Challenging Dogma - Fall 2009

Thursday, May 20, 2010

Applying social marketing theory to skin cancer prevention efforts - Busayo K. Obayan

Since the early 1970s the carcinogenic effects of UV exposure have been known and prevention and awareness efforts were initiated. These first efforts included the creation of educational websites and databases, which were spearheaded primarily by the American Academy of Dermatology (AAD), and the Center for Disease Control (CDC). In addition, research was undertaken to learn more about the different types of skin cancer predominantly exacerbated by UV exposure: basal cell cancer, cutaneous squamous cell cancer, and malignant melanoma. Malignant melanoma is currently the fastest rising cancer in the U.S. It spreads rapidly, often without symptoms, and is more likely than not to result in death (1). Two thirds of cases of melanoma are believed to be caused by excessive exposure to UVA and particularly UVB, the radiation used on tanning beds (1). The CDC estimates that 50,000 people are newly diagnosed each year with melanoma and 7500 die from it (2, 3). Young people comprise a large share of those affected and dying from skin cancer with ½ of all melanoma cases being individuals less than 50 years old (1). These key research findings about the potentially fatal effects of excessive UV exposure led to further prevention efforts in the early 1990s that focused on educating youth in schools and introducing state legislation to require teens to present parental permission before using tanning beds (1, 4). Unfortunately these past attempts at prevention have had a minimal effect on decreasing the rates of skin cancer- in fact, the incidence of melanoma has risen progressively over the years (8). I argue that by passing unsound tanning bed regulations, relying on models of individual behavior change such as the health behavior model, and by taking away such a valued commodity, the desirable glow of a tan, and not replacing it with an alternative, equally appealing commodity, public health efforts to prevent skin cancer were minimally effective.
State legislation to regulate youth UV exposure via tanning beds focuses primarily on requiring parental permission to use a tanning bed, which has not significantly decreased the prevalence of tanning by youth. Many studies have shown that 80% of UV damage to the skin which contributes to skin cancer occurs before the age of 18(6). In addition, evidence supports the fact that persons who begin tanning when under the age of 30 increase their risk of skin cancer by 75% (9). Because of these findings, and the fact that melanoma is the first most common cancer in persons 25-29 and the second most common cancer in those 15-25 (9), public health advocates and physicians have doubled skin cancer prevention efforts targeting youth. As part of endeavors to decrease the incidence of skin cancer many public health advocates and dermatologists began to dialogue with their state representatives about introducing legislation to restrict youth access to tanning beds. Currently in America, at least 31 states have regulations in place to restrict youth access to tanning beds (4). Unfortunately, the majority of these regulations consist mainly of requiring tanning facilities to post warnings in the venue and neccesitating a range of ages from under 14 to under 18 to require parental consent to use tanning services. These parental consent requirements vary from requiring the youth to provide a signed document form to parent, which can be forged, to requiring a notarized document, to requiring the parent to come into the tanning facility and sign a document. Some more extensive parental consent procedures require the parent to remain in the tanning facility the entire time while the youth uses the services (4). Unfortunately, these attempts to restrict the availability of tans to minors have proven insufficient (7).
Studies have shown that states that require a minor to be a certain age in order to use the tanning facilities have been much more successful in decreasing the state-wide prevalence of tanning (7). In the U.S. the most restrictive tanning bed regulation was recently passed in Texas in April of this year. The Texas law prohibits all persons under the age of 16.5 from using tanning beds unless they have a doctor’s note require tanning bed use for medical condition (4). In Wisconsin, a similar law prohibits youth under the age of 16 from using tanning beds. Other states restrict younger ages from using tanning beds. The ideal piece of legislation would be one that restricts tanning bed use to those under the age of 18. As this is the legal age restricted from tobacco consumption, it seems an acceptable cutoff. In addition, several other countries have passed tanning legislation restriction youth under the age of 18 from using tanning beds. In the Australian states of Victoria and South Australia, tanning has been prohibited by those under the age of 18 as well as anyone with the fairest skin, type I, which tends to freckle and burn instead of tan(10). France has also prohibited anyone under the age of 18 from using tanning beds since 1997(11).
The primary reason the U.S. legislation is unsuccessful in decreasing the prevalence of skin cancer is that, unlike other international pieces of legislation, U.S. state legislation have few or no provisions for the enforcement of the regulations. In public health anti-tobacco efforts, many studies noted that the mainstay of an effective tobacco bill were its enforcement provisions ( (7). The tobacco bills included provisions that called for random monitoring and checks of establishments that sold tobacco to prevent selling of tobacco products to minors. This was accomplished in many states by using decoys who were minors and planting them at tobacco shops. Early after the initiation of these activities, store owners caught on and began to require ID from all customers appearing under the age of 30. This enforcement provision greatly decreased youth access to tobacco products. In addition, establishments that were caught selling to underaged customers were fined, and those fines were used to maintain the monitoring of these establishments. These methods could be utilized in efforts to restrict youth access to tanning beds as well. Enforcement provisions are the hardest to pass because they require a fiscal note, which many states, in these hard economic times, are unlikely to pass. Although it can be difficult to include these enforcement provisions, they are of the utmost importance in creating an effective bill that will bolster public health prevention efforts. As the efforts in tobacco have show, enabling the fines collection from tanning establishments that do not abide to the regulations can be used to further efforts to actively monitor and enforce tanning bed regulations.
Past methods of skin cancer prevention have been heavily based on models of individual behavior, particularly the health belief model. Educational methods of public health efforts to prevent skin cancer have relied heavily on the dated concepts illustrated in the health belief model. The model explains only individual-level behavior based on the premise that: 1) The person believes he/she is susceptible to the disease, 2) The individual believes that the disease will have at least a moderate to severe impact on their lives, 3) The prior beliefs will lead to a perceived threat of the disease, which would lead to 4) the individual taking action to prevent the occurrence of disease (12). Other important aspects of the model include the idea that there are modifying factors, such as race, social class, and knowledge about the disease, which will lend to the individual’s perceived threat of the disease (12). Finally, the model includes a component that is necessary to push the individual from perceiving the threat of the disease, to taking action to prevent the disease; this cue to action can vary from family illness to media campaigns about the disease (12). In past public health attempts to prevent skin cancer, advocates have utilized this model extensively by designing programs heavily based in education (1). The assumption being that by educating youth, the greatest group at risk, this will either provide a “cue to action,” that will push these youth from tanning to refraining from tanning. An additional way the model was applied in an attempt to change behavior was by using education as “modifying factor” that would increase the perceived threat of the disease, and thus lead to individual modifying behavior of sun protection and avoiding tanning.
Unfortunately, because of the flaws inherent in the model of individual behavior change, the public health interventions centered on this model have not been successful. Flaws that exist within the health belief model include the fact that it assumes that people who intend to change their behavior will actually change. Young people know that tanning and excessive exposure to the sun will increase their chances of skin cancer because this notion has been introduced to this generation at a young age by both educators and parents (13). Research has found that youth have a high knowledge base about skin cancer, its causes, and how to prevent it, but this does not correlate with a reduction or decreased desirability of tanning (13). Applying the health belief model to explain this behavior leaves one at a loss. This is because this classic model of health behavior does not account for the facts that: 1) human behavior is inherently spontaneous and irrational, 2) Just because a youth knows tanning will lead to skin cancer does not mean that they will take steps to prevent it, and 3) Among youth, there is more of a herd mentality, and tanning is a behavior perceived by groups of teenagers to be aesthetically pleasing and undertaken as a group activity. For example, an individual among a group of 16 year-old Caucasian females at a Boston beach is less likely to slather sunscreen in an attempt to prevent the future consequences of skin cancer because, as her friend applies tanning oil to achieve a look that is rare in the Boston winter months, the pressure to conform and the added perception of a tanned look will lead to her making a decision based on the group’s behavior. When around her parents however, the 16 year old would be more likely, especially if encouraged by her parents, to apply sunscreen to protect her skin. The health belief model poorly explains this spontaneous, paradoxical behavior. Also, as previously mentioned, the majority of youth know the damaging effects of UV exposure and still continue to tan. This finding is supported by several studies that have shown that youth attitude towards tanning places great emphasis on the value of tanning, and inexplicably, the greater the knowledge base of the youth, the higher the perceived value of tanning(13). This is because education efforts have made youth highly aware of the dangers of tanning, but even as education efforts increase, there is still an unchanged attitude about the value of tanning.
Lastly, skin cancer prevention efforts failed because they neglected to replace the idea that a bronzed look of skin is desirable with an equally desirable alternative. As illustrated in various irrational principles of behavior discussed during lecture, human behavior is highly irrational, and the desire to tan despite a high knowledge of the risk of associated skin cancer is a fitting example of the irrationality of human behavior. One of the examples of irrationality discussed included the idea of aversion to loss. The idea consists of the concept that once people have something (in this case, a tan during the summertime), they are loathe to give it up (14). Classic behavioral health theories cannot account for this behavior because they haven’t considered the irrationality of human behavior. So when public health interventions like skin cancer prevention education heavily rely on classical theories of human behavior, they are not taking into account the irrationality of human behavior and are likely to fail. In August, the World Health Organization issued a statement raising the carcinogenic level of tanning beds to Level 1- definitely carcinogenic to humans (15). Even with this announcement, making tanning beds equivalent to cigarette smoke, people nationwide continue to tan and there continues to be resistance to passing anti-tanning legislation. If this is not irrational behavior, I don’t know what is.
As discussed earlier, youth place great emphasis on the importance of the look of tanned skin (12). When education efforts were increased, youth were found to have a higher level of knowledge about actions to prevent skin cancer, but their attitudes were unchanged. The reason that this method failed is that the basic issue at hand is changing the attitude of youth. Education methods do not change teen attitudes toward tanning (12), instead they employ the strategy that increasing youth education about skin cancer will either increase their perceived threat of disease or push them from a state of the perceived threat to protective actions against the disease. Instead of replacing the outlook that tanning is desirable with images of role models with natural, untanned, beautiful skin, public health interventions urge youth to stop tanning but continue to use “sunless tanning products” (5). These sunless tanning products do have the added benefit of not exposing youth to UV light, but if a sun-protective lotion is not used, they are still exposed to UV from sunlight. By replacing a tan from the beach or a tanning bed with sunless tanning, which is more expensive, the basic issue at hand, youth attitude towards tanning, remains unchanged and the skin cancer prevention efforts are still at risk of failing. The answer: An alternative and equally appealing replacement to the bronzed, sun kissed, skin cancer inducing tan.
Marketing theory is based on the premise that by researching a target audience and revealing that group’s wants and needs one can successfully market a product to that group that would fulfill their most intimate needs and desires. The initial component producing a successful product using marketing theory is the idea of “preprogramming idea gathering,” which is when those who plan on marketing the product gather data about the target group (16). The second step is “audience segmentation,” which is the enrollment of a sample of the target group to answer important questions about the group’s needs and wants (17). The third component of the marketing strategy is resource management, assessing and utilizing the program’s budget effectively, the fourth component is the most important, program development. The program development phase consists of the 4 P’s: 1) Product (also known as the “promise”)- The offer made to the target audience through images and messages, 2) the Price- cost of the product, financial as well as psychological and social, the strategy entails using methods to lower the cost of the product so that people will participate in beneficial health-changing behaviors, 3) Place- how the product is delivered- the channels that are used, 4) Promotion- How the product is promoted to the target audience- by use of media, person to person contact, etc (16). The fifth component of an effective marketing strategy consists of evaluation of the program to assess its successes and failures (17). A successful marketing strategy to promote a public health intervention would incorporate the mainstays that make commercial marketing so successful and apply it in a way that would be socially beneficial.
Marketing theory can successfully be applied to skin cancer prevention targeting youth by employing the strategies outlined in successful commercial marketing, which hasn’t often been employed in this area. The first step of a successful campaign would be the preprogramming idea gathering. Advocates interested in preventing skin cancer by targeting youth should research the interests of that group as well as the factors that may prevent them from undertaking the public health message. Many interests of youth have not been taking into account in formulating skin cancer prevention strategy- these interests include that of sports, fashion, music, and entertainment. By gathering data about youth interest in these activities, public health interventionists can get greater insight into what type of message and delivery would greatly appeal to youth. Other important data such as the most effective environment in which to deliver the message should also be thoroughly researched. Most preventative efforts focus on education in schools, assuming that it is an effective learning environment in which the message could be relayed and internalized, but further research would reveal alternative environments that could be much more effective. The next step would be for public health interventionists to enroll a representative group to collect data about the needs and desires of the target population. Because most interventions targeted at youth are created by individuals who are significantly older than the target audience, these interventions are less likely to incorporate the wants and needs of an individual under the age of 18. By assessing the true wants, needs, and desires of this population, public health interventionists will find the true desires consist of the need to be accepted by others (namely- wanting to be perceived as attractive and conforming to group behaviors). This finding would reveal why past prevention efforts have failed- they have not addressed this basic need and want of this target population. The third step would be effectively utilizing the program budget. This may be difficult as public health programs have a significantly lower budget than commercial marketing ventures. However, by being creative by formulating a message that can be disseminated by multiple non-profit organizations such as the American Cancer Society, American Pediatric Society, Nation-wide melanoma foundations, and skin cancer foundations, this barrier would be surmountable. The fourth and most important step of program development should consist of a “product” desirable to our target audience.
The “product” would be an advertisement with a message in white against a black background stating: Tanning salons make 1 billion dollars annually. The advertisement would then show multiple media images of those who were young and tan, for example: Liza Minelli, Coco Chanel, and the Versaces, immediately followed by pictures of what they look like now. I would use a highly popular song to play while the images are being shown, this song would likely be chosen based on responses from the audience segmentation stage. Then the advertisement would show images of more pale or freckeled people such as: Marilyn Monroe, Anne Hepburn, and other famous media images, with following images of what they look like aged, which is much better than those who tan. The end of the message should have a voice over saying: “tanning is associated with a 80% risk in skin cancer. The choice is yours.” I would call this campaign “the choice campaign.” This concept is similar to the marketing methods used in the “truth” campaign against tobacco and would be highly effective in reaching our target population. This message effectively incorporates the need and desire of the target population to be attractive by turning the standard image of attractiveness, the tanned, bronzed look, into the wrinkled prune-like reality of the appearance that age will bring with continued tanning. It also replaces this old standard of attractiveness with one youth can strive for by avoiding tanning: the graceful and naturally pale appearance of natural, untanned skin. The “price” of the product would be giving up idea of a tan as the overriding idea of beauty, but the “cost” would be low because we would be replacing it with a new concept of beauty- the beauty of natural skin. How the product is delivered and promoted will depend on the budget of the public health program- but delivery could be expanded to billboards, pamphlets using images from the “choice” advertisement, key chains and other trinkets frequently used by youth, as well as websites and dissemination of the product to skin cancer organizations nation-wide. The last leg of this marketing strategy, which current public health interventions almost never utilize, is evaluation of the program. Provisions should be made during the initial planning of the budget for assessment of the impact of the product through surveys and evaluations of the target population. The product can then be continuously altered to achieve the most effective end result: the cessation of tanning.
There are many benefits to using the marketing theory to create skin cancer prevention programs targeted at youth. Firstly, it would address the paucity of effective legislation currently being used to regulate youth access to tanning beds by disseminating the message of skin cancer prevention nationwide. Legislators who were previously against bills to regulate tanning may be more likely to support these bills when they are exposed to the marketed message. In addition, by including testimony from past survivors of melanoma in the product, citizens nationwide would be more likely to write to their respective legislators to support the bills. Nationwide, skin cancer organizations can disseminate this information, increasing the education and impact of the message on citizens, the target audience, and legislators. Hopefully, this more effective message would lead to the inclusion of enforcement provisions in current tanning legislation as well as initiation of tanning regulation efforts in states that currently have no legislation. Secondly, the marketing theory is not an individual-level model, like the health belief model used to plan prior public health prevention programs. As such, the model will be able to incorporate research to figure out what the target populations’ needs and desires are before planning an intervention. It would be able to account for the irrationality of human behavior by using responses from the target audience to plan the intervention. Instead of assuming these responses will be rational, the marketing model would be able to collect these irrational responses and benefit from them by using them to create an effective prevention program. As in most successful commercial marketing efforts, this intervention based on marketing theory would rely on the fact that the way the message is framed, and not necessarily the message itself, should be the primary focus of successful public health campaigns. Framing is a large part of what commercial marketing is all about. The “frame” is developed by the needs and wants of the target population, and a “product” presented within that frame is much more likely to be “bought” than previous skin cancer prevention “products.” Thirdly, the marketing theory replaces the previously accepted idea of a tan as beautiful with a new concept that natural, untanned skin is indeed beautiful and highly valued. Human beings, being irrational creatures, are loathe to give up what they already have if it’s not replaced by something else that is not equally or exceedingly appealing (14). By giving youth an alternative and equally appealing replacement to the bronzed, sun kissed skin, a healthy glowing look that popular actors and actresses throughout Hollywood and general media are utilizing, we address the irrationality of human behavior, and are more likely to succeed in our public health interventions. A prime example of the success of the application of social marketing theory to the issue of tanning and skin cancer prevention is illustrated in Victoria, Australia’s SunSmart program (18). This is a program in which youth are primarily targeted and includes a television campaign and a national skin cancer week. The television campaign called “The Dark Side of Tanning,” will include an illustration of what actually occurs to the skin as someone tans as well as interviews with young people affected by malignant melanoma. In addition, the Victorians are initiating a campaign called “Fashion to die for,” targeting women age 18-30, the largest group that visits tanning salons. The purpose of the campaign will be to make this group more aware of the dangers of tanning using vivid images and video. These innovative social marketing efforts in combination with Victoria, Australia’s ban of tanning among youth under age 18, the number of tanning salons has decreased by a staggering 32% (18). Similar efforts initiated in the U.S. would go a long way to reaching youth and effectively decreasing the incidence of skin cancer.

1. Center for Disease Control. Guidelines for School Programs To Prevent Skin Cancer. Accessed Dec 5 2009. Available at:
2. American Cancer Society. Cancer Facts and Figures 2008. Accessed Dec 5 2009. Available at:
3. Health physics society. Ultraviolet radiation and public health. Accessed Dec 5 2009. Available at:
4. National Conference of State L. Tanning Restrictions for Minors: A State-by-State Comparison. Available at: Accessed March 30, 2009.
5. American Academy of Dermatology Press Release. Teens and tanning, a dangerous combination. Accessed Dec 5 2009. Available at:
6. Whiteman DC, Whiteman CA, Green A. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes & Control. 2001;12:69-82.
7. Cokkinides V, Weinstock M, Lazovich D, Ward E, Thun M. Indoor tanning use among adolescents in the US, 1998 to 2004. Cancer. 2009;115(1):190-198.
8. SEER Cancer Statistics Review, 1975-2004 (NCI) Link.
9. The International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: Asystematic review. International Journal of Cancer 2006; 120:1116-1122.
10. Australia S. Radiation Protection and Control (Cosmetic Tanning Units) Regulations 2008 Available at: Accessed on May 25, 2009. 2008.
11. Décre. 97-617 du 30 mai 19977, Article 4 Available at: 1997.
12. Salazaar, Mary. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39:128-135.

13. Dennis LK, Lowe JB, Snetselaar LG. Tanning behavior among young frequent tanners is related to attitudes and not lack of knowledge about the dangers. Health Education Journal. 2009; 68; 232-243.

14. Dan Ariely. Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: HarperCollins Publishers, 2008.

15. Boyles, Salynn. WHO: Tanning beds cause cancer. WebMD. July 28, 2009. Accessed Dec 8 2009. Available at:

16. P. J . Svenkerud and A. Singhal. Enhancing the Effectiveness of HIV/AIDS Prevention Programs Targeted to Unique Population Groups in Thailand : Lessons Learned from Applying Concepts of Diffusion of Innovation and Social Marketing. Journal of Health Communication, Volume 3, pp. 193. 1998.

17. Lefebvre, R. C., & Flora, J. A. (1988). Social marketing and public health intervention. Health Education Quarterly, 15, 299.

18. The cancer council Victoria. “Young Victorians targeted in hard-hitting skin cancer television campaign.” Accessed Dec 8 2009. Available at:

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