Cost-effectiveness of a policy-based intervention to reduce melanoma and other skin cancers associated with indoor tanning.

BACKGROUND: The use of indoor tanning devices causes melanoma and other skin cancers with resulting morbidity, mortality and increased healthcare costs. Policymakers require robust economic evidence to inform decisions about a possible ban of such devices to mitigate these burdens. OBJECTIVES: To assess the health costs and consequences of introducing a policy-based intervention across England to ban commercial indoor tanning with an accompanying public information campaign. METHODS: A cost-effectiveness analysis, adopting a healthcare system perspective, was conducted using a decision model to track a national cohort of 18-year-olds over a lifetime time horizon. A nationwide ban on commercial indoor tanning combined with a public information campaign (the policy-based intervention) was compared with the status quo of availability of commercial indoor tanning. The expected costs (currency, GBP; price year, 2019) and quality-adjusted life-years (QALYs) were calculated. Net monetary benefit (NMB) (net benefit measured in cost compared with an accepted threshold) and net health benefit (NHB) (net gain in QALYs compared with an accepted threshold) of implementation were calculated. A probabilistic sensitivity analysis was used to calculate the probability that the intervention was cost-effective. RESULTS: Compared with the current situation, a ban on commercial indoor tanning combined with a public information campaign would result in 1206 avoided cases of melanoma, 207 fewer melanoma deaths and 3987 averted cases of keratinocyte cancers over the lifetime of all 18-year-olds (n = 618 873) living in England in 2019. An additional 497 QALYs would be realized along with healthcare cost-savings of £697 858. This intervention would result in an NMB of £10.6m and an NHB of 530 QALYS. Multiple sensitivity analyses confirmed the robustness of the findings. At a cost-effectiveness threshold of £20 000, there is a 99% likelihood of this policy-based intervention being cost-effective. CONCLUSIONS: The implementation of a ban on commercial indoor tanning across England with an accompanying public information campaign would be an effective use of healthcare resources.

A qualitative review of misinformation and conspiracy theories in skin cancer.

Misinformation on diseases and treatments is a worldwide threat and can lead to worse outcomes for patients with skin cancer. The aim of this study was to qualitatively assess the content of online misinformation related to skin cancer. Searches were performed via PubMed and Google using the terms 'skin cancer' OR 'melanoma' OR 'non-melanoma skin cancer' OR 'SCC' OR 'BCC' AND 'misinformation' OR 'disinformation' OR 'conspiracy theories'. The most common themes of misinformation related to skin cancer included assertions of the 'dangers' of using sunscreen and alternative sunscreen practices; promotion of tanning and Melanotan (an unlicensed and untested form of α-melanocyte-stimulating hormone) as safe practices; claims that risk of skin cancer are limited to people who are older or have fair skin; and assertions of alternative 'causes' and alternative 'cures' for skin cancer. Sunscreen was particularly vilified as being an ineffective prophylactic measure and a cause of skin cancer. Dermatologists should be aware of misinformation available online relating to skin cancer, and refute and rebut misleading health information.

Encouraging sun protection early in life: from a successful prevention programme in children to the identification of psychological barriers in adolescents.

Children and adolescents have high rates of sunburn and high levels of ultraviolet radiation (UVR) exposure and are therefore at risk of developing skin cancer in later life. Minimizing UVR exposure in childhood and adolescence may be the most important component of skin cancer prevention efforts. Thus, age-adapted prevention campaigns, targeting children, adolescents and caregivers, are needed to change sun protection behaviour among individuals in these age groups. In the first part of this review, we describe the 'SunPass' programme, which was initiated in Germany in 2010 as the first nationwide educational intervention for sun safety designed to teach kindergarten children and their caregivers how to protect themselves from overexposure to the sun. Implemented in 55 kindergartens, this programme has been shown to be effective at improving sun protection behaviour (P < 0.001) and hat use (P = 0.029) among kindergarten children, as well as at improving shade practices and increasing demand for protective clothing (P < 0.001). Up to 40 000 children, 50 000 parents/grandparents and 2500 kindergarten caregivers took part in the SunPass programme in Germany from 2019 to June 2021. The programme has also been adapted and implemented in several other European countries and could be readily adapted for use elsewhere. In the second part of this review, we discuss the specific challenges faced by adolescents and consider how these issues may impact their sun protection behaviour. Adolescents have difficulties suppressing responses to reward-related cues and projecting themselves into the future. They also place a lot of importance on social acceptance and cosmetic appearance, and their higher risk of depression, addiction and impulsivity make them vulnerable to tanning addiction. These specificities need to be acknowledged by dermatologists, so they can adapt their therapeutic relationship and develop effective sun protection interventions for this generation.

Acculturation, Sun Tanning Behavior, and Tanning Attitudes Among Asian College Students in the Northeastern USA.

BACKGROUND: College students participate in high levels of tanning, a skin cancer risk behavior due to ultraviolet radiation exposure, yet little is known about Asian college students' behavior. This study examined the relationship between tanning attitudes, acculturation to the USA (cultural assimilation), and tanning behavior. METHOD: An online survey was used to recruit 211 Asian college students in the northeastern USA (47.4% born outside of the USA) to respond to questions about recent tanning behavior, sun protection strategies, attitudes about tanning, and acculturation to the USA. RESULTS: Attitudes about tanning, particularly desire for a darker skin tone and social norms, along with acculturation to the USA, were predictive of intentional tanning. The sample reported high levels of sun protection, which was associated with low acculturation. CONCLUSION: The significant role of acculturation in this study indicates that it may be a useful factor to include in future tanning intervention studies of relevant populations.

Effects of Engagement with a Social Media Campaign for Mothers to Prevent Indoor Tanning by Teens in a Randomized Trial.

In a social media campaign aimed at reducing mothers' permissiveness for indoor tanning (IT) by their teenage daughters, a secondary analysis of campaign engagement effects on IT outcomes was performed. Mothers (n = 869) with daughters aged 14-17 were recruited in 34 states that did not ban IT by minors under age 18 for a randomized trial with follow-up at 12 months (end of intervention) and 18 months (6 months after intervention) post-randomization. Daughters' (n = 469) baseline and follow-up responses were analyzed too. Mothers received a Facebook feed on adolescent health topics that included posts about preventing IT (intervention) or prescription drug misuse (control). Engagement was measured by extracting reactions (e.g., like, sad, etc.) and comments posted by mothers to the campaign posts. Overall, 76.4% of posts received a reaction and/or comment. Mothers who engaged with IT posts were less permissive of daughters' IT immediately at the conclusion of the campaign (permit IT: -0.39, p < .05; facilitate IT: -0.29, p < .05) and 6 months after intervention (permit IT: -0.32, p < .05; facilitate IT: -0.31, p < .05) than mothers who did not engage with posts. Engagement with posts was essential to the success of a social media campaign for preventing IT by minors by reducing mothers' permissiveness.

Artificial tanning devices (Sunbeds): where do we stand?

Exposure to ultraviolet radiation emitted by indoor tanning devices (sunbeds) has well-documented negative effects on human health, but no clear benefit beyond cosmetic outcomes. Sunbed use is responsible for a significant proportion of both melanoma and non-melanoma skin cancers, especially in patients exposed to this practice in early life, premature skin ageing, immunosuppression, skin burns, and eye damage. Artificial tanning is now seen as a public health issue. In this review we discuss the potential additive effect of indoor tanning, misleading facts regarding sunbed benefit, safety concerns and negative effects on human health, indoor tanning legislation and current position of several international organisations, and the impact of some policies adopted in order to mitigate the effects of this dangerous practice.

To ban or not to ban tanning bed use for minors: A cost-effectiveness analysis from multiple US perspectives for invasive melanoma.

BACKGROUND: Tanning bed use is common among US adolescents, but is associated with increased melanoma risk. The decision to ban tanning bed use by adolescents should be made in consideration of the potential health benefits and costs. METHODS: The US population aged 14 to 17 years was modeled by microsimulation, which compared ban versus no ban strategies. Lifetime quality-adjusted life years (QALYs) and costs were estimated from a health care sector perspective and two societal perspectives: with and without the costs of policy enforcement and the economic losses of the indoor-tanning bed industry. RESULTS: Full adherence to the ban prevented 15,102 melanoma cases and 3299 recurrences among 17.1 million minors, saving $61in formal and informal health care costs per minor and providing an increase of 0.0002 QALYs. Despite the intervention costs of the ban and the economic losses to the indoor-tanning industry, banning was still the dominant strategy, with a savings of $12 per minor and $205.4 million among 17.1 million minors. Findings were robust against varying inspection costs and ban compliance, but were sensitive to lower excess risk of melanoma with early exposure to tanning beds. CONCLUSIONS: A ban on tanning beds for minors potentially lowers costs and increases cost effectiveness. Even after accounting for the costs of implementing a ban, it may be considered cost effective. Even after accounting for the costs of implementing a ban and economic losses in the indoor-tanning industry, a tanning bed ban for US minors may be considered cost effective. A ban has the potential to reduce the number of melanoma cases while decreasing health care costs. LAY SUMMARY: Previous meta-analyses have linked tanning bed use with an increased risk of melanoma, particularly with initial use at a young age. Yet, it remains unclear whether a ban of adolescents would be cost effective. Overall, a ban has the potential to reduce the number of melanoma cases while promoting a decrease in health care costs. Even after accounting for the costs of implementing a ban and the economic losses incurred by the indoor-tanning industry, a ban would be cost effective.

School-based interventions to improve sun-safe knowledge, attitudes and behaviors in childhood and adolescence: A systematic review.

Ultraviolet radiation exposure is the leading cause of skin cancer, and childhood and adolescence is a particularly susceptible life period for exposure. This systematic review assessed whether interventions in elementary and secondary school settings reduced sun exposure, sunburns, and development of melanocytic nevi, and improved sun-safe knowledge, attitudes and sun protection behaviors in childhood and adolescence. A systematic search up to June 2020 of MEDLINE, Embase, CINAHL, Cochrane and ProQuest databases was undertaken, for studies conducted among students in an elementary or secondary school setting that compared an intervention group with a pre-intervention or separate control group. Data were summarized using qualitative synthesis. Pooled effects from meta-analysis with random effects were also reported where appropriate. Sixty-five studies were included (22 randomized, 43 non-randomized). Most studies assessed measures of sun-safe behaviors, knowledge and attitudes (57, 48 and 33 studies, respectively), and observed improved sun protection behaviors and sun-safe knowledge, whereas few studies reduced time in the sun. About half improved participants' attitudes towards tanning desirability. Sunburns and nevus counts were less frequently assessed, but about half of these studies observed a reduction. There was substantial heterogeneity for outcomes except attitudes towards the desirability of tanning (pooled odds ratio from 6 studies: 0.81, 95% confidence interval 0.70-0.94). Key positive intervention features included: elementary school settings, interactive features or multiple components, and incorporating social norm influences. Most studies were classified at high risk of bias. In conclusion, school-based sun-related interventions had positive impacts on behaviors and attitudes among elementary and secondary school children.

The Use of the Video, "Dear 16-Year-Old Me," as a Melanoma Education Tool in Ambulatory Dermatology.

BACKGROUND: Skin cancer continues to be the most common cancer in the United States. The rise of social media platforms and internet use offers an opportunity to present health information through video-based education. The video "Dear 16-Year-OldMe," addresses the risks associated with tanning and sun exposure, the importance of practicing sun protection, and shares stories from melanoma survivors. OBJECTIVE: To evaluate the video "Dear 16-Year-Old Me," as a patient education tool in dermatology clinics and to investigate whether viewing a short educational video can change knowledge about skin cancer risks and intention to improve skin cancer prevention behavior. PATIENTS AND METHODS/MATERIALS AND METHODS/METHODS: English-speaking clinic patients between the ages of 14 to 45 years old were recruited. Exclusion criteria include both a personal or family history of skin cancer, dysplastic nevi, or other medical comorbidities. Forty-five participants agreed to participate; 38 were eligible for analysis. RESULTS: Comparison of prevideo and postvideo responses demonstrated a statistically significant reduction in participants reporting they were likely to tan outdoors (p-value = .001). A significant increase was observed in the reported likelihood to have a professional skin examination (p-value < .001) or self-examination (p-value < .001) in the future. CONCLUSION: and Relevance: Viewing "Dear 16-Year-Old Me," resulted in reported participant changes in intention to tan outdoors and participate in skin surveillance. Although these are encouraging results, future studies with a comparison group are needed to elucidate whether these results correspond to changes in behavior. In the age of viral videos and readily accessible health information via the internet, continued investigation of video media on patient health behaviors should be pursued.

Appearance, Friends, and Feelings: A Two-Study Exploration of Young Women's Emotional Associations and Indoor Tanning Frequency.

BACKGROUND: Knowledge of its potential cancer risk is often not enough to motivate individuals to avoid indoor tanning. Previous research has found that emotions toward indoor tanning and appearance motivations may prompt people to continue despite the risks. METHODS: We conducted two online surveys of US young adult women. Study one included a convenience sample of female undergraduates (N = 502) at a university in the northwestern USA. Study two included young women from a nationwide US online panel (N = 270). RESULTS: Results suggest that emotional associations, both positive and negative, with indoor tanning explain greater variances in indoor tanning behavior than demographics and previously established psychosocial predictors of tanning alone. Appearance motivations were also positively associated with indoor tanning in both samples. CONCLUSIONS: This research has implications for health care providers and health communicators, as indoor tanning prevention messages and campaigns should consider the association between both positive and negative emotions on tanning behaviors as well as appearance motivations.

Acceptability of online sun exposure awareness-raising interventions among young Australian women: an exploratory mixed-methods study.

Melanoma is the most common cancer among young Australians. Despite school-based programs such as 'Sun Smart' leading to increased knowledge among children of the harmful effects of sun exposure, many young adults continue to desire a darker skin tone because of a general perception among their peers that tanned skin is attractive. This 'tanned-ideal' may be challenged through exposure to material posted on social media. This study aimed to investigate the impact of two online interventions on knowledge of skin cancer and intentions to engage in sun tanning and protective behaviours, as assessed by survey. In addition, the likelihood that the intervention would be 'shared' on social media was explored by interview during an intervention session. Eighteen women aged 18-24 years participated in this pilot, mixed-methods intervention study. Participants completed surveys 2 weeks before and 2 weeks after attending an intervention session in which they viewed a video and completed a face-aging activity, with the order of completion balanced within the sample. Two weeks after the intervention, there was a significant increase in knowledge and intended sun protection behaviours and a significant decrease in intended future tanning hours. There was no effect of intervention order. Interview data indicated that younger participants would share the ageing application with peers because it was fun; older participants reported that they would share the video because it was educational. Factors that encourage sharing on social media include being realistic, instructive or personally meaningful, and short in duration.

Health insurance relationship to sun protection practices and beliefs.

PURPOSE: Lower socioeconomic status is associated with decreased sun protection practices. This survey study investigated practices and beliefs surrounding sun protection based on health insurance. METHODS: 401 surveys were administered May to June 2019 at two dermatology clinics in Sacramento, California. 384 surveys by private insurance, Medi-Cal (California's Medicaid), and Medicare coverage were analyzed. RESULTS: Patients with Medi-Cal are twice as likely to rarely or never use sunscreen (OR=2.37; 95% CI 1.45-3.87; P<0.001) compared to those with private insurance. Patients with Medi-Cal or Medicare are less likely to use sunscreen (P<0.001), protective clothing (P=0.025), and sun avoidance (P=0.028). Medi-Cal patients more often used tanning beds (OR=4.90; 95% CI 1.30-18.50; P=0.019). Over half of patients with Medi-Cal agreed it is worth getting burned for a tan (54.6%, OR=2.54; 95% CI 1.41-4.62; P=0.0021). There were no significant differences in opinion that sunscreen is a hassle to apply or expensive. Groups did not differ significantly in ethnicities or skin type. CONCLUSION: Those with Medi-Cal are less likely to use all forms of sun protection and more likely to value tanning. Negative opinions of sunscreen and perceived knowledge and concern for skin cancer were similar, pointing to additional factors influencing these disparities.

Efficacy and Mediators of a Web-Based Media Literacy Intervention for Indoor Tanning Prevention.

Extant media literacy interventions have been delivered in person, limiting their potential for large scale reach, implementation, and dissemination. Although emerging evidence suggests the interventions can impact behavior, the theoretical mediators that can explain the efficacy remain unknown. This study investigated the efficacy and mediators of a web-based media literacy intervention for reducing indoor tanning behavior among young women. Participants were randomly assigned to one of three conditions: a media literacy intervention with counter argument production, a media literacy intervention with counter story production, or an assessment-only control condition. The outcomes of indoor tanning behavior and intention were evaluated with 3- and 6-month follow-ups. Results indicated significant effects of the web-based intervention on reducing indoor tanning behavior at the follow-ups. Changes in perceived media realism completely mediated the intervention effects on behavior. Perceived media realism, positive and negative outcome expectancies, and collective efficacy partially mediated intervention effects on intention. This study demonstrates the efficacy of a web-based media literacy intervention and the theoretical mechanisms underlying the efficacy. It indicates that by altering perceived media realism, outcome expectancies, and collective efficacy, web-based media literacy interventions could generate behavioral effects.

Actions taken by the European commission to address the safety of sunbeds.

The safety of sunbed, especially when it comes to protecting young and vulnerable consumers, is a key concern that the Directorate-General for Health and Consumers has been trying to address in various ways. This document presents a brief overview of activities undertaken at European level to address the main concerns related to the use of this product.

'I am happier with my fairer complexion': factors associated with former indoor tanning and reasons for quitting in college women.

This study of 312 female undergraduates investigated the association of recently, formerly, or never indoor tanning with self-perceptions and social influence, and examined reasons to tan and not to tan. Previous research on indoor tanning has focused on recent or current tanners, and few studies have examined former indoor tanners. By examining self-perceptions and social influence, this study aimed to understand how these common tanning correlates, measured in former indoor tanners, compared to those who have never tanned indoors (i.e., never tanners) and those who have recently tanned indoors. Appearance and global self-perceptions were more positive in former indoor tanners compared to never tanners and recent tanners. Recent indoor tanning was positively associated with both higher outdoor tanning frequency and having a higher number of friends performing skin cancer risk behaviors, and formerly indoor tanning was also associated with both, but to a lesser extent. Appearance and social influence were commonly described as reasons for indoor tanning, and perceived health risk, appearance, and social influence were described as prominent reasons for tanning cessation. This study improves what is known about former indoor tanners, which may be useful for behavior change maintenance efforts and developing approaches for skin cancer screening interventions.

SunSmart news? Traditional media coverage of sun protection issues during springtime in New Zealand.

ISSUES ADDRESSED: Cutaneous melanomas and keratinocyte carcinomas (nonmelanoma skin cancer) are highly prevalent in New Zealand (NZ), making skin cancer a priority area for cancer control. Spring is an important time for encouraging sun-safety, due to ultraviolet radiation (UVR) levels becoming hazardous. The news media have a potential to play an important role in reminding people and emphasising the importance of sun-safety. This study aimed to describe how the traditional NZ media portrayed sun-safety and skin cancer in spring news stories. METHODS: A media monitoring company collated stories related to cancer during spring 2016. These were reviewed for inclusion and content was coded according to the cancer type described. Stories focused on skin cancer and sun protection issues were coded according to the position on the cancer control continuum. RESULTS: Skin cancer and sun-safety represented 3.6% (n = 110) of all cancer stories published. Stories mainly related to primary prevention (72%), early detection (37%) and survivorship (27%). The main risk factors identified included sun exposure (49%) and tanning (25%). CONCLUSIONS: Traditional media coverage of skin cancer remains relatively low during springtime. It is heartening to see that most stories included prevention information. SO WHAT?: Given the impact of skin cancer in NZ, and the importance of springtime as a period for behaviour change to reduce risk, there is considerable scope for increased media coverage and advocacy. Further research could usefully analyse media trends throughout the year and within specific media platforms, both traditional and new, in order to further disseminate information to the NZ public.

Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions.

While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.

Youth access to indoor tanning salons in urban versus rural/suburban communities.

BACKGROUND/PURPOSE: Research suggests that youth proximity to tanning salons may promote use; however, little is known about tanning salon proximity to schools. We assessed the proximity of tanning salons to schools in urban versus rural/suburban communities across Worcester County, Massachusetts (population > 800K). To put findings in context, we compared school proximity to tanning salons to school proximity to McDonald's restaurants, a large franchise that also caters to young people. MATERIALS & METHODS: Accessibility was measured by ArcGIS 10.2 Network Analyzer (ESRI, Redlands, CA, USA) and the most current road network data layer from Massachusetts Department of Transportation (MassDOT). RESULTS: A total of 145 schools were observed in the study area, of which about 39% of schools were within 1 mile from a tanning salon. Urban schools (53.41%) had a higher proportion within 1 mile of a tanning salon than rural/suburban schools (17.54%; P < .001). More schools (39.31%) were within 1 mile of a tanning salon than schools within 1 mile of a McDonald's (22.70%; P < .001). CONCLUSIONS: Schools may be particularly impactful for implementing skin cancer prevention programing.