November 16, 2007

Literature Review of Theory-Based Empirical Studies Examining Adolescent Tanning Practices

By Reynolds, Diane

Lifetime exposure to ultraviolet radiation is a major risk factor for all types of skin cancer. The purpose of this manuscript is to examine theory-guided empirical studies examining adolescent tanning practices. Skin cancer is the most common of all cancers, accounting for nearly half of all cancers in the United States. The American Cancer Society (2006) estimated that melanoma, the most serious type of skin cancer, accounted for about 62,190 cases of skin cancer in 2006 and most (about 7,910) of the 10,710 deaths due to skin cancer. Lifetime exposure to ultraviolet radiation is a major risk factor for all types of skin cancer. Ultraviolet radiation (UV) comes from the sun, sunlamps, tanning beds, or tanning booths. People who have fair skin that freckles or burns easily are at greater risk, as are those individuals who have red or blond hair and light-colored eyes. Just one sunburn increases the risk for skin cancer (National Institutes of Health, 2005).

According to the Skin Cancer Foundation (2006), of the more than 1 million people who tan in tanning salons, 70% are Caucasian women aged 16 to 49. Demko (2003) surveyed 7,000 teenagers and found that indoor tanning among white teenagers is significant, with 30% to 40% of 16 to 18-year-old white females using tanning booths, many of them repeatedly. Continued use of a tanning bed or sunlamp is especially dangerous for teenagers because they are still experiencing tremendous growth at the cellular level and the skin cells are dividing more rapidly than they do during adulthood (Fox as cited in Rados, 2005). Sunbathing and inadequate sun protection further compound the risk for developing skin cancer.

A national survey conducted in 1997 by Koh and colleagues revealed that respondents in the youngest age group (16-25 year olds) sunbathed frequently and were least likely to use the recommended sunscreen. Additionally, they estimated that 2.3 million teens tan indoors in the United States annually. Hall, Jones, and Saraiya (2001) used data collected from the 1999 National Youth Risk Behavioral Study to determine the prevalence and correlates of sunscreen use among high school students in the United States. They found that students aged 14 years or younger were more likely than older students to use sunscreen, and females were more likely than males to do so. Geller and colleagues (2002) used data collected from adolescent 12 to 18 years old who participated in the Growing Up Today study to describe tanning practices among this group and compare them with sun-protection recommendations from federal agencies and cancer organizations. The results were disturbing. Although girls used sunscreen more routinely than boys, they also reported that it was worth getting burned to get a tan, and had incurred at least three sunburns the previous summer. These respondents had nearly double the use of tanning beds than those without this belief.

Search of the Literature

An initial CINAHL search of the literature using search topics of "student attitudes" revealed 5,118 results. Adding "skin neoplasms" to the search revealed 1,526 hits. When these two search terms were combined, only nine results were obtained. An additional search using the terms "health behavior" combined with skin neoplasms yielded 94 results, only three were found in nursing literature and were the same articles discovered in this author's original search. Sinni-McKeenhan (1995) authored an article on the health effects and regulation of tanning salons which was extremely informational but lacked empirical testing.

An additional search was conducted using PubMed to elicit articles from other disciplines that add to the body of knowledge. The index of individual nursing journals was searched to hone in on studies specific to nursing, which netted an additional four articles written by nurses published in the nursing literature. Conducting a citation search was extremely helpful in identifying additional sources of information and for drawing on a broad scope of referenced journals. This time-intensive search identified a gap in the literature in regards to the discipline of nursing in addressing the issue of adolescent tanning practices.

The majority of the studies found in the literature illuminate the issue of adolescent tanning practices and gather information on skin cancer knowledge, rather than address ways in which to promote primary prevention or change existing behavior. Most of the articles found addressed suntanning practices under the umbrella of health behavior and were written by psychologists or those in public health. The theories are based largely on behavioral health and social science. The Health Belief Model by Becker and Rosenstock was the most popular choice among researchers when examining the issue of adolescent tanning practices.

Review of Articles

The risk of melanoma increases if a person has one or more firstdegree relatives (mother, father, brother, and sister) with the disease (Glantz, Saraiya, & Wechsler, 2002). Swedish researchers Bergenmar and Brandberg (2001) conducted a study to describe attitudes toward sunbathing among young adults previously identified as having had two or more family members diagnosed with melanoma. Despite the fact that they were informed about their increased risk, the majority estimated that their own risk for developing melanoma was equal or lower compared with the general population. Although they did not cite the use of a theoretical framework, measurements included "self-efficacy" and "readiness to change," which resonate with components of Bandura's cognitive theory and Prochaska and DiClemente's Transtheoretical model respectively (Pender, Murdaugh, & Parsons, 2006, p. 271).

Despite adequate knowledge of the adverse effects of ultraviolet exposure, such as skin cancer and premature aging, students in a large midwestern public university, freely and frequently used tanning lamps, primarily because they enjoyed a tanned appearance (Knight, Kirincich, Framer, & Hood, 2002). The demographic group was driven by the perceived immediate cosmetic appearance gained through tanning lamp use rather than by the potential longterm deleterious effects of their behavior. Teens may ignore what they know about the skin damage caused by ultraviolet rays because they strive to look like the dark tanned models and actors they see (Gorgos, 2002).

This perceived benefit of a tanned appearance was echoed in a similar study conducted by a professor of nursing. Lamanna (2004) used a survey design to examine the relationships among college students' attitudes about general cancer and their knowledge, perceptions, beliefs, and behaviors concerning sun tanning and skin cancer. One of the instruments used to gather data was the College Student Sun Tanning Inventory, developed by Young in 1995. This instrument was based on several components of the Health Belief Model which hypothesizes that in order for individuals to take action to avoid disease they have to believe they are susceptible to the disease, that acquiring the disease would impact some component of their life, and they would benefit from reducing susceptibility to the disease. The results from random sampling of 224 Caucasian male and female students in a state university in New York revealed that most of the subjects tanned to the point of blistering, although they indicated that they perceived the seriousness of skin cancer and generally had a positive attitude toward cancer prevention. Female subjects engaged in more high-risk behavior than males. The Health Belief Model assumes that individuals who place a high value on health would take action to protect themselves from illness. In this study the model did not account for gender nor did it account for the desire for personal attractiveness and relaxation derived from tanning.

Reynolds and colleagues (1996) found similar results when examining predictors of adolescent sun exposure. Participants who thought that having a tan made them look attractive were 2.1 times more likely not to use sunscreens.

The belief that a tan acquired using a sunbed before a holiday would prevent against sunburn has also been cited as a rationale for tanning lamp use (Cokkinides, Weinstock, O'Connell, & Thun, 2000; Knight et al., 2002).

A 2003 study by Greene and Brinn utilized the perceived susceptibility component of the Health Belief Model to examine its impact on intention to tan as well as its effect on changes in actual tanning behavior. One hundred and forty-one Caucasian college students in the southeast were read randomly assigned messages related to the hazards of tanning. These messages either contained statistical or narrative information on skin cancer. They were also asked to complete self-assessments of their personality. They were later contacted for a followup telephone survey. The statistical messages rated higher on information value, increased perceived susceptibility, and resulted in decreased intention to tan. The narrative message, in contrast, increased perceptions of realism and also worked to decrease intentions to tan. Personality factors explained small portions of variance. This was a well-written article which clearly delineated the pros and cons of using the specific variable of perceived susceptibility when examining health behavior adoption such as the subjective nature of susceptibility. Treharne-Davies (1999) used multiple components of the Health Belief Model to assess health care students' attitudes to sunbathing. Data were collected via a questionnaire that was distributed to 176 health professional students in a university setting in the United Kingdom. The author found that females were more pro-tan than males. The results indicated that as attitudes become more pro-tan, risks taken for UV exposure increase. In general, students did not feel personally susceptible to the disease. These findings were consistent with other studies in the literature.

Predictors of sun-protective practices among other behaviors were addressed in a 2004 study by Von Ah, Ebert, Ngamvitroj, Park, and Kang. Components from the Health Belief Model - perceived threat, perceived benefits and perceived barriers - were used as theoretical framework. The study hypothesized that perceived benefits and barriers would be stronger predictors of health-promoting behavior when perceived threat was high. Selfreported questionnaires were completed by 161 college students. Selfefficacy emerged as the only significant predictor of health behavior. Sun-protective behavior was directly impacted by sun self-efficacy when perceived threat was low. The higher the perceived self-efficacy, the more likely students were to engage in sun-protective behaviors. Perceived threat, benefits, and barriers did not have any significant role in sun-protective behaviors.

The Health Belief Model and Bandura's Social Learning Theory were paired in a 1999 study conducted by Stone, Parker, Quarterman, and Lee. Through self-reported questionnaires, they elicited responses from 43 females, age 20 to 40, regarding skin cancer knowledge and preventive health measures used by parents and their children. The participants reported using minimal sun-preventive behaviors for themselves, but demonstrated moderate skin cancer knowledge levels. The Health Belief Model fails to explain why unsafe tanning practices continue even though there is knowledge of risk. There appears to be a gap between knowledge and actual threat of developing skin cancer, which is consistent with findings from other studies. Social Learning Theory proposes that behavior that is taught in early childhood and reinforced may be carried into later life. Although 62.8% of the participants in this study had taught their children to use sunscreen, that does not necessarily translate into sustained positive practices. Social Learning Theory may be more appropriate in a retrospective study looking at protective tanning practices among adolescents whose parents have modeled positive behaviors. The researchers never state which specific components of either frameworks guided the study, but it seems reasonable that vicarious learning (Bandura) could have been a unitary focus.

Several researchers examined the tanning practices by youth and their parents or caregivers (Cokkinides et al., 2002; James, Tripp, Parcel, Sweeney, & Gritz, 2002; Reynolds et al., 1996; Stryker et al., 2004; Tripp et al., 2003). James and colleagues applied the Theory of Planned Behavior and Social Cognitive Theory when examining correlates of sun-protective practices of preschool staff toward their students. Tripp, who also co-authored the previously mentioned article by James, applied Social Cognitive Theory when assessing sun-protection practices used by parents. The parents, particularly the female head of household, exerted a strong influence on the prevalence of risky tanning practices in these studies. Parents who conveyed approval and permissiveness for tanning, including the use of tanning beds, were more likely to have children who engaged in unsafe practices. These studies suggest that sun-exposure behaviors may be motivated in part by parental role modeling, especially female caregivers, underscoring the need for additional teaching in this area.

Turrisi, Hillhouse, and Gebert (1998) examined cognitive variables relevant to sunbathing among a convenience sample of 263 psychology students using Jaccard's Theory of Alternative Behavior. According to the framework, an individual's behavior is based upon the attitude they have toward performing the behavior as well as other behavioral alternatives. The researchers sought to examine sunbathing behavioral tendencies, attitudes towards sunbathing, and attitudes and perceptions about sunbathing alternatives, using questionnaires to collect data. The authors hypothesized that a decrease in favorable sunbathing attitudes would translate to a decrease in sunbathing tendencies, which was supported by the findings. The results were not reported by gender, leaving the reader wondering if there were alternative behaviors that were more important to males versus females. The questions that were to elicit attitudes and perceptions about sunbathing alternatives addressed activities such as shopping, watching television, going to a movie, working out, and also included feelings about the appearance of a tan, which didn't seem to fit with the other behavioral variables. These preselected alternatives may have excluded other individual preferences.

A similar study design, based on the Theory of Alternative Health Behavior, was used by Danoff-Burg and Mosher (2006). A convenience sample of 164 undergraduates completed questionnaires that assessed tanning salon use, attitudes towards tanning salon use, and attitudes towards alternative behaviors for enhancing appearance, relaxing, and socializing. Results were presented logically in separate regression tables. Attitudes toward alternatives for enhancing appearance such as through the use of diet, clothing, exercise, and sunless tanning products were not significantly related to tanning salon use. Attitudes towards behavioral alternatives for relaxing such as watching television, going to the movies, meditating, yoga, going out with friends, or engaging in a favorite hobby were inversely related to frequency of tanning salon use. Lastly, attitudes for socializing such as going to the gym, going to restaurants or bars, and going to parties accounted for 14% of the variance. Tanning salon use was negatively correlated with favorable attitudes toward going to the gym to socialize and positively correlated with favorable attitudes toward going to a tanning salon to socialize. The authors provided a single sentence which states the main intent of the theory but never described any of its components. This study, unlike the earlier one outlined by Turrisi et al. (1998), reported gender differences in attitudes towards behavioral alternatives to tanning salon use.

In an effort to reduce UV exposure from tanning booth use among college students, Mahler and colleagues (2005) conducted an interventional study to examine the efficacy of UV photographs and information about photoaging, defined as the premature appearance of wrinkles and age spots. Their objectives were twofold: to determine whether UV photographs and information on photoaging could increase sun-protection intentions and behaviors, and also whether the intervention could be enhanced by providing a non-UV alternative for achieving a tan (sunless tanning lotion). The later assumption was guided by the Theory of Alternative Behavior. The research had a control and two experimental groups. The control group completed an initial questionnaire regarding sunbathing behaviors and a second questionnaire designed to assess future intentions to use sunscreen. The intervention for each of the experimental groups consisted of an initial questionnaire followed by a 12 minute informational video on sun protection and a black and white photograph as well as a UV photograph taken of each participant. Prior to completing the second questionnaire, some of the participants in the experimental group were given a sample of sunless tanner cream. Analysis of the results found that the experimental groups scored higher on self-efficacy for sunscreen use, higher perceived susceptibility of photoaging, and higher perceived efficacy for sunscreen prevention of photoaging, than did the control group. Additionally, the participants who received the intervention plus the sunless tanner cream scored significantly higher on perceived susceptibility to photoaging than those in the intervention only group.

Gibbons, Gerrard, Lane, Mahler, and Kulik (2005) also employed UV photography to highlight the damage to facial skin caused by previous UV exposure (tanning booth use). The authors used the Prototype-Willingness Model as a theoretical framework for the study. The model suggests that willingness is an inclination to engage in risky behavior if given the chance and argues that adolescents' perceptions of the type of person who engages in risky behavior influences their participation in that behavior. They hypothesized that altering the tanner image should reduce the tanning behavior. All participants filled out a primary questionnaire followed by random assignment to either a UV photo or no-UV photo group. The UV group had their picture taken which highlighted visible damage from UV exposure. Both groups received informational brochures describing photoaging, melanoma, and sunprotection methods. All students were called for a retest 4 weeks later. The researchers discovered that the use of the UV photos did change tanners' attitudes about tanning as well as their images of the type of person who tans.

Myers and Horswill (2006) used Ajzen's Theory of Planned Behavior which is an extension of an earlier Theory of Reasoned Action (Fishbein & Ajzen, 1975), to examine social cognitive predictors of sun-protection intention and behavior. Ajzen added the perceived behavioral control variable to the Theory of Reasoned Action which posits that attitudes and subjective norms are amenable to change. Eighty-five participants between the ages of 16 to 27 completed a questionnaire before the summer and a second questionnaire in October. One item on the initial questionnaire that was used to measure intention asked the participants if they planned to use a high-factor sunscreen, but they never quantify "high factor." The authors reported that the model predicted both behavior and intention to use sun protection, with 45% of the variance of self- reported sunscreen use and 32% of the variance in intention explained by the Theory of Planned Behavior. Previous studies using the Theory of Planned Behavior reported similar results (Godin & Kok, 1996; Hillhouse, Turrisi, & Kastner, 2000). Based on The Theory of Planned Behavior, a study of 131 (predominately female) students from a southeastern university revealed that attitudes were strongly associated with high-risk intentions such as not utilizing sunscreen, and the use of tanning salons (Hillhouse, Adler, Drinnon & Turrisi, 1997). Subjective norms were less predictive of behavior. Perceived behavioral control moderated the relationship among attitudes, norms, and intentions to sunbathe and tan at a salon.

Grunfeld (2004) applied the Protection Motivation Theory to examine 239 adolescents' intentions to perform safe sun-exposure behaviors. This theory predicts that people's intentions to engage in certain health behaviors are influenced by their attitudes and beliefs about both adaptive and maladaptive responses. Threat appraisal and coping appraisal are its two main components. Specific components of threat appraisal include perceived severity, and perceived vulnerability, which are reminiscent of the Health Belief Model. Specific components of coping appraisal include self- efficacy, and attitudes towards performing adaptive behaviors, which are suggestive of Social Cognitive Theory. Students from two British universities completed questionnaires that the authors state represented the components of Protection Motivation Theory. This research project supported results from other studies that found greater awareness and knowledge of the risks of sun exposure were not predictive of safe sunexposure practices. Previous performance of similar behaviors emerged as the strongest predictor of intention to perform safe sun-exposure behaviors, which is consistent with Pender's revised Health Promotion Model.


Based on the literature search, it appears that efforts that focus on increasing knowledge in order to effect change in tanning practices among adolescents seems to be missing the mark perhaps due to perceptions of invulnerability in this group. Among the adolescent population, it appears that immediate benefits outweigh trepidation about long-term implications associated with tanning practices. Despite available nursing theories, which may be applied to studying tanning practices of adolescent youth, theories from behavioral and social sciences seem to be the gold standard. It is surprising that the nursing literature is scant in regards to identifying the magnitude of the health behavior problem of adolescent tanning practices. When nursing's contribution to this salient issue is represented, the studies are mainly atheoretical or based on theory outside of nursing. Many of the studies outlined that were theoretical in nature assumed that the reader was familiar with the components of the theory. While this author recognizes the value of interdisciplinary teamwork, I am left wondering why nursing doesn't draw from strengths that lie within rather than go outside of nursing to seek answers?


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Hall, H.I., Jones, S.E., & Saraiya, M. (2001). Prevalence and correlates of sunscreen use among U.S. high school students. Journal of School Health, 71(9), 453-457.

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Knight, J.M., Kirincich, A.N., Framer, E.R., & Hood, A.F. (2002). Awareness of the risks of tanning lamps does not influence behavior among college students. Archives of Dermatology, 138, 1311-1315.

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Lamanna, L.M. (2004). College students' knowledge and attitudes about cancer and perceived risks of developing skin cancer. Dermatology Nursing, 16(2), 161-176.

Mahler, H.I.M., Kulik, J.A., Harrell, J., Correa, A., Gibbons, F.X., & Gerrard, M. (2005). Effects of UV photographs, photoaging information, and use of sunless tanning lotion on sun protection behaviors. Archives of Dermatology, 141(3), 373-380.

Myers, L.B., & Horswill, M.S. (2006). Social cognitive predictors of sun protection intention and behavior. Behavioral Medicine, 32(2), 57-63.

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Diane Reynolds, EdD(c), RN, OCN, CNE, is an Assistant Professor of Nursing, Long Island University, Brooklyn, NY.

Copyright Anthony J. Jannetti, Inc. Oct 2007

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