Tanning behavior among young frequent tanners is related to attitudes and not lack of knowledge about the dangers

OBJECTIVE: To examine the importance of tanning among students in relation to attitudes and knowledge regarding skin cancer prevention. DESIGN: A cross-sectional survey. SETTING: College students at a major Midwestern university METHODS: Students were recruited to complete a self-administered questionnaire that included information on sun-sensitivity, knowledge and tanning attitudes and behaviors. Survey sampling statistical techniques that account for clustering among the 163 students recruited were used. RESULTS: We found a high level of skin cancer prevention knowledge; however knowledge was not related to a reduction in the importance of tanning. In many cases, higher levels of knowledge corresponded to a greater emphasis on the importance of tanning. Sunscreen use was low among this population. Those who placed an importance on tanning more often checked that they believed that "sunless tanning creams are safer than the sun". CONCLUSIONS: This population's belief that they look healthier and feel better with a tan strongly influences the desire to tan. Therefore, future cancer information campaigns or other prevention efforts should directly address the desire to tan by encouraging the use of sunless tanning products as an alternative method of tanning.     

Efficacy of a Media Literacy Intervention for Indoor Tanning Prevention

Indoor tanning leads to melanoma, the fifth most common cancer in the USA. The highest rate of indoor tanning is among young women whose exposure to tanned images in the media is linked to protanning attitudes. This study evaluated the efficacy of a media literacy intervention for reducing young women’s indoor tanning. Intervention participants analyzed the content and functions of the media influencing protanning attitudes and produced counter-messages to help themselves and peers resist harmful media effects. The message production was of two types: digital argument production or digital story production. The control group received assessments only. This three-group randomized design involved 26 sorority chapters and 247 members in five Midwestern states where indoor tanning is prevalent. At 2- and 6-month follow-up assessments, those in the two intervention conditions were less likely to be indoor tanners (p = .033) and reported lower indoor tanning intentions (p = .002) compared to those in the control condition. No difference between the two intervention groups was found for behavior. Although the argument group exhibited slightly weaker indoor tanning intentions than the story group, the difference was not significant. The results provide the first evidence of the efficacy of a media literacy intervention for indoor tanning reduction. Implications for participative engagement interventions are discussed.     

Acculturation,Skin Tone Preferences,and Tanning Behaviours Among Young Adult Asian Australians

Australia has a significant proportion of residents of Asian heritage. Although the incidence of skin cancer is lower in those of Asian heritage than Caucasians, their prognosis is often worse. Sociocultural variables are central to the tanning behaviours of individuals from Western cultures. We examined the role of sociocultural variables in the tanning behaviours (outdoor tanning, indoor/solarium and fake tan use) among Asian Australians. A sample of 399 young adults identifying either as a person of Asian heritage or as Asian Australian participated in an online survey. Our results suggest that Asian Australians are at risk of skin cancer; over 35 % of the sample reported engaging in outdoor tanning and over 10 % in solarium tanning. After controlling for demographic factors and skin cancer knowledge, preferring a darker skin tone and being acculturated to Australia were significantly associated with tanning behaviour. Participants’ low levels of skin cancer knowledge are of concern, and possibilities for improving knowledge levels in this group are considered. Further, we recommended that future research studies investigate sociocultural and appearance-related beliefs associated with tanning behaviours in this population, in order to determine best avenues for intervention.     

Modeling tanning salon behavioral tendencies using appearance motivation, self-monitoring and the theory of planned behavior

The constructs of appearance motivation and self-monitoring were added to the Theory of Planned Behavior in the prediction of tanning salon use in young people. The variables of the Theory of Planned Behavior proved effective at predicting tanning salon behavioral intentions and tendencies. Intentions and perceived behavioral control predicted tanning salon behavioral tendencies, while attitudes, subjective norms and perceived behavioral control predicted tanning salon behavioral intentions. Appearance motivation did not show any direct or interaction effects in the prediction of tanning salon behavioral intentions. It did, however, prove superior to health orientation in the prediction of tanning salon attitudes. Self-monitoring interacted with subjective norms in the prediction of tanning salon intentions, with high self-monitors showing stronger subjective norm-intention relationships than low self-monitors. These results imply that appearance-related interventions could prove efficacious in reducing young people's tanning salon behavioral tendencies. Furthermore, it may be important to consider individual's self-monitoring status when targeting skin cancer prevention information to young people.     

Framing Indoor Tanning Warning Messages to Reduce Skin Cancer Risks Among Young Women: Implications for Research and Policy

Objectives. We investigated the impact of indoor tanning device warnings that communicate the risks associated with indoor tanning (i.e., loss framed) or the benefits of avoiding indoor tanning (i.e., gain framed).Methods. A convenience sample of non-Hispanic White women aged 18 to 30 years who tanned indoors at least once in the past year (n = 682) participated in a within-subjects experiment. Participants completed baseline measures and reported indoor tanning intentions and intentions to quit indoor tanning in response to 5 warning messages in random order. A text-only control warning was based on Food and Drug Administration–required warnings for indoor tanning devices. Experimental warnings included graphic content and were either gain or loss framed.Results. In multivariable analyses, gain-framed warnings did not differ from the control warning on women’s intentions to tan indoors, but they prompted stronger intentions to quit than the control message. Loss-framed warnings significantly reduced intentions to tan indoors and increased intentions to quit indoor tanning compared with control and gain-framed warnings.Conclusions. The public health impact of indoor tanning device warnings can be enhanced by incorporating graphic content and leveraging gain- and loss-framed messaging.Skin cancer is the most common malignancy in the United States, where approximately 3.5 million cases of nonmelanoma skin cancer and 75 000 cases of melanoma are diagnosed each year.1,2 Although most skin cancers are preventable by reducing ultraviolet radiation exposure, their incidence is increasing.3–6 An estimated 9000 deaths occur each year as a result of melanoma,2 and the costs of skin cancer treatment exceed $8 billion annually.7Indoor tanning is major concern for skin cancer prevention.4,8 Approximately 380 000 skin cancer cases are attributable to indoor tanning annually in the United States.9 Recent meta-analyses have indicated that indoor tanning increases lifetime risks of nonmelanoma skin cancer by 29% to 67% and melanoma by approximately 20%.10,11 Among US adults, the prevalence of indoor tanning is highest among young adult, non-Hispanic White women, with nearly 30% tanning each year and 15% tanning 10 or more times each year.12,13 Indoor tanning before age 30 years and tanning more frequently further increase lifetime skin cancer risks,10,11,14,15 and tanning at a young age is associated with early-onset skin cancer.16As in other areas of public health, policies are advocated as part of a comprehensive approach to skin cancer prevention.4,17 Until recently, the US Food and Drug Administration (FDA) regulated indoor tanning devices as class I medical devices presenting minimal risks and largely exempt from premarket controls.18 In part because of advocacy for tighter regulations,17 the FDA recently published a new rule changing indoor tanning devices to class II devices with additional premarket controls and revised labeling requirements. Now, indoor tanning devices are required to display a text-only warning reading “Attention: This sunlamp product should not be used on persons under the age of 18 years.”19 Consumer-facing information for indoor tanning devices is also required to include several contraindication and warning statements.19Unfortunately, the required warnings do not reflect evidence for skin cancer prevention messaging20,21 and are inconsistent with warnings for other FDA-regulated products with associated health risks, such as tobacco.22 The FDA’s strategic plan for regulatory science emphasizes designing evidence-based public health messages to empower consumers to make healthy decisions about regulated products.23 The public health impact of indoor tanning device warnings could be enhanced through additional research to determine how to best promote preventive behavior. Under federal rulemaking procedures, the FDA could issue new labeling requirements based on the available evidence, and this evidence could also inform state and local policies on indoor tanning. Unlike warnings for tobacco,24 little published research is available on how to design indoor tanning warnings to enhance their public health impact.According to prospect theory, framing health messages in terms of the costs of engaging in risky behavior (i.e., loss framed) or the benefits of avoiding risky behavior (i.e., gain framed) differentially affects behavioral outcomes.25,26 The message-framing concept draws from fundamental tenets of behavioral economics and communication science that postulate that health messages can be crafted around gains or losses to shape perceptions and motivate behavior.25 Although recent reviews have indicated that loss-framed skin cancer prevention messages can promote behavior change,20,21 2 meta-analyses drew different conclusions regarding gain- and loss-framed skin cancer prevention messages,27,28 and no study has tested message-framing effects for indoor tanning warnings. Research has also consistently demonstrated that graphic warnings incorporating imagery to depict the health risks of tobacco use are more effective for promoting behavior change than text-only warnings because they more effectively attract attention, evoke an emotional response, and affect perceived risks and attitudes toward tobacco use.24,29–32 Although the available evidence on skin cancer prevention messages has suggested that graphic messages can promote preventive behaviors,20,21 no study has investigated the effects of graphic content for indoor tanning warnings.Given the theoretical support and empirical evidence indicating that gain- and loss-framed messages incorporating graphic imagery may be important to prevent and reduce indoor tanning, we examined the impact of these message features on indoor tanning intentions and intentions to quit indoor tanning in a convenience sample of young adult women. We compared gain- and loss-framed warnings with graphic imagery with a text-only warning, such as those required by the FDA. We focused on young adult women because of the high prevalence of indoor tanning in this population and evidence that indoor tanning early in life further increases skin cancer risks.10,11 This makes young adult women a priority population for public health skin cancer prevention efforts. We hypothesized that graphic, loss-framed messages conveying the health risks associated with indoor tanning would produce the greatest impact.     

Efficacy and Mediators of a Web-Based Media Literacy Intervention for Indoor Tanning Prevention

Extant media literacy interventions have been delivered in person, limiting their potential for large scale reach, implementation, and dissemination. Although emerging evidence suggests the interventions can impact behavior, the theoretical mediators that can explain the efficacy remain unknown. This study investigated the efficacy and mediators of a web-based media literacy intervention for reducing indoor tanning behavior among young women. Participants were randomly assigned to one of three conditions: a media literacy intervention with counter argument production, a media literacy intervention with counter story production, or an assessment-only control condition. The outcomes of indoor tanning behavior and intention were evaluated with 3- and 6-month follow-ups. Results indicated significant effects of the web-based intervention on reducing indoor tanning behavior at the follow-ups. Changes in perceived media realism completely mediated the intervention effects on behavior. Perceived media realism, positive and negative outcome expectancies, and collective efficacy partially mediated intervention effects on intention. This study demonstrates the efficacy of a web-based media literacy intervention and the theoretical mechanisms underlying the efficacy. It indicates that by altering perceived media realism, outcome expectancies, and collective efficacy, web-based media literacy interventions could generate behavioral effects.     

Agenda-Setting Effects of Sun-Related News Coverage on Public Attitudes and Beliefs About Tanning and Skin Cancer

The topics and framing of news stories relevant to skin cancer prevention have shifted over time. This study examined agenda-setting effects of such news stories on public attitudes and beliefs about tanning and skin cancer. Content analysis data on 516 articles published in two major daily newspapers in Melbourne, Australia, from 1994 to 2007 were combined with circulation data to generate indices of potential news exposure. Associations between these indices and cross-sectional telephone survey data from the same period on 6,244 adults’ tanning attitudes and perceived susceptibility to skin cancer were examined using logistic regression models, accounting for the temporal precedence of news content. Pro-sun protection stories on attitudes and behavior were associated with older adults not thinking a tan looks healthy. Pro-sun protection stories on solaria were associated with less preference for a deep tan among young adults who like to suntan. Stories on vitamin D that were unsupportive of or ambiguous about sun protection were associated with a number of pro-tan attitudes among younger adults. Results indicate news coverage during 1994–2007 served an important agenda-setting role in explaining the public's attitudes and beliefs about tanning and skin cancer. Vitamin D stories appeared most influential, particularly among young adults.     

Messages influencing college women's tanning bed use: statistical versus narrative evidence format and a self-assessment to increase perceived susceptibility

Understanding the effect of messages and other influences on health decision-making has the potential to decrease risky behavior such as tanning bed use. This study explores the effect of type of evidence, self-assessments of risk for skin cancer, and personality factors on intention to use and use of tanning beds among Caucasian female college students. Specifically, it targeted the perceived susceptibility component of the Health Belief Model and its impact on intention to tan as well as changes in actual tanning behavior. College students (N=141) in the southeast United States read randomly assigned messages and self-assessments, filled out surveys, and were later contacted for a follow-up telephone survey. The statistical message was rated higher on information value and also resulted in decreased intention to tan, decreased tanning behavior, and increased perceived susceptibility to skin cancer. The narrative message, in contrast, increased perceptions of realism and also worked to decrease intentions to tan. Additionally, the self-assessment manipulation resulted in increased susceptibility and decreased intention to tan and post tanning behavior. Personality factors explained small portions of variance. Key limitations and directions for future research are also addressed.     

The Effects of Gain-, Loss-, and Balanced-Framed Messages for Preventing Indoor Tanning among Young Adult Women

Indoor tanning (IT) increases the risks of skin cancer, but evidence on how to design health education messaging targeting IT among young adult women remains limited. This study investigated the effects of theory-guided gain-, loss-, and balanced-framed IT prevention messages. Young adult women ages 18–30 who indoor tan (n = 552, mean age = 24.9 years [standard deviation = 3.1]) were recruited online, completed pre-exposure measures, and were randomized to view a gain-, loss-, or balanced-framed message. Participants completed post-exposure measures of message response (emotional response, message receptivity), IT risk (perceived severity, susceptibility), and efficacy (self-efficacy, perceived benefits of avoiding IT) beliefs, and IT behavioral intentions. Loss- and balanced-framed messages promoted significantly greater emotional response and message receptivity and lower IT behavioral intentions than gain-framed messages. The effects of loss- and balanced-framed messages on IT behavioral intentions were mediated by greater emotional response and message receptivity compared with the gain-framed message. These results can inform the development of public health education campaigns to prevent and reduce IT among young adult women. Future research can build from these findings by investigating additional message themes and tailoring strategies to maximize their effects, examining the effects of framed messages prospectively, and investigating ways to enhance message receptivity, such as through novel message delivery channels (e.g., mobile devices).     

Opportunities for Skin Cancer Prevention Education among Individuals Attending a Community Skin Cancer Screening in a High-Risk Catchment Area

Despite the highly preventable nature of skin cancer, it remains the most commonly diagnosed form of cancer in the United States. Recommendations for a complete skin cancer prevention regimen include engaging in photoprotection (e.g., sunscreen use), avoiding skin cancer risk behaviors (e.g., tanning), and receiving total body skin exams from a health care provider. The current study examined reported engagement in these behaviors among participants attending a community skin cancer screening (N?=?319) in a high-risk catchment area to assess the need for increased health education on skin cancer prevention. Participants’ responses indicate a history of suboptimal avoidance of skin cancer risk behaviors. Over half of participants (52%) reported four or more blistering sunburns before age 20, and 46% reported indoor tanning at least one during their lifetime. There is a need among this population for education regarding a complete skin cancer prevention regimen, which could improve adherence to photoprotection and avoidance of skin cancer risk behaviors, thereby reducing morbidity and mortality due to skin cancer.     

Use of indoor tanning devices by adults--United States, 2010

Indoor tanning is associated with an increased risk for skin cancer, the most common form of cancer in the United States. The World Health Organization considers ultraviolet (UV) tanning devices to be a cause of cancer in humans. Exposure to UV radiation, either from sunlight or indoor tanning devices, is the most important, avoidable known risk factor for skin cancer. Annually, skin cancer costs an estimated $1.7 billion to treat and results in $3.8 billion in lost productivity. Reducing the proportions of adolescents and adults who report using artificial sources of UV light for tanning are Healthy People 2020 objectives. Current state-level policies to restrict indoor tanning are directed at youths aged <18 years. To examine the proportion of the adult U.S. population reporting indoor tanning in the past 12 months, CDC and the National Cancer Institute analyzed data from the 2010 National Health Interview Survey (NHIS). Overall, the age-adjusted proportion of adults reporting indoor tanning in the past 12 months was 5.6%, with higher rates among whites, women, and adults aged 18-25 years. Nationwide, the highest rates of indoor tanning were among white women aged 18-21 years (31.8%) and 22-25 years (29.6%). Among white adults who reported indoor tanning, 57.7% of women and 40.0% of men reported indoor tanning ≥10 times in the past 12 months. Continued public health efforts are needed to identify and implement effective strategies for reducing indoor tanning among adults in the United States, particularly among whites, women, and adults aged 18-25 years.     

Tanning beds: effect on skin cancer risk unclear

Recent estimations show that over 25% of the Dutch population make regular use of tanning equipment. This use is still increasing, in spite of improving knowledge on the potential hazards of ultraviolet radiation. There are different motivations to use the tanning equipment. Younger women are largely represented in the group of sunbed users. Recent studies have brought the testimony that intermittent sun exposure (e.g. during holidays) is an important risk factor for skin cancer (notably basal cell carcinoma and melanoma). The investigations have not provided convincing evidence on the relation between the use of artificial devices and the development of skin cancer. This is partly caused by the fact that sunbed users are generally very motivated to get a tan. It is therefore difficult to distinguish between the effect of natural sun and of artificial UV radiation. In the Netherlands, the analyses of scientific data provide the basis for recommendations concerning sun exposure and use of sunbeds. There is an effort to provide the general public with qualified, professional information on the responsible way of tanning.     

Skin Cancer Risk Behaviors Among US Men: The Role of Sexual Orientation

The current study assessed skin cancer risk behaviors by sexual orientation in a nationally representative prospective sample of US men (n = 1767), sampled at ages 16 and 29 years. At age 16 years, sexual minority men were 3.9 times as likely as heterosexual men to indoor tan. Participants did not significantly differ in the use of sunscreen or the frequency of outdoor tanning. Thus, sexual minority men might be an at-risk group for developing skin cancers because of their indoor tanning behaviors.Skin cancers (i.e., melanoma, basal cell, and squamous cell carcinomas) disproportionally affect men in the United States. In 2013, the American Cancer Society estimated that men would have a 40% increased risk of being diagnosed with and have nearly a 100% increased risk of dying from skin cancers, compared with women.1 Despite awareness of these gender differences, to date, there have been limited investigations of demographic characteristic differences among men regarding skin cancer risk behaviors.Sexual minority (i.e., gay and bisexual) men may represent a group that is at increased risk for skin cancer. Behaviors such as indoor and outdoor tanning and use of sunscreen are strongly related to appearance concerns,2 and sexual minority men report elevated body dissatisfaction compared with heterosexual men.3 Our aim in the present study was to test, in a US nationally representative sample of men, differences in skin cancer risk behaviors as a function of sexual orientation. We hypothesized that sexual minority men would report greater skin cancer risk behaviors compared with heterosexual men.     

Multiple skin cancer risk behaviors in the U.S. population

BACKGROUND: The incidence of all types of skin cancer has increased over the past 3 decades in the United States. Increased skin cancer risk is associated with exposure to ultraviolet radiation. This study examined the age-stratified prevalence and correlates of multiple skin cancer risk behaviors (infrequent use of sun-protective clothing, staying in the sun when outside on a sunny day, infrequent use of sunscreen, indoor tanning, and receiving a sunburn) among U.S. adults. METHODS: 28,235 adults participating in the 2005 National Health Interview Survey (NHIS) answered questions regarding sun-protection behaviors, indoor tanning in the past year, and sunburns in the past year. Examined correlates included geographic location, demographics, healthcare access, BMI, physical activity, smoking, alcohol use, melanoma family history, perceived cancer risk, skin sensitivity to the sun, and receipt of a total skin exam. RESULTS: The most commonly reported skin cancer risk behaviors were infrequent use of sun-protective clothing and infrequent use of sunscreen. The majority of individuals reported multiple skin cancer risk behaviors. Although significant correlates varied according to age, individuals reporting more risk behaviors were more likely younger, residing in the Midwest, male, non-Hispanic white, less-educated, smokers, risky drinkers, and had skin that was less sun-sensitive. CONCLUSIONS: The majority of the U.S. population engage in multiple skin cancer risk behaviors. A comprehensive approach to skin cancer prevention requires attention to multiple skin cancer risk behaviors that are common in the U.S. population.     

How Do Perceived Descriptive Norms Influence Indoor Tanning Intentions? An Application of the Theory of Normative Social Behavior

Indoor tanning bed use is highly influenced by perceived norms about a tanned appearance. The theory of normative social behavior (TNSB) details the many ways in which norms can impact intentions and behavior, but has never been assessed in the context of indoor tanning. Considering this, we conducted a survey among female university students (N = 274) to determine the extent to which the TNSB predicted intentions to use indoor tanning beds. Overall, the path model predicted about 46% of the variance in intentions, and the majority of significant indirect effects were witnessed through the outcome expectation variables included in the TNSB, suggesting that these may be the most salient mechanisms—as predicted by the TNSB—through which norms can impact tanning intentions. In light of these results, theoretical and practical implications are discussed, and specific recommendations are given to extend the predictive utility of the TNSB in the context of indoor tanning.     

State Indoor Tanning Laws and Adolescent Indoor Tanning

Objectives. Recently, several state indoor tanning laws, including age restrictions, were promulgated to reduce indoor tanning among minors. We examined the effects of these laws on adolescent indoor tanning.Methods. We used nationally representative data from the 2009 and 2011 national Youth Risk Behavior Surveys (n = 31 835). Using multivariable logistic regression, we examined the association between state indoor tanning laws and indoor tanning among US high school students.Results. Female students in states with indoor tanning laws were less likely to engage in indoor tanning than those in states without any laws. We observed a stronger association among female students in states with systems access, parental permission, and age restriction laws than among those in states without any laws. We found no significant association among female students in states with only systems access and parental permission laws or among male students.Conclusions. Indoor tanning laws, particularly those including age restrictions, may be effective in reducing indoor tanning among female high school students, for whom rates are the highest. Such reductions have the potential to reduce the health and economic burden of skin cancer.Skin cancer is the most common cancer in the United States. Approximately 3.5 million cases of nonmelanoma skin cancers are treated annually, while more than 60 000 melanomas are diagnosed annually.1,2 In addition, skin cancer poses a substantial economic burden, with annual direct medical costs of treatment estimated at $1.7 billion in 2004.3 During the past decade, while most cancers decreased, melanoma increased, especially among young adult women.4 Indoor tanning is thought to be partially responsible for this increase.4–6 Indoor tanning before age 35 years increases the risk of melanoma by 59%,5,7 and indoor tanning before age 25 years increases the risk of basal cell carcinoma by 40% and squamous cell carcinoma by 102%.8 Despite these known health risks, indoor tanning is common among adolescents—6.2% of male high school students and 20.9% of female high school students engaged in indoor tanning in 2011.9In recent years, several states have enacted laws restricting youth access to indoor tanning and laws aimed at reducing consumers’ risk, including facility and operator responsibilities, safety and equipment standards, enforcement authority, and penalties.10 Previous studies that were primarily focused on youth access laws found poor compliance rates among tanning facilities for parental permission laws.11–13 In addition, such laws were ineffective in reducing indoor tanning among adolescents.14,15 Since these earlier studies were conducted, the number of states implementing youth access laws, particularly age restrictions, has increased substantially.16 Although some evidence has suggested that age restrictions may reduce access to indoor tanning among minors,17 no national or international studies have examined the effects these laws have on adolescent indoor tanning behavior. We examined the association between state indoor tanning laws, including age restrictions, and indoor tanning among high school students.     

A preliminary investigation of the predictors of tanning dependence

Objectives: To investigate possible predictors of tanning dependence including demographic variables, exposure and protective behaviors, and other health-related behaviors. Methods: This study consisted of an online survey of 400 students and other volunteers from a university community. Results: Twenty-seven percent of the sample was classified as tanning dependent. Tanning dependence was predicted by ethnicity and skin type, indoor and outdoor tanning and burning, and lower skin protective behaviors, as well as smoking and body mass index. Conclusions: Young adults are at risk for tanning dependence, which can be predicted by specific demographic and behavioral variables.     

Examining HPV Threat-to-Efficacy Ratios in the Extended Parallel Process Model

The Extended Parallel Process Model (EPPM) posits that an effective fear appeal includes both threat and efficacy components; however, research has not addressed whether there is an optimal threat-to-efficacy ratio. It is possible that varying levels of threat and efficacy in a persuasive message could yield different effects on attitudes, beliefs, and behaviors. In a laboratory experiment, women (n?=?442) were exposed to human papilloma virus (HPV) prevention messages containing one of six threat-to-efficacy ratios and one of two message frames (messages emphasizing the connection between HPV and cervical cancer or HPV and genital warts). Multiple mediation analysis revealed that a 1-to-1 ratio of threat to efficacy was most effective at increasing prevention intentions, primarily because it caused more fear and risk susceptibility than other message ratios. Response efficacy significantly mediated the relationship between message framing and intentions, such that participants exposed to a genital warts message reported significantly higher intentions, and this association can be explained in part through response efficacy. Implications for future theoretical research as well as campaigns and intervention research are discussed.