an intense desire for cigarettes or other tobacco product. dependence: An altered physical or psychological state produced by repeated use of a drug (such as nicotine in tobacco products), and that requires continued use to avoid the physical and psychological discomforts of withdrawal.

nicotine: The active ingredient in tobacco products that is the chief cause of physical addiction through its effects on brain chemistry. smoking cessation: To stop smoking after one has become addicted. withdrawal symptoms: The range of unpleasant physiological and emotional reactions of the body in response to withholding a drug that the body has become addicted to.

Page 9.5.1

Lesson 9-5:

Hooked! What Is It to Be Addicted?

Procedures: 1.

Ask your students the following questions about the process of starting to smoke: 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:

L95_8thGrade; Source: Monitoring the Future, 2004

L95_10thGrade; Source: Monitoring the Future, 2004

L95_12thGrade; Source: Monitoring the Future, 2004

Page 9.5.2

Lesson 9-5:

Hooked! What Is It to Be Addicted?

Procedures (continued) 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. 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

Teacher’s Note: Scientists make a careful distinction between ever use and current use. Ever use is defined by having ever smoked a cigarette, even if just one puff. Current users are those who are actively using tobacco, either on an occasional or regular basis. Current use is often measured by 30-day prevalence—that is, the number of people who have used a tobacco product one or more times within the past 30 days.

five—currently smokes.

L95_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 still be smoking.


Page 9.5.3

Lesson 9-5:

Hooked! What Is It to Be Addicted?

Procedures: (continued) 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.


Page 9.5.4

Lesson 9-5:

Hooked! What Is It to Be Addicted?

Procedures: (continued) 2.

Explain to your class: In the previous lesson (9-4), we learned about many of the harmful effects of smoking. We also learned in earlier lessons (9-2 and 9-3) why people still feel compelled to smoke, even though they may know smoking and other tobacco use can be harmful. So what is the main reason why people continue to smoke, once they’ve started to smoke regularly? The Answer: Addiction


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

The substance produces a pleasant feeling.


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


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


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


In tobacco, the drug nicotine is the substance that causes addiction to smoking and other tobacco use. Nicotine is found in all tobacco products: cigarettes, cigars, pipe tobacco, smokeless (chewing) tobacco, bidis, kretek, etc. Show the Addiction Cycle graphic of how a young person can quickly become addicted to tobacco. Pleasant feelings: Smoking a cigarette may cause some initial dizziness or nausea as a person becomes accustomed to inhaling smoke. But it also produces a pleasant sensation almost immediately. This sensation is caused by nicotine. Within seconds of inhaling tobacco smoke (or placing a plug of smokeless tobacco in the mouth),

Page 9.5.5

Lesson 9-5:

Hooked! What Is It to Be Addicted?

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

Feeling restless


Feeling irritable, moody or tense




Headaches or dizziness


Sweating and unsteadiness


Nausea or physical illness

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.

Page 9.5.6

Lesson 9-5:

Hooked! What Is It to Be Addicted?

Procedures: (continued) 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.”

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


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


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


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


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


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



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

Journal: Knowing what you know about the harmful substances in tobacco, what do you think about becoming addicted to

One Addict’s Story: A moving account of the difficulty of quitting—even in the face of the death of a loved one from lung cancer—can be found at: http://whyquit.com/whyquit/ BryanLeeCurtis.html or on the accompanying CD (in the folder “WebPages”, titled “Smoking Kills - Bryan Story”). The story is an apt illustration of the absolute hold of tobacco addiction.

smoking? What do you think is the best way to avoid becoming addicted to tobacco?

Page 9.5.7

Smoking Kills

"He Wanted You to Know"

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

by Sue Landry

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

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

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

[Photo: Curtis


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

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

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

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

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

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

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

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

Last Updated on August 10, 2003 byJohn R. Polito

Lesson 9-5 Graphic: The Addiction Cycle

The Addiction Cycle


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


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


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

4 Your brain starts to crave

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


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


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

Lesson 9-6

Knowing the Rules about Smoking Introduction:

The goals of this lesson are to familiarize students with the school's tobacco use policies, to consider why such policies are important, and to think about the responsibilities leaders in the schools—students and educators—and in the broader community have to promote healthful and safe behavior.

Lesson Objectives: By the end of Lesson 9-6, students will: W

be familiar with school policy related to smoking by reviewing the school's code of conduct.


know and understand the rules and regulations that govern tobacco use in their local community.

Materials: W

School smoking policy in student or faculty handbook (if available)

Key Terms: penalty: consequences of disregarding policies, or disobeying rules and regulations policy: rules and regulations that govern behaviors such as smoking

Page 9.6.1

Lesson 9-6:

Knowing the Rules about Smoking

Procedures: 1.

Teacher’s Note:

Review the school policy related to smoking on campus: W

Is anyone allowed to smoke at school?


Are there designated smoking areas?


Can adults smoke at extra-curricular activities on campus

Ask the students what they think of these rules and regulations. Are they fair? Are they enforced? Are they enough? Do they need to do more?

such as sports events? What about on weekends?



What support does the school provide to help smokers quit?


What are the consequences of students smoking?

Point out that students often interpret school rules as simply yet another restriction on students’ behaviors. Yet what about smoking outside of school?

Ask your students: W

Are there rules outside of school that control where people may or may not smoke? What about smoking at the mall? In the park? At the beach? In the workplace? In restaurants?


Data Resource: It is useful to be familiar with the ordinances governing smoking and tobacco use in your local community. Your community’s ordinances may be listed on sites such as the following:

Why do you think these rules were made? Ask your class to consider rules governing smoking in places beyond the school, including: the workplace, restaurants and bars, public spaces such as parks, etc.

www.no-smoke.org/lists.html In addition, some state and local governments and other private agencies maintain state-specific lists, such as the following for New Jersey:

Students may interpret school rules as simply another


restriction on their behaviors. Point out the role of such restrictions in other aspects of regular life for everyone (e.g., working, shopping, going to the park or mall, seeing a movie, etc.). Point out that rules seen as restricting student behaviors may also be seen as designed to promote health and discourage unhealthful behaviors.


Ask students to consider the following questions: W

Do older students influence younger students? In what ways? What about popular students? Athletes?


Do teachers and other adults at school influence students? In what ways?


If a student who is on the basketball team or in a school club gets caught smoking, should they be excluded from games or club activities?


Is it okay for some people to break smoking rules? Who?


Do you think it is cool to break rules?

Page 9.6.2

Lesson 9-6: Knowing

the Rules about Smoking

Procedures: (continued) 4.

Teacher’s Note:

Ask students to consider the following statement: Some people have a strong influence on others because of who they are or what they do. These people should have to behave more responsibly to set good examples for others. Divide the class into two groups. Each group will take opposite

You may have to provide an example of, for example, a sports star who behaves badly, or a movie star who smokes. Are these people sometimes allowed to break the rules? Why do you think this is so?

positions on this statement—for and against. Explain to students that they must argue these positions as though they very firmly believe them! The discussion must include the following rules: W

Be respectful of others


Don't interrupt

Allow each team five minutes to express their views initially. Then allow each team an additional five minutes to provide a rebuttal statement to the other team’s arguments. Finally, ask each team to make a summary statement.


Facilitate a discussion to find out what the experience was like, what they learned, and whether anyone’s opinions were swayed one way or another on this issue.

Journal: Who are the people that you look up to? Why do you look up to them? If they did something that was unhealthy, unkind, or wrong, how would it affect your feelings and actions?

Page 9.6.3

Lesson 9-7

Saying “No!� to Tobacco Introduction:

In this lesson, students are asked to critically examine advertising strategies that have been undertaken by tobacco companies. They are also asked to examine samples of anti-tobacco advertising that have borrowed similar strategies to market the ideas of avoiding tobacco. Students are encouraged to think about how they are influenced and in turn can influence others when it comes to behaviors such as tobacco use.

Lesson Objectives: By the end of Lesson 9-7, students will be able to: W

Critically examine both tobacco and anti-tobacco advertising strategies


Present arguments, via a composed letter to an imaginary person who is considering smoking, for being smoke-free


Present strategies for refusing cigarettes when offered.

Materials: W

Anti-tobacco advertising samples (provided on CD)


Stationery for letters

Page 9.7.1

Lesson 9-7:

Saying “No!” to Tobacco

Procedures: 1.

Review with your students the Tobacco Advertisement worksheets handed out in Lesson Module 9-3. Ask first about instances in which students saw smoking or tobacco usage on television. As students relate the circumstances, ask them to think about how the act of smoking was portrayed. For example, a nervous character might be seen to reach for a cigarette, portraying the notion of a “relaxing smoke”; or a popular character may pull out a cigarette and light up in front of friends, portraying the notion of “cool”; or a character may intimidate another by blowing smoke in the other’s face, portraying the notion of “power”; or a character may be shown as looking foolish when they smoke, providing a negative portrayal of smoking. Discuss how people’s views of smoking can be shaped by what they see on television and in the movies. Ask students to review the places they observed tobacco advertisements. See who came up with the greatest number of locations and types of advertisements. If people noticed clothing, explain that these items are often promotional items—given away for free—that were once distributed by the tobacco companies. Ask students to think about why a company would give away a free shirt or hat. Discuss how this type of marketing might influence a person’s decision to buy certain products. Ask students if anyone saw smoking in a movie. Discuss with students that cigarette companies used to pay to have their products displayed in movies (product placement). Ask the students if they think this type of advertising works or not.

Teacher’s Note: As part of the 1998 Tobacco Master Settlement Agreement that was reached between major tobacco companies and 46 states, the tobacco industry agreed to a number of new restrictions on tobacco advertising (joining the ban on television advertisements for tobacco products). Included in these restrictions are bans on the use of cartoons in advertising or packaging for tobacco products; elimination of most outdoor advertising, including billboards, and signs and placards in arenas, stadiums, shopping malls, and on transit (e.g., buses and trains); and forbids the sale or distribution of apparel and merchandise with brand name logos (although many tobacco companies continue to give away free merchandise in exchange for “points” or “coupons” that accrue with each purchase of cigarettes. The Master Settlement Agreement also bans payments to promote tobacco products in movies, on television shows, in videos and video games, and other entertainment. Tobacco companies are also prohibited from brand name sponsorship of events with a significant youth audience (football, basketball, baseball, hockey and soccer). You can read more about this at: http://caag.state.ca.us/tobacco/resources/ msasumm.htm

An Interesting Anecdote: Although it may be dated to discuss Steven Spielberg’s movie E.T., it may be instructive to relate the tale of how the film boosted sales of a particular brand of candy. In the movie, the young boy Elliot uses candy to lure E.T. into his home. The scene established the bond between the boy and the extra-terrestrial that is at the heart of the film. The scene shows E.T. making satisfying noises as it follows and eats the colorful trail of candy into Elliot’s bedroom. The filmmakers approached the makers of

M&M candies to see if they could use that product in the film. But the Mars Candy company balked, unsure if they wanted their candy associated with a “space and aliens” movie. The filmmakers instead turned to the makers of Reese’s Pieces, and the distinctive orange packaging was clearly displayed throughout the scene. After the release of the movie, sales of Reese’s Pieces jumped dramatically, even though the name of the product was never mentioned in the film.

Page 9.7.2

Lesson 9-7: Saying

“No!� to Tobacco

Procedures: (continued) 2.

Ask students if any of them have ever seen advertisements against tobacco—that is, anti-tobacco advertising? Ask them to describe these advertisements and messages. Review other available printed anti-smoking advertisements. Ask the following questions: W

What messages do you see in these anti-tobacco advertisements and messages? (e.g., smoking is bad for health, smoking is stupid, smoking is bad for non-smokers, tobacco companies are making a hard-sell, tobacco companies lie, cigarettes are like poison, etc.)


Which of these messages do you think best communicates an anti-smoking message? Why?


Which of these messages do you think work best for Deaf youths? Or, do you think that the messages could be adapted in a better way to reach Deaf youth? How?


Which of their arguments do you find the most convincing, and why?


Source: www.trinketsandtrash.org

How do these ads get their message across? Are their messages clear? Why or why not? Do you think the messages are effective?


Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org

Page 9.7.3

Lesson 9-7: Saying

“No!� to Tobacco

Procedures: (continued)



Source: www.trinketsandtrash.org

Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org

s What about these ads that use humor? What do you think the messages are? Are they effective? Why or why not?


Source: www.trinketsandtrash.org

What about this advertisement? Who do you think the target is? Do you think the message is clear?


Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org

Page 9.7.4

Lesson 9-7: Saying

“No!” to Tobacco

Procedures: (continued)




Source: The American Legacy Foundation

Source: The American Legacy Foundation


Source: The American Legacy Foundation

Source: The American Legacy Foundation

s Are you familiar with the Truth advertisements? These advertisements were created by the American Legacy Foundation as part of a campaign targeted especially at young people: The Truth Campaign.


Source: The American Legacy Foundation

The focus of these advertisements has been to get the “truth” out about tobacco, and that has been hidden by the companies that make tobacco products. How convincing or effective are these advertisements?

Teacher’s Note: Students can explore for themselves the American Legacy Foundation’s website at: www.thetruth.com

Page 9.7.5

Lesson 9-7: Saying

“No!� to Tobacco

Procedures: (continued)



Source: www.trinketsandtrash.org


Source: www.trinketsandtrash.org

Source: www.trinketsandtrash.org



Source: www.trinketsandtrash.org

Source: www.trinketsandtrash.org

s What about these messages aimed at different ethnic groups? Looking just at those non-English advertisements, can you still figure out the message of the ad? What might this say about the need to reach out to those groups that are less literate in English?


Source: www.trinketsandtrash.org

Page 9.7.6

Lesson 9-7: Saying

“No!� to Tobacco

Procedures: (continued)


Source: www.trinketsandtrash.org

s L97_ChewComponents


Source: www.trinketsandtrash.org


What about these advertisements that point to the content of cigarettes and smokeless tobacco?

Ask students to think about the best ways to reach Deaf youth like themselves with anti-tobacco information. What would the best channels be? Television? The internet? In school? Through plays or other popular entertainment? What about the use of media that have been adopted by the Deaf, such as instant messaging, text messaging, the internet, and other communication modes?

Ask your students: W

If you were trying to reach the Deaf with anti-tobacco information, which approach would you use?


Ask students to review the facts and myths they have learned about smoking in Lesson 9.5: W

Most smokers started when they were young. By the 8th grade, 28%, or about 3 out of 10 persons say they have tried smoking. By 10th grade, 43%, or about 4 out of 10 persons. By 12th grade, 53%, or a little more than half of all young people say they have tried smoking at least once.

Page 9.7.7

Lesson 9-7: Saying

“No!� to Tobacco

Procedures: (continued) W

Most smokers wish they had never tried smoking. More than one out of every three young people who ever try smoking a cigarette become regular, daily smokers before leaving high school.


Most young smokers think they can stop whenever they want. 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 still be smoking.


Most smokers have a hard time quitting because nicotine is very addictive. By high school, nearly three out of every four regular smokers have already tried to quit smoking, and failed.


Review (from lessons 9-2 and 9-3) for your students some of the reasons why young people start to smoke cigarettes or use tobacco.


The following exercise can be done individually or in groups. Explain to students that a person their age named Jamie is thinking about smoking. Jamie has not yet decided but feels a lot of pressure to smoke. The task for your students is to write a letter to Jamie to convince him NOT smoke. Remind your students to think about the following: W

What anti-smoking messages do you find to be the most compelling?


What strategies do you think Jamie can use to resist the pressure to smoke?

Remind students of the refusal skills that have been discussed in Lesson 9-2:



Be direct


Change the subject


Think of a clever response




Walk Away or Avoid the Situation


Blame an Adult

When the letters are complete, ask your students to share their letters with the class. Discuss the range of ideas that were suggested.

Journal: Did you ever do something because of peer pressure that you regretted later on? What would have stopped you? Who could have influenced you to make a different decision?

Page 9.7.8

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