Canning Indoor Tanning: Evaluating The Current Public Health Approach And Offering Advantageous Changes To Be Made -Tara LePage
“Kiss by the Sun,” “Desert Sun,” and “Bermuda Bronze” are three clever names of tanning salons in south eastern Massachusetts, advertising to consumers a guaranteed healthy glow. What these consumers are not getting from these salon titles is the FDA’s perspective; advising that sunlamps and tanning beds promising consumers the bronzed body year-round, are posing serious health risks from the exposure to ultraviolet (UV) radiation (1). In addition to skin cancer, the most common of all cancers in the United States (2), the FDA warns about the associations of tanning with premature aging, immune suppression, eye damage, and allergic reactions (1). Despite empirical reports denouncing the use of indoor tanning beds, the indoor tanning industry continues to flourish. An article by Denise Woo and Melody Eide, “ Tanning beds, skin cancer, and vitamin D: an examination of the scientific evidence and public health implications” reports that as one of the fastest growing industries in the United States, indoor tanning businesses are accruing an estimated 5 billion dollars in annual revenue (2). The Skin Cancer Foundation estimates that nearly 30 million Americans tan annually at 50,000 U.S. tanning facilities; while the American Cancer Society estimates that there will be about 70,000 new cases of melanoma and about 9,000 melanoma related deaths this year (3). With projections like these, it is clear that tanning salons have successfully warranted demand across the country; however, unless meaningful intervention is in place soon, the latter of the above statistics will also continue rising, ultimately resulting in severe negative health consequences for the public.
Honing in on defining the scope of the problem of indoor tanning is rather alarming. While all age groups are victim to the advertisements and pressures of keeping up with a tan, vulnerable populations have been found as the most frequent users of the indoor tanning salons. “Persistent use of tanning facilities has become especially apparent within adolescent female populations” (4). Girls as young as eight years old are exposing their developing bodies to the dangers of indoor tanning, and according to some physicians, the risks are especially high for this population whose skin cells are both dividing and changing rapidly (4). The Center for Disease Control (CDC) reports that, “nearly 9% of teens aged 14-17 years old have used indoor tanning facilities, and girls aged 14 -17 years old were seven times more likely than boys within that age group to use the devices” (5). As part of the Healthy People 2020 cancer objectives, the goals include reducing the 14% of adolescents grades 9-12 who report using artificial sources of UV light for tanning as well as reducing the 13.7% of adults aged 18 or older who report using artificial sources of UV light for tanning (5). The statistics could not be more clear.
What does this mean for public health officials? Intervention is needed. Over the past decade, a variety of Public Health Campaigns have begun efforts to challenge the epidemic of indoor tanning. The general approach to combating indoor tanning has currently been derived from the traditional public health education of groups at risk, along with proposed legislative bans and misled ignorance of impactful social learning and modeling in today’s culture. It is clear from the numbers above, many of which have been reported within just the past two years, that these current approaches of intervention against the negative impacts of the indoor tanning industry have failed. Analyzing this public health problem with a more progressive perspective on social and behavioral health will yield great benefits towards the creation of new intervention approaches.
Flaw #1: Misuse of the Traditional Health Belief Model
The Health Belief Model has been a longstanding, traditional foundation for public health interventions, originating in the 1950’s from the work of social psychologists, Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels (6). Basing its mechanism on the understanding that people weigh the scale of perceived benefits of practicing a behavior versus the opposing costs, there are six main principles influencing people’s decisions about whether or not to take action under the health belief model, including: “perceived susceptibility, are they at risk; perceived severity, are the consequences serious; perceived benefits, will taking action reduce risk and consequences; perceived barriers, are costs outweighed by benefits; cue to action, will intention prompt action; and self efficacy, is one confident in his or her ability to take action” (7). Assuming that individuals are rational in their evaluation of costs and benefits is a major limitation of the health belief model that directly ignores elements of external and social influence as well as disparities in knowledge among individuals (6).
Evidence of this model is manifested throughout the current approach working to defeat indoor tanning use. The Skin Cancer Foundation’s, “Go With Your Own Glow” campaign, published a variety of PSA announcements through the use of cartoon color print advertisements, along with libraries of educational videos explaining the process of UV radiation developing skin cancer (8). The CDC has supplemented their “Choose Your Cover” campaign with published educational brochures, posters, and print advertisements with the intention of emphasizing the statistics to stake their message (9). With these types of initiatives, public health officials from pristine agencies such as the CDC and The Skin Cancer Foundation are incorrectly assuming that by providing and explaining the risks and ultimate costs of exposure to indoor tanning UV radiation, that their target audiences, often young adolescent females, will rationally conclude with similar analysis of data that they should eliminate indoor tanning from their behavior cycle. Countering irrational mindsets with educated information alone has proven unlikely to be successful in many prior campaigns, and again in the case of diminishing the use of indoor tanning facilities.
Flaw #2: Legislative Bans Represent Heavy Hand Authority
Another major focus of anti-tanning campaigns has been their association with government intervention. A number of campaigns have teamed up with state lawmaking bodies, to propose and pass legislation concerning tanning restrictions for minors; the target audience for intervention. California is now banning the use of tanning beds for all minors under the age of 18; at least thirty one states regulate the use of tanning facilities by minors; and some counties are also involved in regulating the use of specific tanning devices (10). The International Agency for Research on Cancer has openly encouraged policy makers to “consider enacting measures, such as prohibiting minors and discouraging young adults from using indoor tanning facilities, to protect the general population from possible additional risk for melanoma” (10). While intervening on the macro level shows great initiative and responsibility, heavy handed authority is not always a successful route through which to take public health intervention, especially with a target audience at the adolescent development stage.
Turning to behavioral science for analysis of this approach, “psychological reactance was first defined in 1966 by Brehm, as the motivational state directed toward the reestablishment of a threatened or eliminated freedom” (11). The four elements that are fundamental to psychological reactance theory include freedom, threat to freedom, reactance, and restoration; which have each been researched extensively concerning their association with message rejection.
Described in the article by Rains and Turner, “Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model”, interventions such as educational efforts, warnings, and legal restrictions have all produced boomerang effects largely consistent with the conditions necessary to, and responses predicted by, psychological reactance theory. Through limiting or threatening freedoms, health messages have the potential to elicit reactance and, as a result, lead individuals to ignore the message, perform the opposite of the behavior advocated, or otherwise attempt to restore their threatened or lost freedom (9).
As we concluded from the previously mentioned statistics, adolescents under the age of 18 were those most likely to be frequent consumers at indoor tanning facilities. Evaluating the restrictive bans in terms of Brehm’s theory, the passed legislation inadvertently added to the increasing profits of the tanning industry, as opposed to decreasing the number of individuals dangerously exposed to UV radiation through indoor tanning, the intended goal. While their health and well being were at the foundation of the age restrictive bans, the legislation directly threatens the freedom of this particular population. Taking psychological reactance into account before intervening on behalf of the public’s health is an important component for any intervention. In doing so, the challenge for public health officials is to initiate interventions that will avoid threatening individual freedoms. If the intervention fails, psychological reactance becomes an additional risk factor for the unhealthy behavior, specifically indoor tanning.
Flaw #3: Ignoring Social Learning and Modeling as a Major Impact of Current Society
It is interesting to uncover that the desirability of associating a tan with attractiveness was not adopted until early in the twentieth century. Historically, suntanned skin represented working-class farmers and outdoor laborers, whereas fair skin represented nobility and wealth. Shortly after sun tanned skin was utilized by clothing designers as a new fashion statement, the American culture also adopted the appearance as a popular beauty trend. Extending beyond physical appearance, a suntan was considered a sign of good health, wealth, and prestige. (12) These messages did not end with fashion shows. “The mass media is constantly changing and evolving, and over the last twenty years, different media has emerged including music videos, computer games, and the internet; thriving in popularity amongst adolescents” (13). Today, a suntan is advertised in magazines, television shows, movies, and more. “Effects of Media Images on Attitudes Toward Tanning,” a paper written by Mahler, Beckerley, Vogel, described experiments determining whether exposure to images in these types of media showing attractive models who do not have a tan, relative to those who do, might result in less favorable attitudes towards tanning (12). Ultimately, the results concluded, that as popular media revealed attractive models with a suntan, the favorability towards a tan increased (12).
What can be pulled from these data is that many decisions made by adolescents incorporate influence from the environment around them, often times media exposure. Overwhelmingly in the current approach to reach adolescents concerning the danger of indoor tanning, public health officials and organizations are targeting the individual for change. This approach misses a significant impact of the vulnerable adolescent lifestyle, their models. In understanding the Social Learning Theory/Social Cognitive Theory, individual behavior is part of a triangle; an interaction between an individual, his or her behaviors, and the environment (14). As one of the first traditional health belief models to include group level factors, “Bandura emphasizes, in the social learning theory, the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. He states that, “learning would be exceedingly laborious, if people had to rely solely on the effects of their own actions to inform them what to do;” (15) therefore they proceed by the examples of others. When creating interventions targeting adolescent behavior, it is important to take into consideration the impact of models on this specific population.
Changing the Approach:
From the examples provided above, it is clear that there is significant support behind the efforts put forward to decrease the danger of indoor tanning. That being said, the methods through which they have focused their approach have been ineffective. Altering the current approach will result in a world of difference concerning both the public’s perception and well being, as it is associated with indoor tanning. A more meaningful intervention will move away from dependence on the rational education of the traditional health belief model, and will divulge deeper than just statistics, to show the public impactful stories of individuals suffering from their decisions to choose to expose themselves to the dangers of indoor tanning. In addition, the intervention will also separate itself from the adoption of legislative bans, thus avoiding common psychological reactance occurrence in the target population. Lastly, this new approach will appreciate and incorporate the impact of social norms on societal decisions; selling the movement at a group intervention level will yield much more successful results. The role of communicating this public health message will be complex, and understanding these advances from the traditional approaches will only progress the success of public health initiatives in years to come.
Intervention #1: Moving Education away from Statistics
Educating the public on their health has been, and will continue to be an important role of public health officials and those who work on behalf of public health interventions. However, the traditional manner of presenting statistics is not always as successful as we would hope. In using the health belief model, the law of small numbers and optimistic bias are more progressive social behavioral principles addressing human irrationality that are directly ignored. The law of small numbers explains that humans have a distorted view of probability and without a proper perspective on statistics relating to risk, it is impossible to expect humans to be able to relate to the numbers. In public health, the truth is often used as support, highlighting statistics and probabilities, in an effort to convince the masses to change their behavior; however, the masses have this distorted understanding of numbers so much so that they are not impacted by the numbers provided. (16) Complementing this idea, “Optimistic bias means that people have the tendency to judge their own susceptibility for a disease or other negative outcome as lower than other’s susceptibility. People in general expect positive events in their futures even if there is no reason to assume this outcome” (17). Interestingly, while they underestimate risk and probability of negative outcomes in their own lives, individuals commonly overestimate risk and probability of negative outcomes in the lives of the general population.
Smoking studies have been another area of public health in which these phenomenons have been apparent. Smokers are able to define the negative health risks of smoking as much greater than the actual numbers in discussion of the smoking population overall. However, when asked about their personal risk, smokers feel inferior to those negative health outcomes, underestimating the personal probability (16). Specifically targeting adolescents, Richard Branstrom and Yvonne Brandberg concluded in their study “that adolescents have strong positive optimistic bias for several of the most important health risks, diminishing the importance of their individual health behavioral risk, while identifying these same risks as the most dangerous to other people’s health in the general population”(17). It is clear that this irrationality is programmed in humans; most likely a technique for avoiding depression, building self esteem, and coping.
Learning from the aforementioned studies, these concepts present a much different understanding of the impact of statistics; these biases are in effect and they simply are not acceptable. Rethinking the strategies of facts and statistics moves education in a new direction. Approaches that take advantage of this human quality of irrationality will likely result in positive change for the indoor tanning efforts. How to proceed? A new intervention will target one or two powerful examples of the negative effects of indoor tanning exposure rather than discuss the probabilities of hundreds in a mathematical format. Those at risk already understand the danger of the masses; we need a message that will strike the individual much more personally. Finding ways to utilize the media, the television, radio, and internet, to share the narrative of an individual suffering from skin cancer caused by excessive exposure to indoor tanning radiation, will be much more relatable for the adolescent population than numbers. This one compelling story, if employed in a manner that reaches the masses, will have a disproportionate effect on those targeted, one that is much different than their original inclinations of inferiority. Controlling for these factors, as well as understanding the need for and implications of this change, will be the first positive step in changing the intervention.
Intervention #2: Avoiding Psychological Reactance
Health communication researchers and practitioners are becoming increasingly aware of the risk of activating psychological reactance in the process of translating health awareness resulting in less effective or even counterproductive results (18). From what we have learned about the reactions to threatened freedom, it is necessary for public health officials to take caution in creating intervention approaches that avoid reactance from the target adolescent population. Three key techniques to focus on in avoiding psychological reactance are explicitness, dominance, and reason. In order to enhance persuasion over the developing adolescents, the message needs to be clear to the point where it does not make use of obvious manipulation. The message should also minimize the tone of dominance, or extent of highlighting that the source of the message is in control; and lastly, should strategize for significant support behind it’s reasoning in order to soften the perceptions of intrusiveness observed from the target population (19).
Working from these recommendations, it is clear why current interventions supporting the legislative bans against miners using indoor tanning facilities have backfired. Because adolescents are extremely perceptive in defending their freedom, it is important to frame any intervention goals at invoking their most prized core value of freedom, as opposed to taking it away. For a most effective approach, a message needs to project affirmation rather than contradiction towards individuals’ beliefs and attitudes in order to encourage behavior change. Incorporating similarities between the source and the recipient of the message is a common tool used to significantly decrease reactance. Also, in acknowledging these tendencies of young people, another study suggests that “health campaigns utilize slick production effects, hip music, lively camera work, and sharp editing techniques to produce messages effective at capturing the attention of the highly at risk target audiences” (20). Culminating these suggestions encourages an approach that emphasizes representativeness to the adolescent in the message we project. Of great importance will be choosing the right messengers to capture the attention of the target population in addition to investing creativity that matches the creativity and technology so familiar to today’s youth. Rather than telling them what choices to make, our message needs to covertly persuade them to believe our mission is already engrained in their own belief systems. Similar to smoking cessation programs, perhaps we can frame the tanning industry as the “bad guys” who are eliminating their future freedoms of life. In doing so, we can join forces with the target population to restore the threatened value and ultimately make advances in their health. Despite public health support of legislative actions targeted to protect the health of adolescents, it will be important to separate those initiatives from employed interventions. Adolescents need to know that our mission shares commonalities with their deepest values and beliefs, and each of these changes will develop relatable characteristics. We’re about what they’re about, and together we will continue to preserve their freedom to be healthy-- not destroy their freedom to make choices.
Intervention #3: Realizing the Group versus the Individual
Lastly, moving beyond the traditional Social Learning Theory, and progressing towards group level approaches can be much more impactful. Three basic premises of alternative models highlight the power of group level thinking that are not accounted for in traditional models of public health intervention. First, a group is more than just the sum of individuals; therefore, group behavior cannot be explained by models at the individual level because mob mentality takes over and negates the individual decision making. Second, groups of individuals can be affected at the same time, specifically influencing behavior change; and thirdly, behavior is in fact, often unplanned, out of our control and dynamic including visceral drives and aspects of environmental context that take a significant amount of human decisions out of immediate control. (21)
Components from the Social Expectations Theory, Social Network Theory, and the Diffusions of Innovation Theory all contribute a unique new twist of new ideas and the ability of understanding the parts of the current intervention that have been left out, until now. Social expectations theory states that much of people’s behavior is explained and dictated by their perception of how members of their social group behave; therefore, if harmful behavior is perceived as the standard in a social group, the social urge to conform will ultimately rule the decision making process of the individual group members (22). This message mirrors behaviors from inside the classroom to relationships across the country. Once the idea of social norms is grasped, diffusions of innovations theory models how behavior is picked up in a pattern overtime and eventually results in the change of those social norms. Tracking the percentage of the population adopting specific intervention practices overtime gives light to the period, also known as the point of inflection or tipping point, in which the ideas of the intervention take off and influence the population’s conformity (23). Lastly, social network theory, similar to the concepts of social norms, considers the specific network of family and friends that individuals associate and identify themselves with as the target for intervention. For adolescents this could be groups such as sports teams, extracurricular activity groups, student government, or simply just best friends.
Turning to our specific health focus, the dangers of indoor tanning, the current approaches have targeted individuals to motivate change. They have simply been missing a huge factor in the influence of the adolescent lifestyle; social norms and networks. Aside from the media impact mentioned earlier, direct environmental factors are also in effect on this population’s decision making. Perhaps the most powerful change of the new approach to this public health issue will result from the understanding of the dictation of social norms. We will be able to reframe the new intervention with an environmental approach that seeks to impact both social and cultural environments as the way to then influence individuals (22).
From the current numbers, we know that the practice of indoor tanning, especially among adolescents, is socially acceptable and even desirable. The job of the new approach is to change the social norm. We are surrounded by historic successes of this approach every day including the elimination of the deviant behavior of spitting in public, the acquired use of seatbelts in automobiles, all the way to the adoption of smoke free bars and restaurants across the country! It works. Without much studying, we know the peer effects that occur in the adolescent developmental stage. Rather than targeting each teen as before, it will be more beneficial to intervene at the group level, targeting the teen through his or her whole social network to relay our message. If this intervention has succeeded, behavior will begin to increasingly change in the direction of the intervention message across the population over time. Once the majority of the population has adopted the new norm, we too will reach the tipping point in popularity. With the technological advances of today’s world, there are a number of ways to target social networks including campaigns utilizing Facebook and Twitter, as well as professional networking sites such as Linked In. In these domains, our message not only reaches the masses, but the groups of those specific individuals who are at risk; influencing the herd mentality that ultimately negates individual decision making in a new way.
Identified in this analysis are three of the major flaws in the current approach to the dangers of indoor tanning facilities, specifically targeting the adolescent population. Highlighting the imperfections has turned up the volume on the call for new intervention. It is clear that the support is present to fight for the health of this population. However, change is needed. Addressing each of these flaws with progressive theories and concepts of social and behavioral science will only lead to success. In this new intervention, the focus will control for the misuse of traditional health belief model’s educational use of statistics and rational decisions, reactance against threatened freedom, as well as the influence of social norms and networks on the developing adolescent. Powerful stories, invoking the core value of freedom, as well as taking a group level approach will combine together to steer the campaign against indoor tanning facilities in a new and more successful direction --ultimately attracting the adolescent population to join the movement against the use of indoor tanning facilities. Using this evaluation, the public health message will find a way to shine brighter in the eyes of the growing adolescents than the “Bermuda Bronze” and “Desert Sun” advertisements for unhealthy behavior.
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