Introduction
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).
Conclusion
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.
References
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