Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Choose Your Cover: The Failure of a Skin Cancer Prevention Campaign to Consider Teenage Perceptions And Developmental Issues- Emily Learner

In 1920, French designer Coco Chanel inadvertently introduced a new fashion trend to the world, which has since become a major public health problem. While on vacation, Ms. Chanel accidentally obtained a suntan. Tanned skin was not popular at the time, but Ms. Chanel embraced the look. Tan skin nicely complemented her new fashion designs, which were styled to reveal more skin (1 ,2). Almost overnight, tan skin became a mark of beauty, and a popular fashion trend. Fashion magazine, Vogue, quoted Coco Chanel as saying, a “girl must be tanned. A golden tan is the index of chic” (2). Tan skin became a sign of beauty, health, and youth, and it has grown to become a widespread cultural obsession.
Public health officials are now trying to curb this obsession because of the serious the health problems associated with tanning. Studies have shown a positive correlation between UV exposure and skin cancer, and tanning is strong predictor of skin cancer development (3, 4). This is of particular concern, as the incidence of skin cancer has more than tripled in the past 30 years, and the rates continue to rise while the mean age of diagnosis of melanomas continues to fall (3, 4). To combat the nation’s “tanorexia”, the Center for Disease Control has introduced a campaign to educate people about the dangers of tanning and to encourage people to practice skin prevention techniques. This campaign, called Choose Your Cover, was created with the goal of decreasing dangerous UV exposure among young people. Despite Choose Your Cover’s education initiatives, however, the campaign has not had a significant impact on teenagers (3, 4). The Choose Your Cover Campaign has been unsuccessful in changing the tanning behaviors of teenagers because it fails to address tanning from a teenage perspective, and does not consider the psychological and cognitive development of teenagers.
Teenage Perceptions and Social Norms
The underlying assumption of Choose Your Cover is that education about the risks of tanning will influence teenagers’ intentions to protect their skin and ultimately cause them to avoid tans. Research shows that this is not the case. A study organized by the American Association of Dermatology shows that among young adults,“79% are aware that getting a tan from the sun can be dangerous for their skin and 81% know that the sunburns they got as a child increase their risk of developing skin cancer as an adult” (3 ,4,). Still, only around 30% of teenagers (12-18 years old) use sun protection and 80% admit to getting at least one sunburn a year, which significantly increases skin cancer risk (3 ,4). Furthermore, surveys show that between 30% and 40% of teens visit indoor tanning salons eight to fifteen times a month (3, 4). Clearly, ignorance of the dangers of UV radiation and how to protect one’s skin is not a contributing factor to tanning behavior.
Social pressure is a contributing factor however. The influence of societal norms on teenagers is especially strong, as teens base decisions on peer norms and image norms (5- 7). Teenagers are especially “likely to engage in harmful types of behavior, such as tanning, if they perceive the behavior to be typical among peers (5). Research has shown that tanning is both typical and prevalent among teens (6), and teenagers’ tendencies to tan have been correlated with having friends who tan. This peer pressure to tan is complemented by image pressure. Tans are looked upon with positive attitudes, as bronze-skinned fashion icons and celebrities depict tan skin to be sexy, beautiful and fashionable (2,5). Furthermore, the failure to use preventative techniques has been directly related to self-perceived “image vis-a-vis peers” (6). This suggests that even if adolescents have the self-efficacy for sun protection, “they may be unwilling to forgo a suntan, given strong perceived advantages of tanning” (7). These perceived advantages certainly outweigh the risks. A college student explained, “I like the way that my skin looks. I feel healthier, although I know it's not healthier… It's worth it for me to have the color and feel good about myself” (8). Theoretical and anecdotal evidence shows that teens are highly influenced by social pressure, and that social norms lead teens to believe that the benefits of tanning, namely looking and feeling more attractive, and fitting in with one’s peers, outweigh the risks of tanning.
The Choose Your Cover campaign underestimates the importance of these social norms on teenagers. Although the campaign does suggest that social norms be taken into account, it fails identify which specific social norms are most valued by teenagers and which are most influential on their behavior. As a result, image norms and peer norms are neglected and not incorporated into the campaign’s design. This neglect is evident through the campaign’s encouragement to cover skin. The campaign instructs teenagers to cover up by wearing long sleeved shirts, long pants and wide brimmed hats, all made of UV protective fabrics, and wearing wrap around sunglasses (9). For a demographic concerned primarily with physical appearance and fitting in, asking teenagers to cover up is practical, yet completely unrealistic. To teenagers, these suggestions mean compromising their physical appearance, self-concept and social status not only by having pale skin but also by wearing unpopular clothing and clothing styles (6-8). A more successful approach should take into account teenage perceptions; preventative techniques that are more compatible with teenage social norms would be more likely to appeal to the teenage demographic.
Perhaps the largest oversight of Choose Your Cover with respect to social norms is its failure to address intentional tanning. The campaign does not differentiate between passive tanning and active tanning, and it treats these passive and active behaviors as one. The suggestions to apply sunscreen and wear protective clothing are relevant only to teens who spend a lot of time in the sun playing sports, attending camp or working outdoors. These teenagers tan, but the tan is secondary to other activities. Many teenagers consciously and intentionally tan via sunbathing and artificial tanning. Surveys suggest that some 2.3 million teens use tanning salons, and that teenagers visit tanning salons more frequently than all other age groups (3, 10). These visits put the teenage demographic at considerably higher risk for skin cancer, as the UV rays of tanning beds and booths are ten to fifteen times higher than natural UV rays (3). Teenagers who intentionally tan are highly influenced by social norms, as they feel compelled to look tan. Suggestions to cover up and wear sunscreen do not address the behavior of actively tanning, and are therefore inappropriate and irrelevant. A more careful consideration of teenage social norms by Choose Your Cover would generate skin protection approaches that address intentional tanning, such promoting the use sunless tanners to achieve a tanned appearance. Unfortunately, the campaign’s failure to recognize the social norms that motivate teenagers results in its failure to change skin protection behaviors of teenagers.
Teenage Developmental Issues
Psychological and cognitive development also play important roles in determining teenage behavior, but Choose Your Cover does take these developmental issues into consideration. The campaign lacks sensitivity towards teenage attitudes and learning processes. Specifically, Choose Your Cover neglects teenage attitudes and behavior in response to authority. Part of the transition from childhood to adolescence involves the establishment of independence, and this is often characterized by rebellion and defiance (11). The campaign’s authoritative, instructive tone has the intention of preventing teenagers from engaging in the risky behavior of tanning, but it actually has the opposite effect. This boomerang effect can be explained by reactance theory, which predicts that people are threatened by perceived restrictions to their freedom (11, 12). These threats make behaviors resisting the restrictions more attractive. Teenagers have a need to declare independence, and are “predisposed to respond with reactance to any forms of persuasion advocating change in their health-risk behavior” (12). The combination of being “influenced by an awareness of the many social and commercial forces that promote” (11, 12) tanning and an authoritative voice telling them to avoid tanning causes teens to consciously avoid protection and to actively tan.
The Choose Your Cover threatens teenage autonomy not only by merely telling people to avoid tans, but also by advocating for the implementation of policies that would cause social, behavioral and environmental changes. One of these policies would require schools and youth organizations to urge parents and caregivers to routinely provide to their youth advice and information concerning skin cancer prevention. Strangely, the campaign does recognize that teens may interpret this advice as a type of parental control and that “direct influence of parents might decrease and be subordinated by peer influence,” (9) but it fails to suggest an alternative policy. Instead, the campaign treats the reactance as dismissible by saying “nonetheless, family support plays a key role in extending the desirable effects of school skin cancer prevention efforts” (9).
A second campaign policy change is geared towards promoting protective clothing in school, with the hopes that using protective clothing will translate to non-school activities as well. Specifically, the campaign recommends that schools “develop policies that encourage or require students to wear protective clothing, hats, and sunglasses to prevent excessive sun exposure. These measures could be employed during physical education classes, recess, field trips, outdoor sports or band events, and camping or field trips” (9). Again, teenagers will not readily take to this change in policy as it threatens not only their perceived attractiveness, but also their autonomy. Telling kids to wear specific clothes, hats and sunglasses will likely inspire them to avoid wearing these things. Choose Your Cover barely considers reactance theory and teenage attitude in its policies, which sets up the campaign for failure.
Finally, Choose Your Cover is ineffective because the campaign’s guidelines for educational programs are appropriate cognitively and behaviorally only for elementary school children, and not for teenagers. However, the campaign suggests that its materials be used in all levels of schooling. Choose Your Cover acknowledges curriculums should vary with the age of students and that educational “activities should be tailored to the cognitive and behavioral level of the students.” (9) The campaign does a credible job of addressing cognition and learning processes by suggesting that younger student might learn through repetitious rhyming or games, while older students might learn better from more intellectually challenging activities, such as understanding the scientific basis of solar radiation and global climates. These suggestions are cognitively age-appropriate, but the campaign makes no mention of how to shape curriculums to be behaviorally age appropriate. It does not consider that teenagers have unique psychological developmental characteristics that affect how they make decisions.
The Choose Your Cover campaign does not make a distinction between behaviors of younger children and teenagers, and therefore does not address how optimistic bias, perceived susceptibility and perceived invulnerability influence teenage decision-making. Teenagers exercise a high degree of optimistic bias, which causes them to believe that they are less susceptible to unpleasant circumstances than the general population (13). Optimistic bias also causes teens to have an unrealistic perceived delay of onset, which refers to believing in an unrealistically long length of time between the behavior and the occurrence of a negative event associated with the behavior (14). This lack of perceived personal susceptibility and unrealistic perceived delay of onset, and a high degree egocentrism accounts for the “it won’t happen to me” attitude of teenagers, and contributes to their decision-making (13-15). As seen in smoking and lung cancer campaigns, steroid use and muscle deterioration campaigns, and drug use and brain damage campaigns, teenagers are superficially aware of adverse health consequences, but they decide to engage in these risky behaviors because they perceive themselves less susceptible and at times invincible to these health risks (15). Teenage perceived risk of tanning is no different. Teens continue to tan because of their distorted perception of vulnerability; they cannot imagine any other state of being than the “bloom and resilience of youth.”
While education about the health risks caused by tanning is certainly necessary, failing to consider teenage behavior, psychology and decision-making trivializes the message and minimizes the impact of the educational campaign (14). Adjusting educational programs for cognitive ability is not enough. Consideration of how teens make decisions links what teenagers know with how they use that knowledge, and the failure to incorporate optimistic bias into education programs renders Choose Your Cover educational guidelines ineffective.
The Future
With skin cancer rates on the rise, promoting skin protection techniques and discouraging indoor tanning have become increasingly important. The Choose Your Cover campaign is the necessary first step in causing widespread behavior modification, but it must examine tanning from the perspective of children as well as teenagers, and differentiate social and behavioral factors between the two groups in order to be effective. Teenagers engage in risky behaviors not because they are unaware of the dangers of their behaviors, but because they are highly influenced by social norms, are unrealistically optimistic about their futures, and react strongly to authority. Choose Your Cover’s educational approach, therefore, is only half of the battle. Continued emphasis on the dangers of tanning is important, but to effectively reach teenagers and cause behavior change, Choose Your Cover must figure out how to portray tanning as unpopular and unattractive in a manner that does not threaten autonomy but does imply personal risk.
1. Health 24. A History of Tanning. 2006. Available at Accessed April 4, 2007.
2. Randle H. Suntanning: Differences in Perceptions Across History. Mayo Clinic Proceedings. 1997; 72:461-466.
3. American Academy of Dermatology. Skin Disorders and Diseases. 2006. Available at Accessed April 4, 2007.
4. Skin Cancer Foundation. 2007 Skin Cancer Facts. 2007. Available at Accessed April 4, 2007.
5. Jackson K, Aiken L. Social Model of Sun Protection and Sunbathing in Women: The Impact of Health Beliefs, Attitudes, Norms and Self-Efficacy for Sun Protection. Health Psychology. 2000; 19: 469-478.
6. Wichstom L. Predictors of Norwegian Adolescents' Sunbathing and Use of Sunscreen. Health Psychology. 1994; 13: 412-420
7. Jackson K, Aiken L. Evaluation of a Multicomponent Appearance-Based Sun-Protective Intervention for Young Women: Uncovering the Mechanisms of Program Efficacy. Health Psychology. 2006; 25: 34-46
8. MSNBC. Teens know tanning’s risks, do it anyway. 2005. Available at Accessed April 4, 2007.
9. Center for Disease Control and Prevention. Choose Your Cover. 2006. Available at Accessed April 4, 2007.
10. Center for Disease Control and Prevention. Health Youth! Health Topics Skin Cancer. 2006. Available at Accessed April 4, 2007.
11. Dillard J, Shen L. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 2005; 72: 144-168.
12. Czyzewska M, Ginsburg H. Explicit and implicit effects of anti-marijuana and anti-tobacco TV advertisements. Addicted Behaviors. 2007; 32: 114-127.
13. Sjoberg L, Holm L, Ullen H, Brandberg Y. Tanning and Risk Perception in Adolescents. Health, Risk and Society. 2004; 6: 81-94.
14. Chapin J. It Won’t Happen to Me: The Role of Optimistic Bias in African American Teens’ Risky Sexual Practices. The Howard Journal of Communication. 2001; 12: 49-59.
15. Clarke V, Williams T, Arthey S. Skin Type and Optimistic Bias in Relation to the Sun Protection and Suntanning Behaviors of Young Adults. Journal of Behavioral Medicine. 1997; 20: 207-222.

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