J. DRUG EDUCATION, Vol.

41(2) 135-159, 2011

TOBACCO PREVENTION EDUCATION IN SCHOOLS

FOR THE DEAF: THE FACULTY PERSPECTIVE*

BARBARA A. BERMAN, PH.D. ADJUNCT PROFESSOR EMERITUS

University of California, Los Angeles
DEBRA S. GUTHMANN, Ed.D.
California School for the Deaf, Fremont
WEIQING LIU, M.S.

LEANNE STREJA, DrP.H.

University of California, Los Angeles

ABSTRACT

We report results of a survey of tobacco education practices and perspec-

tives among faculty at four Schools for the Deaf participating in the trial
of a tailored tobacco prevention curriculum. Few faculty (20.4%) included
tobacco use among the three most important health problems facing their
students, although 88.8% considered tobacco education to be worthwhile.
Despite perceived unmet needs among their students, classroom or school-
wide attention to tobacco prevention was limited. Only 13.9% reported
delivering tobacco programming in the prior year, most often reporting lack
of deaf-friendly curriculum and materials (60.9%), time (47.8%), and training
(43.5%) as barriers to program delivery. Perceptions, attitudes, and institu-
tional issues, including lack of tailored curriculum, were seen as contributing
to the limited focus on this important health problem.

*This research was supported by grants from the University of California Tobacco-Related
Diseases Research Program (TRDRP) (6RT, 0047, 8BT-1701, 10GT-3101; 12HT-3201).

135

2011, Baywood Publishing Co., Inc.

doi: 10.2190/DE.41.2.b
http://baywood.com
136 / BERMAN ET AL.

INTRODUCTION

Smoking is the most preventable cause of death in the United States and a press-
ing pediatric problem. Most tobacco initiation begins in childhood and adoles-
cence, rapid addiction makes cessation difficult, and there are significant health
consequences for tobacco users of all ages (American Cancer Society, 2009; U.S.
Department of Health and Human Services, 1994, 2004). School-based tobacco-
related education has been an important element in efforts to prevent tobacco
initiation and use among young people for over 50 years (Centers for Disease
Control and Prevention, 1994, 2007; Flay, 2009), with motivated and prepared
faculty identified as a key element in curriculum uptake, delivery, and fidelity
(Basen-Engquist, OHara-Tompkins, Lovato, Lewis, Parcel, & Gingiss, 1994;
Dusenbury, Brannigan, Falco, & Hansen, 2003; Parcel, OHara-Tompkins, Harrist,
Basen-Engquist, McCormick, Gottlieb et al., 1995; Tortu, & Botvin, 1989).
Unfortunately, little attention has focused on school-based tobacco prevention
education among deaf and hard of hearing youth, including regarding the per-
spectives of faculty serving the approximately half-million deaf and hard of
hearing students receiving special educational services in state residential and/or
day Schools for the Deaf, and in mainstream school programs that range from
separate self-contained classes to placement in hearing classrooms (American
Annals of the Deaf, 2009; Holden-Pitt & Diaz, 1998). This lack of information
is a concern in that the limited research that is available suggests that deaf and
hard of hearing youth may be at risk for unhealthful practices, including tobacco
use, and experience gaps in health knowledge, including about tobacco (Berman,
Bernaards, Eckhardt, Kleiger, Maucere, Streja, et al., 2006; Berman, Streja,
Bernaards, Eckhardt, Kleiger, Maucere, et al., 2007; Berman, Guthmann, Crespi,
& Liu, 2011), in part due to communication barriers that impede access to
incidental preventive messages in clinical and other settings (e.g., Tamaskar,
Malia, Stern, Gorenflo, Meador, & Zazove, 2000). Many deaf and hard of hearing
youth identify themselves as part of the Deaf community, and consider American
Sign Language (ASL) a visual/spatial/gestural language with its own grammar,
morphology, and syntax as their primary language (Lane, Hoffmeister, & Bahan,
1996). Other communication modalities are also used, which may include
signed English. However, for many deaf and hard of hearing people, English
is a second language. On average, high school graduates read English on a
fourth-grade reading level (Gallaudet Research Institute, 1996; Holt, Traxler, &
Allen, 1997), and use of spoken language often occurs with difficulty. Although
deaf and hard of hearing youth and young adults identify schools as the best
place to receive anti-tobacco education, many of these young people report
not being exposed to appropriate programming in school settings (Berman et al.,
2006, 2007, 2011).
To address this gap in tobacco-related prevention, the State of Californias
Tobacco Related Diseases Research Program (TRDRP) funded a program of
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 137

research aimed at identifying the tobacco related knowledge, attitudes, and prac-
tices of deaf and hard of hearing youth (Berman, Eckhardt, Kleiger, Wong, Lipton,
Bastani, et al., 2000; Berman et al., 2006, 2007) and at designing and testing a
tailored tobacco prevention curriculum for this cultural and linguistic minority
population (Berman et al., 2011; Sternfeld, Barnabei, Kriger, Guthmann, Lester,
Berman, et al., 2004). Four residential/day Schools for the Deaf in three states
participated in the quasi-experimental randomized trial of the curriculum. Recog-
nizing their central role in curriculum delivery, all faculty at the four schools
were invited to complete a tobacco-related survey at baseline (Fall 2004), prior
to initiation of the main study. We report here on results of that survey, conducted
as a secondary component of the research.

METHODS

Survey Content
The Teacher Survey (WestEd) utilized in the state of California tobacco edu-
cation program (TUPE), was used with permission as the basis for a 50-item
survey (McCarthy, Dietsch, Hanson, Zheng, & Aboelata, 2005) with modifi-
cations made to address aspects of education for deaf youth. The TUPE survey
is administered statewide every 2 years and has a high level of reliability and
validity. Teachers in each classroom of surveyed students are asked to complete
a 63-item questionnaire on attitudes toward school-based tobacco use prevention
activities, tobacco use prevention programs and policies at their school, and
their own personal tobacco-related attitudes and behaviors. A school site adminis-
trator (e.g., principal, assistant principal, or vice principal) from each school is
asked to complete a 39-item questionnaire regarding the administration of tobacco
programs at their school. A 67-item multiple choice and free-response (blank
spaces, one open-ended question, and a section for comments) questionnaire is
given to TUPE site coordinators or health teachers at each school site. Reliability
of the TUPE faculty survey was assessed by examining the concordance of
answers to similar questions given by the school administrator, the school tobacco
use prevention education coordinator, and the sampled school teachers. Personal
tobacco use questions were taken from standard questions used in previous
national tobacco use surveys. Many of the questions assessing the quality of
tobacco use prevention education activities were prompted by the CDC guidelines
for school-based tobacco use prevention. Our survey included questions regard-
ing faculty demographic and professional characteristics, smoking history, pro-
vision of tobacco education, perceptions of tobacco use among their students
and deaf and hard of hearing youth generally, health education priorities, and
school tobacco-related programming, policies, and practices. Teachers in our
study were asked about very specific tobacco prevention programs used, which
supported the validity of these items and this instrument.
138 / BERMAN ET AL.

Survey Participants
Survey completion was voluntary and anonymous, and participants were not
aware of their schools subsequent study status (intervention or control). Three
hundred and fifty copies of the survey were mailed to the schools; the schools
agreed to make the questionnaires available by placement in individual mail-
boxes or in a common area; 166 interested faculty mailed completed surveys to
the study research office (UCLA).

Statistical Methods
Data were analyzed using SAS version 9.1. Frequencies and percentages are
reported for categorical data. Continuous data are reported by mean (SD) and
range. One-way ANOVA and Chi-square tests were used to detect differences
among schools. We used a significance level of .05.

RESULTS
Faculty Characteristics
Personal characteristics (gender, deafness status) and professional charac-
teristics (role in school, grade levels, and subject areas taught) are reported
in Table 1. About half of the survey respondents were deaf or hard of hearing
(54.9%, n = 90). On average, respondents (n = 158) reported working for
12.2 years at their current school (SD = 10.1, range: 1 month to 34 years).
A quarter of respondents indicated that they were ever smokers (26.8%,
n = 44/164), and 11 (6.9%, n = 11/159) reported smoking in the previous month
(current smokers).

Tobacco Prevention Teaching Activities

A quarter of the respondents (24.7%, n = 41/166) indicated that they were
expected to teach tobacco prevention lessons as part of their classroom cur-
riculum, and of them 14 reported actually having taught such curriculum in
the prior year. Nine other faculty members reported providing tobacco related
lessons though they were not expected to do so, for a total of 23 respondents
reporting teaching tobacco prevention education in the previous year, 13.9%
of the sample overall All four schools offer a residential program for some
students, and three of these 23 faculty members reported introducing
tobacco-related content into their schools residential counseling and edu-
cational program, as did an additional eight respondents. Of the 139 faculty
responding when asked about incidental provision of tobacco education,
14 (10.1%) who did not report having taught tobacco education indicated
that they had, nonetheless, introduced tobacco-related content into math,
history, or other lessons.
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 139

Table 1. Survey Participants Personal and Professional

Characteristics (n = 166)

N (%)

Personal characteristics
Gender (female) 115 (70.1)
Hearing status (deaf and hard of hearing) 90 (54.9)

Professional characteristics
School rolea
Teacher 120 (72.3)
School counselor 13 (7.8)
Administrator 11 (6.6)
Otherb 27 (16.3)

Number of grade levels taught

One grade level 34 (21.4)
Multiple grade levels 91 (57.2)
No grade/ungraded 34 (21.4)

Grades taughta
Ungraded 8 (5.0)
Elementary (Pre-K5th) 23 (14.5)
Junior high (6th8th) 37 (23.2)
High school (9th12th) 82 (51.6)

Number of subjects taught

One subject 115 (71.0)
Multiple subjects 47 (29.0)

Subjects taughtb
Health 20 (12.4)
English 49 (30.3)
Math 35 (21.6)
PE 7 (4.3)
Science 24 (14.8)
History 19 (11.7)
Social science 26 (16.1)
None specific 31 (19.1)
Otherc 58 (35.8)
aMultiple responses possible.
bOther roles included RN, teacher specialist, interpreter, social worker, etc.
cOther subjects included career counseling and life skills, etc.

Note: Missing: gender (2), hearing status (2), grades (7), subjects (4), years of experi-
ence (8).
140 / BERMAN ET AL.

Table 2 provides a description of the grades in which the 23 faculty members

taught tobacco-related curriculum, the number of hours devoted to this subject
matter, the content provided, and the source of the curriculum. These faculty
members described offering tobacco-related curriculum in a range of classes (e.g.,
health, English, language arts, physical education, and science); indicated more
often using classroom discussion, role play, and small group activities than other
strategies, and reported no use of trained peer helpers, peer educators, or peer
counselors. Four respondents indicated that the curriculum they used was tailored
for deaf and hard of hearing youth, focusing on visual elements. Most of the 20
faculty who responded to questions about the effectiveness of the curriculum they
used in the prior year reported that it was somewhat effective (70.0%, n = 14/20),
two described it as very effective (10.0%), two others that it was not very effective,
and two indicated that they did not know or could not remember. Student interest
was described as moderate by faculty who provided lessons in the prior year
(87.0%, n = 20/23), with only one faculty member reporting that students were
very interested (4.4%) and two that students were not too interested (8.7%).

Barriers to Delivering Tobacco-Related

Programming
Respondents were asked about barriers to delivering tobacco programming,
how well prepared they considered themselves to be to deliver such programming,
and the number of hours of training they had received in this subject area. Table 3
has a comparison of responses for faculty who had taught tobacco prevention
education in the prior year (n = 23) and those who indicated that they were
expected to teach in this area but had not done so (n = 27). Those who taught
tobacco prevention education in the prior year most often described a lack of
adequate tailored material as a barrier, with a lack of time and training also
frequently noted. About a quarter indicated that they were not at all prepared to
teach this subject matter. Those reporting that they were expected to teach tobacco
prevention education but had not done so most often indicated that it was not
part of their curriculum, with about half indicating that they were not prepared to
teach tobacco-related curriculum. Thirteen respondents reported having received
any training relevant to teaching tobacco prevention. Of these, four were expected
to teach tobacco-related education and had done so, one not expected to teach
had nevertheless offered such lessons, and one expected to teach had not
done so; seven others who had received training were not expected to teach and
reported not doing so in the previous year.

Faculty Feedback
A third of the survey respondents (n = 55) provided open-end comments and
suggestions regarding tobacco-related curriculum and materials for their students,
emphasizing that tailored curriculum was lacking and would be valuable for
 Table 2. Tobacco Education Provided in Prior School Year (n = 23)
N (%) N (%)
Grade(s) in which tobacco was taught Source of materials or curriculum useda
6-8 6 (26.1) Developed themselves 8 (35.8)
9-12 5 (21.7) Did not use curriculum/materials 7 (30.4)
Multiple levelsb 3 (13.0) Internet 5 (21.7)
Not indicated 9 (39.1) Developed specifically for their school 4 (17.4)
Developed by other teacher at this/other school 3 (13.0)
Hours spent teaching tobacco in prior year Commercial company 3 (13.0)
< 3 hours 14 (60.9) School district or state Board of Education 3 (13.0)
3-6 hours 4 (17.4) Community or church organization 2 (8.7)
More than 6 hours 5 (21.7) D.A.R.E. Program 2 (8.7)
Other 1 (4.3)
Content taughta
Health effects of tobacco use 22 (95.6) Strategies utilized to teach tobaccoa
Social influences that promote tobacco use 16 (69.6) Classroom discussion 20 (87.0)
Behavioral skills for resisting tobacco offers 14 (60.9) Role play 14 (60.9)
Reasons why young people smoke 14 (60.9) Small group activities 12 (52.2)
Second hand smoke 13 (56.5) Student worksheets 9 (39.1)
Other types of tobacco use 13 (56.5) Lecture 7 (30.4)
The social consequences of tobacco use 10 (43.5) Guest speaker 2 (8.7)
How many young people smoke 8 (34.7) D.A.R.E. program 1 (4.3)
General personal and social skills 9 (39.1)
Tobacco advertising or marketing 8 (34.8)
Tobacco use cessation 3 (13.0)
Other (e.g., cultural aspects of smoking) 3 (13.0)
aMultiple responses possible.
TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 141

bMultiple levels included 5th and 4th grades.

142 / BERMAN ET AL.

Table 3. Perceived Barriers and Preparation for Providing

Tobacco Education

Expected to
teach but did
not in prior Taught in prior
year (n = 27)b year (n = 23)
N (%) N (%)

Perceived barriers
Lack of adequate tailored materialsa 1 (3.7) 14 (60.9)
Lack of timea 1 (3.7) 11 (47.8)
No tobacco prevention education traininga 4 (14.8) 10 (43.5)
Not my priority compared to other aspects 0 (0) 7 (30.4)
of curriculuma
Not a school priority 3 (11.1) 6 (26.1)
Not mandated in school 2 (7.4) 6 (26.1)
Not part of assessed outcomesa 0 (0) 4 (17.4)
Other/None of these 6 (22.2) 2 (8.7)
Not part of my curriculuma 11 (40.7) 1 (4.4)

Level of preparation
Very prepared 3 (13.0) 3 (13.0)
Somewhat prepared 9 (39.1) 14 (60.9)
Not at all prepared 11 (47.8) 6 (26.1)

Hours of training
0 21 (95.5) 18 (78.3)
1-2 1 (4.6) 2 (8.7)
3-8 0 (0) 1 (4.3)
More than 8 0 (0) 2 (8.7)
aP value < 0.05 by chi square test comparing those expected but did not teach tobacco
and those who taught in prior year.
bThis column reports data from three schools; at the fourth school all teachers indicating
that they were expected to teach reported that they actually did so.
Note: Missing: expected group level of preparation (4), expected group hours of
training (5).

students and staff. Comments noted the importance of: emphasizing visual
elements (models, photos, pictures, posters, hands on materials); limiting written
text, and when using text keeping the language simple and direct, preferably
on a first or second grade reading level; featuring images of deaf and hard
of hearing people; demonstrating the health effects of tobacco use; providing
health statistics from hospitals and clinics; and including content that examined
manipulation of youth by tobacco companies and that addressed peer pressure.
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 143

Respondents mentioned the need for: culturally tailored videos, public service
announcements, and internet messages that use ASL and captions; testimonials
by deaf and hard of hearing individuals and panels, including smokers and
non-smokers and cancer survivors and tobacco victims, with relevant life
experiences; inclusion of tobacco prevention in school-wide programs such as
Red Ribbon Week and school assemblies, and as a requirement in health classes.
Two respondents indicated that more research was needed.

Anti-Tobacco School Programs

and Policies

Respondents perceptions of their schools tobacco prevention programs and

policies are described in Table 4. About a quarter of the respondents reported
that their school offered no anti-tobacco programming. One hundred and five
respondents provided an estimate of the percentage of students they thought
received such programming; the average estimate was 36.6% (SD = 35.8). More
than two-thirds (69.2%, n = 115) indicated that they were not sure or did not
know if the school or community offered a smoking cessation program for
students, and few reported ever receiving information as to where faculty or
staff could turn for cessation help. Although there was a high level of support for
anti-tobacco school policies, there was considerable uncertainty (i.e., responses
of dont know) regarding estimates of non-compliance among students, faculty,
or staff, or the outcome of student non-compliance.

Tobacco Use as a Problem and

Health Education Priority

Faculty perceptions of tobacco use as an important problem and educational

priority are reported in Table 5. Most participating faculty indicated that at least
some students at their school smoked (91.5%, n = 108/118), but, overall, the
estimate of use was low, on average 15.1% (SD = 16.1). About two-thirds (64.6%,
n = 106) of the respondents indicated that they believed tobacco use to be about
the same or less among deaf and hard of hearing youth as among hearing youth,
and 37.0% (n = 61) described tobacco use as a very or somewhat serious problem
among deaf and hard of hearing young people. Friends and family smoking
were most often described as the most important risk factors for this behavior.
Few respondents described tobacco prevention education as a high priority in
their school, nearly a quarter (22.7%, n = 37/163) indicated that it should be highly
prioritized, and half indicated that they believed more should be done to combat
smoking among students in their school (54.9%, n = 90/164). While most faculty
responded that tobacco prevention education was a very or somewhat valuable use
of student time (88.8%, n = 143/161), tobacco use was least often listed as the most
important, or one of the three most important, health problem facing their students.
 144 / BERMAN ET AL.

Table 4. Perception of School Programming and Policies (n = 166)

N (%) N (%)
Programs offered at schoola Ever received cessation information for faculty/staff
Drug Free or Red Ribbon Week 73 (44.0) Yes 29 (17.9)
Other activitiesb 36 (21.7) No 82 (50.6)
School offers no activities 43 (25.9) No teacher uses tobacco 3 (1.9)
Dontt know/Dont remember 48 (29.6)
Tobacco education coordinator
Yes 45 (28.3) Signs at schools that tobacco use is prohibited
No 46 (28.9) Yes 69 (42.6)
Dont know 68 (42.8) No 54 (33.3)
Dont know 39 (24.1)
Student cessation help availablea
Yes at school 26 (15.7) School policies that apply to:
Yes in the community 32 (19.3) Students 124 (74.7)
No 11 (6.6) Teachers/staff 127 (76.5)
Dont know/not sure 104 (62.6) Visitors 110 (66.3)
School has no policy 5 (3.0)
Dont know 24 (14.5)
Policy enforced Perceived rate of student smokers
A great deal 71 (43.6) non-compliance
Moderately 39 (23.9) None 17 (10.3)
Not too much/Not at all 18 (11.0) Any 36 (21.8)
Dont know/No opinion 35 (21.5) Dont know/Not sure 112 (67.9)
Support for policy
Yes, for students 153 (96.2) Perceived rate of faculty/staff smokers
Yes, for faculty and staff 146 (92.4) non-compliance
None 34 (20.9)
Outcome of student non-compliance Any 62 (38.0)
Suspension/expelled 39 (23.5) Dont know/Not sure 67 (41.1)
Referred to adult counselor 34 (20.5)
Parents called in 23 (13.9)
Otherc 22 (13.3)
Dont know 94 (56.6)
aMultiple responses possible.
bOther activities include: assembly/other prevention event, special day (Great American Smokeout, Smoke Scream, etc.), contest, anti-tobacco
club, activities with Health Department or voluntary organization (e.g., American Cancer Society); smoking cessation classes; other activities.
cOther outcomes of student non-compliance include: referral to special class/cessation program; referred to peer counselor; permitted to smoke
in certain locations, other.
Note: Missing: school has signs (4), policy enforced (3), support policy for students (7), support policy for faculty and staff (8), perceived rate of
non-compliance among student smokers (1), perceived rate of non-compliance among faculty/staff smokers (3), tobacco education coordination
(7), student cessation help available (3), ever received cessation information for faculty/staff (4).
TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 145
 Table 5. Tobacco Use as a Problem and an Educational Priority (n = 166)
N (%) N (%)
Tobacco use as a problem among deaf/ Priority tobacco education has in school program
hard of hearing youth High 18 (11.2)
Very/Somewhat serious 61 (37.0) Moderate 37 (23.0)
Not very serious/No problem at all 47 (28.5) Low 44 (27.3)
Dont know/No opinion 57 (34.5) Dont know/Not sure 62 (38.5)
146 / BERMAN ET AL.

Tobacco use among deaf/hard of hearing Priority tobacco education should have in
compared to hearing youth school program
More deaf use 1 (0.6) High 37 (22.7)
Fewer deaf use 32 (19.5) Moderate 90 (55.2)
About the same 74 (45.1) Low 20 (12.3)
Dont know/No opinion 57 (34.8) Dont know/Not sure 16 (9.8)

One of three most important risk factors for Tobacco use prevention as a valuable use of
student tobacco use student time
Friends use 139 (86.3) Very valuable 85 (52.8)
Family use 127 (78.8) Somewhat valuable 58 (36.0)
Availability 64 (39.7) Not at all valuable 2 (1.2)
Media messages 45 (28.0) Not sure/No opinion 16 (10.0)
Insufficient tobacco prevention education 33 (20.5)
Use of other drugs 32 (19.9) More should be done to combat tobacco use
Ethnic background 19 (11.8) among students
Family income 2 (1.2) Yes, more should be done 90 (54.9)
Being deaf/hard of hearing 2 (1.2) No, enough is being done 25 (15.2)
Other (such as low self-esteem) 6 (3.7) Dont know/No opinion 49 (29.9)
None of these 3 (1.8)
Most important health problem among: One of three most important health problems
HIV/AIDS 85 (57.8) among:
Depression 15 (10.2) HIV/AIDS 123 (83.7)
Other drug use 12 (8.2) Alcohol 73 (49.7)
Diet/Nutrition 11 (7.5) Depression 61 (41.5)
Alcohol 10 (6.8) Other drug use 57 (38.8)
Violence 10 (6.8) Violence 48 (32.7)
Tobacco 3 (2.0) Diet/Nutrition 38 (25.9)
Tobacco 30 (20.4)
Note: Missing: tobacco among deaf and hard of hearing youth (1), tobacco among deaf and hard of hearing youth compared to hearing
youth (2), three most important risk factors for tobacco use among students (5), priority tobacco education has in school program (5), priority
tobacco education should have in school program (3), tobacco use prevention as a valuable use of student time (5), more should be done to
combat tobacco use among students (2), important health problems (19).
TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 147
148 / BERMAN ET AL.

Between School Differences

While we primarily report on the overall findings in our study, we did find some
significant school-specific variations (p < .05) in faculty perception of their
schools programs and policies. For example, the proportions of faculty at each
of the four schools reporting that there was a tobacco advocate at their school
was 0.0%, 20.3%, 38.1%, and 42.4%; indicating that their school offered a Drug
Free or Red Ribbon Week was 5.0%, 11.1%, 45.9%, and 62.7%; expressing
awareness of no smoking signs was 30.3%, 33.9%, 75.0%, and 82.3%; describing
a great deal of enforcement of their schools no smoking policies was 22.9%,
50.0%, 56.2%, and 61.1%; and assessing tobacco as one of the three most
important health problems facing their students was 5.6%, 25.0%, 29.4%, to
43.8%. Reports of not being aware of what is in place with respect to tobacco-
related policies and programs were fairly consistent across schools. For example,
39.0%, 42.1%, 44.4%, and 50.0% of respondents reported that they did not
know if there was an advocate for tobacco education at their school.

DISCUSSION
Faculty play a key role in delivery of school-based substance use prevention
education, including with respect to tobacco use. However, information about
faculty views, activities, and preparation for delivering such programming is
sparse, especially for educators serving special populations, such as deaf and
hard of hearing youth. Results from this first-ever tobacco-related survey
among faculty at residential/day Schools for the Deaf point to a number
of issues regarding delivery of school-based tobacco prevention education for
this population.

Limited Tobacco-Related Education

Reached Youth at Participating Schools
Deaf and hard of hearing youth and young adults have described schools as
the best place to deliver tobacco prevention programming (Berman et al., 2006,
2007); two of the three states with Schools for the Deaf in our study mandate
anti-tobacco education (National Association of State Boards of Education,
2007); and over 98% of secondary schools in these states report seeking to
increase knowledge in tobacco use prevention in required health education
classes (Grunbaum, Kann, Williams, Kinchen, Collins, Baumler, et al., 2000).
Nevertheless, our survey provided evidence of limited focus on tobacco-related
programming at participating schools. The programming that is offered is not
seen as a faculty-wide responsibility but as the responsibility of a relatively
few faculty. Only a quarter of our respondents indicated that they were expected
to teach in this area. This is fewer than the 36% reporting this expectation in
a population-based survey of 828 teachers in 325 randomly selected California
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 149

middle and high schools (McCarthy et al., 2005). Of those expected to teach
tobacco education, 72.8% of the teachers in the California survey reported
actually having done so, while this was true for only 34.1%, 14 of 41 faculty in
our study. Only a small proportion of the faculty we surveyed, 13.9%, reported
delivering tobacco-related education, a far smaller proportion than the 39.3%
reported in the California survey, although comparable to reports for teachers
elsewhere (Thomas, Fick, & Henderson, 1992). Faculty members in our schools
that did teach this subject matter reported devoting very few hours to tobacco
education, and there were few reports of tobacco education in the elementary
school grades, prior to the ages at which youth are most at risk for experimentation
with tobacco products (Johnston, OMalley, Bachman, & Schulenberg, 2006).
This confirms what was learned regarding limited exposure to tobacco education
from students in our current study (Berman et al., 2011) and in an earlier survey
of 226 deaf and hard of hearing high school students and 241 college students
(Berman et al., 2006, 2007). Although describing schools as the best place to
reach deaf and hard of hearing young people with anti-tobacco programming,
27.9% of the high school students overall (n = 63/226), an even higher proportion
among the subset of high school students attending Schools for the Deaf (35.5%,
n = 36/110); and 41.5% (n = 100/241) of the college sample reported no exposure
to a classroom lesson on this subject. Among those reporting tobacco education,
24.6% (n = 41/167) of the high school students and 23.6% (n = 34/144) of the
college students reported no consideration of self-esteem or decision making,
important omissions in light of what is considered state-of-the-art curriculum
content (Botvin & Kantor, 2000; Hansen, 1992; Orlando, Ellickson, McCaffrey,
& Longshore, 2005; USDHHS, 1994).
Although not a substitute for classroom teaching, school-wide programming
and linkage to media and other community activities have been found to
be valuable elements of comprehensive tobacco-prevention programming (Flay,
Hansen, Johnson, Collins, Dent, Dwyer, et al., 1987; Flynn, Worden, Secker-
Walker, Badger, Geller, & Costanza, 1992; Lee, Wu, Lai, & Chu, 2007;
Lohrmann, Alter, Greene, & Younoszai, 2005; Pentz, 1999; Reinert, Carver, &
Range, 2004). It is therefore significant that faculty reports of such activities in
our study were also very limited: many respondents were not aware of whether
or not a coordinator for tobacco education was in place in their school; and schools
are described as not often taking advantage of local voluntary agency services or
guest speakers, or participating in community events relating to tobacco control.
State-mandated policies, an important element of school-based anti-tobacco
efforts (Kumar, OMalley, & Johnston, 2005; Pentz, Brannon, Charlin, Barrett,
MacKinnon, & Flay, 1989), are in place at all four of the schools in our study, and
there seems to be little reported faculty smoking or adult smoking on campus.
However, some faculty members seemed unaware of these school policies or of
the consequences of non-adherence, and many did not seem to know if cessation
programs were available for students or faculty at school or in the community.
150 / BERMAN ET AL.

Factors Contributing to Limited Tobacco

Prevention Education

There are a number of factors that may help explain the indication of limited
attention to tobacco use in the curriculum or in school-wide programs. First,
this may relate to survey participation. We were only allowed to administer one
survey to school personnel, and know that a number of school staff, over a quarter
of our respondents, elected to complete the survey who did not have teaching
responsibilities (e.g., residence counselors) as did a number of teachers who are
not traditionally responsible for tobacco education (e.g., teachers of math, English,
and other subject areas). It may also be that educators who deliver tobacco-related
prevention education may have chosen not to participate in the survey. The limited
programming at the elementary grade levels that we found may reflect a low level
of survey participation on the part of elementary school teachers.
Second, perception of tobacco use as less of a problem than other high risk
behaviors and health issues may undermine delivery of tobacco education. Our
faculty respondents overwhelmingly expressed the view that tobacco use preven-
tion was an appropriate element for the curriculum at their school, a valuable use
of their students time, and that more should be done to prevent tobacco use among
deaf and hard of hearing youth. Most respondents reported that at least some of
their students use tobacco products, and the estimates of use among their students
were fairly close to the anonymous baseline self-reports given by the students
themselves. The average faculty estimate of smoking was 15.1% compared to the
students self-reported estimate of current (past month) smoking that ranged
from 9.6% to 22.7% in the four participating schools (Berman et al., 2011).
Likewise, the faculty perception of use among their students in comparisons to
hearing youth was also fairly accurate. In 2004, when this survey was conducted,
the rate of current smoking for students in California was 9.3% for 9th graders,
13.1% for 10th graders, 14.5% for 11th graders, and 17.1% for 12th graders
(McCarthy, Dietsch, Hanson, & Zheng, 2007). Nationwide, rates were reported
as 9.2% for 8th graders, 16.0% for 10th graders, and 25% for 12th graders
(Johnston, OMalley, Bachman, & Schulenberg, 2010). This suggests that faculty
recognize that student use is a problem, at least among some of their students,
as for youth generally. However, although not linked to an underestimation of
tobacco use among their students as in some other settings (DiLorenzo, Welton,
McCalla, Finger, Brownson, & Van Tuinen, 1991), very few respondents seemed
to consider tobacco use as the most important health problem facing their students,
or even among the three most significant issues.
The apparent contradiction in the perception of tobacco use as an important
health problem and as an element of health education seems to reflect the con-
flicting views expressed by other educators. Among 281 middle- and high-school
teachers surveyed in New Orleans, 83% reported smoking prevention among
the three most important health education topics that needed to be included in
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 151

the school curriculum (Thomas, Fick, & Henderson, 1991). Yet a survey con-
ducted among Texas educators (130 principals and 128 health coordinators)
found that only 17% of health coordinators reported that the majority of teachers
viewed tobacco use prevention education as very important compared to other
subjects, and 15% of principals ranked this subject among their three most
important priorities (Boerm, Gingiss, Huang, Alo, & Kropp, 2001).
Third, the importance of institutional commitment and support in prevention
education adaptation, dissemination, maintenance, and fidelity are well estab-
lished (Collins, Robin, Wooley, Fenley, Hunt, Taylor, et al., 2002; Gingiss,
Gottlieb, & Brink, 1994; Gingiss, Roberts-Gray, & Boerm, 2006; Parcel, Eriksen,
Lovato, Gottlieb, Brink, & Green, 1989; Pentz, 1999). Therefore, it is not sur-
prising that the barriers identified by our respondentsa lack of adequate time,
resources, training, and in some instances, awareness of existing policies and
services, factors noted in other school settings (Barr, Tubman, Montgomery,
& Soza-Vento, 2002; Lee et al., 2007; McCarthy et al., 2005; Rohrbach, Graham,
& Hansen, 1993)would serve to minimize education in this subject area.
The most frequently noted barrier, cited by 60% of respondents, was the lack
of adequate materials and curriculum tailored to the cultural and linguistic needs
of deaf and hard of hearing youth. It is unlikely that effective school-based
intervention will occur unless faculty have adequate curriculum and materials
in hand (Thomas & Perera, 2006), and for educators of deaf and hard of hearing
children and adolescents, appropriate curriculum needs to not only embody
state-of-the-art tobacco use prevention principles and strategies, but approaches
that address the unique educational requirements of this cultural and linguistic
minority population, as well (Kluwin, Moores, & Gaustad, 1992; Mason &
Ewoldt, 1996; Nover & Andrews, 1998; Stinson & Antia, 1999). In addition to
elements such as visual elements, use of simple, direct, and repetitive written
text, and inclusion of images of deaf and hard of hearing people noted by our
respondents, this tailoring must also relate to program content. For example,
when providing tobacco prevention education, faculty participants more often
reported focusing on the health consequences of tobacco use than on other
aspects of this problem, confirming survey findings from our prior research
(Berman et al., 2006, 2007). In this earlier work, many of the youth reporting
receipt of tobacco programming indicated exposure to information about health
consequences, but not to a number of other curriculum elements considered
important to smoking prevention: consideration of tobacco advertising or mar-
keting, reasons why young people smoke, normative patterns, or behavioral or
general personal and social skills (Botvin & Griffin, 2002; Botvin & Kantor,
2000, Hansen, 1992; USDHHS, 1994).
This emphasis on the health consequences of tobacco use raised an interesting
issue for our community-academic partnered research group. On the one hand,
there is evidence suggesting that information provision, including regarding the
health consequences of smoking, is not effective in preventing tobacco use
152 / BERMAN ET AL.

among young people (Thomas & Perera, 2006). On the other hand, in focus
groups conducted with educators of deaf and hard of hearing youth during the
formative stages of our research, and in subsequent conversations with inter-
vention site faculty involved in program implementation, while not excluding
other elements of effective programming, these educators emphasized the gaps
in the health-related knowledge of deaf youth and adults, and the importance
of providing such health-related information to this population. In doing so,
these educators underscored an important theme in the literature describing
the experiences of deaf and hard of hearing people that needed to be taken
into account when developing tailored curriculum: that communication barriers
put this population at risk for not receiving adequate health-related information in
clinical settings (Iezzoni, ODay, Killeen, & Harker, 2004; Steinberg, Barnett,
Meador, Wiggins, & Zazove, 2006; Zazove, Niemann, Gorenflo, Carmack, Mehr,
Coyne, et al., 1993) or incidental health messages available to hearing persons
(Tamaskar et al., 2000).
With respect to training, faculty in our study that expected to teach who did
not do so most often indicated that it is not part of their curriculum, and faculty
who did address tobacco in their classroom lessons noted a lack of time and
reported very limited training. This limited preparation is certainly not unique
to educators in Schools for the Deaf. Although often responsible for delivery
of tobacco-related education, one-third of health, physical education, and middle
school science teachers in a survey of 828 California high school and middle
school teachers reported receiving any in-service training in this area (McCarthy
et al., 2005). In a national survey, between 28.8% and 66.5% of schools across
states had a lead health educator that had received at least 4 hours of in-service
training in tobacco education in the prior year (Grunbaum et al., 2000).
This lack of training is a particular concern in that faculty preparation has
been found to be effective in enhancing skills, and the amount, intensity, and
content of training have been found to play a significant role in effective, sustained
delivery of tobacco prevention education (Kealey, Peterson, Gaul, & Dinh, 2000;
Perry-Casler, Price, Telljohann, & Chesney, 1997; Sy & Glanz, 2008). Training
sessions can serve as an opportunity to improve skills relating to program delivery,
inform faculty of policies and available services, and reinforce the importance
of the tobacco use problem among young people, including among deaf and hard
of hearing youth. This could be done through review of: the health consequences
of tobacco use; the enormous burden this behavior poses for health in relation to
other high risk behaviors (Mathers & Loncar, 2006); the relationship among high
risk behaviors including among children with disabilities (Eaton, Kann, Kinchen,
Ross, Hawkins, Harris, et al., 2006; Hollar, 2005); the role of tobacco use as a
gateway drug to other substance use (Kandel, 1975; Wagner & Anthony, 2002);
the relationship between tobacco use and emotional and psychological problems
such as depression (Fergusson, Goodwin, & Horwood, 2003); and the existence of
anti-tobacco school policies and availability of school and community services.
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 153

Finally, our findings of low levels of delivery of tobacco education may

well have reflected a perception of inadequate curriculum, institutional com-
mitment, and training for those who perceived themselves as responsible for
delivery of tobacco related programming. However, it may also be that this
reflects how few faculty see themselves as expected to offer such education
to their students. This raises an important issue regarding pre-service education
for all teachers and faculty-wide orientations. These are opportunities in which
it is possible to convey to educators generally that tobacco education is a
broad responsibility. Educational elements can be included in virtually all
subject areas, and certainly in residential counseling. The perspective that
every teacher is a health teacher can be extremely valuable in encouraging
educators in Schools for the Deaf, as elsewhere, to include elements of cur-
riculum, and incidental tobacco-related messages and materials, in their class-
room activities and other efforts.

CONCLUSION
The faculty survey that serves as the basis for this report is part of a first-ever
program of research aimed at understanding and addressing the tobacco pre-
vention education needs of deaf and hard of hearing youth. School-based tobacco
prevention education is certainly not a perfect solution to the problem of tobacco
use among young people (Centers for Disease Control and Prevention, 2001;
Clayton, Cattarello, & Johnstone, 1996; Peterson, Kealey, Mann, Marek, &
Sarason, 2000). However it represents one element in the continuing effort to
curb youth initiation and shift to regular use, and a component of prevention
efforts that may well be particularly important for young people who experience
barriers to receipt of other prevention messages and programs (Bat-Chava, Martin,
& Kosciw, 2005; Joseph, Sawyer, & Desmond, 1995). Learning from educators
that serve students in Schools for the Deaf regarding their experiences in providing
tobacco education can offer insights not only into how this programming can
be improved, but how to improve deaf-friendly efforts to address other high risk
practices, including other types of substance abuse, as well. What is learned
with respect to school-based programming for deaf and hard of hearing youth
may also prove useful in the development and delivery of prevention education
for other linguistic and cultural minority populations.

Limitations
Findings from this first-ever survey of faculty at four Schools for the Deaf
in three states cannot be generalized to all educators or educational settings
serving deaf and hard of hearing youth. There were eligible faculty members
who did not participate in our survey and self-selection may have biased what
was reported.
154 / BERMAN ET AL.

ACKNOWLEDGMENTS

We wish to acknowledge with appreciation permission to use items from

the Teacher Survey, California In-School Tobacco Use Prevention Education
Program (TUPE) 2001-2002 (WestEd). We wish to express our deep appreciation
to the faculty, staff, and administration of 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 survey.

REFERENCES
American Annals of the Deaf. (2009). Educational programs for deaf students. Schools
and programs in the United States. American Annals of the Deaf, 154(2), 97-179.
[PubMed: 19839104]
American Cancer Society. (2009). ACS Facts and Figures.
Barr, J. E., Tubman, J. G., Montgomery, M. J., & Soza-Vento, R. M. (2002). Amenability
and implementation in secondary school antitobacco programs. American Journal
of Health Behavior, 26, 3-15. [PubMed: 11795603]
Basen-Engquist, K., OHara-Tompkins, N., Lovato, C. Y., Lewis, M. J., Parcel, G. S., &
Gingiss, P. (1994). The effect of two types of teacher training on implementation
of smart choices: A tobacco prevention curriculum. Journal of School Health, 64(8),
334-339. [PubMed: 7844976]
Bat-Chava, Y., Martin, D., & Kosciw, J. G. (2005). Barriers to HIV/AIDS knowledge
and prevention among deaf and hard of hearing people. AIDS Care, 17(5), 623-634.
[PubMed: 16036248]
Berman, B. A., Bernaards, C., Eckhardt, E. A., Kleiger, H. B., Maucere, L., Streja, L., et al.
(2006), Is tobacco use a problem among deaf college students? American Annals of
the Deaf, 151(4), 441-451. [PubMed: 17225639]
Berman, B. A., Eckhardt, E. A., Kleiger, H. B., Wong, G. C., Lipton, D. S., Bastani, R.,
et al. (2000). Developing a tobacco survey for deaf youth. American Annals of the
Deaf, 145(3), 245-255. [PubMed: 10965587]
Berman, B. A., Guthmann, D. S., Crespi, C. M., & Liu, W. (2011). Development and
testing of an anti-tobacco school-based curriculum for deaf and hard of hearing
youth. American Annals of the Deaf, 155(5), 592-604.
Berman, B. A., Streja, L., Bernaards, C. A., Eckhardt, E. A., Kleiger, H. B., Maucere, L.,
et al. (2007). Do Deaf and Hard-of-Hearing youth need anti-tobacco education?
American Annals of the Deaf, 152(3), 344-355. [PubMed: 18018676]
Boerm, M. C., Gingiss, P. W., Huang, P., Alo, C., & Kropp, R. (2001). Status of implemen-
tation of tobacco use prevention education (TUPE) in secondary schools. Proceedings
of the annual meeting of the American Public Health Association, Atlanta, GA.
Botvin, G. J., & Griffin, K. W. (2002). Life skills training as a primary prevention
approach for adolescent drug abuse and other problem behaviors. International
Journal of Emergency Mental Health, 4, 41-47. [PubMed: 12014292]
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 155

Botvin, G. J., & Kantor, L. W. (2000). Preventing alcohol and tobacco use through Life
Skills Training. Alcohol Research & Health, 24, 250-257. [PubMed: 15986720]
Centers for Disease Control and Prevention (CDC). (1994, February 25). Guidelines
for school health programs to prevent tobacco use and addiction. MMWR Recom-
mendations and Reports, 43(RR-2), 1-18. [PubMed: 8145711]
Centers for Disease Control and Prevention (CDC). (2001, August 10). Effectiveness
of school-based programs as component of a statewide tobacco control initiative
Oregon, 1999-2000. MMWR Morbidity & Mortality Weekly Reports, 50(31), 663-666.
[PubMed: 11785566]
Centers for Disease Control and Prevention. (2007, October). Best practices for com-
prehensive tobacco control programs. Atlanta: 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.
Reprinted with corrections.
Clayton, R. R., Cattarello, A. M., & Johnstone, B. M. (1996). The effectiveness of Drug
Abuse Resistance Education (project DARE): 5-year follow-up results. Preventive
Medicine, 25(3), 307-318. [PubMed: 8781009]
Collins, J., Robin, L., Wooley, S., Fenley, D., Hunt, P., Taylor, J., et al. (2002, March).
Programs-that-work: CDCs guide to effective programs that reduce health-risk
behavior of youth. Journal of School Health, 72(3), 93-99. [PubMed: 11962230]
DiLorenzo, T. M., Welton, G. L., McCalla, T. L., Finger, W. W., Brownson, R. C., &
Van Tuinen, M. (1991). Underestimates of student substance use by school per-
sonnel: A cause for concern? Journal of Behavioral Medicine, 14(4), 397-407.
[PubMed:1942017]
Dusenbury, L., Brannigan, R., Falco, M., & Hansen, W. (2003). A review of research
on fidelity of implementation: implications for drug abuse prevention in school
settings. Health Education Research, 18(2), 237-256. [PubMed: 12729182]
Eaton, D. K., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Harris, W. A., et al. (2006).
Youth risk behavior surveillanceUnited States, 2005. MMWR Surveillance Sum-
maries, 55(5), 1-108. [PubMed: 16760893]
Fergusson, D. M., Goodwin, R. D., & Horwood, L. J. (2003). Major depression and
cigarette smoking: Results of a 21-year longitudinal study. Psychological Medicine,
33(8), 1357-1367. [PubMed: 14672244]
Flay, B. R. (2009). School-based smoking prevention programs with the promise of
long-term effects. Tobacco Induced Diseases, 5, 6. [PubMed: 19323826]
Flay, B. R., Hansen, W. B., Johnson, C. A., Collins, L. M., Dent, C. W., Dwyer, K. M.
et al. (1987, December). Implementation effectiveness trial of a social influences
smoking prevention program using schools and television. Health Education
Research, 2(4), 385-400.
Flynn, B. S., Worden, J. K., Secker-Walker, R. H., Badger, G. J., Geller, B. M., & Costanza,
M. C. (1992). Prevention of cigarette smoking through mass media intervention and
school programs. American Journal of Public Health, 82(6), 827-834. [PubMed:
1585963]
Gallaudet Research Institute. (1996). Stanford Achievement Test, 9th Edition, Form S,
Norms Booklet for Deaf and Hard-of-Hearing Students. Washington, DC: GRI,
Gallaudet University.
156 / BERMAN ET AL.

Gingiss, P. L., Gottlieb, N. H., & Brink, S. G. (1994). Increasing teacher receptivity toward
use of tobacco prevention education programs. Journal of Drug Education, 24(2),
163-176. [PubMed: 7931926]
Gingiss, P. M., Roberts-Gray, C., & Boerm, M. (2006). Bridge-It: A system for predicting
implementation fidelity for school-based tobacco prevention programs. Prevention
Science, 7(2), 197-207. [PubMed: 16791522]
Grunbaum, J. A., Kann, L., Williams, B. I., Kinchen, S. A., Collins, J. L., Baumler, E. R.,
et al. (2000, August). Surveillance for characteristics of health education among
secondary schoolsSchool health education profiles, 1998. MMWR CDC Sur-
veillance Summaries, 49(8), iv-41. [PubMed: 10994805]
Hansen, W. B. (1992). School-based substance abuse prevention: A review of the state of
the art in curriculum, 19801990. Health Education Research, 7, 403-430. [PubMed:
10171672]
Holden-Pitt, L., & Diaz, J. A. (1998). Thirty years of the Annual Survey of Deaf and
Hard-of-Hearing Children and youth: A glance over the decades. American Annals of
the Deaf, 143(2), 72-76. [PubMed: 9569718]
Hollar, D. (2005). Risk behaviors for varying categories of disability in NELS:88.
Journal of School Health, 75(9), 350-358. [PubMed: 16255721]
Holt, J. A., Traxler, C. B., & Allen, T. E. (1997). Interpreting the scores: A users guide
to the 9th Edition Stanford Achievement Test for Educators of Deaf and Hard-of-
Hearing Students. Washington, DC: Gallaudet Research Institute Technical Report
97-1, Gallaudet University.
Iezzoni, L. I., ODay, B., Killeen, M., & Harker, H. (2004). Communicating about health
care: Observations from persons who are deaf or hard of hearing. Annals of Internal
Medicine, 140(5), 356-362. [PubMed: 14996677]
Johnston, L. D., OMalley, P. M., Bachman, J. G., & Schulenberg, J. E. (2010). Monitoring
the future national results on adolescent drug use: Overview of key findings, 2009
(NIH Publication No. 10-7583). Bethesda, MD: National Institute on Drug Abuse.
Johnston, L. D., OMalley, P. M., Bachman, J. G., & Schulenberg, J. E. (2006). Monitoring
the future national survey results on drug use, 1975-2005: Volume I, Secondary school stu-
dents (NIH Publication No. 06-5883). Bethesda, MD: National Institute on Drug Abuse.
Joseph, J. M., Sawyer, R., & Desmond S. (1995). Sexual knowledge, behavior and
sources of information among deaf and hard of hearing college students. American
Annals of the Deaf, 140(4), 338-345. [PubMed: 8849663]
Kandel, D. (1975). Stages in adolescent involvement in drug use. Science, 190(4217),
912-914.
Kealey, K. A., Peterson, A. V., Jr., Galu, M. A., & Dinh, K. T. (2000). Teacher training
as a behavior change process: Principles and results from a longitudinal study.
Health Education and Behavior, 27(1), 64-81.
Kluwin, T. N., Moores, D. F., & Gaustad, M. G. (1992). Toward effective public school
programs for deaf students: Context, process, and outcomes. New York: Teachers
College Press.
Kumar, R., OMalley, P. M., Johnston, L. D. (2005). School tobacco control policies
related to students smoking and attitudes toward smoking: national survey results,
1999-2000. Health Education and Behavior, 32(6), 780-794. [PubMed: 16267148]
Lane, H., Hoffmeister, R., & Bahan, B. (1996). A journey into the deaf world. San
Diego, CA. Dawn Sign Press.
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 157

Lee, P. H., Wu, D. M., Lai, H. R., & Chu, N. F. (2007). The impacts of a school-wide
no smoking strategy and classroom-based smoking prevention curriculum on the
smoking behavior of junior high school students. Addictive Behaviors, 3(2), 2099-
2107. [PubMed: 17320304]
Lohrmann, D. K., Alter, R. J., Greene, R., & Younoszai, T. M. (2005). Long-term
impact of a district-wide school/community-based substance abuse prevention initia-
tive on gateway drug use. Journal of Drug Education, 35(3), 233-253. [PubMed:
16871738]
Mason, D., & Ewoldt, C. (1996). Whole language and deaf bilingual-bicultural
education-Naturally! American Annals of the Deaf, 141(4), 293-298. [PubMed:
8936704]
Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Medicine, 3(11), e442. [PubMed: 17132052]
McCarthy, W. J., Dietsch, B. J., Hanson, T. L., & Zheng, H. (2007). Evaluation of the
in-school tobacco use prevention education program, 2003-2004: Technical findings
and documentation (p. 30). Sacramento, CA: Tobacco Control Section, California
Department of Health Services.
McCarthy, W. J., Dietsch, B. J., Hanson, T. L., Zheng, H., & Aboelata, M. (2005).
Evaluation of the in-school tobacco use prevention education program 2001-2002
(191 pp.). Sacramento, CA: Tobacco Control Section, California Department of
Health Services.
National Association of State Boards of Education (NASBE). (2007). State-level school
health policies: State-by-state alcohol, tobacco, and drug use education. Retrieved
February 2, 2007, from http:/www.nasbe.org/HealthySchools/States/Topics.asp?
Category=A&Topic=7&Mode=Print
Nover, S., & Andrews, J. F. (1998). Critical pedagogy in deaf education: Bilingual
methodology and staff development. Year 4 (2000-2001). Sante Fe, NM: New Mexico
School for the Deaf.
Orlando, M., Ellickson, P. L., McCaffrey, D. F., & Longshore, D. L. (2005). Mediation
analysis of a school-based drug prevention program: Effects of Project ALERT.
Prevention Science, 6(1), 35-46. [PubMed: 15766004]
Parcel, G. S., OHara-Tompkins, N. M., Harrist, R. B., Basen-Engquist, K. M.,
McCormick, L. K., Gottlieb, N. H., et al. (1995). Diffusion of an effective tobacco
prevention program. Part II: Evaluation of the adoption phase. Health Education
Research, 10(3), 297-307. [PubMed: 10158027]
Parcel, G. S., Eriksen, M. P., Lovato, C. Y., Gottlieb, N. H., Brink, S. G., & Green, L. W.
(1989). The diffusion of school-based tobacco-use prevention programs: Project
description and baseline data. Health Education Research, 4(1), 111-124.
Pentz, M. A. (1999). Effective prevention programs for tobacco use. Nicotine and Tobacco
Research, 1(Suppl 2), S99-107. Review. [PubMed: 11768193]
Pentz, M. A., Brannon, B. R., Charlin, V. L., Barrett, E. J., MacKinnon, D. P., & Flay, B. R.
(1989). The power of policy: The relationship of smoking policy to adolescent
smoking. American Journal of Public Health, 79(7), 857-862. [PubMed: 2735472]
Perry-Casler, S. M., Price, J. H., Telljohann, S.K., Chesney, B. K. (1997). National
assessment of early elementary teachers perceived self-efficacy for teaching tobacco
prevention based on the CDC Guidelines. Journal of School Health, 67, 348-354.
[PubMed: 9425611]
158 / BERMAN ET AL.

Peterson, A. V., Jr., Kealey, K. A., Mann, S. L., Marek, P. M., & Sarason, I. G. (2000).
Hutchinson Smoking Prevention Project: Long-term randomized trial in school-
based tobacco use preventionResults on smoking. Journal of the National Cancer
Institute, 92(24), 1979-1991. [PubMed: 11121460]
Reinert, B., Carver, V., & Range, L. M. (2004). Anti-tobacco messages from different
sources make a difference with secondary school students. Journal of Public Health
Management Practice, 10(6), 518-523. [PubMed: 15643375]
Rohrbach, L. A., Graham, J. W., & Hansen, W. B. (1993). Diffusion of a school-based
substance abuse prevention program: Predictors of program implementation. Pre-
ventive Medicine, 22(2), 237-260.
Steinberg, A. G., Barnett, S., Meador, H. E., Wiggins, E. A., & Zazove, P. (2006). Health
care system accessibility. Experiences and perceptions of deaf people. Journal of
General Internal Medicine, 21(3), 260-266. [PubMed: 16499543]
Sternfeld, C. B., Barnabei, S. M., Kriger, K., Guthmann, D. S., Lester, F., Berman, B. A.,
et al. (2004). Hands off Tobacco: An anti-tobacco program for deaf youth. Cur-
riculum developed with funding from the Tobacco Related Diseases Research
Program, University of California (TRDRP).
Stinson, M., & Antia, S. (1999). Considerations in educating deaf and hard-of-hearing
students in inclusive settings. Journal of Deaf Studies and Deaf Education, 4(3),
163-175. [PubMed: 15579885]
Sy, A., & Glanz, K. (2008). Factors influencing teachers implementation of an innovative
tobacco prevention curriculum for multiethnic youth: Project SPLASH. Journal of
School Health, 78(5), 264-273. [PubMed: 18387026]
Tamaskar, P., Malia, T., Stern, C., Gorenflo, D., Meador, H., & Zazove, P. (2000).
Preventive attitudes and beliefs of deaf and hard-of-hearing individuals. Archives of
Family Medicine, 9(6), 518-525. Discussion 526. [PubMed: 10862214]
Thomas, S. M., Fick, A. C., & Henderson, J. A. (1991). Assessment of attitudes toward
school-based health promotion programs. Journal of the Louisiana State Medical
Society, 143(4), 37-40. [PubMed: 2051124]
Thomas, S. M., Fick, A. C., & Henderson, J. A. (1992). Meeting the needs of special
populations: A formative evaluation of a school-based smoking prevention
program. Journal of the Louisiana State Medical Society, 144(4), 157-161. [PubMed:
1613305]
Thomas, R. E., & Perera, R. (2006). School-based programmes for preventing smoking.
Cochrane Database of Systematic Reviews, 2006(3). ART. No.: CD001293. doi:
10.1002/14651858.CD001293.pub2. [PubMed: 16855966]
Tortu, S., & Botvin, G. J. (1989). School-based smoking prevention: The teacher training
process. Preventive Medicine, 18(2), 280-289. [Pub Med: 2740297]
U.S. Department of Health and Human Services (USDHHS). (1994, July). Preventing
tobacco use among young people: A report of the Surgeon General. Atlanta, GA: 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. Reprinted with corrections.
U.S. Department of Health and Human Services (USDHHS). (2004). The health
consequences of smoking: A report of the Surgeon General. Atlanta, GA: Centers
for Disease Control and Prevention, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health.
 TOBACCO EDUCATION FOR DEAF AND HARD OF HEARING YOUTH / 159

Wagner, F. A., & Anthony, J. C. (2002). Into the world of illegal drug use: Exposure
opportunity and other mechanisms linking the use of alcohol, tobacco, marijuana,
and cocaine. American Journal of Epidemiology, 155(10), 918-925. [PubMed:
11994231]
Zazove, P., Niemann, L. C., Gorenflo, D. W., Carmack, C., Mehr, D., Coyne, J. C., et al.
(1993). The health status and health care utilization of deaf and hard-of-hearing
persons. Archives of Family Medicine, 2(7), 745-752.

Direct reprint requests to:

Barbara A. Berman, Ph.D., Adjunct Professor Emeritus
Division of Cancer Prevention and Control Research
School of Public Health and Jonsson Comprehensive Cancer Center
University of California, Los Angeles
Room A2-125 CHS
650 Charles Young Drive South
Box 956900
Los Angeles, CA 90095-6900
e-mail: bberman@ucla.edu