Not All Tanners Are Created Equal: Title and subTitle BreakImplications of Tanning Subtypes for Skin Cancer Prevention

Recently, the idea that UV risk behaviors can be characterized by subtypes defined by specific behavioral patterns has emerged in the skin cancer literature.^{1 - 2} Further support is provided by O’Riordan et al³ in this issue of the Archives. They used latent class analyses to classify visitors to a Hawaiian beach into subtypes based on their degree of skin cancer risk, sun protection practices, and tanning motivations. The findings of this latest study parallel the study by Pagoto et al² of visitors to Lake Michigan beaches in Chicago, Illinois. In this study, 4 subtypes of beachgoers were identified, 3 of which were strikingly similar to the ones described by O’Riordan et al³ : (1) low-risk sun worshippers, (2) moderate-risk sun worshippers (tan seekers), and (3) high-risk individuals who sunburn easily (“sunburners”). The largest subtype in both of these studies included individuals with a strong desire to tan despite having a skin type that is conducive to sunburning. These individuals perceive themselves as at risk for skin cancer and use sunscreen but do not seek shade or wear protective clothing. This group is of greatest concern to physicians because their motivation to tan seems to override their perceived and actual risk for skin cancer.² Overall, more than two-thirds of individuals in both beach samples reported that they were at the beach with the intention of tanning to improve their appearance.

Almost 2 decades of study have clearly demonstrated that the belief that a tan improves appearance is one of the strongest predictors of UV exposure behaviors,^{4 - 8} although other factors, most notably social factors,^{9 - 11} perceived susceptibility to skin cancer,^{12 - 13} and factors related to relaxation and dependency^{14 - 17} are also implicated. Of great concern is the fact that the largest and most at-risk subtypes were both seemingly aware of their skin cancer risk, yet at the same time were highly motivated to expose themselves to enough UV radiation to acquire a tan they believed would improve their appearance. One implication of this finding is that interventions that focus on promoting sun protection use without simultaneously having an impact on tanning motivation are likely to be limited in their effect on this group of tanners. What is clearly needed is further understanding of the factors driving these individuals' motivation to tan. Furthermore, improving our ability to identify and classify individuals who engage in risky behavior will also help researchers to better design and match interventions to the various subtypes within the population.

Media and peer influences are strong forces that steadily reinforce the value of a tanned appearance.⁵ It is difficult to have an impact on the social norm for the attractiveness of a tanned appearance given (1) the long history of this belief in the culture and (2) the number of tanned media images saturating the public. Despite this, recent studies^{18 - 22} have begun to focus on appearance-related beliefs in skin cancer prevention interventions with good success. Although several of these have attempted to counteract media- and peer-influenced perceptions of the attractiveness of tanned skin, their success, in terms of impact on tanning attitudes and perceptions of peer and media norms, has been variable. Potentially further complicating these efforts is the growing popularity of the look of sunless spray-on tanning among celebrities. For example, celebrity contestants in the popular prime-time show “Dancing With the Stars” routinely use sunless spray-on tanning before each episode. On the one hand, the increasing popularity of spray-on tanning, now considered a form of body art by many, may perpetuate the social norms about tanned skin, potentially undermining efforts to promote pale skin as a beauty standard. On the other hand, a vast literature across a wide variety of health behaviors demonstrates that it is possible to simultaneously promote both abstinence-based and harm-reduction strategies without reinforcing positive attitudes toward the behavior^{23 - 24} when that approach also promotes healthy alternatives.

A number of healthy alternatives are available for individuals motivated to tan for the purpose of improving their physical appearance. For example, some individuals may choose to forgo tanning as a means of improving appearance, instead concentrating on other methods of appearance enhancement, such as clothing, that do not require a tan to be complimentary¹⁹ or reallocating tanning funds toward other types of appearance enhancement (eg, manicure, clothing, cosmetics). Another approach is sunless spray-on tanning or self-applied sunless products, which create the appearance of a tan but do not carry the UV risk. Given that tanning motivation can be strong, often overriding health risks, and potentially resistant to traditional interventions, promoting alternatives may be helpful to lure sunbathers out of the sun.

Behavioral economics represents a framework for understanding health behavior decisions based on alternatives. This theory has been successfully applied to dietary intake,²⁵ smoking,²⁶ and substance abuse.²⁷ It posits that (1) as the cost (eg, in time, money, and physical or emotional risks) of engaging in a behavior rises, the rate of behavior declines (eg, as cigarettes become more expensive, rates of smoking have declined), and (2) as behavioral substitutes become available, the rate of the target behavior also declines, especially if the relative cost of the substitute is less than that of the target behavior (eg, with the introduction of sugar substitutes into the marketplace, the rising consumption of diet carbonated beverages is associated with reduced consumption of sugar-sweetened carbonated beverages).²⁸ Behavioral economics includes a number of principles that may be helpful for designing effective messages for reducing skin cancer risk. First, delayed outcomes (eg, long-term health) have less impact on behavior than immediate outcomes (eg, having tanned skin). Changing behavior requires that the immediate outcomes for not engaging in the behavior or for engaging in alternative behaviors outweigh the immediate outcome of engaging in the behavior. Second, behaviors with highly desired outcomes (eg, tanned appearance) but limited alternatives are more resistant to change even as the cost rises. For example, despite the current dramatic increases in gasoline prices, demand remains high. Similarly, if no alternatives exist, rising skin cancer rates might not be accompanied by reduced rates of sunbathing. Finally, non–mutually exclusive behaviors, such as UV and sunless tanning, can be affected by changing their relative perceived costs. Therefore, as the costs of sunbathing and indoor tanning (eg, perceived risk for skin cancer, skin damage, sunburns) accumulate, the use of alternatives such as spray-on tanning that produce the same outcome with fewer costs should increase. Behavioral economic theory dovetails well with Jaccard's behavioral alternative model,²⁹ which emphasizes the importance of promoting positive attitudes toward behavioral alternatives and has been successfully used to change a large variety of health behaviors, including UV risk.^{19 ,30}

The identification of tanning subtypes in these studies cited, by providing more detailed information on individual tanning motivations, should improve our ability to identify relevant costs and desired outcomes by type in a way that will improve the saliency and effectiveness of behavioral alternatives. For example, Table 1 shows each outdoor tanning subtype according to Pagoto et al,² along with the main reasons each subtype reported for sunbathing and for not using sunscreen. Most people in the low-risk sun worshipper subtype (people with skin types 3 or 4 and who are motivated to tan) and the moderate-risk sun worshipper type (people with skin types 1 or 2 and who are motivated to tan) report that their belief that a tan is attractive is the primary motivation for sunbathing. For these groups, providing low-cost (in terms of price and lack of negative effects) alternatives such as sunless tanning may prove to be a relevant harm reduction strategy. Simple encouragement of sun protection strategies will probably prove insufficient for these subtypes given that they report that their primary reason for not using sunscreen is that it interferes with the tanning process. Here is a case in which promoting sun protection as a stand-alone intervention is likely to fail because it conflicts with other important motivations.

However, the sunburner subtype (people with skin types 1 or 2, with high-risk awareness, and who are not motivated to tan) and the subtype comprised of individuals who are indifferent to tanning (people with skin types 3 or 4 and who are not motivated to tan) report both physical appearance and social reasons for sunbathing. They seem to find themselves at the beach as much to spend time with friends as for physical appearance reasons. Spray-on and self-tanning are less likely to appeal to such subtypes because they would represent less salient alternatives for their beach experience. Instead, interventions that target alternative social activities that do not require UV radiation exposure, as recommended by Danoff-Burg and Mosher,¹⁴ or encourage sun protection strategies might prove more successful. Turrisi et al³⁰ have used just this approach with middle school students with some success.

Tanning subtypes have also been observed among indoor tanners, a group sharing many characteristics with the 2 sun worshipper subtypes. Although the beachgoer subtypes were developed based on perceived and actual risks, use of sun protection behaviors, and general tanning motivations, Hillhouse et al¹ developed indoor tanning subtypes based on tanning patterns of indoor tanners (ie, “event tanners” who primarily tan before special events, regular tanners who tan on a frequent regular basis throughout the year, and mixed-type tanners who tan regularly in 1 or 2 seasons and “event tan” during their “off season”).

We believe that combining aspects of these 2 categorization schemes will produce a multidimensional model of intentional tanning behavior that would be useful from a clinical and research standpoint. This new model of intervention urgency is based on the pattern of the tanning behavior (event, regular, or mixed), the risk profiles, protection behaviors, tanning source, and tanning motivation. Table 2 represents 1 potential way these factors might be combined to better reflect the complexity of intentional tanning subtype patterns, the urgency with which intervention is needed, and the characteristics that should be targeted by interventions. The number of features in the high intervention urgency level column in Table 2 determines the priority level for intervening on that risk group. The specific characteristics identified should then guide the intervention message, and the priority should be strongly determined by the proportion of the population affected. We recommend that the highest priority for interventions should be those that target subgroups that comprise more than 40% of the population, whereas low-priority interventions are those that target subgroups that comprise less than 10% of the population. For example, a high-priority subgroup comprises those in the high-risk, sun worshipper subtype, who describe their tanning pattern as regular, their desire to be tan high, their tendency to become sunburned high, and who comprise more than 49% of the target population.² Furthermore, it is apparent that they are using both sunscreen and tanning beds to control the tanning experience, thus achieving high UV radiation exposure rates. Traditional admonitions to not tan and to use sun protection are unlikely to have much effect here. Instead, approaches using alternatives that address sun worshippers' motivation are more likely to prove effective. However, low-risk sun worshippers who are event tanners may be easier to move from tanning toward protective behaviors but represent a lower priority subtype given that they comprise only 13% of the target population.²

Further complicating matters is the growing evidence that mood, dependence, and other pathological processes may have a role in some tanning behavior.^{16 - 17 ,31 - 32} Improved mood and a sense of relaxation seem to strongly motivate both indoor tanning^{1 ,14 ,32} and outdoor tanning.¹⁵ Still, the desire to be tan continues to be the strongest predictor of both sunbathing and indoor tanning behaviors, and reducing that desire remains difficult for both clinicians and skin cancer prevention researchers. The development of intentional tanning subtypes that more accurately reflect risk, motivation, and behavioral patterns will greatly improve the ability of both the researcher and clinician to understand and treat patients at risk. The effectiveness of skin cancer prevention messages may vary considerably by tanner subtype. For example, Mahler et al³³ reported a small but statistically insignificant increase in sun protection behavior in a group of college students who were given self-tanning products as an alternative to UV tanning. It is possible that such a simple intervention could have had a more important impact if it had targeted sun worshipper subtypes who regularly tan. Empirical studies are needed to determine if individuals will be more responsive to messages tailored to their particular subtype.

Possible recommended messages that could be tailored to each subtype are provided in Table 1. Although some overlap exists, more precise messages could be tailored to the motivations of each subtype, which may have the potential to improve message effectiveness for the various subtypes. For example the sunburner subtype and the subtype of those who are indifferent to tanning are likely to report that forgetting to use sunscreen and avoiding the hassle of using it are more important reasons for not using sunscreen than their desire to acquire a tan. As such, interventions that encourage greater use of shade and protective clothing, as well as provide prompts and reminders to use sunscreen regularly, could be effective.

The advantages of the development of a tanning typology will not be fully realized until brief assessments that can accurately classify patients are developed and empirically verified. We believe that the latent class analysis used by O’Riordan et al³ to identify and define their subtypes is an important step in this process. Such assessments, together with messages tailored to each subtype, will give clinicians a way to identify those patients in greatest need as well as the most effective messages to deliver to specific patients. Given the time constraints of the typical patient-clinician interaction, such systems may very well maximize the efficiency of delivering UV safety information. Public health skin cancer prevention programs may also benefit from the improved accuracy of risk identification as well as the ability to tailor messages to various tanning subtypes, perhaps using interactive online intervention programs.

Although many tanners share the desire to improve appearance from UV exposure, not all tanners are created equal. Tanning subtypes provide insights into tanning motivations and behaviors that are useful for both the clinician and the researcher. Combining these insights with powerful social health behavior models, such as behavioral economics and/or the behavioral alternative model, allows the researcher and ultimately the clinician to understand the competing costs and benefits of the various options available to tanners in a way that can lead them to better and safer decisions about skin health.

Correspondence: Dr Pagoto, University of Massachusetts Medical School, Department of Medicine, Division of Preventive and Behavioral Medicine, 55 Lake Ave N, Worcester, MA 01655 (sherry.pagoto@umassmed.edu).

Financial Disclosure: None reported.

Funding/Support: This editorial was funded by National Cancer Institutes grants 5 R21 CA10967 (Dr Pagoto) and 5 R21 CA116384 (Dr Hillhouse).