How routine mammography of women under 50 diverts attention from cancer prevention and environmental factors - Lynn Rosenbaum

Setting the stage
Breast cancer in the United States is a highly prevalent and dangerous disease for women. According to the Breast Cancer Fund, a woman has a one in eight chance of getting breast cancer in her lifetime, and more women between the ages of 20 and 59 die from breast cancer than from any other cancer. From the 1930’s to the end of the 1990’s, a woman’s risk of breast cancer continually increased, and between 1973 and 1998 alone, increased by 40%. [1] In the last decade, we have finally seen a decrease in both incidence and mortality for women; however, the research is unclear as to whether these positive results were only relevant to women over age 50 [1,2]. Many sources agree that the decline was probably due mainly to the decrease in post-menopausal hormone replacement therapy which, in 2002, was found to be associated with an increased risk for breast cancer[1].
So what is the most effective way to prevent breast cancer? And what exactly do we mean by prevention? One of the most prevalent public health strategies to address breast cancer is screening through the use of mammograms. According to The American Cancer Society “Getting a mammogram is one of the best things a woman can do to protect her health.” They recommend, “Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.” [3]
But does screening mammography truly prevent breast cancer? In this paper I will argue that an emphasis on routine screening mammography among average risk women under 50 is neither safe nor effective; it directs attention and resources to secondary rather than primary prevention; and it results in minimizing the links between environmental toxins and breast cancer.

Mammograms can be unsafe and ineffective
Although regular mammograms have been shown to offer benefits to post menopausal women, mammograms carry associated risks, and are not proven to offer the same benefits to healthy women under age 50. The first risk of routine mammography screening in premenopausal women is unnecessarily exposing them to radiation, which is potentially dangerous. Although many experts believe that this low-dose exposure radiation is of low risk (perhaps causing 1 additional breast cancer death per 10,000 women) [4], other researchers have argued that the risk has been underestimated and cannot adequately be predicted by models based on higher doses or radiation [1]. It has also been found that “young women with the very mutations that lead them to begin mammography screenings at earlier ages are actually more vulnerable to the cancer-inducing effects of early and repeated exposures to mammograms.” [1]
The second risk of routine mammography is that it may lead to unnecessary medical interventions. Mammograms, particularly for younger women whose breast tissue tends to be more dense and less likely to yield accurate results, can lead to both false positives and false negatives. As a result of false positives, women may end up getting dangerous and unnecessary surgeries and radiation treatments. “It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period.”[5]
In the 1980-1990’s, according to a study by Horner 2009, rates of diagnosis of the non-invasive condition ductal carcinoma in situ (DCIS) increased by 4 times, mostly due to the greater use of mammogram screenings. [1] Because, current medical science cannot tell us which cases of DCIS will end up actually leading to cancer and, in fact, most do not [4], many women have been unnecessarily subjected to the risks of subsequent surgical biopsies, radiation and Tamoxifen.
There is very minimal evidence of benefits to outweigh the above risks. Some research has shown that for women between 40-49, after a seven year follow-up, there was no effect on mortality, and in order to even extend one life, it is estimated that 2500 women would have to be screened regularly. [4]
In 2009, the U.S. Preventive Services Task Force (USPSTF) published a controversial revision to its policies. It weighed the potential benefits (reduced chance of dying from breast cancer) and potential harms (for example, false-positive results and unnecessary biopsies) and then concluded that “there is moderate evidence that the net benefit is small for women aged 40 to 49 years.”
It recommended biennial mammograms to women age 50 and over, rather than annual screenings to women 40 and over, and for women of average risk, age 40-49, it recommended against routine screening. [6]
Despite this report and the evidence cited above, The American Cancer Society, National Cancer Institute, Susan B. Komen and others continue to recommend regular screening mammography for younger women[7], although other organizations such as the Cancer Prevention Coalition and Breast Cancer Action are in accordance with the Task Force’s recommendations in discouraging healthy young women to be screened [8,9]. And then there are those organizations such as the Center for Disease Control which have backed off of any strict recommendations and instead encourage women to talk with their doctors to make an individual decision based on the research and their particular set of conditions [10].
Another problem with a policy of routine mammograms for women under 50 is that women may think that getting a mammogram is all they need to do to avoid getting breast cancer, at the expense of attending to important lifestyle and environmental factors. Women are subject to the “illusion of control,” which refers to the expectation that one has more control over a situation than is objectively warranted by probability. This illusion is enhanced when one is involved or takes action in the situation at hand. [11] So in this case, young healthy women who take a specific action by getting mammogram screenings may feel more in control of preventing the likelihood of their getting breast cancer, even though the mammogram is a tool to potentially detect existing cancer rather than to prevent it and, as argued above, has questionable benefits. In order to truly prevent cancer, that is, address its underlying causes, young women should be encouraged to focus on controllable lifestyle factors, such as diet, exercise and alcohol consumption and perhaps more importantly, on environmental factors, such as toxins which permeate our food, air, water, and consumer products.

Primary versus secondary prevention
An emphasis on mammogram screening directs focus and resources at secondary prevention, that is, researching and promoting how to detect cancer early enough to treat it, instead of at true primary prevention, which identifies and eliminates preventable causes of the disease. The way in which a problem is framed determines what is seen as important. “Elements left out of the story are outside the frame and are thought to be unimportant.” [12] The framing of a medical problem in this way is not limited to breast cancer. “The dominant focus in epidemiology and perhaps the American culture in general is on individually-based risk factors that lie relatively close to disease in a causal chain.” [13] Thus the medical establishment has framed the issue such that both doctors and patients tend to approach breast cancer prevention as an individual level problem – it’s up to individual women to make sure they get regular mammograms and to monitor their individual risk level and their behavior around diet, exercise, and alcohol consumption.
Framing is very important in determining what types of interventions are used to address the problem. The medical establishment tends to frame breast cancer in such a way that leads to “downstream” solutions rather than “upstream” solutions. The money, research, and attention focused on detection, treatment, and finding a cure, greatly outweigh addressing causal factors, such as environmental toxins, which are contributing to the development of the disease in the first place.
The predominant frame described above is reinforced by both public health campaigns and the media. According to Agenda Setting Theory [14], how much the news media covers a particular issue directly affects how important people think the issue is. The media not only reflects the news agenda, but shapes it as well. The media emphasizes mammogram screenings, and to a lesser degree, diet and lifestyle, and thus encourages women to value these same issues. One recent analysis by Michigan State University of news stories covering breast cancer found that 31% focused on treatment, while just 18% addressed prevention [15]. Newspapers, television and advertising offer widespread coverage and promotion of fundraising walks such as the Avon Walk for Breast Cancer and the Susan B. Komen Race for the Cure, which are corporate sponsored and raise money mostly for screening, treatment and finding a cure, while spending very little on primary prevention [7,16].

Environmental factors
One major consequence of the framing of breast cancer as a downstream rather than an upstream issue, is that environmental factors of breast cancer are minimized and under funded. According to researchers at Cornell University, “Because established risk factors for breast cancer account for less than half of all cases, scientists believe environment may play a role in this disease.” [17] And despite the fact that breast cancer research is the most funded of all cancers [18] over the last decade, only a small percentage is spent on environmental links to the disease.
When underlying environmental toxins are addressed, they often point to large corporations, which are responsible for producing harmful chemicals in almost every area of life. These corporations often have a vested interest in continuing to produce these chemicals because of the profits they bring in. The close financial and political ties between large pharmaceutical/chemical corporations and some cancer organizations influence the “anti-cancer” agenda that is promoted. Several progressive organizations such as the Cancer Prevention Coalition, have pointed out that Breast Cancer Awareness Month is completely controlled by Astra/Zeneca, a multimillion dollar donor to the American Cancer Society. Astra/Zeneca is one of the world’s top ten largest pharmaceutical companies, formerly a part of Imperial Chemical Industries, and the producer of Tamoxifen, a drug used in breast cancer treatment and prevention. AstraZeneca retains the right to oversee all of the promotional materials of the awareness campaign and heavily promotes mammograms and treatment – including Tamoxifen – while ignoring links between industrial toxins and breast cancer [19].
Despite the relative lack of funding for research on links between environmental toxins and breast cancer, there is still much that we do know and need to be concerned about. “There are over 85,000 synthetic chemicals on the market, and fewer then 10 percent have been tested for their effects on our health.” [20] The harmful effects of toxins are particularly relevant to breast cancer because many toxins are concentrated in fat and thus breast tissue. And according to the Center for Disease Control and the Environmental Working Group, over 200 chemicals have been found in our body fluids. Furthermore, studies reveal 216 chemicals associated with increased mammary gland tumors in animals [21].
Harmful chemicals reach into virtually every aspect of our lives including our food, air, water, and consumer products. We ingest pesticides and additives in the foods we eat, are exposed to chemicals used in food packaging and production, and are subject to synthetic hormones in milk and meat. For example, recombinant bovine growth hormone (rBGH ) which is given to cows to increase their milk production, has been shown in several studies to contribute to links to increased risk of breast cancer, and has been banned in Europe, Canada and elsewhere. [21]
Plastics, which are used extensively in household products, toys, and electronics, contain many chemicals of concern, such as styrene, bisphenol A (BPA), and phtalates. For example some baby products such as bottles are particularly concerning because they contain a combination of carcinogens, such as vinyl chloride, and several endocrine-disrupting compounds, namely, BPA and phtalates. Cosmetics, including makeup, soap, and sunscreen, are rife with harmful chemicals which may affect our hormonal systems and affect breast development. Some of the chemicals have already been banned in European nations, but are still permitted in the United States. [21]
In sum, young healthy women do not need to undergo routine mammograms and take on their associated risks and resulting unnecessary interventions, all in the name of prevention. Instead, we must address the underlying root causes of the disease, particularly environmental toxins in our daily lives. We need to fund more research on links between environmental toxins and breast cancer, persuade corporations to use more caution in putting untested chemicals into our lives, and demand that our government increase its testing and regulation of harmful chemicals.

An Alternative Approach
So what is a truly effective way to prevent breast cancer among young healthy women? We can focus on changing corporate and governmental practices to remove from our daily lives the environmental toxins that put people at risk for breast cancer. We need to involve and empower young women and others in the population to bring about these changes. It is not enough to recommend that people individually try to avoid toxic chemicals by buying certain consumer products; this is not always possible to do, especially for those with limited income and accessibility. Furthermore, we all deserve to live in a society where we are not exposed to toxins which are known or suspected to increase risk for cancer.
One organization that advocates for this approach is Breast Cancer Action (BCA), a small non-profit organization which often works as part of larger coalitions to make social change. Despite its limited size and budget, it has succeeded in several of its campaigns to change policies. For example, in 2008, BCA’s “Think Before you Pink” campaign, successfully persuaded Yoplait yogurt to change its practices. Yoplait, which is manufactured by General Mills and touted as a “pink” company because it donates money to breast cancer treatment and sponsors the Susan B. Komen Race for the Cure, was producing yogurt from cows treated with rGBH, a suspected cancer-causing hormone. Through an online campaign in which thousands of consumers contacted General Mills in protest, BCA was able to exert enough public pressure to convince the company to commit to sourcing its dairy products from cows not treated with rGBH. After this victory, Dannon yogurt, a competitor, followed suit [22].
Unlike mammography screening, a campaign such as this was safe and effective : there were no medical risks involved for women (though speaking out against the status quo often involves other types of political/social risks.) Women were empowered by taking action, and unlike with mammography, were exerting real control in taking a step to reduce breast cancer risk as opposed to just the illusion of control; the campaign resulted in the actual elimination of the suspected cancer causing hormone from the source of the dairy products.
The Yoplait campaign took a group level approach which enabled change to happen quickly on a large scale, affecting thousands of consumers simultaneously. The campaign also framed the issue as one of primary prevention – targeting the company producing the yogurt, rather than targeting individuals’ buying or eating habits. This is an example of an effective upstream approach.
Finally, by focusing on rGBH, the Yoplait campaign raised awareness of environmental toxins, which not only affected Yoplait, but Dannon as well. Given that these 2 companies represent two thirds of America’s dairy products, it is likely that their change will also affect the practices of farmers, since they will no longer be able to supply these companies with milk unless they stop injecting their cows with the harmful hormone.
We need to continue to launch and expand upon policy campaigns such as the Yoplait example. A current environmental campaign which is in the works and is supported by a coalition of nearly 300 environmental health organizations is the proposed reform of the Toxic Substances Control Act of 1976 [23]. One way to motivate people to join a campaign for changing policy is to emphasize the ways in which women’s freedoms are being threatened by corporations and governmental agencies. According to the theory of psychological reactance, developed by Jack W. Brehm in 1966, as human beings we all need to feel in control of influencing our own environment. When we feel that our ability to be in control is threatened, we will experience “reactance” and resist against whatever is threatening us [24].
We can use this understanding of human psychology to our advantage in crafting a public health campaign. For example, the “Think Before you Pink” campaign used a form of psychological reactance by highlighting the hypocrisy of Yoplait in its giving money to breast cancer organizations while at the same time manufacturing a product thought to increase breast cancer risk. When women learned that they were being used in this way, they likely felt a threat to their sense of control and fairness and were motivated to write to General Mills in protest.
We need to deliver promotional messages to women that show how corporations who market harmful products are taking advantage of the public by profiting off of the chemicals which they produce and similarly, how governmental agencies who design environmental policies are failing to enforce them. As women learn about the way their freedoms are being squashed, they are likely to be motivated to fight back and join a campaign to restore those freedoms. In other words, if women feel like they are being duped, they are likely to take action.
We can make campaigns most effective by using tools honed by the advertising industry, which include making large promises to meet the needs of our target population, supporting these promises and appealing to universal core values [25]. This approach was used very successfully in the late 1990’s by the anti-tobacco Truth Campaign, which significantly reduced smoking rates among Florida youth. The campaign designed commercials, among other tools, aimed at the core value of rebelliousness among youth. They showed young people how they were being manipulated and lied to by big tobacco companies. The campaign promised them the “truth” and opportunities to rebel against the tobacco industry. Youth responded by joining in community activities directed against the tobacco industry and ultimately deterring more young people from starting to smoke [26].
Simon Sinek, a leader from the advertising industry, explains how to create an effective message that will inspire people to action. He describes the “golden circle” of three rings in which the message should start in the center with “why,” your purpose or cause. The “why” relates to universal core values, such as freedom and fairness. (Unfortunately “health” is not as important a core value to most people.) The next outer ring in the golden circle is “how,” the specific actions to take. And the final ring is “what,” the actual results [27].
So, for example, these tools could be applied to the campaign to reform the Toxic Substances Control Act (TSCA). The messages should emphasize the ways in which we are being duped by the law – we have been lead to believe that products brought to market have been tested and are safe, when it fact this is not the case. Thousands of chemicals in the marketplace have never been tested. The message should first introduce the “why” - we want our control back! We don’t want to be manipulated – and joining this campaign will allow all of us to do that. The “how” is to take concrete steps such as contacting legislators, garnering media attention, and raising money. Finally, the “what” is the result that we will all have healthier lives and less risk of breast cancer and other diseases.
In conclusion, in order to prevent breast cancer among young healthy women, we must bring more attention and action to the production, distribution and regulation of environmental toxins in our daily lives. In order to do so we need to inspire the public to put pressure on corporations and governmental agencies which are responsible for the manufacturing and regulation of chemicals. By using lessons learned from the social sciences and advertising, we can effectively mobilize the public to participate in campaigns which are safe and effective and ultimately change policies.

REFERENCES

1. Gray, Janet. State of the Evidence: The Connection Between Breast Cancer and the Environment, 6th Ed, Breast Cancer Fund, 2010.
2. American Cancer Society. Cancer Facts and Figures 2010. Atlanta: American Cancer Society, 2010.
3. American Cancer Society. “Mammograms Matter” 9/14/2010. http://www.cancer.org/Healthy/ToolsandCalculators/Videos/mammograms-matter-video
4. Love, Susan. Dr. Susan Love’s Breast Book, 4th Ed. Cambridge, MA: Da Capo Press, 2005.
5. Edison Imaging Associates. 2009. http://www.njradiology.net/what-is-mammography/
6. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;151:716-726.
7. Susan B. Komen for the Cure. http://ww5.komen.org
8. Cancer Prevention Coalition. http://www.preventcancer.com/
9. Breast Cancer Action. http://bcaction.org/
10. Center for Disease Control. http://www.cdc.gov/cancer/breast/
11. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975;32:311-328.
12. Dorfman, Lori, Lawrence Wallace, and Katie Woodruff. More than a message:Framing public health advocacy to change corporate practices. Health Education & Behavior, Vol. 32 (3): June 2005; 320-336. DOI: 10.1177/1090198105275046
13. Link,BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995;35(extra issue):80-94.
14. McCombs, Maxwell.The Agenda-Setting Function of the Press (Chapter 9). In: Overholser, Geneva and Jamieson, Kathleen Hall, eds. Institutions of American Democracy: The Press. Oxford: Oxford Press, 2006.
15. Michigan State University (2008, April 15). Media Coverage of Breast Cancer Focuses Too Little on Prevention, Study Suggest. Science Daily. http://www.sciencedaily.com/releases/2008/04/080415111718.htm
16. Avon Walk for Breast Cancer. www.avonwalk.org
17. Program on Breast Cancer and environmental Risk Factors. Cornell University. 2010. http://envirocancer.cornell.edu/learning/basics.cfm
18. National Cancer Institute. Funded Research Portfolio http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site
19. Epstein, Samuel and Liza Gross, “The High Stakes of Cancer Prevention.” Tikkun Magazine, Nov/Dec 2000.
20. Breast Cancer Action http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site

21 Nudelman, Janet and Connie Engel. State of the Evidence: From Science to Action. Breast Cancer Fund, 2010
22. Breast Cancer Fund. http://thinkbeforeyoupink.org/?page_id=10
23. Safer Chemicals, Healthy Families. www.saferchemicals.org
24. Dillard, Price James and Michael Pfau. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage Publications, 2002.
25. Siegel, M. and Lotenberg, LD. Chapter 3 in Marketing Social Change: An Opportunity for the Public Health Practitioner, 2nd Ed . Sudbury, MA: Jones and Bartlett, 2007.
26. Bauer, U.E., Johnson, T.M., Hopkins, R.S., and Brooks, R.G. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
27. Simek, Simon. http://www.startwithwhy.com/What/TheBook.aspx

Tanning Bed Use Among Adolescents: Hw the Current Approaches Aimed at Reducing This Behavior Have Failed to Apply Social Science Theories – Rachael B

Introduction

Skin cancer is currently the most commonly diagnosed cancer in the United States, yet it is largely a preventable disease. There are three main categories of skin cancer: basal cell and squamous cell carcinomas, which are not tracked by cancer registries, non-epithelial, and melanomas. Melanomas are the most deadly type of skin cancer. According to the Centers for Disease Control (CDC), in 2007 there were 58,094 people in the United States diagnosed with melanomas of the skin and 8,461 people who died from the disease (1). In 2010, it was expected that there would be 74, 010 new cases of skin cancer (excluding basal and squamous cell), 68,130 of which would be melanomas, and 11,790 deaths from skin cancer, 8,700 of which would be from melanomas (2-4).

Not only is melanoma a significant health problem, but it is also a growing health concern. Over the past several decades, melanoma incidence has increased, especially among women ages 20 to 39. According to the CDC, the U.S. trends in incidence of melanoma show significant increases of 3.1% per year from 1986 to 2006 for men, and 3.0% per year from 1993 to 2006 for women. Melanoma mortality rates have also increased (5).

A primary cause of skin cancer is exposure to UV light. It is thought that approximately 65-90% of melanomas as caused by UV light exposure (6). The International Agency for Research on Cancer (IARC) classifies UV radiation as a Group 1 carcinogen, implying that it is known to cause cancer (7). While for many, primary exposure to UV light occurs through outdoor sunlight, there are also a substantial number of individuals who use artificial light, primarily via tanning beds, to intentionally expose their skin to this danger. Tanning devices such as tanning beds are actually also now classified by IARC in the Group 1 carcinogenic category, the same category that contains cigarettes and plutonium. Many studies over the years have linked tanning bed use to significantly increased risk for skin cancer (8).

The indoor tanning industry has grown tremendously over the past several decades, despite the known health risks. It is reported that on an average day, more than one million Americans will use tanning salons, and in one year, more than 2.3 million teenagers will tan indoors (9-10). Adolescents are a particularly vulnerable group to the risks of tanning. For many people, the majority of extreme exposure to UV light occurs during their adolescent years, and such exposure during one’s youth can lead to skin cancer years up the road.

According to 2005 data from CDC’s Morbidity and Mortality Weekly Report (MMR), 8.7% of teens ages 14 to 17 had used indoor tanning devices, and that percent significantly increased with age, so while only 3% of 14 year-olds reporting indoor tanning, approximately 18% of 17 year-olds reported engaging in the behavior (12). According to MMR’s 2009 Youth Risk Behavior Surveillance data, nationwide, 15.6% of high school students reported having used an indoor tanning device at least once within the prior 12 months (with a prevalence of 25.4% among females and 6.7% among males). Prevalence of indoor tanning also increased with increasing school year: it ranged from 16% among ninth-grade females to 33.7% among twelfth-grade females. Similar trends were seen with the male students (13).

It is clear from this data that a substantial number of adolescents are currently engaging in indoor tanning, and the numbers are only increasing with time. The current approaches aimed at reducing tanning bed use among minors are not working, and this should be considered a major public health concern. Issues that are leading to this failure include the lack of emphasis on parental opinions of indoor tanning, the lack of focus on social behavior, and the use of statistics rather than stories to relay the message that indoor tanning is dangerous.

The Flaws of Current Approaches

Part 1: Parents Need Training, Too

The most common approach that is currently being used to limit minors’ tanning bed use is state law requiring those under the age of 18 to obtain parental consent. There are currently 31 states which require parental consent for minors to use tanning beds, the majority of which require the consent be given in-person (14). Of these 31 states, only 11 have any age limits at all (most don’t allow those less than 14 years old to tan, regardless of parental consent). The rationale for this measure has been that parents will have a better understanding of the health risks than will their children, and thus will deny their children permission to use tanning beds.

While requiring parental consent could be considered a step in the right direction, what this approach does not consider are parental beliefs and parental perceptions surrounding indoor tanning. In a recent study being published this May in the American Journal of Public Health, investigators gathered information on indoor tanning use among adolescents ages 14 to 17 in one-hundred U.S. cities. They found that adolescent use of tanning beds is not significantly associated with residing in a state where youth-access legislation is in place (11). This means that adolescents living in states where parental consent is required are tanning just as frequently as those living in states where parental consent is not required. Thus, the laws requiring parental consent are clearly not serving their intended purpose of decreasing tanning bed use among teenagers.

In their approach, states fail to address social science theories which demonstrate that many parents who may currently use or have previously used tanning beds, or perhaps just spend a lot in time in the sun, are likely to believe or rationalize that tanning beds do not pose a significant threat to their child’s health. When a parent regularly tans, whether it be just in the summer months or year round, at the beach or at a tanning salon, that parent is not likely to either understand or acknowledge the serious harm to which they are exposing themselves. Perhaps the parent has come up with justifications for why it is not unhealthy for them to tan, or perhaps the benefit of looking tan outweighs their concerns for any potential adverse health outcomes. When the parents cannot rationally understand and acknowledge the risks of this behavior, and in doing so disengage from the behavior, how are they expected to actively prevent their children from behaving in such a way?

Cognitive Dissidence Theory states that people will behave in ways which correspond to their beliefs. If a person’s behavior and beliefs are at odds with one another, then that person will either change their behavior to match their beliefs or modify their beliefs to coincide with their behavior (15). It is a theory that explains how people try to make sense out of their behaviors and beliefs (16). Simply by asking parents to give their children consent to engage in a behavior which they do not truly consider dangerous will not result in decreased use of tanning beds among teenagers.

Many believe that federal or state law should completely ban tanning bed use for those under 18. While this would be the most effective way to address the issue, at this point in time, no such laws are in place. Without a change in the law itself, the only way to make these new laws requiring parental consent serve their intended purpose is to reduce the number of parents willing to give their children consent to use tanning beds. In order to do this, we must modify the parents’ attitudes and beliefs about indoor tanning. The best way to accomplish this is to create a movement that the parents can involve themselves with, a movement which will lead to a change in their attitudes towards indoor tanning, and will subsequently lead to a change in their behavior.

Part 2: Lack of Focus on Social Behavior

Public health campaigns aimed at reducing tanning among adolescents primarily approach the issue at the individual level. The CDC has published guidelines for school programs related to skin cancer prevention; however, their recommendations primarily involve changing individual behavior. Tanning-related behaviors such as wearing sunglasses and hats, as well as regularly applying sunscreen are emphasized (17). With such a focus on individual behavior, not enough attention is paid to how one’s social environment affects one’s behaviors. And this is especially important for adolescents, who are greatly impacted by their social networks.

A social science theory which could be used to tie in social factors to reducing the use of tanning beds is the Social Network Theory, which has been largely ignored in this setting. The Social Network Theory is a group level model which is based on the idea that behavior spreads through social networks. This theory states that the behavior of the people in one’s social network is the primary determinant of how that person will behave. Individual’s actions are viewed as interdependent rather than independent (18). Personal relationships become channels for not only the transfer of information but also for the encouragement to continue or disengage in certain behaviors.

Much research has been done on how social networks affect health-related behaviors. One study, published in 2008, investigated the dynamics of smoking within social networks. In the studied population, the researchers found that there existed clusters of smokers and nonsmokers, and that smoking cessation appeared to be related to social networks. Their results indicated that social groups of people were quitting smoking at the same time (19). These results have significant implications for public health interventions. By focusing on getting people within the same social networks to quite unhealthy behaviors together, these disengagements in behaviors will likely spread through that network and possibly even on to other linked networks.

Part 3: Statistics Won’t Cut It

It is well known that many people have a difficult time relating to numbers and statistics, but just how difficult a time do people have understanding health risks when presented as statistics? The Law of Small Numbers suggests that people have a very difficult time interpreting the significance of numbers. Specifically, it suggests that judgmental bias occurs as a result of people assuming that a small sample is representative of a larger sample. People tend to make generalizations based on insufficient data (20). As applied to public health, this theory is relevant because it demonstrates the difficult time that people generally have understanding statistics, and thus their perception of risks from unhealthy behaviors may be distorted.

The CDC has series of podcasts available on their website related to a range of health topics. The podcasts related to indoor tanning primarily use statistics to convey the message that indoor tanning is potentially harmful to one’s health. One podcast states that frequent indoor tanning leads to 2.5 to 3 times increased risk for melanoma (21). Adolescents will have a difficult time interpreting how this statistic applies to their personal risk for the disease. It should also be noted that since no definition for what is considered ‘frequent’ tanning is defined in the podcast, adolescents are likely to consider their own tanning bed use as less than frequent.

The American Academy of Dermatology (AAD) also makes use of statistics in an attempt to demonstrate the dangers of indoor tanning. The AAD has created a series of skin cancer prevention posters aimed at reducing indoor tanning among adolescents. A few of the posters note that one American dies of melanoma almost every hour. Can adolescents (or their parents for that matter) really relate to a fact such as this? Do they understand the health implications of such a statistic?

Rather than using statistics to present the facts to adolescents, which is common among current campaigns, instead we must tell stories that provide familiarity and context. We must tell stories that adolescents can relate to and use these stories as a means to convey the dangers of indoor tanning. The AAD does actually have one young melanoma victim that they use in their campaigns—a woman who had frequented tanning booths as a teenager only to be diagnosed with melanoma at the age of 21. After years of treatment, she finally succumbed to the disease at the age of 29. While this is certainly a compelling story, the AAD does not use the story in a way in which it will have the most impact on adolescent indoor tanning. They have two posters which contain quotes from the woman’s family members, but each of these posters also contains the statistic noted above, regarding one American dying of melanoma almost every hour. They also have a short video clip of the victim’s mother giving a brief account of her story, and in this clip, they end with another statistic about the increased risk of melanoma from indoor tanning. While this story could be used as part of an effective campaign, the current way in which it is being used has many flaws.

New Approaches to the Battle Against Adolescent Indoor Tanning

Part 1: Educate and Sell a Movement to the Parents

Following the arguments made above, it is clear that new approaches are needed in order to reduce tanning bed use among adolescents. One major component of a new approach must address parental views related to the health risks of tanning. In order to change parents’ behavior and encourage them to deny their children the consent to tan indoors, we must sell a movement which involves first educating the parents, then modifying their beliefs about indoor tanning, and in doing so get them to commit to behaving in a way which reflects their new beliefs.

An internet-based program could be developed to create a social network of parents who are dedicated to preventing their teenage children from getting skin cancer. Using the principals of the Cognitive Dissidence Theory, the program must first educate the parents on the dangers of tanning beds, thereby encouraging changes in their attitudes so that instead of thinking of indoor tanning as a social activity that boosts their teenager’s self-confidence, they will think of it as a dangerous activity with the potential for serious adverse health effects. Parents who commit to being part of the movement, especially those who stay actively involved with it, will be more likely to tell their children “no” when it comes to indoor tanning.

Not only will the program need to educate on health risks, but it will also need to shift the parent’s perceptions of tans as looking healthy to tans as being indicators of damaged skin. Thinking of tans in a negative light will make it easier to avoid the behaviors that lead to tans. Emphasis could be place on alternative means to look and feel healthier, such as increased physical fitness, the use of make-up, or different hair styles. Sunless tanning, such as tanning lotions or stray tans, could even be suggested for those that are determined to maintain a ‘bronzed’ appearance. Ultimately, it would add to the benefits of the program if the parents were to pass on their new found knowledge and beliefs to their children. Not only would this impact their child’s tanning habits, but perhaps it would also end up having a positive impact on their own skin protection beliefs, thereby serving a dual purpose.

Part 2: Refocus on Social Networks

Rather than focusing on individual behavior, the new approaches towards reducing tanning bed use among adolescents must involve shifting the focus to adolescent social groups. Campaigns aimed at addressing this public health issue could target social networks through high schools, community centers, religious centers or even local malls. The idea would be to target groups of teenagers rather than individual teens, and in doing so, change the behaviors of entire adolescent social groups at once.

According to the Social Network Theory, people will behave in ways which coincide with the behavior of those in their social networks. If we can get groups of adolescents to commit to eliminating their use of tanning beds, this behavior could spread throughout their social network and later on to other linked networks. A campaign involving public service announcements and group information sessions could address large groups of teenagers at once. On key aspect of the campaign should involve having fellow adolescents serve as the spokespeople, as they will better be able to effectively communicate the message than will adults. Another key component would be specifically targeting locations where teens frequent as a means to reach as many people as possible with each campaign component.

As studies have suggested, not only do negative behaviors spread through social networks, but so do positive ones. Once the behavior of avoiding sunless tanning is adopted, that will become the new norm, and once teens begin to see their friends skipping the tanning salons, they will be far more likely to skip it themselves.

Part 3: Use Stories, Not Statistics

As described above, people do not generally understand the implications of statistics. For this reason, it is typically more effective to use stories to adequately relay messages regarding public health issues. The Canadian Dermatology Association (CDA) has a campaign named “Indoor Tanning is Out,” which does a nice job of using personal stories to relay messages concerning the dangers of indoor tanning (22). The current stories being used are those of six young women who were all frequent tanning bed users. Each of these young women was diagnosed with melanoma, at an age ranging from 18 to 35 years. Reading these women’s stories certainly makes one reconsider their views about participating in a behavior that could lead to cancer at such a young age. These are seemingly normal, average women, and teenagers might think that if this could happen to these women, it could happen to anyone, including themselves.

While the “Indoor Tanning is Out” campaign uses these stories very effectively, the video portion of their program is not nearly as effective, as it doesn’t actually include any of the narratives. A new, effective campaign could use the stories of young women such as the ones used in CDA’s campaign to reach adolescents via media advertising. Profiling the stories of young women with melanoma will make adolescents better able to relate and could serve to change their beliefs related to indoor tanning. If they see that people who were just like they were as teenagers could be affected, they may begin to believe that they too could get skin cancer as a result of using tanning beds.

While indoor tanning campaigns may be aimed at both male and female adolescents, the vast majority of young tanning bed users are female. The melanoma incidence rate is also quite higher among young females than among young males. According to the National Cancer Institute’s Surveillance Epidemiology and End Results, the 2006 to 2008 melanoma incidence among females ages 15 to 34 years was 37.8 per 100,000, while in the same time frame it was 19.4 per 100,000 for males of the same age range. Not only is the melanoma incidence rate higher for young females, but the incidence rate also significantly increased for females from the 1996-1998 to the 2006-2008 time period, while it decreased for males (2).

This data suggests that the most effective campaigns may be those targeting the adolescent female population. When considering whose stories you want to tell in a campaign such as this, telling the stories of young women as opposed to young men, such as the CDA campaign does, will likely have the biggest impact. With melanoma incidence rates at the level that they are and tanning bed use so frequent among female adolescents, one could assume that there are many young women in the United States who have experienced melanoma diagnoses and it is very possible that they were frequent tanning bed users as well. These stories could go a long way in making adolescents think twice before hopping into a tanning bed.

Conclusion

Tanning bed use among adolescents is common, especially among sixteen and seventeen-year-old females. While in many societies this is considered the normal behavior by the teens as well as by their parents, there are serious health risks associated with tanning bed use, specifically the occurrence of melanoma. Current approaches aimed at reducing tanning bed use among adolescents include state laws requiring parental consent for those under 18, targeting changes in individual behavior, and using epidemiological statistics to explain the risks associated with the behavior. The common problem among these approaches is that they fail to apply social science theories and therefore have substantial flaws which will result in their failure to reduce teenage tanning bed use.

New approaches must incorporate social science theories in order to be effective. Cognitive Dissidence Theory, Social Network Theory and the Law of Small Numbers are among the theories which could be applied to interventions aimed at addressing this public health issue. Changing the attitudes and believes, and consequently the behavior of parents who consent to their children using tanning beds is one important tactic. Next, implementing campaigns targeted at influencing teen behavior through social networks is a must. Finally, using stories rather than statistics will be a much more effective means to make an impact on adolescent tanning behaviors.

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