Challenging Dogma - Fall 2011

Monday, December 19, 2011

“There’s Nothing Healthy About A Tan”: A Critique of The Dark Side of Tanning Campaign- Emily Olson

Laws instigating the abolishment of smoking indoors have swept across the United States. Will laws initiating prevention of indoor tanning soon follow? At first glance smoking and tanning seem vastly different however, with a closer look, and an emphasis on public health effect, there are many similarities between the two. For example, both have been proven addictive (1), both are known to cause cancer and both target teens and adults alike. Perhaps most interestingly, both continue to wreak havoc on the user’s health due to repetitive use despite the known risks of engaging in the behaviors. Tanning, as an industry, has grown to bring in about $5 billion dollars per year (2). Tanning is a major public health concern. It is estimated that 65% of the world’s melanoma cases are caused by too much ultraviolet exposure (UV) (3-4). Many cases of skin cancer, cataracts, and premature skin aging are caused by artificial UV radiation and are therefore preventable (5). Tanning also has been shown to induce cutaneous and ocular burns, altered immune responses, photosensitivity and DNA mutations in the skin (2). Indoor tanning beds have been increasingly popular, according to the American Journal of Public Health surveys, due to: quickly visible results, being tan is seen as appealing, social and ambiance factors at salons, and avoiding burns (6). According to the Skin Cancer Foundation, almost 30 million people tan indoors in the U.S. each year (7). It is unclear what this statistic is worldwide. It is not just indoor tanning public health practioners have to worry about. Efforts for skin cancer prevention due to any UV exposure, sunlight and artificial UV exposure included have been in the public health eye around the world for more than 25 years (8). Australia and New Zealand lead the world in melanoma incidence (8). Public health interventions for both indoor and outdoor UV exposure are necessary on a global and international scale.
Dozens of studies have examined the long term effects of UV exposure, which populations are at the greatest risk for developing disease after exposure, who tans and why they do it, and effectiveness of policies around restricting the use of indoor tanning beds by those most at risk. Several studies have concluded that the risk for developing melanoma increases by 75% in people that use tanning beds (7, 9, 10). Of the 30 million people that frequent tanning parlors each year in the U.S. 71% are young women between 16-29 years old (7). The World Health Organization (WHO) is spreading the message about the dangers of tanning and recently announced a recommendation to completely ban the use of tanning beds by minors (9). On October 9, 2011 California became the first state to ban indoor tanning by people under the age of 18 (9). To date, only 36 U.S. states employ tanning bed restrictions to minors (9). In July of 2009 the WHO increased the classification of tanning beds to its highest category of “carcinogenic to humans (11).” In Britain, melanoma rates have tripled over the last 3 decades (12). With greater than 2 diagnoses of melanoma cases per day, Britain has implemented the “Sun-bed regulation act” banning minors from the use of indoor tanning beds altogether (12). Complete bans are not the only route governments and public health officials are taking to reduce UV exposure risks. Anti-tanning campaigns, taxation, promotion of sunless self tanning cosmetic products, and other legislation activity around the world are all means of communicating and reducing the risks of UV exposure.
The Intervention:
The Cancer Institute of New South Wales has designed a public health campaign with a series of advertisements geared toward challenging beliefs that a tan looks healthy (13). The campaign title is “The Dark Side of Tanning.” The advertisements use animations to show damage to the skin cells before the burn can be seen and how melanoma works its way through the body (14). The Dark Side of Tanning campaign uses 3 different 30 second television commercials and several print posters to spread the message about melanoma, tanning and what to do to protection from UV exposure (14). Will public health interventions such as “The Dark-side of Tanning” be effective enough to counter the influence of celebrity reality stars like the “Jersey Shore” cast members who glorify this risky behavior? Or will it fall short in reducing the droves of people that willingly put themselves at risk? The Dark Side of Tanning campaign falls short by failing to connect on an emotional level with its targeted audience, too much emphasis on the long term effects of UV exposure and the inappropriate use of body image to portray tanning as unattractive and unhealthy.
Failure to connect on an emotional level:
The Dark Side of Tanning Campaign fails to connect emotionally with the targeted audience. The majority of the campaign commercial message is given during an animation of a melanoma forming, growing and spreading throughout the body. During this message, a male voice narrates the biological process of getting a melanoma and how years later it can spread to other parts of your body. In Dr. Siegel’s October 13, 2011 lecture on advertising theory it was discussed that effective advertisements appeal to human emotion and our core values by using support of visual images, stories and music to make those connections. The Dark Side of Tanning Campaign did in fact use visual images and a story to portray the risks of UV exposure however it failed in the appropriateness of the images and the story told. The 3 campaign commercials start out with a young female at the beach, a young male surfer, and a group of young males playing a sport outdoors. These are all appropriate messengers but the campaign loses viewer focus when the message changes to an animation and narration of how a melanoma develops and gets into the blood stream. Studies have shown that the underlying core values for subjecting oneself to UV exposure is physical attractiveness (6, 15). The melanoma animation doesn’t appeal to the attractiveness core value and although the narrator doesn’t state specific statistics about the risks of melanoma the viewer is not swayed by the evidence it does offer. The outcome as with many public health interventions is impending doom. The change from the young person to an animation and a narrator as the messenger distances the audience from thinking of themselves as someone who is at risk. The narrator tells a story that the viewers don’t want to hear, distancing them even farther from the message. The Dark Side of Tanning Campaign doesn’t appeal emotionally to its targeted viewers and doesn’t address the value of attractiveness therefore weakening the anti-tanning message.
Too much emphasis on the long term effect of tanning:
The Dark Side of Tanning Campaign has mistakenly prepared an intervention that focuses on the long term effects of tanning targeted to young adults and teens who more greatly value the short term product of UV exposure – an attractive tan. The theory of reasoned action by Ajzen and Fishbein suggests that a person’s attitude combined with their perception of how other people would view them if they acted on a certain behavior is predictive of how they will act (16). This theory also posits that each belief and certain people’s influence can have a higher weight and more pull toward a certain behavior (16). For example: A young person may have the belief that tanning causes cancer and also have the belief that having a tan is attractive. This person may also be influenced by people in their social networks to different extents. As a young person, the importance of a friend’s opinion might have more pull on their behavior than say a grandparent. So, as a young person who believes that a tan can cause cancer and that a tan is attractive may subject themselves to UV exposure because it is more important to be attractive with regard to a friend than a grandparent. What is more interesting is that the mother’s role in UV exposure has been brought to light. Studies have shown that young women who are introduced to tanning by their mothers are 4.6 times more likely to become heavy tanners throughout their lives (7). Additionally, the short term value of a tan such as attractiveness has more weight than the long term possibility of cancer. One teen interviewed in a Time Magazine article about teens and tanning said, “It may make my skin wrinkle a little bit earlier but I’m going to look good while I can (17).” This kind of attitude is rampant among teen and young adults (6, 17, 18). In the commercials for this campaign the main focus is developing a melanoma. Meanwhile, the popular influences on teens and young adults are the here and now. Our society’s impressive value on attractiveness crushes any opponent. Famous icon’s and reality stars like the cast members of “Jersey Shore” sport a year round tan (17). Tanning is attractive and sexy. Those are the messages being heard.
Another seemingly erroneous message from the narrator in this campaign is that all of these long term outcomes like melanoma and the spreading of cancer throughout the body happen “before you’ve even started to burn” and the data suggests that tanning before the age of 35 increases your risk of developing melanoma by 75% (12). People who tan are generally aware of the health risks (18, 19). So why is it that they still partake in the behavior? It is not an error of fact but, as Neil Weinstein describes it, “an error in judgment that can be labeled unrealistic optimism (20).” Unrealistic optimism is accompanied by someone’s underestimate of the probability that negative things will happen to them (20). Tanners are aware for the most part that UV exposure can damage the skin and lead to negative health consequences later on in life but they just don’t think it will happen to them. In the Dark Side of Tanning campaign, the facts and statistics about the risk of tanning and melanoma are just not enough to deter people from exposing themselves to UV rays. Cosmetic use and attractiveness of having a tan in the short term outweigh the perceived risk of the future. The Dark Side of Tanning Campaign needs to re-evaluate its focus on the long term risks and find a way to send a message that UV risk takers can’t ignore.
Inappropriate portrayal of a tan as unhealthy/unattractive and underutilization of UV protection methods to model:
Initially, the commercials for the Dark Side of Tanning campaign feature a young woman in a bikini lying on the beach, a group of boys playing Frisbee outdoors, or a shirtless young man watching waves at the beach. These are all adequate messengers to relay a message to teens and young adults. The campaign commercials become less effective as soon as they deviate from these messengers to an animation. This can be explained with the help of the Social Learning Theory and Modeling. The social learning theory was developed by Albert Bandura and explains how “individuals observe other people’s actions and how they come to adopt those patterns of action as their own (21).” The animation of a melanoma developing is not something that viewers can model. We can’t see a melanoma spreading into our brain, liver or lung. What we can see is a tan. And what we see everywhere else, in magazines, on TV, and sported by many celebrities – a nice bronze tan. The sign of skin in trauma is any change in color, including a tan (22). The campaign tells us “tanning is skin cells in trauma” but it fails to show us that it is unattractive. The campaign features young, attractive people, enjoying the outdoors but only briefly. It also shows them intentionally exposing themselves to UV rays without protection. If that portion was enough for viewers to model, the campaign creates the behavior it’s trying to prevent. Only 1 poster out of the 7 media advertisements (3 commercials and 3 print posters) gives suggestions on how to protect oneself from exposure to UV rays. Getting the attention of your viewers and changing behavior should come from someone they can imitate (21). Additionally, portraying messengers that look tan and healthy further instills the belief that it is in fact, healthy. The Dark Side of Tanning campaign needs to revamp the commercials to portray a tan as unhealthy in a way that viewers can adopt a similar belief and provide UV protection methods that can be modeled. Using animation to display the risk isn’t the most effective way to reach the targeted audience.

Proposed intervention:
A superior intervention to reduce UV exposure and promote UV protection compared to the current Dark Side of Tanning campaign includes an emotional connection to the audience through an individual’s story about their experience with skin cancer, emphasis on UV protection, and a societal change of the belief that a tan is attractive. Outlined below are some ways to achieve this and supporting evidence of the growing need for similar interventions world-wide. The outlined suggestions will create a more impactful approach to reducing the risk of indoor and outdoor UV exposure in teens and young adults not only in New South Wales but around the globe.
Connect emotionally through a story that aligns with core values:
One commercial could feature a mother and daughter telling their story of how skin cancer has affected their lives and how they wished they had not started tanning and were more wary and persistent about using UV protection on a regular basis. The mother and daughter could connect to viewers on an emotional level because research has shown that children of women who tan are more likely to go tanning (7) and that young women who first experience tanning with their mother are 4.6 times more likely to become heavy tanners throughout their lives (7). Encouraging mothers to stop tanning and prohibiting their children from tanning might be helpful in reducing the incidence of skin cancer and UV exposure related disease around the world. Also, if the commercial featured this mother and daughter pair using proper sun protection and avoiding indoor tanning going forward, it may be a useful situation for mother daughter viewers to model.
Another commercial opportunity would be having a celebrity talk about the dangers of UV exposure and comment on natural skin as being an attractive quality, and have that celebrity endorse a UV protection product. In addition to this, the campaign might target magazine advertisements and work to replace tanning exposure in magazines with natural skin tone promotions or emphasize methods of UV exposure protection. Magazines, especially those targeting young women, have been shown to cause an increase in the likelihood of attempting to get a tan and having a pro-tan belief system (23). Phasing the tan out of magazines may be a step toward a culture that so wholeheartedly views tan as an attractive quality to one that values natural beauty on a greater scale. A third commercial could feature a young male losing out on an opportunity to be outdoors in the sun with his friends because of a developed photosensitivity or condition due to lack of UV protection. Or a young male leading by example and encouraging his friends to wear UV protection. This would give the campaign balance based on the information that both men and women are affected by skin cancer (18).
Redirect emphasis toward use of UV protection and avoidance of indoor tanning:
The Dark Side of Tanning campaign offers very little opportunity to discuss skin cancer prevention by way of UV protection. Only 1 of the 7 media opportunities poses the options for protection. As mentioned previously, studies have shown that teens and young adults would rather have a tan now to look good than to be diligent in preventing future skin cancer disease. A societal change in viewing a tan as being attractive to one that values natural skin pigments is also necessary. This will not happen overnight. One method for emphasizing UV protection is to get doctors involved in the campaign. A study revealed that for young adults, a physician is the most trusted source of information about tanning (24). Creating interpersonal similarity between the Doctor and the viewers will decrease the reactance to a “don’t tan” message (25). Another way to create massive change is to run a portion of the campaign that gives teens and young adults a chance to actively participate and be a part of an anti-tanning movement. The campaign could create a UV protection pledge that teens and young adults can have signed by a physician. Giving prizes away for recruiting friends might be part of that incentive. This creates commitment and ownership as discussed in Dr. Siegel’s September 22nd lecture. Replacing the existing animation in the Dark Side campaign with messengers that have similarities with teens and young adults would be a better use of the campaign material and improve use of UV protection and decrease rates of indoor tanning bed use. Another method to reduce indoor tanning specifically would be to raise the tax on indoor tanning bed use. On July 1, 2010 as part of the Obama administration’s healthcare plan a 10% tax was placed on each visit, raising the price by $1.70 (26). I think the Dark Side of Tanning campaign should push for an even bigger increase in the coming years. One study suggests that teens between 16-18 years old have the most disposable income out of any other age group (27). These 16-18 year olds are in the group that tans the most. Is $1.70 going to stop them from tanning? Cigarette taxes have been shown to reduce youth smoking by 7% for every 10% tax increase (28). With tanning and cigarette use in the same category “carcinogenic to humans” according to the WHO (11), why not raise the tanning tax? Not to mention the monetary gain to use elsewhere.
Societal change toward a belief that natural skin tone is attractive and much safer than a tan:
In July 2009, the International Agency for Research on Cancer, which is part of the World Health Organization, elevated tanning beds to its highest risk category: carcinogenic to humans (18). The Dark Side of Tanning campaign should redirect advertising efforts to send the message that a natural skin tone is attractive and healthy. This will not happen overnight but the Social Expectations theory by Melvin Defluer posits that if you change the behavior first, the attitudes and social norms will follow (21). An example of this would be smoking in bars across the United States. Laws prohibiting this behavior were enacted and now NOT smoking in bars and restaurants has become the social norm country-wide. On October 9, 2011 California became the first state to ban indoor tanning by people under the age of 18 (9). To date, only 36 U.S. states employ tanning bed restrictions to minors (9). Federal implementation of a tanning ban for those under 18 would be a good way to simply stop the behavior. Social norms that exist now, such as “year round tanning by the high school cheerleading squad” (17) will change. The teens that are so influenced by the “Jersey Shore” cast simply will resort to sunless tanning products or simply change who they model. The evidence is clear that tanning before the age of 35 leads to a 75% increase in the risk of developing melanoma (7). If the federal government follows the WHO recommendation to ban tanning to all minors, there would be far fewer, almost 2.3 million teenagers, at risk for developing a melanoma each year (26). Another part of changing the societal view of a tan as healthy would be to promote celebrities and spokespeople as natural and tan free. Having them endorse UV protection products and openly discuss why a natural skin tone is attractive to them. Justin Bieber is a young celebrity with millions of teen girls as fans. Perhaps he could be the first young celebrity to promote anti-tanning. Diffusion of innovations theory suggests that multiple people can be changed at the same time and only enough individuals to get to the tipping point are needed to create massive change in a population (29). Getting Justin Bieber to be an “early adopter” might just be the way.
Tanning by adolescents is influenced by many factors. These factors range from individual beliefs, psychosocial and environmental factors, cultural factors and even policy regulations (18). The New South Wales Dark Side of Tanning campaign can be more beneficial with the above proposed changes. Implementing prevention campaigns that connect emotionally, send a message aligned with the core values of the audience, and delivered by someone with perceived similarity to the viewers will be more successful in changing behavior. A tan as an attractive quality was instigated by emotion, core-values, and messengers like the “Jersey Shore” cast and other celebrities. Using these same techniques to implement the idea that natural skin tone is attractive and that a tan is unhealthy should be doable. Public health interventions world-wide should take into account social science research to successfully intervene in public health problems. Changes in attitude and social norms may not happen overnight but there are plenty of examples to show that if we target the behavior first, the attitudes and social norms will follow. UV exposure is a public health concern world-wide. Campaigns geared toward an emotional connection with the audience, emphasis on UV protection, and a societal change of the belief that a tan is attractive will be successful in reducing the rates of skin cancer, melanoma and other disease caused by unprotected UV exposure.

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