Saturday, May 8, 2010

Crash and Burn—A Critique of Anti-Tanning Public Service Announcements to Provide an Effective Melanoma Prevention Message-Susan Yanik

The haunting noises of clocks ticking, faint breathing and the sound of sizzling skin are some of the most provocative and memorable features of The Melanoma Foundation of New England’s video public service announcement titled “Tanning Is out, Your Skin Is In.” The ad features a young, white woman entering an indoor UV tanning bed lit like a carnival ride, and shows her skin beading with sweat, and the choppy shots of her body and the exterior of the tanning bed, which evokes a casket. Meanwhile, ominous statistics are flashed, stating the drastically increased risk of melanoma that results from indoor tanning, and the severity and growing threat of melanoma in teens and adults ages 15-29. The ad closes with the message “There is No Safe Tan—Tanning is Out, Your Skin Is In” [1]. If the purpose of this message was to nauseate and frighten viewers, this ad should be highly effective. However, it is clear that the Melanoma Foundation would want a multi-faceted advertisement, one that both discourages tanning and other risky behaviors, yet positively encourages safe sun practice, specifically sun-protection and early detection of melanoma. That said, the anti-tanning public service announcement by the Melanoma Foundation of New England (MFNE) and similar ones produced by the American Academy of Dermatology (AAD) [2] are flawed for a variety of reasons: the reliance on the Health Belief Model, a failure to target men and people of color, and it’s inability to deliver a positive message and practical solutions to combat the problem of melanoma.
To understand the need for effective sun protection messages, it is important to realize the dangers of early adulthood sun exposure and melanoma mortality. Melanoma is the most deadly form of skin cancer, and the most common form of cancer for Americans between the ages of 25-29 [3]. Melanoma is often fatal if allowed to spread, and approximately one American dies from melanoma every hour. However, if the melanoma is detected early, or before it spreads to the lymph nodes, the 5 year survival rate is about 99% [4]. Statistics from “Surveillance Epidemiology and End Results” (SEER) study from the National Cancer Institute state that the age adjusted incidence rate for melanoma was 20.1 cases per 100,000 men and women per year between 2003-2007 [5]. White men and women lead the annual incidence rates among the racial groups studied, with 29.7 per 100,000 men and 19.1 per 100,000 women, though blacks show about 1.0 incidence per 100,000 people, and incidences of melanoma among American Indians and Hispanics are about 3.9 per 100,000 people and 4.6 per 100,000 people, respectively. In addition, the trends in the rates of melanoma appear to be significantly increasing from 1975-2007 in men and women [6]. Studies have shown and overall worldwide increase in melanoma incidence, particularly in Australia and Western Europe, and often in the older male population in most countries [7]. Indeed, UV radiation is seen as a cause in at least 65% of melanoma cases [8] though other risk factors such as family history of melanoma, atypical mole syndrome (AMS) [9] and epigenetic factors, such as change in DNA methylation state [10] are proposed have a role in melanoma development.

Critique I: Use of the Health Belief Model

The anti-tanning public service announcements both serve to make viewers feel alarmed by the statistics presented and more aware of their vulnerability to melanoma. This design is part of the Heath Belief Model (HBM), used to explain and promote healthy, disease preventative behavior. The HBM was formulated in the 1950s by researchers from the U.S. Public Health Service, designed by breaking down health seeking behavior in four basic factors: 1) Perceived Susceptibility 2) Perceived Severity 3) Perceived Benefits of Taking an Action 4) Perceived barriers to taking an action [11]. The HBM has been in use since its creation, though over time various factors have been added to the model, such as “cues to action” (reformulated as the Social Learning Theory), and self-efficacy. The HBM was designed to confront the positive and negative forces in a person’s life, sway behaviors by encouraging steps away from negative decisions through emphasizing the perceived susceptibilities and seriousness of developing a condition in addition to the benefits of taking an action, while weighing the barriers to the action [12]. This model has been shown to be a relatively good predictor of individual level behaviors guided by an objective logical thought process [13].

While the model has been an effective tool in modeling behavior, its framework and attributes are not immune from criticism. The faults found in the HBM include its design as an individually-centered model, the assumption that health is a highly valued outcome among most people, its inability to account for spontaneous or irrational behaviors and reliance on likelihood and severity of beliefs as the only predictors of motivation [14]. Many studies have shown disadvantage of focusing on the individual, rather than the environment in model design, ignoring the social context and cultural norms of the society in which one functions [13, 15].Additionally, the HBM states that knowledge is considered to be gained only when an individual’s behavior has changed, which would fail to take into account the necessity for affective and cognitive portions of the learning process [16].
When the critiques of Health Belief Model are extended to the anti-tanning advertisements, many of the same problems still exist. The ads very effectively target two of the main HBM tenets, perceived susceptibility and severity, by describing the high incidence levels of deadly melanoma in the targeted age group. In the context of the model design, these are effective forces in pushing individuals away from a negative behavior towards a positive one. The trouble is, the positive benefits of not using a tanning bed are not explicitly stated. In addition, the perceived barriers to the behavior are also not mentioned in the public service announcements. While perhaps less applicable in a cessation message, barriers have been shown to be the most strongly associated variable in the model for sun protective practices, as shown in a study applying the HBM to relatives of melanoma patients [17]. Perhaps a more appropriate use of the HBM would be in a behavior adoption process, such as adoption of sun protective behaviors, whereby barriers to prevention and detection can be addressed.
Further addressing HBM use, an individually based anti-tanning model will appear less effective in a culture that praises tan skin, as shown by studies highlighting the importance of context and society on health behaviors [18]. Our current culture appears to place a high value on the appearance of tan skin, as evidenced by the approximately one million people visit who visit tanning beds on a given day [19], and about 28 million Americans have ever visited a tanning bed [20]. Sunbathing has been shown to be much more prevalent in adolescents whose social group, parents or friends also tan [21], a finding which may be harnessed in sunscreen adoption interventions.
Finally, the HBM is unable to account for spontaneous and irrational behaviors, including a spontaneous or infrequent desire to tan, which still may result in increased melanoma risk. People who tan for a special occasion or before going on vacation may not believe they are susceptible to an increased risk of melanoma, when a history of repeat (though potentially infrequent) sunburns and likeliness to burn is associated with developing melanoma as an adult [22, 23]. An example of irrational behavior is the finding that the majority of individuals who tan are those who have skin classified as “likely to burn”, but cite an appearance improvement as an impetus to tan [24].

Critique II: Failure to Target Men and Minorities

A meta-analysis examining 15 indoor tanning behavior studies in Europe and America found that girls are two to three times more likely to visit an indoor tanning bed than boys of the same age, and gender is a commonly controlled variable in studies of tanning bed users [21, 25]. A study reviewing melanoma epidemiology and trends found that in countries with high incidences of cutaneous melanoma, such as the US and Australia, the ratio of men and women developing melanoma is about equal, while in countries of low melanoma incidence, the rates of women diagnosed are higher than men [26]. Furthermore, the probability of men developing melanoma is 1:58, whereas the probability for women is 1:82, and men are approximately twice as likely to be diagnosed with melanoma between the ages of 60-79 [27]. A five year survival rate, calculated based upon relative survival in comparison to the general population showed a higher survival in women than men [6]. While melanoma development in men, especially in white men, is likely due to UV exposure, campaigns targeting UV exposure pathways other than tanning beds are needed to increase melanoma prevention and detection.
As previously stated, the melanoma incidence rates are higher for white men and women than Hispanic and Black minorities, but compared to Non-Hispanic whites, melanomas among minority populations are more likely to be detected at a later stage, and more metastatic, resulting in overall poorer health outcomes and decreased survival time [28]. Furthermore, the annual rate of increase among Hispanics in the US is 2.9%, nearly the same as the 3.0% increase seen in white non-Hispanics [6]. Many specific risk factors in non-white populations are still unknown, but research currently suggests that sun exposure may have less to do with melanoma in darker-skinned populations, due to the protective effects of increased skin melanin content, which is able to more efficiently scatter energy than lighter skin [29]. Additionally, high variation in DNA repair mechanisms within racial groups suggests the heterogeneous ability to control cellular mutations even within one race [30], while in vitro studies of melanocytes from blacks and whites showed that cellular melanin content can provide only partial protection from UV radiation [31]. Due to the different anatomical sites where primary melanoma tumors are found between minority populations and whites, in addition to potentially different exposure pathways to disease, melanoma has been seen as a heterogeneous cancer with potentially many underlying causes, one of which is UV radiation [29, 32].
However, as more studies are performed, understanding of behavioral and epidemiological risk factors for melanoma continues to increase. For example, it has been shown that African American men are four times as likely to develop melanoma than African American women [33], strikingly different than findings in whites. Additionally, a study of Hispanic high school students reported a perceived risk significantly lower than their white counterparts, and lower adherence to sun-protective behaviors [34], and Hispanics and blacks adults report full skin cancer screens less likely than non-Hispanic whites [35]. Together these findings suggest that the perceived risk for melanoma for Hispanics and blacks is lower among members in minority communities and health care providers.
Thus, because men and minorities are less likely to visit tanning beds, and because a large part of melanomas in minorities are found on areas of low sun-exposure, public service announcements focusing solely on the indoor tanning industry are flawed by missing a groups of people with increasing incidence rates of melanoma. By explicitly targeting the very specific demographic of tanning bed users (young, Caucasian women), the message may be lost on men and minorities, who arguably need the message as much as the white women. This failure to provide culturally and gender-specific messages about melanoma risk, prevention and detection is a major deficit in the anti-tanning melanoma prevention campaign.

Critique III: Failure to Promote Adoption of Preventative Behaviors and Melanoma Detection

In spite of previous sunscreen campaigns, and anti-tanning messages such the ones produced by the MFNE and AAD, one study showed that the rates of sunscreen usage among adolescents have only increased about 2% between the years of 1998-2004 [36], while melanoma incidences are increasing about 3% annually [6]. As previously discussed, the anti-tanning PSAs provide statistics to increase perceived risk and severity for their audience. Thus according to the message, the benefit to indoor tanning cessation is the potential to minimize mortality risk. While clearly important, it fails to remind viewers that there are other methods to decrease melanoma susceptibility, such use of sun screen and other sun protective practices, which should be utilized by all, not just indoor tanners.
Research shows that consistent sunscreen usage should be emphasized across genders and age groups. A study comparing daily sunscreen use with actual UV readings taken from personal monitoring devices found that women significantly applied sunscreen more frequently and on more high-risk days than males, while no difference was found in overall UV exposure between the genders [37]. The study also found that sunscreen was mainly used on days of high UV exposure, which is beneficial, but also implies that daily sunscreen use is may not be a common practice for many people. Sunscreen has been deemed an ideal sun protection measure, yet often times fail to protect against sunburn due to poor application practices [38], or sunscreen use before intentional suntan seeking behavior [39]. An effective melanoma prevention message ought to include encouragement not only for sun protective behaviors, such as use of protective clothing and limiting daytime sun exposure, but also include information on proper use of sunscreen.
Finally, the anti-tanning campaigns lack emphasis on early melanoma tumor detection and treatment, which are ultimately the most effective means in increasing survival time [40]. The ABCD mnemonic, a public health campaign developed in 1985 [41] is an effective tool used by both physicians and lay people in early detection of potential melanoma tumors and has since been augmented by the addition of “E” for evolving lesions [42]. However, physician performed or self performed skin evaluations are necessary to detect the tumors, though the exams are often unperformed by primary care physicians, due to lack of time or confidence in tumor diagnosis [43]. Approximately 24% of Caucasian adults in one study [44] performed a yearly self-skin evaluation, though this number is a far cry from ideal for a free, simple and life saving measure. A public service announcement attempting to decrease melanoma occurrence and increase survival time after diagnosis should surely mention sun protective behaviors and early detection practices, and the anti-tanning PSAs fail to do so.

Overview of Proposed Intervention: Advertising Theory

Tanning subgroups have been previously classified on the basis risk of developing melanoma after UV exposure, to better suit potential interventions [45]. For the purpose of this proposed intervention, three main groups at risk of melanoma will be targeted: the intentional tanners, the unintentionally exposed and the misinformed. The intervention will be guided by the principles used in the advertising theory. This model has been successfully used by marketers for decades, and is fit to replace the Health Behavior Model as a fresh way to appeal to the targeted groups, account for spontaneous decision making and effectively create a brand around healthy, protected skin. The foundations of the advertising theory lie in promises made to consumers, and assurance that the promises will be supported by the advertiser [46], or in this case, the melanoma prevention groups. The intervention builds upon the aforementioned flaws in the previous anti-tanning messages, and rather than addressing them in an outlined fashion, the intervention describes the new approaches needed for three distinct subgroups of the target population, and how this model enhances the former. The concept behind the proposed intervention lies on an overarching promise of healthy, beautiful and melanoma-free skin, and a disease free life. Instead creating a doom and gloom statistic-laden portrait of the tanning industry, the purpose of this intervention is to prevent melanoma by careful sun protection, and a behavioral shift away from tanning based on images of pure and natural beauty.

Intervention 1: Targeting Intentional Tanners

To maintain consistency with the originally anti-tanning messages, it is appropriate to focus on the same subgroup of people—those who intentionally tan and practice high-risk sun behaviors. Approximately 70% of the target audience would be Caucasian women in the 16-29 year old age group [47]. The intention is to brand the product of healthy, beautiful skin to these young girls, replacing the previous model of overly tanned skin. In public health branding, the relationship between consumer and public health sector is strongly valued [48], and in the proposed PSAs, the relationship between intentional tanner and the melanoma foundation should be more like one of mother-daughter or sister-sister, rather than a cold reading of didactic knowledge. The campaigns, which would be composed of a series of television and magazine ads would emphasize the true beauty that comes from natural skin. In this way, the campaign would also resemble the successful Green Movement in praising the natural, wholesome and peaceful [49]. These advertisements should feature photos and sketches of women of all skin tones, and relay the message that the most beautiful skin is healthy. The Skin Cancer Foundation provides a perfect example of a positive message with their “Go With Your Own Glow” campaign [50], using appealing images and endorsements by popular celebrities. A motto for this portion of the proposed intervention could read “Safe Skin is Sexy Skin”, in an effort to not only encourage protective behaviors, but also to attract the target audience to the ideals of beauty and appearance. Hopefully, with time and with enough social encouragement, the image of natural skin will be sold on the intentional tanners, and tanning bed use will become obsolete, especially in light of the added restrictions on tanning beds as recommended by the US FDA in March, 2010 [51]. This proposed intervention using advertising theory should be an improvement on the previous public service announcements constructed around the Health Belief Model through targeting of positive core values and lack of fear tactics in supporting the melanoma prevention message.

Intervention II: Targeting the Unintentionally Exposed

Selling sun safety to the general population, especially those who unknowingly experience UV radiation would be a huge step for the melanoma prevention program. Ideally, it would be advantageous to gather opinions from several groups at risk for melanoma, including adolescent males, adult males who appear to have the most rapidly increasing melanoma rates [6], and those who spend a large portion of their day outdoors. Ideally, these groups would provide feedback and elucidate the problems associated with sun protection and detection. The main intervention goal is to show sun protection as a current issue to maintain healthy skin in the present, rather than warn against the probability of future melanoma, which has reported as a barrier to motivation [45]. Not having feedback, it can be assumed that a main problem in sunscreen use arises from failure to apply adequate amount over a long enough time [38]. To counter the problem of sunscreen access, this section of the intervention would promote use of sunscreen in an affordable, easy to use and appealing vehicle. One possible idea would be to work with sunscreen manufacturers and produce sunscreen towelettes in age- and gender appropriate fragrances that can be purchased in a vending machine system at public beaches, outdoor concerts and festivals, where exposure to sun may be high. Also, to incorporate the core values of sexuality and attractiveness, the sunscreen adoption campaign could be advertised with pictures of adolescents applying sun screen to themselves and to others in a playful and engaging fashion. While this may not be the approach supported by family morality groups, it should definitely attract the attention of adolescent viewers. To target an older subset of the population, sunscreen use should still be emphasized in addition to advertisements showing fashionable sun protective clothing. It would be ideal for the melanoma foundation to partner with a clothing company to design appealing, wearable clothes that effectively block UV rays, and market them as sun-safe.
In this unintentionally exposed group, the message of detection is also extremely necessary. As mentioned in Critique III of the original intervention, rates of self-skin evaluations are not keeping pace with the melanoma incidence rate, and not helped by the failure of many primary care physicians in performing total body exams [43]. Therefore, a series of campaigns to promote self skin examinations (SSEs) are timely and could result in the detection of many pre-metastatic tumors. The American Academy of Dermatology coined the phrase “check your birthday suit on your birthday” [52], which is a clever and catchy message, though it does imply that checks should be performed only annually. It would be advantageous to design an advertisement extending the message of SSEs, and attempt to integrate them as part of a more frequent, monthly route, like paying rent and bills. Another example of a detection message could be targeted to people who spend recreation time outdoors, such as gardeners and golfers. One example of a slogan should show a picture of a gardener and state “If you leave no stone unturned, then why leave your skin unchecked?”

Intervention III: Dispel misconceptions and promote sun safe behavior in minority populations

Addressing a major criticism of the anti-tanning messages, culturally sensitive and specific messages are needed to dispel myths and provide African Americans and Hispanics with information regarding melanoma and preventative measures. As previously cited, Hispanic and black minorities have been shown to report a lower perceived risk of melanoma and are less likely to be screened for melanoma tumors at doctor’s office visits [34, 35]. The need for sun protective and early detection practices in minorities is more important than ever, with Hispanics becoming one of the fastest growing populations in the US [53], and in light with the increasing melanoma rates in the Hispanic populations [6]. An ideal campaign would be designed with feedback from members of the black and Hispanic communities, regarding approaches that are likely to appeal or repel the target audience. Without the input, a basic first step in designing melanoma prevention messages would use the format of embracing healthy natural skin, as shown in Intervention I. This proposed print/video public service announcement would show groups of people, including members of different ethnicities and genders, and promote the motto: “In all types of skin, healthy skin is the most beautiful.” This approach would target the core value of attractiveness and inclusion, and would help to raise awareness across racial groups. Furthermore, the unequal screen exams performed by physicians can be addressed with melanoma posters placed in doctor’s offices, reminding physicians to “Check all skin types at check-ins,” or a similar message to support total skin examinations in all patients. Finally, emphasis on culturally specific SSEs should be introduced, which would promote skin examinations of common anatomical tumor sites in darker skinned people, including arcral sites, such as feet and ankles. One static suggests that while 72% of melanomas are proximal the ankle in Caucasians, 90% are distal to the ankle in African-Americans [54]. Another potential intervention can show images of feet and stress the simplicity but importance in checking for potential tumors. These messages would be effective in dissolving misconceptions of no melanoma risk among minority populations, while giving a practical way to keep skin healthy.


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At May 13, 2010 at 9:51 AM , Anonymous Mary Barrow said...

This is an important message and one that should be accorded serious attention. Reaching every segment of the population with one message that includes methods for both prevention and detection is fundamental to any campaign to lower the incidence of skin cancers. A number of professional skin cancer organizations have adopted SunAWARE as that message as the acronym is easy to understand and provides five universally accepted steps for skin cancer prevention and detection. You can find out more by going to


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