In-group rationalizations of risk and indoor tanning: A textual analysis of an online forum

Abstract

Unlike other health behaviors, there does not appear to be a strong relationship between perceived skin cancer risk and reduction or cessation of indoor tanning bed use. This study seeks to address this inconsistency by determining how indoor tanning bed users rationalize skin cancer risk with their tanning behavior. Qualitative textual analysis of indoor tanning message board posts (N = 330) revealed varied perceptions of risk, including acknowledging the risk of indoor tanning; denying or downplaying risk, often citing perceived health benefits associated with tanning; blaming outside forces for cancer, such as lotion or genetics; and fatalistic beliefs about cancer. These results highlight the nuanced relationship between perceived skin cancer risk and indoor tanning bed use.

Keywords

indoor tanning message board analysis risk perceptions skin cancer

Perceived risk, often conceptualized as perceived susceptibility and severity of a particular health concern, is often viewed as a primary motivator for the development, reinforcement, and change of health behaviors (Champion and Skinner, 2008). Troublingly, the relationship between perceived cancer risk and ultraviolet (UV) exposure reduction has been inconsistent at best. Some have found a significant, negative relationship between perceived risk and protective intentions and behavior (Jackson and Aiken, 2000; Lamanna, 2004), some have not (Greene et al., 2010), and some found mixed results comparing types of messaging materials (Greene and Brinn, 2003). These varied conclusions are reflected in current theorizing on motivations to reduce indoor tanning (IT), which suggests that appearance-based motivations have the strongest relationship with IT, followed by socio-normative motivations, and perceived health threats (Hillhouse et al., 2008).

The lack of clear relationships witnessed between cancer risk perceptions and IT suggests one of the three possible reasons: (1) indoor tanners are more concerned with immediate perceived appearance benefits than long-term health effects, as previously suggested (Cafri et al., 2006; Hillhouse et al., 1999); (2) the relationship between perceived cancer risk and IT is more complex than currently represented in the literature; or (3) the presence of intervening mediating or moderating variables such as self-efficacy.

While any or all of these are possible, there is merit in beginning this investigation by determining how indoor tanners perceive cancer risk before exploring potential intervening variables between perceived risk and health behaviors. Scientific literature and media representations are in conflict about the connection between IT and skin cancer. For instance, some medical doctors talk about the benefits of IT as a way to increase vitamin D exposure (Tangpricha et al., 2004). Vitamin D has drawn much research attention lately in clinical studies for its possible role in preventing certain cancers, including breast, colon, and prostate cancers (see Fleet, 2008). The tanning industry has capitalized on this research, citing it as a health benefit associated with IT (Reykdal and Smith, 2009). Similarly, there are researchers who advocate IT as a safer alternative to sunbathing, citing the fact that UV dosage is carefully controlled to minimize burning and emit a consistent level of radiation, compared to unpredictable UV levels of sun exposure (Sayre and Dowdy, 2003). A content analysis from the Harvard Medical School explored advertising strategies used in IT ads, finding numerous similarities with tobacco advertising concerning how messages incorporate scientific evidence to mitigate health concerns, appeal to beliefs of the social acceptability of tanning, and emphasize the mood-elevating benefits of tanning (Greenman and Jones, 2010). Others have found that IT advertisements frequently target adolescents, advertising “unlimited” tanning packages while ignoring the cancer risk that such an endorsement could yield (Freeman et al., 2006). These inconsistent messages likely affect indoor tanners’ conceptualization of cancer risk, as some research suggests that tanning bed users believe that IT is safe (e.g. Hoerster et al., 2009), or at least safer than sunbathing (e.g. Mackay et al., 2007). This highlights the importance of understanding how indoor tanners perceive and rationalize skin cancer risk.

One way to investigate this relationship is to study in-group rationalizations about cancer that occur on IT message boards. As opposed to structured interviews or survey research, using qualitative research methods to analyze message board posts allows a form of observational research removing the researcher from the process; this mitigates any response bias from interaction with out-group members (the researchers), allowing for a more honest discussion. This type of research is also crucial for understanding how indoor tanners conceptualize and justify their risky behavior to other members of their community, which may become the basis for others’ future argumentation strategies. This approach is consistent with previous research investigating health-based message board interactions (e.g. Gooden and Winefield, 2007). Our study seeks to describe the ways in which people talk about cancer risk on IT message boards, and in doing so, advance our theoretical understanding of the impact of cancer risk perceptions on IT.

1. Methods

Materials

An Internet search was conducted with the following search terms to identify websites for inclusion: “indoor tanning” AND “message board”; “indoor tanning” AND “forum;” “tanning message board;” AND “tanning forum.” These searches yielded three websites that had message boards targeted toward indoor tanners: www.iamtan.com, www.tantalk.com, and www.tantoday.com. We chose only to include posts from www.iamtan.com.¹ The other forums were geared toward tanning salon owners. Institutional Review Board (IRB) approval was not required: these data were publicly available online for viewing without a password.

All forum posts were searched using the term “cancer”; 291 threads were identified in which the word “cancer” appeared. In these 291 threads, there were 3594 individual posts; however many posts were unrelated to the search term. To narrow our sample to a manageable number of posts accurately reflecting our search term, we restricted the sample in two ways: (1) threads must be related to skin cancer and (2) threads must reference cancer in the first post.² These qualifications yielded a sample consisting of 82 threads and 1028 posts. Of these, 698 did not reference cancer and were excluded, yielding a final total of 330 posts. Materials analyzed were posted between June 2009 and March 2013.

Analysis

Qualitative, conventional content analysis was conducted of IT message board posts (Hsieh and Shannon, 2005). This methodology was chosen because categories displayed in the data were not necessarily mutually exclusive; it is possible for one to acknowledge the connection between tanning and cancer as well as display fatalistic beliefs about cancer, which may be obscured using alternative content analysis techniques.

The procedure consisted of three main stages: open coding, axial coding, and selective coding, conducted by three of the authors (E.V.C., A.M.G., and T.S.). In Stage 1, the authors separately read through a random selection of 10% of the message board threads and engaged in open coding to identify themes (Glaser and Strauss, 2009; Strauss and Corbin, 1998). The researchers read each post and highlighted key words or phrases, identifying one or more themes for each post. During Stage 2, axial coding, the researchers met to discuss their conclusions, triangulate perspectives, and develop connections between individual themes identified in Stage 1 (Lindlof and Taylor, 2010). Constant comparison was used to identify similarities and differences between the initial coding, and conceptually similar codes were grouped. Five categories were developed concerning IT risk rationalization, presented below. In Stage 3, the researchers read through all posts together and selectively coded data that pertained to each category (Strauss and Corbin, 1998).

2. Results

Acknowledgement

The majority of posts about skin cancer on this message board acknowledged the connection between IT and skin cancer (n = 230; 69.7%). These posts expressed distress, or otherwise acknowledged the connection between IT and skin cancer. Table 1 represents categories identified through the thematic analysis. To illustrate, the following post explicitly acknowledges the connection between IT and cancer risk:

The tanning reaction is a result of DNA damage. Your skin gets “hurt” so it makes itself darker to protect it next time. All moles are tumors of some sort, some (melanoma) are fasting growing and spreading (cancerous). If you are concerned about increasing your risk of melanoma, do not tan at all. There is no “safe” tanning, indoors or out. If you are not okay with increasing your risk of UV related skin cancer, get a spray tan.

Table 1.

Categories identified through thematic analysis.

Thematic category	Frequency	Qualities	Exemplar
Acknowledgement	230/330 (69.7%)	Express distress or perceived risk at prospects of getting cancer from indoor tanning bed use.	“I am ALWAYS worried. I get my moles checked out every year. I take vitamins (mostly antioxdants) every day, I drink a lot of water, and I try not to tan that often. I prob go like once a week or once every 2 weeks. I actually had a skin cancer scare a week ago I noticed one of my moles got bigger so I got it checked out right away lol, thank goodness I’m fine.”
Uncertainty	15/330 (4.5%)	Question whether indoor tanning is related to skin cancer.	“[…] does the tanning cause, or should I say, put you at higher risk for cancer? Or is it repeatedly burning your skin that causes cancer?”
Denial	55/330 (16.7%)	Deny or downplay the risk of skin cancer from indoor tanning bed use.	“[…] realistically there is NO real proof that tanning or the sun causes skin cancer. Im in Arizon and there is a new episode of 20/20 tonight and on of the stories is on tanning beds … and their ‘dangers’.”
Outside forces	42/330 (12.7%)	Attribute association between skin cancer and indoor tanning to outside forces, such as genetics or lotions.	“Fact: There is more evidence linking chemical sunscreens (most commonly used) to potential cancer causes than tanning. Fact: While there is and never had been a conclusive link between tanning and skin cancer, overexposure (slight to major burning) to UV light is one of many probable causes. Fact: There are many potential sources of cancer and every cancer case between every person can be from different sources and produce different results. Smoking can be a probable cause of skin cancer, living near a polluted factory, etc.”
Fatalistic beliefs	53/330 (16.1%)	Believe that everything causes cancer or that there is nothing that can be done to prevent cancer.	“EVERYTHING causes cancer nowadays. I mean the way all the scientists talk, we should all have cancer right now. Makes people want to hole up in their houses and never go outside.”

UV: ultraviolet.

Some posts that acknowledge the connection between tanning and cancer do not acknowledge the severity of skin cancer:

I don’t understand. Everything I’ve read says skin cancer is very treatable, especially if it is caught early. If that is true, what is so wrong with tanning year-round as long as you’re getting checked every few months or so for skin cancer? I feel like I’m missing something here.

One poster accepts that tanning likely influenced her cancer, but feels unable to quit. This is consistent with recent research suggesting that some people demonstrate clinical symptoms of addiction to the UV light emitted by IT beds (Mosher and Danoff-Burg, 2010):

I just had basal cell cancer removed from my arm and was ordered to stop tanning. I originally planned on listening and getting the other questionable spots tested, but after not tanning for a few weeks I know I can’t keep it up. I plan on purchasing a month of tanning …

A final way that people acknowledged the connection between IT and cancer was through touting the cancer-preventive properties of other substances and products. People discussed various strategies to ameliorate risks associated with IT: drinking coffee, taking grape seed extract, using lotions with forskolin (to increase the skin’s resistance to UV burning), and a handful of commercial products to prevent skin damage to combat cancer risk. These tips were often accompanied by a link to an article detailing the results of recent scientific investigations. To illustrate, one poster published a link to a peer-reviewed article that uses mouse-models to show that caffeine can decrease skin carcinogenesis.

Uncertainty

This category included indecisiveness about whether IT was related to cancer. It manifested most-often in a question about the link between IT and cancer, but also when people were non-committal about the link between skin cancer and tanning. It was less frequent for people to display uncertainty about the connection between IT and skin cancer (n = 15; 4.5%). Often, uncertainty was expressed in the form of a question starting a discussion about IT and skin cancer (Table 1).

Denial

Nearly one in seven cancer-related posts contained elements of denial of the link between skin cancer and IT, or downplayed the link by highlighting the health benefits of IT (n = 55; 16.7%). These posts often used strong language and incorporated logic-based argumentation. As an example, this response was posted to a question about whether there is a connection between IT and cancer:

There is TONS of research going on. There is no link to tanning and skin cancer. None. What the media finds is a report or two and they ignore the word “overexposure”. Cigarettes are bad, but if you smoke one a day it will have minimal impact. Smoke a pack a day and you are overexposed thus exceeding the body’s capacity to remove the harmful toxins. Someone also said most drowning are linked to water. Is water deadly? Lol.

Posts incorporating denial appeared to be the most strongly worded. Consider the following exemplar from a frequent poster who used science-based argumentation to challenge the link between IT and skin cancer:

The tanning causes skin cancer is simply a myth. There is enough evidence out there that regular sun exposure helps to treat skin cancer and reverse it, and prevent it. There is a greater factor into play, such as your diet rich in animal fats and proteins that do cause everything bad for you to happen (literally), lifestyle and to a smaller degree carcinogens in the environment (such as toxins in tap water) or toxins applied to your skin from cosmetics to a lesser degree. Eventually, carcinogens from the air due to radioactive isotopes will become a large factor in cancers.

Another common argument was to downplay possible links between tanning and cancer by highlighting the cancer-preventive properties of vitamin D through UV exposure:

Lets just face the facts, and those are that there has never been any research done on indoor tanners to prove that it causes skin cancer, in fact research does show that 75% of cases of melanoma (the only type of skin cancer that is deadly) occurs MOST OFTEN in INDOOR workers…not construction workers who spend all day in the sun! So obviously there is no clear cut connection. […]VIT D which we get from the sun MEDIATES OVER 29 DIFFERENT types of cancer (including but not limited to breast and ovarian for women, testicular for men) …

Outside forces

Sometimes forum posters blamed factors other than UV exposure for increased skin cancer rates (n = 42; 12.7%). Many believe that skin cancer incidence is largely determined by genetics: “Those with fairer skin types and family history are more prone to cancer and general damage than those with other genetics.” Another popular outside cause of IT was burning due to UV exposure. The researchers coded this as an outside force because of the way it was discussed on the forum; people tended to distinguish between tanning as a treatment effect of UV exposure, and burning as a side effect. Burning was often viewed as the true culprit:

from everything i’ve learned (which is proably only 1% of information out there), the biggest risks for skin cancer is from repeated sunburns especially during childhood. if that’s the case i’m a lost cause, back then everyone believed you have to burn first to get a tan. no one in my family has had a diagnosis of skin cancer. i am naturally fair, so if i stick with tanning indoors i dont get burned. outdoors, if i’m not really careful i will burn …

A final reason for the association between IT and skin cancer was tanning lotions and sunscreen:

I have read more information on SPF-chemicals being bad for your skin lately than anything else AND there have been studies that using SPF causes skin cancer …

Fatalistic beliefs

Fatalistic beliefs were defined as content that matches Powe and Finnie’s (2003) conceptualization of cancer fatalism: there is nothing one can do to prevent cancer (n = 53; 16.1%). As examples, “if you are going to get cancer you just are and if you arent you arent …” In response to a post that asks people if they will stop tanning now that research exists connecting IT and cancer: “Nope it didn’t affect me. […] everything can cause cancer so probably in my lifetime I will get some kind of cancer sooner or later.”

Co-Occurrence of themes

Individuals may hold multiple orientations toward cancer risk, identified through categorical co-occurrences. The most common co-occurrence was the belief that tanning could cause cancer and that outside forces caused cancer (n = 23; 7%). Generally, these arguments were used together in an effort to justify IT, stating that although cancer may be a possible outcome of IT, skin cancer could also be caused by genetics, lotions, and other outside forces. The next most common co-occurrence was the belief that tanning could cause cancer and holding fatalistic beliefs about cancer (n = 19; 5.8%). This manifested in posters acknowledging the connection between tanning and cancer, but also arguing that everything can cause cancer, so why deny yourself? Other co-occurrences were minimal.

3. Conclusion

Unlike other site-specific cancers, skin cancer risk perceptions do not appear to range solely from low- to high-risk of cancer. Our results suggest there are at least four distinct ways in which people conceptualize and rationalize skin cancer risk associated with IT: (1) those who acknowledge the risk but choose to tan anyway, (2) those who deny IT is associated with cancer, or believe the cancer-preventive benefits of vitamin D through UV exposure outweigh risk, (3) people who believe that other factors are responsible for the association between tanning beds and cancer, and (4) those who hold fatalistic views about cancer.³

Although most posters acknowledged that tanning can cause skin cancer, there was a clear lack of concern. This finding is consistent with previous research suggesting that indoor tanners tend to value short-term benefits in perceived attractiveness over long-term health consequences (Hillhouse et al., 2008). If people generally believe that skin cancer is treatable and not serious, then it may be necessary to test alternative messaging strategies beyond traditional fear appeals: messages highlighting the financial burden of skin cancer treatment, or emphasizing the decrease in general attractiveness associated with skin cancer removal and scarring.

A number of forum posts did not recognize the connection between IT and cancer: they tended to come from a small, but vocal contingency of users. These arguments may influence other users and change the ways in which others will defend their own IT. Many of these posts incorporated scientific research highlighting cancer-preventive benefits of vitamin D, a by-product of IT, despite the Centers for Disease Control and Prevention (CDC)’s efforts to counteract this belief.⁴

Perhaps most noteworthy was that people used outside forces to explain the connection between IT and skin cancer. Many forum users appear eager to blame other phenomena, such as genetics or chemicals included in lotions, for increasing skin cancer incidence. This finding is important as it shows that people are concerned about cancer risk, but deny the dangers of tanning behavior. Tanners also tended to blame burning as the source of cancer. Although burning increases risk of cancer beyond tanning alone, it is not solely responsible for cancer incidence (Owen and Telfer, 2005).

Fatalistic beliefs were also a common theme. Many believed that everything causes cancer, and nothing can prevent it. This viewpoint may be especially difficult to combat. Much research has shown that cancer fatalism negatively impacts prevention and screening behaviors, but little work has been done to combat fatalistic beliefs, a gap that should be filled.

Some risk rationalizations identified here are similar to those suggested by research on different health topics. DeSantis (2002) found that cigar smokers rationalize their cancer risk by downplaying the danger of cigars compared to cigarettes and rationalized their own risk by highlighting the health benefits of cigars, such as reduced stress. Others have downplayed the risk of contracting a sexually transmitted infection by highlighting the perceived benefits of unprotected sex, such as enhanced pleasure (Sheer and Cline, 1994). These studies support our findings, suggesting that people tend to rationalize risk in similar ways across health contexts.

Cognitive dissonance theory (CDT) may help make sense of these categories. CDT suggests that dissonance arises from perceived inconsistency between attitudes and actions (Festinger, 1957). If indoor tanners feel their behavior can cause cancer, dissonant cognitions could arise. To reduce dissonance, one can (1) increase the value or salience of pro-tanning cognitions (reinforcing the perceived health benefits of IT), (2) decrease the value or salience of anti-tanning cognitions (downplaying the risk of cancer from tanning beds by arguing outside forces cause cancer, or incorporating fatalistic views), or (3) stop performing the dissonance-causing behavior. Our study gives insight into the types of argument indoor tanners could use to reduce dissonance and rationalize their behavior. This information is essential to develop persuasive message materials to combat these attitudes.

Moreover, these results can advance our theoretical understanding of IT. For instance, models that utilize fear appeal constructs, such as the extended parallel process model (Witte, 1994) and the health belief model (Janz and Becker, 1984), may help to understand IT behavior among people who acknowledge the link between IT and skin cancer, but perhaps not for those who have alternative representations. People who deny the risk, or blame outside forces for cancer incidence, may respond to other frameworks. For instance, frameworks such as the theory of normative social behavior (Rimal and Real, 2005) may be better suited to model IT than traditional fear-based models, as much research highlights the normative aspects of IT (Hillhouse et al., 2007). Others have developed attitudinal frameworks to assess IT, such as the physical attractiveness reasons for tanning scale (PARTS, Cafri et al., 2006). It is possible that people who hold different cancer risk perceptions may also hold different IT attitudes. One strategy to advance theory in this area would be to explore the extent to which IT attitudes vary among people with qualitatively different skin cancer risk perceptions related to IT.

Limitations & future research

A limitation of this study is its generalizability. First, website users may not represent all IT bed users. Hillhouse et al. (2008) suggest that there are four types of indoor tanners, ranging from infrequent, event-tanners to regular, habitual tanners. People who use message boards devoted to IT may be highly vested in the behavior, thus more likely to be regular tanners. It is unclear the extent to which cancer risk perceptions of regular tanners represent those of different types of tanning bed users. Second, the data were from one website only. Third, qualitative analysis techniques can limit generalizability. Still, these results are valuable as they begin to describe the different views that tanners can hold regarding perceptions of cancer risk and IT behavior.

Future research could explore the extent to which these perceptions occur in the larger population of indoor tanners and focus on developing and validating measures to determine people’s perceptions of IT risk, and upon doing so, explore any attitudinal, normative, or behavioral differences among these groups that researchers can target in subsequent interventions. Another avenue for research would be to connect rationalizations of risk identified here with promotional materials from the IT industry to determine the extent to which industry messages influence risk perceptions. Finally, future tailored interventions can benefit from this research by developing different message strategies for various skin cancer risk perceptions related to IT.

Footnotes

Acknowledgements

The authors would like to thank Chan Proctor for her help in the initial phases of this project.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Notes

Author biographies

Nick Carcioppolo (PhD, Purdue University) is an Assistant Professor in the Department of Communication Studies at the University of Miami. His research in cancer communication focuses largely on the development and assessment of interventions to increase cancer prevention and screening practices.

Elena V. Chudnovskaya holds MBA and MA in Communication from Ball State University. She is a PhD student in Communication Studies at the University of Miami.

Andrea Martinez Gonzalez is a PhD Student at University of Illinois at Urbana–Champaign.

Tyler Stephan is an MA student at the University of Miami.

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