A randomized controlled trial of an appearance-focused intervention to prevent skin cancer.

With more than 1.3 million diagnoses, over 10,000 deaths, and more than $1 billion spent annually for skin cancer treatment in the US, skin cancer represent a serious public health threat.1,2 Despite laboratory, case-control, and prospective studies all pointing toward a positive relation between youthful indoor tanning (IT) and melanoma and squamous cell carcinoma,3-5 IT is gaining popularity, particularly among youth. The IT industry has an estimated 30 million individual US users.6 Recent reviews report approximately 10% of US adolescents under age 15 have used IT in the past year, with prevalence among older adolescent females estimated at 25% to 40%.7 Studies indicate that appearance factors are most predictive of IT use,8-16 followed by social factors,17 perceived susceptibility to skin damage,18,19 and dependence on ultraviolet (UV) light exposure.20,21 Recent interventions have emphasized the appearance damage associated with UV tanning18,22-27 (see Table 1 for a summary). Although these efforts demonstrate good efficacy, there are limitations that need to be empirically addressed before wide-scale diffusion is feasible. For example, Hillhouse and Turrisi23 used a booklet emphasizing appearance damage in young women. Although this intervention is a relatively easy and low-cost method, the study used a small, limited sample. Furthermore, they did not examine mediatory processes underlying intervention efficacy. TABLE 1 Summary of Appearance-focused Skin Cancer Prevention Interventions Similarly, Gibbons et al22 reported promising results getting young people to alter UV-risk behavior through the use of UV photographs. However, valid UV photography currently requires significant equipment expense and interpretative expertise,28 and can only be administered to 1 individual at a time, limiting its feasibility for large-scale campaigns. Failure to focus on viable, healthy alternative behaviors is another limitation.24,25 Literature from other health domains (eg, teen pregnancy, alcohol abuse, etc)29,30 have demonstrated the need to simultaneously improve attitudes toward behavioral alternatives for long-term sustainability of behavior change. The dearth of information concerning healthy, appearance-enhancing alternative choices currently limits potential for long-term stability of effects. Thus, although promising, there remain gaps in the literature examining sustainable interventions with a strong evidence base, which can be delivered to large audiences easily and cost effectively. The present research extends prior efforts to address these limitations. It evaluates an appearance-focused intervention designed to reduce IT tendencies using a randomized controlled trial. The study used a larger, more diverse sample. It examined mediational processes related to intervention effectiveness, and was guided by strong theoretical models that focus on providing healthy alternatives. The intervention was a 24-page booklet (available upon request from the authors) based on decision-theoretical frameworks in general,31,32 and the Jaccard behavioral alternative model33 in particular. The Jaccard model focuses on the decision to use IT as well as healthy alternatives to this. For example, young people often use IT before important events like a prom. A typical young woman preparing for a prom is faced with the decision of whether to use IT. This decision is influenced, in part, by the way she construes IT, and in part by the alternatives she perceives to be available to her. An effective analysis involves consideration of IT, along with other viable alternatives, such as tanning using sunless tanning products, choosing a dress that does not require a complimentary tan, etc (see Fig. 1). Effective interventions reduce unhealthy behavioral motivations by 1) reducing positive attitudes toward the behavior, 2) decreasing positive subjective norms (ie, the perception that the behavior is approved by others), and 3) increasing perceived susceptibility to significant negative effects, while simultaneously increasing motivation for healthy alternative behaviors by improving attitudes and norms toward the healthy behavior. Although cessation of deliberate tanning is the ultimate goal, research indicates that harm reduction strategies can mitigate harm for frequent users.34 FIGURE 1 A theoretical model is shown of appearance intervention influence on indoor tanning outcomes. AF indicates appearance-focused. Understanding mediational processes is critical for prevention campaigns. According to the model, IT behaviors are directly affected by IT attitudes and attitudes toward viable alternative behaviors such as fashion choices and sunless tanning. Attitudes toward alternatives are proximal mediators. Attitudinal constructs, in turn, are impacted by core variables identified in previous empirical work13: 1) perception that tans are attractive, 2) perception that IT is relaxing, 3) belief that IT increases skin damage susceptibility, 4) belief that IT increases skin cancer susceptibility, 5) IT subjective norms, 6) descriptive norms for peers (ie, perception of how much peers use IT), 7) image norms (ie, norms for an attractive body image) for IT relating to peers, and 8) image norms for IT relating to media stars. The present study evaluated a brief appearance-focused intervention based on a theoretical model with mediational analyses designed to assess whether observed program effects are a result of changes in targeted individual level variables.