Randomized controlled trial of a web-based indoor tanning intervention: Acceptability and preliminary outcomes.

Indoor tanning beds (IT) that emit artificial ultraviolet (UV) radiation are implicated in an estimated 450,000 cases of non-melanoma skin cancer and 11,300 cases of melanoma each year in the United States, Northern and Western Europe, and Australia (Wehner et al., 2012). In the United States, the increasing popularity of IT over the past 2 decades among young adult women (Robinson, Kim, Rosenbaum, & Ortiz, 2008) has been accompanied by increasing melanoma incidence in this group (Coelho & Hearing, 2010). Nearly 1 in 3 young adult Caucasian women report using IT in the past year (Guy, Berkowitz, Watson, Holman, & Richardson, 2013), making this an important group for melanoma prevention efforts. The 2014 Surgeon General’s Call to Action to Prevent Skin Cancer highlights the need for innovative IT behavioral interventions that address underlying motives for tanning including “the desire to look attractive and healthy and to conform to societal beauty standards” (U.S. Department of Health and Human Services, 2014). Body image theory may provide insights into developing such interventions. Body image theories posit that one’s thoughts and actions related to their appearance are largely socially determined by perceptions of societal beauty standards, or beauty ideals (Stice, 2001; Thompson & Stice, 2001). This beauty ideal is further reinforced by interpersonal experiences. A young woman who internalizes the beauty ideal as her own appearance goal will feel pressured to match her appearance to them. Perceived discrepancies between the internalized ideal and one’s appearance leads to body image dissatisfaction. Appearance-altering behaviors, like IT, become powerfully reinforcing because they help to alleviate body dissatisfaction by aligning one’s appearance more closely with the ideal. The application of body image theory to IT would suggest a young woman’s societal experiences can lead her to form a tan beauty ideal, defined as the belief that being tan is a defining aspect of being an attractive woman. A young women who internalizes a tan ideal will value being tan as important to her own attractiveness, be motivated to use IT, and experience appearance dissatisfaction when she is not tan. Evidence is beginning to emerge that supports an association between body image constructs and IT attitudes and behavior (see review by Thompson, Ata, Roehrig, & Chait, 2012). The desire to possess the same tan as favored celebrities, a marker of tan ideal internalization, is linked to IT among young adults (Cafri, et al., 2008). Also consistent with internalization, IT users monitor, evaluate, and compare their tan to their desired or ideal tan level (Cafri et al., 2008; Gillen & Markey, 2012; Prichard, Kneebone, Hutchinson, & Wilson, 2014). Appearance monitoring influences IT intentions through increasing body dissatisfaction (Stapleton, Turrisi, Todaro, & Robinson, 2009). Skin tone dissatisfaction, defined as perceived discrepancy between one's current and ideal tan, is associated with tan ideal internalization and tanning behavior among adolescent girls (Pritchard, et al., 2014). Body image investment in IT may explain why some users think the short-term appearance benefits and self-confidence gained with IT are more important than or worth the risks (Banerjee, Hay, & Greene, 2013; Cafri, Thompson, Jacobsen, & Hillhouse, 2009). This study describes the pilot test of a web-based IT intervention informed by body image theory-guided interventions designed to prevent disordered eating among young women. The intervention targets an IT user’s perceptions of the benefits and value of tanning and addresses the role of body image in IT. The intervention was targeted to young women as they report the highest rates of IT. The intervention included persuasive techniques informed by non-clinical cognitive behavioral interventions that engage participants in reflection and cognitive restructuring of beliefs (Heinicke, Paxton, McLean, & Wertheim, 2007; Stewart, Carter, Drinkwater, Hainsworth, & Fairburn, 2001; Stice, Rohde, Durant, & Shaw, 2012). Psychoeducational content was designed to engage participants in reflecting on how their IT behavior may be influenced by their societal experiences related to tanning, the internalization of the value that a tanned appearance is an ideal body image, and resulting dissatisfaction. Restructuring IT-related beliefs involved thought exercises that presented tan ideal counter perspectives, including evidence against a tan beauty ideal as well as alternative viewpoints about the personal and social benefits of tanning. Participants were also encouraged to consider strategies for counteracting body dissatisfaction and plans for reducing their IT. Several IT interventions with evidence of efficacy target perceptions of the short-term appearance benefits of IT through raising awareness of the negative appearance effects of IT (e.g., premature skin aging and wrinkling) (Hillhouse, Turrisi, Stapleton, & Robinson, 2008; Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005; Greene & Brinn, 2003). This intervention shares important key features with these and other skin cancer intervention approaches (Jackson & Aiken, 2006; Lazovich et al., 2013; Mahler, Kulik, Butler, Gerrard, & Gibbons, 2008; Pagoto, Schneider, Oleski, Bodenlos, & Ma, 2010) including reframing perceptions of tanning benefits, targeting normative perceptions regarding the attractiveness of tanning, and promoting healthy alternatives to tanning. Innovative aspects of this intervention include the web-based format and the use of thought exercises to target central body image constructs including perceptions of a tan ideal, tan ideal internalization, and perceptions of the role of dissatisfaction in IT. The first study aim was to describe the acceptability of the intervention as determined by participants’ intervention evaluations. The second aim was to report the preliminary behavioral outcomes measured on a 6-week intervention follow-up assessment. The study hypothesis was that intervention participants would report less IT and a lower likelihood of using IT in the future at follow-up compared to control participants. We also examined whether rates of sunburns, a marker of IT and other risky UV exposure, were lower among intervention participants.