Abstract
Perceived social norms are routinely observed as positive predictors of indoor tanning. Past research has suggested that messaging interventions target normative perceptions to reduce indoor tanning behavior. Despite this call, little empirical research has investigated the utility of taking a social norms approach in behavioral interventions. The present study addresses this gap by conducting a quasi-experiment (N = 206) assessing the effect of an intervention message correcting normative misperceptions on indoor tanning intentions at different levels of tanning frequency. Results suggest that tailored normative intervention messages can successfully reduce tanning intentions among high-frequency tanners, those who scored at the 75th and 90th percentile of tanning frequency (f2 for interaction = .015). These results provide preliminary empirical evidence to support previous theorizing on the efficacy of social norms interventions among high-frequency indoor tanners.
Indoor tanning is an undeniable predictor of skin cancer, classified as a Group 1 risk category by the International Agency for Research on Cancer (Robertson & Fitzgerald, 2017). A recent meta-analysis demonstrated that the risk of cutaneous melanoma increased by 20% for those who have ever used indoor tanning beds, and melanoma risk doubles for those who start before age 35 years (Boniol, Autier, Boyle, & Gandini, 2012). In 2014, the U.S. Surgeon General stressed the importance of developing more effective message strategies to reduce indoor tanning, stating that previous interventions are promising but preliminary (U.S. Department of Health and Human Services, 2014). If conventional message interventions to reduce indoor tanning are insufficient, perhaps a novel persuasive technique should be considered. In this brief report, we demonstrate how and why normative intervention messages may be effective to reduce indoor tanning. In particular, we develop individually tailored messages to highlight discrepancies between perceived and actual indoor tanning norms in an attempt to reduce indoor tanning intentions.
Literature Review
Much survey research has shown a positive relationship between perceptions of tanning norms, indoor tanning intentions, and behavior (Cafri et al., 2006; Carcioppolo, Orrego Dunleavy, & Yang, 2017; Hillhouse, Turrisi, & Shields, 2007; Noar, Myrick, Morales-Pico, & Thomas, 2014). Some suggest that normative motivations may be among the most influential predictors of indoor tanning behavior, recommending that future research investigates the efficacy of normative appeals that take a harm reduction strategy to reduce indoor tanning (Hillhouse et al., 2007). Harm reduction strategies aim to reduce indoor tanning rates gradually over time, rather than advocating for immediate cessation, which may cause boomerang effects. For example, advocating cessation among heavy indoor tanners may cause psychological reactance (Hillhouse et al., 2007), whereas messages advocating a reduction in tanning behavior may be more acceptable. Despite the promise of normative interventions in this area, little intervention research has used normative appeals to influence indoor tanning behavior.
To address this gap, we will assess an intervention strategy based on social norms marketing approaches (SNA), a specific type of normative appeal. The purpose of SNA is to develop messages to correct normative misperceptions about a specific behavior in order to yield beneficial behavior changes (Borsari & Carey, 2003). For example, most students overestimate the amount and frequency of peers’ alcohol consumption and their own drinking behavior increases to conform to these normative perceptions (Borsari & Carey, 2003). SNA interventions highlight this normative misperception, which alleviates the normative pressure experienced when drinking with peers, resulting in reduced alcohol consumption (Lewis & Neighbors, 2006). Such campaigns have been successfully implemented as a harm-reduction strategy on a host of college campuses to reduce problematic drinking behavior (Lewis & Neighbors, 2006).
Implementing SNA interventions among indoor tanners requires three steps: (1) survey the target audience to identify the actual indoor tanning norm (e.g., number of tanning sessions in the past year), (2) asking participants to provide their perceptions of the tanning norm (e.g., their best guess about others’ tanning over the past year), and (3) highlighting the discrepancy between the two numbers. Research on alcohol studies found that, in general, the strongest beneficial impact on drinking behavior is observed when normative misperceptions are high, that is, when perceptions of the norm are much higher than the actual behavioral norm.
We argue that correcting normative misperceptions can have both a direct and an indirect effect on indoor tanning intentions. Decades of alcohol studies suggest that correcting normative misperceptions reduces alcohol consumption (Lewis & Neighbors, 2006), providing evidence for a direct effect. In the context of indoor tanning, this relationship is likely influenced by tanning frequency, or the extent to which one uses tanning beds. Previous research in alcohol studies also suggests that normative appeals may function better among high-frequency drinkers (DeJong, 2002). Similarly, highlighting normative misperceptions will likely be more effective among those who tan 100 times per year (drastically above the normative level) than among those who tan 5 times per year (below the normative level). Considering this, the following hypotheses are proposed:
Method
Participants and Procedure
Recruitment occurred at a large, Midwestern university through an online research participation pool. Study eligibility was restricted to females who had used indoor tanning beds at least once in the previous 12 months, as females are much more likely to use indoor tanning beds than males (Demko, Borawski, Debanne, Cooper, & Stange, 2003). Eligible participants (N = 206) filled out a brief, cross-sectional survey assessing their own indoor tanning behavior and normative perceptions, or estimates of the frequency with which the average female tanner at the university used indoor tanning beds over the past 12 months. This information was used to immediately create a tailored message for each participant. After receiving and reading this message, all participants completed a brief posttest measuring demographics, attitudes, beliefs, and indoor tanning intentions. All participants were provided with extra credit. The university institutional review board approved this study.
Stimulus Message
Following normative manipulations conducted in the literature on college drinking behavior (DeJong et al., 2006; Lewis & Neighbors, 2006; Perkins, Linkenbach, Lewis, & Neighbors, 2010), the message manipulation was composed of three main components: (1) participants’ self-report estimate of their own indoor tanning behavior over the past 12 months, to establish a baseline reference for the normative comparison; (2) participants’ estimate of the descriptive norm measured in the pretest (assessing perceptions of indoor tanning frequency other female tanners at the same university engaged in during the past 12 months); and (3) report the actual descriptive norm identified through separate survey research at the university (i.e., 15 indoor tanning sessions over the past year). The actual descriptive norm was identified through survey research, asking participants to identify how often indoor tanners at the university used indoor tanning beds per year. As this was a positively skewed distribution, the median was highlighted in the stimulus materials to provide a more accurate depiction of estimates. Messages were printed and provided to participants to read before taking the posttest. The printed messages featured complementary images (e.g., illustration of a woman and a tanning bed) and colors (soft pinks and light greens) to increase the likelihood that participants would want to read and engage with the materials. A copy of the intervention materials can be obtained by emailing the corresponding author.
Measures
Normative misperceptions were calculated by subtracting the median value of self-reported tanning bed use (15; identified through a separate survey of this population) from participants’ estimates of the tanning norm. This resulted in a scale variable ranging from −13 to 235 (M = 44.51, SD = 52.53). Tanning frequency was assessed using a five-item measure designed to aid recall of past tanning behavior, asking about participants tanning bed use over the previous 2 weeks and 1, 3, 6, and 12 months. Recall items such as these are popular ways by which to assess frequency (Hillhouse et al., 2007; Hillhouse & Turrisi, 2002). Only the estimate for the entire 12 months was used in analysis (M = 31.59; SD = 41.65). Intentions were measured using a three-item scale. The final score was computed as the mean of item scores (α = .81; M = 2.67; SD = 1.08; Hillhouse & Turrisi, 2002). Three covariates were also assessed. Previous research has suggested that indoor tanning is most influenced by three broad classes of constructs: attractiveness beliefs, norms, and susceptibility. The following covariates were included in the analysis: perceived risk, measured using a three-item scale (α = .88; M = 3.85; SD = 0.91) modified from previous research (Witte, Cameron, McKeon, & Berkowitz, 1996), and two measures of attractiveness motivations: general attractiveness (five items, α = .92; M = 3.67; SD = 1.06), assessing the belief that a tanned appearance increases attractiveness, and skin aging (four items, α = .86; M = 3.35; SD = 1.05), assessing the belief that a tanned appearance can decrease attractiveness. Both scales were taken from previous research on indoor tanning (Cafri et al., 2006). The final scores of the covariates were computed as the mean of all item scores.
Results
A simple moderation model was assessed using PROCESS (Model 1), a statistical package for testing direct and indirect effects using OLS regression (Hayes, 2013). See Table 1 for models depicting results with and without covariates. Coefficients reported are standardized. After adjusting for susceptibility, general attractiveness, and skin aging, the model was a significant predictor of indoor tanning intentions, F(6, 199) = 29.45, p < .0001, R2 = .47. There was a positive, significant direct effect of tanning frequency on future intentions, β = .62, SE = .08, t = 7.51, p < .0001, 95% confidence interval (CI) [.46, .79], such that those who tan most often report higher intentions to tan in the future. No significant direct effect was observed for normative misperceptions on tanning intentions, β = −.11, SE = .06, t = −1.73, p = .09, 95% CI [−.24, .02], thus no support was found for Hypothesis 1. However, this was qualified by a significant interaction as the effect of normative misperceptions on tanning intentions varied across different levels of tanning frequency (see Figure 1). We probed this interaction using the pick-a-point approach to identify the effect of normative misperceptions on tanning intentions at different levels of tanning frequency (the 10th, 25th, 50th, 75th, and 90th percentiles of tanning frequency, representing tanning frequency of 2, 6, 16, 40, and 80 times within the past year). The relationship between normative misperceptions and tanning intentions was significant for scores at the 75th percentile of tanning frequency, β = −.13, SE = .06, t = −2.06, p = .04, 95% CI [−.26, −.01]; as well as at the 90th percentile, β = −.23, SE = .08, t = −2.92, p = .004, 95% CI [−.39, −.08]. R2 change = .015, f2 = .015. These results support Hypothesis 2 and suggest that correcting normative misperceptions among high-frequency tanners reduces future tanning intentions among this audience.
Summary of OLS Regression Analysis for Moderation Models (N = 206).
Note. Table details the effects of predictor variables on indoor tanning intentions. Model 1 does not include any covariates; Model 2 adjusts for the effect of other salient predictors of indoor tanning intentions.
p < .05. **p < .01. ***p < .001.
Moderation analysis detailing the relationship between normative misperceptions and indoor tanning intentions at five different percentiles of tanning frequency.
To evaluate the impact of extreme cases of both predictor variables on the model, these values were replaced with the highest standardized scores below 3. The moderation model was significant with or without covariates and thus still supported Hypothesis 2 (see Table 2). The interaction between normative misperceptions and tanning frequency was still significant at the 75th and the 90th percentiles of tanning frequency. R2 change due to interaction was .011. Thus, the inclusion of outliers in the predictor variables did not change the results of the hypothesis testing.
Summary of OLS Regression Analysis for Moderation Models with Outlier Values Replaced (N = 206).
Note. Table details possible effects of predictor variables on indoor tanning intentions with outlier values of both predictors replaced with the highest standardized values below 3. Model 3 does not include any covariates; Model 4 adjusts for the effect of other salient predictors of indoor tanning intentions.
p < .05. **p < .01. ***p < .001.
Discussion
The present report represents a small scale, proof-of-concept demonstration highlighting the importance of normative misperceptions for indoor tanning decision making among high-frequency tanners. The results have implications for indoor tanning theory and applied intervention. First, this study is the first to empirically demonstrate that normative misperceptions, an important predictor of binge drinking, are also related to indoor tanning. For high-frequency tanners, intentions to tan were lowest when normative misperceptions were high, demonstrating that simply drawing attention to the difference between perceived peer behavior and actual peer behavior can influence tanning intentions. These findings contribute to theory by empirically verifying previous theorizing on the contributions of normative perceptions on indoor tanning decision making (Hillhouse et al., 2007). These results suggest that normative interventions targeted toward high-frequency tanners may be most efficacious compared with a normative intervention targeted toward those who tan less frequently.
We also add to this literature by highlighting the importance of discrepancies between normative perceptions and the actual tanning norm. Although we found mixed evidence of a direct effect of misperceptions on tanning intentions—the analysis trimming predictor variable outliers was significant, whereas the analysis without trimming was not—this was qualified by a significant interaction effect, demonstrating that normative misperceptions become more important as tanning frequency increases. These results suggest that interventions designed to convey accurate information about normative indoor tanning bed use may be an efficacious persuasive strategy, especially among high-frequency tanners. It may also prove efficacious to combine normative messaging strategies with other proven intervention strategies. For instance, previous research found that highlighting appearance harms as a result of indoor tanning use (i.e., demonstrating how tanning prematurely ages and wrinkles skin) can reduce tanning intentions and behavior (Hillhouse & Turrisi, 2002). Perhaps adding a normative appeal to appearance-based interventions can increase effectiveness. To provide an example, researchers can show how those who tan at high levels are actually harming their appearance more than those whose tanning behavior is more normative.
Limitations and Future Research
One limitation of this article is that, as preliminary research, it focused on intentions rather than behavioral outcomes. The effect of normative misperceptions on actual tanning behavior remains unknown. Second, the reliance on intentions may not accurately detect potential boomerang effects. Subsequent research should investigate whether normative tanning interventions do not encourage low-frequency tanners to increase their tanning behavior in order to become more normative. Future research should also measure both intention and behavioral outcomes to identify such effects.
While this study provides evidence suggesting that interventions designed to correct normative misperceptions may successfully reduce indoor tanning, there are nevertheless some situations where normative interventions should be avoided. Consider that some tanners visit tanning salons with friends. In these cases, the tanning norms of their friend groups may supersede the tanning norms of the local university population. If a group of friends meet weekly to socialize at the tanning salon, this ritual may be more important than conforming to the more distal normative behavior of other tanners. Future research in this area should be cognizant of this and account for it in measurement to determine the extent to which it may affect the efficacy of normative intervention appeals. Future research should also consider how social norm propagation relates to media consumption. Recent research shows that indoor tanning outcome expectations are associated with interpersonal and social media use but not mass media use (Myrick, Noar, Kelley, & Zeitany, 2017). Understanding how social norms about indoor tanning are communicated may inform intervention distribution strategies.
Conclusion
Norms have been identified as an important motivation for indoor tanning; however, little research has examined the efficacy of using normative messaging appeals to reduce indoor tanning bed use. The present investigation developed tailored messages highlighting normative misperceptions between perceived and actual peer tanning behavior. Results serve as a proof-of-concept demonstration of the efficacy of normative interventions to reduce indoor tanning, particularly among high-frequency indoor tanners.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health, National Cancer Institute R25CA128770 (D. Teegarden) Cancer Prevention Internship Program (Nick Carcioppolo) administered by the Oncological Sciences Center and the Discovery Learning Research Center at Purdue University.