According to the National Cancer Institute, skin cancer is the most common cancer in the United States today, and although rare, diagnosis of melanoma has increased over the last 40 years. This increase has been seen among white women ages 15-39, where there has been a 50% increase in melanoma from 1980 to 2004 (1). A study by Brady in 2012 found an increased risk of melanoma in indoor tanners, especially when using tanning beds before age 35. Both the UVA and UVB rays emitted by lamps in tanning beds are carcinogenic radiation, which strengthens the relationship between indoor tanning beds and skin cancer (2).
An estimated 30 million Americans tan indoors each year (2). According to the Centers for Disease Control and Prevention, white women ages 18-21 comprises the largest customer base for the tanning industry, with approximately 32% tanning indoors in 2010. While skin cancer diagnosis is on the rise, the tanning industry has showed slow, but continued growth over the last three years (4). According to IBISWorld, the annual revenues for the tanning industry are expected to be approximately $5 billion by 2017. Along with the industry’s economic growth, many advocacy organizations have been formed, including: Indoor Tanning Association, Tanning Truth, Ultraviolet Foundation, Vitamin D Council (5).
The Indoor Tanning Association began an ad campaign in 2008, claiming that there were no links between tanning and melanoma. The association supported UV light as a beneficial source of “disease-fighting” vitamin D, and promoting “safe tanning” as healthy (2, 5). The tanning industry targets youth through promotional strategies (i.e. discount deals for multiple tanning sessions) and images of young, “healthy” tan people (5).
In response to the tanning industry and its supporting organizations, the National Council on Skin Cancer Prevention and the Skin Care Foundation fought back with their own campaigns. The National Council on Skin Cancer Prevention created the “Truth About Indoor Tanning” campaign, which provides educational brochures, posters and print advertisements (6). The information provided highlights the statistics and the extensive research done to communicate their message that tanning is “bad for your health”. The Skin Care Foundation launched the, “Go With Your Own Glow” campaign, providing numerous public service announcements in beautifully drawn color cartoon advertisements, in addition to educational videos explaining how you develop skin cancer (7).
Critique Argument #1: Health Belief Model
In an attempt to “fight back”, the National Council on Skin Cancer Prevention and the Skin Care Foundation used the traditional health belief model. Both organizations used statistics and research to drive their campaigns, making education the focus. The basis of the health belief model is that provided information, people weigh the perceived benefits of a behavior against the perceived costs of a behavior and make a rational decision (8). There are six principles to the health belief model: perceived susceptibility, or the beliefs about the risk level; perceived severity, or beliefs about the seriousness of the consequence; perceived benefits, or the beliefs about the action to reduce risk; perceived barriers, or the beliefs about the total costs of taking the action; cues to action (i.e. readiness to change); and self-efficacy, or the confidence to one’s ability to take action and change (8).
The health belief model is driven by the assumption that individuals are rational in their decision-making. The CDC and Skin Care Foundation attempt to educate young women and men about the risks of using indoor tanning bed, with their campaigns, by providing a place to find proven research, facts and statistics. Their campaigns are also based on the assumption that people are rational, but this assumption has proven to fail in public health interventions.
Critique Argument #2: Misuse of the Social Learning Theory
The Social Learning Theory is based on the premise that people do not learn behaviors isolated from society, but when they are observing society (8). The theory contributes the adoption of behaviors to one observing society and imitating the actions of others within that society. Taking into account the behavior and its consequences, the observer will adopt the new behavior if there is value. Social learning is driven by three principles: 1) observational learning is acquired by translating the behavior to an image or symbol before performing the behavior; 2) the modeled behavior is easily learned if its consequences are valued by the observer; 3) if the behavior is highly valued, and serves a purpose for the individual, that individual is more likely to adopt the modeled action (8).
The adolescent population is ideal for using the Social Learning Theory to reduce indoor tanning bed use. Popular perceptions of beauty, color and stereotyping have been found to motivate skin tone alterations, especially amongst vulnerable youth (9). These popular perceptions stem from peers and media placing value on beauty, driving young women and men to change their appearance to reflect social norms of beauty.
The tanning industry has used the Social Learning Theory to attract more clientele, who in turn become models for this behavior. The National Council on Skin Cancer Prevention and the Skin Care Foundation have unsuccessfully applied the Social Learning Theory to their campaigns. Both organizations fail to connect with their young audience, or find a consequence of value to teens and young adults.
Critique Argument #3: Hard Regulations
In response to the issue, California regulated tanning bed, and prohibited use by individuals younger than 18 years of age (2). Twenty-six other states restricted minor’s access to indoor tanning either by requiring parental consent, or setting an age limit for legal access (2). Yet, according to Brady (2012), tanning bed use in the 100 most populous U.S. cities was comprised of 17% girls and 3.2% boys ages 14-17, despite the U.S. Food and Drug Administration restrictions on the use of tanning beds for those younger than 18 years.
Recent studies have identified psychological reactance as a major barrier when regulating behavior (10). Brehm (1966) defines psychological reactance as: the motivational state directed toward the reestablishment of a threatened or eliminated freedom. The psychological reactance theory has four major fundamentals: freedom, threat to freedom, reactance and restoration (12). By regulating indoor tanning, it is perceived as taking away a freedom, and the reaction is to rebel by doing the risky behavior. Regulation alone will not reduce the number of young people using indoor tanning beds, and should be coupled with other interventions in order to be successful.
Proposed Alternative Intervention
With the increase in cases of skin cancer amongst a younger population, there is mounting evidence against the safety of indoor tanning bed use, especially among teens and young adults. Although resources have been used to address the issue, the tanning industry continues to grow and the number of skin cancer cases continues to rise. With an adjustment to the theories driving the current campaigns, more effective and progressive interventions can be put into place.
Public Health organizations should focus on the impact of individual stories, and move their focus away from statistics and research. Compelling stories of young individuals who have been negatively impacted by the use of indoor tanning beds will create more of an impact amongst young indoor tanning bed users. Also, targeting the intervention to youth groups instead of focusing on the individual will have a wider public health impact. Lastly, public health organizations should work with media outlets and social media to create a “new social norm” that identifies natural skin tones as beautiful in an attempt at a long-term intervention.
Defense of Intervention: Stop Using Numbers
The use of the health belief model can be replaced with a more progressive social behavior theory such as the law of small numbers. The law of small numbers focuses on the distorted view of probability that individuals have, and without a perspective on the statistics provided, it is difficult for individuals to relate to the risk (13). To improve the public health interventions, the campaigns should move away from statistics and focus on individual stories. By simplifying the approach to reflect the outcome for one individual, people will be able to relate their behavior with the risk of indoor tanning. Compelling stories can be told with the use of graphics, media, and radio to better demonstrate to the public the consequences of tanning.
Defense of Intervention: There is no “I” in Team
Through social learning theory, it has been found that social norms influence an individual’s decisions making (8). By updating that concept to the social network theory, the focus can be taken off of the individual and focused on small groups, or populations of people. The social network theory is a model that focuses on the specific network of family and friends that an individual associates and identifies with as the intervention target (13). Adolescents are a part of many groups including sports team, drama groups, extracurricular activity groups, friends, and family.
Public health organizations should work with different groups to make an impact on adolescent behavior. Tailoring each public health message to a specific groups interest will be more effective in attracting and communicating to that specific population. A long term goal should be to work with major industries (i.e. the fashion industry), sports stars, and other prominent popular culture figures, to change the current social norm that tan skin is beautiful to the “new beautiful” of natural skin tone.
Defense of Intervention Section: The Softer Side of Regulations
Focus should be taken away from regulations to avoid psychological reactance. When addressing regulations, three techniques should be emphasized to deflect reactance: explicitness, dominance, and reason (10). Public health communications to adolescents should be clear to avoid the perception of manipulation. The messaging should avoid a tone of dominance, and should also provide reasons for the regulation to diminish the idea that regulations are intrusive. Regulations can support the public health interventions, but should not be the public health intervention in order to make an effective impact (10).
Although the National Council on Skin Cancer Prevention, and the Skin Care Foundation have attempted to address the increasing cases of skin cancer amongst teens and young adults, they have failed due to three major flaws: 1) the traditional use of the health belief model; 2) the misuse of the Social Learning Theory; 3) and hard regulations. By addressing each flaw, and updating their methods to more progressive public health interventions, both organizations could vastly improve their impact on reducing skin cancer. An alternative intervention is to replace their research and statistics laden materials with compelling stories of young individuals who have been negatively impacted by indoor tanning beds. Tailoring these stories to specific groups will allow the organizations to reach more people with their messages, and have more of an influence on their behaviors. Lastly, by “down-playing” regulations, individuals will not perceive the intervention as a freedom being taken away, but a support mechanism to help them make healthier choices.
1. National Cancer Institute. Skin Cancer. http://www.cancer.gov/cancertopics/types/skin 27 April 2013.
2. Brady, M. S. (2012). Public health and the tanning bed controversy. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 30(14), 1571–3. doi:10.1200/JCO.2011.40.9359
3. Centers for Disease Control and Prevention. Skin Cancer: Indoor Tanning. http://www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm. 27 April 2013
4. IBISWorld (2012). IBISWorld Industry Report 81219c. Tanning Salons Market Research Report
5. Retrieved April 27, 2013 from IBISWorld database.
6. Sinclair, C., & Makin, J. K. (2013). Implications of Lessons Learned From Tobacco Control for Tanning Bed Reform. Preventing Chronic Disease, 10(8), 1–6. Retrieved from http://dx.doi.org/10.5888/pcd10.120186
7. “Truth About Indoor Tanning.” The National Council on Skin Cancer Prevention. http://www.truthaboutindoortanning.org/education/truth-about-indoor-tanning. 27 April 2013.
8. “Go With Your Own Glow.” The Skin Care Foundation. http://www.SkinCare.org 27 April 2013.
9. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Insitute, 2005, pp9-21 (NIH Publication No. 05-3896)
10. Karelas, G. D. (2011). Community dermatology Social marketing self-esteem : a socio-medical approach to high-risk and skin tone alteration activities. International Journal of Dermatology. 50, 590–592
11. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
12. Rains, Stephen, and Monique M. Turner. (2007). "Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined." Human Communication Research 33: 241-69.
13. Siegel, Michael. “Social Network Theory, Maslow’s Hierarchy of Needs, the Law of Small Numbers, Optimistic Bias, and the Illusion of Control.” SB721. Boston University, Boston. 25 April 2013. Lecture.
14. Ng, A. T., Chang, A. L. S., Cockburn, M., & Peng, D. H. (2012). Report A simple intervention to reinforce awareness of tanning bed use and skin cancer in non-medical skin care professionals in Southern California, 1307–1312.
15. Zhang, M., Qureshi, A. a, Geller, A. C., Frazier, L., Hunter, D. J., & Han, J. (2012). Use of tanning beds and incidence of skin cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 30(14), 1588–93. doi:10.1200/JCO.2011.39.3652
16. Lazovich, D., & Forster, J. (2005). Indoor tanning by adolescents: prevalence, practices and policies. European journal of cancer (Oxford, England : 1990), 41(1), 20–7. doi:10.1016/j.ejca.2004.09.015
17. Lostritto, K., Ferrucci, L. M., Cartmel, B., Leffell, D. J., Molinaro, A. M., Bale, A. E., & Mayne, S. T. (2012). Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates. BMC public health, 12(1), 118. doi:10.1186/1471-2458-12-118
18. Wehner, M. R., Shive, M. L., Chren, M.-M., Han, J., Qureshi, a. a., & Linos, E. (2012). Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. Bmj, 345(oct02 3), e5909–e5909. doi:10.1136/bmj.e5909