Effects of UV Photographs, Photoaging Information, and Use of Sunless Tanning Lotion on Sun Protection Behaviors

EVIDENCE-BASED DERMATOLOGY: STUDY

A cooperative effort of the Clinical Epidemiology Unit of the Istituto Dermopatico dell’Immacolata Istituto di Ricovero e Cura a Carattere Scientifico (IDI-IRCCS) and the Archives of Dermatology Effects of UV Photographs, Photoaging Information, and Use of Sunless Tanning Lotion on Sun Protection Behaviors

Heike I. M. Mahler, PhD; James A. Kulik, PhD; Jody Harrell, MA; Alma Correa, BA; Frederick X. Gibbons, PhD; Meg Gerrard, PhD

Objectives: To examine the efficacy of UV photo- intervention plus use of sunless tanning lotion, and a con- graphs and information about photoaging (eg, trol condition. wrinkles and age spots) for increasing the sun protection intentions and behaviors of young adults and to Main Outcome Measures: Participants sun protec- determine whether any effects of this appearance- tion intentions as assessed immediately after the inter- based intervention could be enhanced by providing a vention and sun protection behaviors during the month non-UV alternative for achieving a tan (ie, sunless tan- after the intervention as assessed during a surprise tele- ning lotion). phone follow-up.

Design: Randomized control trial with 1-month follow- Results: The intervention resulted in significantly stron- up. ger sun protection intentions (PϽ.001) and greater sun protection behaviors (PϽ.05) relative to controls. Further- Setting: Two universities in Southern California. more, the group that also used sunless tanning lotion tended to engage in greater sun protection behaviors than the group Participants: A volunteer sample of 146 college stu- that received the intervention alone (PϽ.08). dents, 91.1% of whom completed the “surprise” 1-month follow-up. Conclusion: The UV photographic intervention holds promise as a cost-effective approach to motivate prac- Intervention: A UV facial photograph and a brief vid- tices that may ultimately result in health benefits (ie, re- eotape describing the causes and consequences of pho- duced skin cancer rates). toaging. The study tested the effects of the photoaging information/UV photographic intervention only, the Arch Dermatol. 2005;141:373-380

HE INCIDENCE OF NEW SKIN Section Editors cancer cases is increasing at 1 Michael E. Bigby, MD, Beth Israel a rate of 3% to 4% per year, Deaconess Medical Center, Harvard and the incidence of the Medical School, Boston, Mass most deadly form of skin Rosamaria Corona, DSc, MD, Istituto cancerT (melanoma) is increasing more rap- Dermopatico dell’Immacolata, idly than that of any other type of can- Rome, Italy cer.2 It is widely recognized that most skin Damiano Abeni, MD, MPH, Istituto cancer cases could be prevented.1 Preven- Dermopatico dell’Immacolata Alexa B. Kimball, MD, MPH, Author Affiliations: University tion behaviors include limiting sun expo- Massachusetts General and Brigham of California, San Diego sure during midday hours (10 AM–3 PM and Women’s Hospitals, Boston (Drs Mahler and Kulik and [formerly 10 AM–2 PM]), wearing protec- Moyses Szklo, MD, MPH, DrPH, Mss Harrell and Correa); tive clothing, and wearing sunscreen with The Johns Hopkins University, California State University, a solar protection factor (SPF) of at least Baltimore, Md San Marcos (Dr Mahler and 1 Hywel Williams, MSc, PhD, FRCP, Ms Correa); and Iowa State 15. For the past several decades, researchers across various disciplines have sought Queen’s Medical Centre, Nottingham, University, Ames (Drs Gibbons England. and Gerrard). to understand the mechanisms underly- Financial Disclosure: None. ing sun exposure and sun protection be-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 haviors. Although public education programs and me- efficacy for using sunscreen regularly. Finally, we hy- dia attention have succeeded in raising awareness of the pothesized that individuals who received the intervention health risks (skin cancer) of UV exposure,3 health- plus a sunless tanner sample would display the greatest based education interventions have been considerably less sun protection intentions and behavior. successful at motivating behavioral change.4-11 Young adults in particular, motivated by the perceived appear- METHODS ance-enhancing benefits of tanned skin, are continuing to receive large amounts of intentional and uninten- tional exposure to UV radiation.3,8,12-14 In this popula- STUDY POPULATION AND PROCEDURES tion, the possibility of developing skin cancer in the dis- The study population consisted of 54 undergraduates from the tant future may not weigh as heavily in behavioral decision University of California, San Diego (41 women and 13 men) making as the certainty of improving physical appear- and 92 undergraduates from California State University, San ance immediately. Marcos (73 women and 19 men). Participants signed up for a Interventions that address individuals’ concerns about study titled simply “Health Attitudes” in partial fulfillment of appearance may be more effective than health warnings requirements for introductory psychology courses at both in- alone for countering the strong normative influences for stitutions. tanning.8,15-22 A small but growing body of work sug- Participants were run individually or in pairs (separated by gests that an effective strategy might be to emphasize that a partition). The condition to be run during each session was UV exposure can have negative consequences for ap- determined at the beginning of the data collection period us- pearance (eg, wrinkles and age spots).19-21,23 For ex- ing a block randomization procedure. After providing written 15 informed consent, all participants completed the first ques- ample, Mahler et al made the negative appearance con- tionnaire that assessed demographic information and baseline sequences of UV exposure more salient, certain, and sunbathing and sun protection behaviors. Thereafter, individu- immediate for individuals by showing them a photo- als in the control group proceeded directly to a second ques- graph of their own faces taken with a UV filter, which tionnaire designed to assess future intentions to use sun- depicted nonuniform epidermal pigmentation caused by screen and several measures of their perceptions of photoaging chronic UV exposure. Both college students and beach and sun protection. patrons who viewed their UV photographs expressed Prior to completing the second questionnaire, participants greater sun protection intentions than did controls. Fur- in the intervention groups viewed the photoaging video and thermore, in a 1-month follow-up conducted with the had their UV photographs taken and shown to them. Imme- beach patrons, those who had viewed their UV photo- diately after the intervention and before they completed the second questionnaire, participants in the intervention plus sun- graphs reported engaging in greater sun protection be- less tanner sample group received a 6-oz (177-mL) bottle of haviors than did controls. While these initial results are either Neutrogena (Los Angeles, Calif) or SkinMedica (Encini- promising, we must be able to replicate them. Also, the tas, Calif) sunless tanning lotion containing dihydroxyac- beach patrons in Mahler et al15 were aware that a fol- etone. The experimenter explained to these participants how low-up would be conducted, and so they may have al- to use sunless tanning lotion, stated that using sunless tanner tered their behaviors in anticipation of the follow-up. is the only safe way to get a tan, and informed participants that One purpose of the present study was to determine sunless tanning lotion does not provide sun protection. whether the findings of Mahler et al15 could be repli- At the end of the session, all participants were provided with cated when participants were unaware that they would a sunscreen sample, ostensibly as a thank you gift for partici- be contacted for follow-up. In addition, we sought to de- pating in the study. The study procedures were approved by the institutional review board at each institution. termine whether the effects of the UV photographic intervention could be enhanced by offering individuals an alternative method of obtaining a tan: a sunless tanning UV PHOTOGRAPHIC AND PHOTOAGING lotion. The assumption was that sunless tanning lotion INFORMATION INTERVENTION is an effective low-risk alternative to UV exposure that can produce the same appearance benefits associated with The intervention consisted of a 12-minute video and a UV fa- actual UV exposure. Thus, based on the Theory of Al- cial photograph taken with an instant camera. The video de- 24,25 fined photoaging (premature wrinkles and age spots due to UV ternative Behaviors, increasing individuals’ percep- radiation) and discussed ways to reduce the effects of UV ex- tions of the risks of UV exposure while simultaneously posure (using a sunscreen with an SPF of at least 15 and avoid- presenting them with a viable alternative for obtaining a ing the sun between the hours of 10 AM and 2 PM). The video tan should be particularly effective in changing sun pro- also provided general information about sunscreen, for ex- tection behaviors. ample, explaining what the SPF means and how much sun- We expected that receiving photoaging information screen to use. and viewing a UV facial photograph would result in in- The UV facial photographs were taken with a single-lens re- creased sun protection intentions and behaviors. We also flex camera equipped with Polaroid 667 professional black- hypothesized that the intervention would affect several and-white instant film (Waltham, Mass) and a UV filter. This perceptions regarding photoaging and sun protection. Spe- filtered UV light is absorbed by the melanin in the skin. The resulting black and white photograph highlights clearly and dra- cifically, we expected that the intervention would result matically the nonuniform epidermal pigmentation that has re- in lower perceived costs of sun protection and rewards sulted from chronic sun exposure.26,27 Each person who had a of sun exposure and greater perceived susceptibility to UV photograph taken also had a natural-light instant photo- photoaging, severity of photoaging, efficacy of sun pro- graph taken for comparison. In all cases, the natural-light black tection for the prevention of photoaging, and self- and white photograph was shown to participants first, fol-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 lowed by the UV photograph. Participants were told that any “dark, freckled, or pitted areas” in the UV photograph (that did 146 Randomized not appear in the natural-light photograph) indicated existing underlying skin damage that would continue to worsen if they did not engage in greater sun protection behaviors (than they currently did). 50 Allocated to UV 46 Allocated to UV 50 Allocated to Control Photograph/ Photograph/ Condition MEASURES AND SCALES Photoaging Photoaging Information Condition Information Plus 50 Received Allocated Sunless Tanner Baseline UV exposure and protection assessment included self- Intervention Condition reports of (1) number of hours sunbathing during the previ- 45 Received Allocated Intervention ous weekend; (2) number of hours spent in the sun doing ac- 1 Did Not Receive tivities other than sunbathing during the previous week and Allocated weekend, respectively; (3) frequency of sunscreen use on face Intervention Due to Error and body (on a 0% to 100% scale) while sunbathing and, separately, while doing other activities in the sun; and (4) SPF level of sunscreen used on face and body while sunbathing and, sepa- 742Lost to Follow-up Lost to Follow-up Lost to Follow-up rately, when doing other outdoor activities. (Unable to Reach) (Unable to Reach) (Unable to Reach) Nine items, rated on separate 5-point scales (1, strongly disagree–5, strongly agree), assessed intentions to use sunscreen in the future (eg, “I plan to use sunscreen on my face more fre- 49 Analyzed 45Analyzed 49 Analyzed quently when I sunbathe” or “I plan to use sunscreen on all 1 Excluded From None Excluded From 1 Excluded From exposed areas of my body on a daily basis”). As in previous Analyses Analyses Analyses work,15,20 these 9 items displayed high internal consistency (Cronbach ␣=0.92), and therefore they were averaged into an Figure. Flowchart of the progress of participants through the study process. intentions index for analyses. Several short scales were developed to assess participants’ photoaging and sun protection perceptions. Most of the spe- To assess intentional sun exposure, participants were asked cific items for these scales were derived from previous studies to estimate the number of hours they had sunbathed since their on sun protection,6,18 and all have been used successfully in pre- 15,20 participation. Participants also were asked to estimate the av- vious work by our team. Participants indicated their level erage number of hours they had spent in the sun doing other of agreement with each item on separate 5-point scales (1, activities on a typical weekday and weekend, respectively. These strongly disagree–5, strongly agree). The perceived rewards of ␣ estimates were then averaged to form an incidental sun expo- sunbathing and of being tan were assessed with 10 items ( =.89; sure index (r [130]=0.58; PϽ.001). In addition, participants eg, “I think I look healthier when I have a tan”). Twelve items ␣ were asked whether they had used any sunscreen during the assessed the costs of using sunscreen ( =.76; eg, “It is too nice most recent time that they had sunbathed (yes, no) and the fre- during the summer to avoid going out between 10 AM and 2 quency with which they had used sunscreen on their face and PM”). Perceived susceptibility to photoaging was assessed with ␣ body when sunbathing (0%-100%) since their participation. Par- 8 items ( =.77; eg, “I don’t spend enough time in the sun to ticipants were also asked these same 3 questions with regard be concerned about getting wrinkles and age spots”). Four items ␣ to incidental sun exposure. assessed perceptions of the severity of photoaging ( =.79; eg, Separate 3-item indices of sunbathing protection (␣=.77) and “It would be terrible to have wrinkles on my face”). Perceived of incidental sun protection (␣=.75) were subsequently created response efficacy of sunscreen use for the prevention of pho- ␣ by first standardizing (via z scoring) and then averaging the rel- toaging was assessed with 4 items ( =.65; eg, “Whether people evant items. Next, participants were asked (yes, no) whether they develop wrinkles and age spots is directly related to how fre- had used the free sunscreen sample, whether they had given the quently they use sunscreen when spending time in the sun”). sample away, and whether they had purchased any sunscreen Finally, to assess self-efficacy for regular sunscreen use, par- since participation in the experiment. Responses to these 3 items ticipants indicated on 12 separate 10-point scales (1, certain I were averaged to create an index of sample use and sunscreen pur- could not do to 10, certain I could do) how confident they were chase. Those who had been given a sunless tanner sample were that they could motivate themselves to use sunscreen despite ␣ also asked how many times they had used the sample. Finally, obstacles ( =.92; eg, “Use sunscreen even when I’m feeling too participants were asked with how many family members or friends lazy to bother with it”). This self-efficacy measure was based (if any) they had discussed information learned as a result of their closely on similar measures used successfully by researchers participation. They were then fully debriefed. in other domains.28,29 STATISTICAL ANALYSIS TELEPHONE FOLLOW-UP PROCEDURES AND MEASURES To determine the initial equivalence of the groups, 1-way analyses of variance were used to compare the intervention and con- Approximately 1 month after the intervention (mean [SD] follow- trol groups with respect to demographic characteristics and base- up, 27.36 [7.42] days), participants were unexpectedly con- line sun exposure and sun protection variables. Any demographic tacted by telephone (91.1% were reached) and asked several ques- or baseline variable found to differ across groups and to be sig- tions regarding their sun exposure and sun protection behaviors nificantly related to the outcome measures was controlled for since their initial participation in the study (Figure). Partici- in subsequent analyses. pants provided oral informed consent at the time of telephone Future sunscreen use intentions and all of the 1-month fol- contact (consistent with the institutional review board policies low-up measures were analyzed using a set of planned orthogo- at both institutions). Interviewers who conducted the follow-up nal comparisons30 that involved comparing the 2 intervention were unaware of each participant’s group assignment. groups with the control group and separately comparing the

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 less tanner sample; 1 owing to a medical condition that Table 1. Characteristics of 146 Participants required daily sunscreen use; and 1 because reported hours of sunbathing were more than 35 SDs above the Characteristic Finding* mean). Race The results indicated no significant differences or White 67.8 trends among the 3 groups in age, ethnicity, education Asian 16.4 level, skin type,31 whether participants had ever had skin Hispanic 6.8 African American 2.1 cancer, or number of close family members who had ever Other 6.9 had skin cancer. Similarly, there were no group differ- History of skin cancer 1.4 ences in baseline measures of time spent sunbathing the Family history of skin cancer 41.8 weekend prior to participation; time of incidental sun ex- Skin type posure the week or weekend prior to participation; fre- Burns, never tans 7.6 quency of sunscreen use on the face during sunbathing; Burns easily, then develops light tan 24.1 or frequency of sunscreen use on either the face or body Burns moderately, then develops light tan 22.1 Burns minimally, then develops moderate tan 24.1 during incidental sun exposure. Does not burn, develops dark tan 15.9 Participants in the intervention-only group reported Does not burn, naturally dark skin 6.2 lower (P=.05) mean frequency of sunscreen use on the No. of hours sunbathing last weekend, mean (SD) 0.65 (1.56) body during sunbathing (37.1%) than did those in either No. of hours incidental sun exposure, mean (SD) 5.33 (4.35) the intervention plus sunless tanner group (61.0%) or last weekend the control group (52.4%). Thus, to statistically control No. of hours in incidental sun exposure, mean (SD) 8.02 (7.22) last week for the possible confounding influence of this baseline Frequency with which sunscreen used variable, it was included as a covariate in the analyses of during sunbathing, % of time any outcome measure with which it was correlated at On face 67.0 PϽ.10. On body 50.9 The same pattern of results reported for the total sample Frequency with which sunscreen used during incidental exposure, % of time were obtained when analyses were conducted for par- On face 42.3 ticipants from each campus separately, for white partici- On body 21.6 pants only, and for individuals with high incidental exposure only (those scoring above the median in hours *Unless otherwise noted, data are presented as percentage of participants. of incidental exposure at baseline).

INTENTIONS TO USE SUNSCREEN intervention-only group with the intervention plus sunless tanner group. We controlled for the respective levels of baseline Consistent with our expectations, analysis of the inten- sun exposure or sun protection in the analyses of the 1-month tions scale indicated that participants in both interven- follow-up sun exposure and sun protection measures. To minimize the number of tests and experimentwise er- tion groups expressed significantly stronger intentions ror, the multiple measures of photoaging and sun protection to use sunscreen regularly in the future than those in the perceptions were first analyzed using multivariate analyses of control group (PϽ.001). As listed in Table 2, the mean covariance followed by the separate planned comparisons for value on the scale used to measure intention to use sun- each measure. screen was higher for participants in the intervention plus sunless tanner group than for those in the intervention RESULTS only group, though this difference was not significant (P=.37). DESCRIPTION OF SAMPLE AND BASELINE EQUIVALENCE OF GROUPS PHOTOAGING AND SUN PROTECTION PERCEPTIONS Participants were primarily white and were a mean (SD) of 22.21 (4.66) years old (age range, 17-44 years). Twenty Multivariate analysis of covariance results indicated that percent of participants reported sunbathing at least 1 hour participants’ overall perceptions of photoaging and sun during the previous weekend; 93.8% reported spending protection were also altered by the intervention (PϽ.02). at least 1 hour in the sun doing something other than The univariate comparisons revealed that relative to con- sunbathing during the previous weekend; and 96.6% spent trols, participants in the intervention groups reported sig- at least 1 hour in the sun doing something other than nificantly higher self-efficacy for regular sunscreen use sunbathing during the previous week. Fifty-six percent (PϽ.05), higher perceived susceptibility to photoaging of participants reported knowing at least 1 person with (PϽ.002), and higher perceived efficacy of sunscreen for skin cancer, and 41.8% reported having at least 1 family prevention of photoaging (PϽ.004). In addition, partici- member with skin cancer. Table 1 lists additional demo- pants in the intervention plus sunless tanner group ex- graphic and baseline sun protection characteristics of the pressed marginally higher self-efficacy for sunscreen use sample. The data from 3 individuals (1 in each group) (PϽ.08) and significantly higher perceived susceptibil- were excluded (1 because the individual was acciden- ity to photoaging (PϽ.01) than those in the intervention- tally given a second sunscreen sample rather than a sun- only group.

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Intervention F Score Intervention Plus Sunless Only Tanning Control Interventions vs Intervention Only vs Characteristic (n = 49) (n = 45) (n = 49) Control Intervention Plus Sunless Tanner Intentions to use sunscreen 3.43 (0.78) 3.63 (0.81) 2.79 (0.94) 18.73 (PϽ.001) 0.80 (NS) Perceptions of photoaging and sun protection Rewards of tanning 3.08 (0.72) 3.14 (0.74) 3.02 (0.94) 0.34 (NS) 0.08 (NS) Costs of sunscreen use 2.57 (0.65) 2.68 (0.70) 2.80 (0.64) 1.83 (NS) 0.42 (NS) Susceptibility to photoaging 3.72 (0.67) 4.06 (0.49) 3.55 (0.67) 9.55 (PϽ.01) 6.93 (PϽ.01) Severity of photoaging 3.81 (1.02) 4.08 (0.75) 3.70 (1.00) 2.20 (NS) 1.98 (NS) Efficacy of sunscreen use 4.04 (0.74) 4.12 (0.65) 3.73 (0.62) 8.69 (PϽ.01) 0.32 (NS) Self-efficacy 7.35 (1.42) 7.94 (1.15) 7.11 (1.41) 4.09 (PϽ.05) 3.21 (NS) Hours sunbathing† 2.05 (4.32) 0.88 (2.98) 1.42 (3.73) 0.004 (NS) 1.11 (NS) Sunbathing protection index‡ −0.08 (0.94) 0.72 (0.12) 0.18 (0.75) 0.18 (NS) 2.74 (NS) Incidental sun index, h† 2.65 (1.90) 2.60 (1.56) 2.81 (1.91) 0.28 (NS) 0.01 (NS) Incidental sun protection index† 0.06 (0.87) 0.45 (0.68) −0.10 (0.84) 5.52 (PϽ.05) 3.22 (NS) Sample use index (0, no; 1, yes)§ 0.44 (0.21) 0.52 (0.22) 0.39 (0.21) 3.02 (NS) 1.10 (NS) No. of friends/family members told† 2.27 (3.34) 3.00 (2.89) 0.55 (0.90) 15.99 (PϽ.001) 0.92 (NS)

Abbreviation: (NS), not significant. *Unless otherwise indicated, data are presented as mean (SD). All means are adjusted for covariates except those of susceptibility to photoaging, severity of photoaging, efficacy of sunscreen use, and number of friends and family members told. †n = 42 for intervention condition;n=14forintervention plus sunless tanner condition; andn=47forcontrol condition. ‡n = 8 for intervention condition;n=3forintervention plus sunless tanner condition; andn=9forcontrol condition. §n = 27 for intervention condition;n=11forintervention plus sunless tanner condition; andn=35forcontrol condition.

1-MONTH TELEPHONE FOLLOW-UP MEASURES The intervention also did not affect the amount of incidental sun exposure that individuals reported receiving Only 37% of those individuals who were provided with during the subsequent month. However, the intervention the sunless tanner sample reported using it. Our goal was significantly increased use of sun protection during inci- to determine whether having an alternative method of dental sun exposure. Specifically, analyses of the follow- obtaining a tan would boost sun-protection behaviors. up index of protective behavior during incidental expo- Because those who did not try the sample did not have sure indicated that subjects in the intervention groups were the opportunity to experience sunless tanning lotion as more apt to use protection than were controls (PϽ.02). a viable alternative method, the analyses reported be- Furthermore, the use of sunless tanner tended to further low included only those individuals in the intervention increase the level of protective behavior during the follow- plus sunless tanner group who reported using the upperiodrelativetotheinterventionalone(PϽ.08;Table2). sample at least once and do not include the 8.9% of par- Analyses of the sunscreen use index demonstrated that ticipants who could not be reached for follow-up. How- participants in both of the intervention groups tended ever, the same pattern of results were obtained when in- to be more likely than controls to use the free sample of dividuals in the intervention plus sunless tanner group sunscreen and to purchase additional sunscreen (PϽ.09). who did not use the sunless tanner were included in the Again, those in the intervention plus sunless tanner group analysis. had the highest mean scores (Table 2), but these scores As detailed in Tables 1 and 2, and consistent with pre- did not differ significantly from those in the intervention- vious research of our team15 and previously published only group (P=.30). population norms for San Diego residents,32 the present Finally, 61% of the participants indicated that they had study participants reported very few hours of inten- told at least 1 friend or family member about what they tional sun exposure both before and after the interven- had learned from the study about UV damage and sun tion. Neither the intervention alone nor the interven- protection. As expected, analyses indicated that partici- tion plus sunless tanner use significantly reduced these pants in the intervention groups (who had received pho- already low sunbathing rates, although the mean re- toaging information and viewed their UV photographs) ported hours spent sunbathing was lowest for those in talked to significantly more friends and family about what the intervention plus sunless tanner group (Table 2). they had learned than did those in the control group For those individuals who reported at least 15 min- (PϽ.001; Table 2). There were no differences between utes of sunbathing during follow-up (n=20), analyses of the 2 intervention groups. the index of sun protective behaviors while sunbathing found that participants in the intervention plus sunless tanner group reported the highest sun protection dur- COMMENT ing sunbathing (Table 2). However, likely owing to the small sample size, the effects did not reach statistical sig- Given escalating rates of skin cancer, it is important to nificance (PϾ.11 in all analyses). develop effective risk-reduction interventions. Al-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 though health-based interventions have had some lim- ceptions were more consistent than the effects on be- ited success in reducing risky behaviors, such interven- havior. Changing intentions and risk perceptions is nec- tions generally ignore one of the primary motivators for essary, but not always sufficient, to produce behavior skin cancer risk behaviors—immediate appearance en- change. hancement. The present results add to the data suggest- Unfortunately, the effects of providing individuals with ing that appearance-based interventions hold promise for sunless tanning lotion as a safe alternative to UV expo- motivating practices that will ultimately result in health sure were not substantial. Although the mean values benefits (ie, reduced skin cancer rates). Although there showed improvement for all 7 of the outcomes for which were no significant effects of the intervention on inten- a difference was expected, the intervention plus sunless tional or incidental sun exposure, there were significant tanning lotion group differed from the intervention-only changes in sun protection behavior (ie, sunscreen use). group on just 1 of those outcomes and then only margin- Specifically, individuals who received information about ally (greater use of sun protection during incidental ex- photoaging and were shown their UV facial photo- posure). The most likely explanation for these weak ef- graphs developed stronger intentions than controls to pro- fects is the lower statistical power of the small sunless tanner tect themselves from the sun, were more likely to report group: it only included participants who had actually used having used sun protection during subsequent inciden- the sample. During our telephone follow-ups we found that tal sun exposure, and were more likely to use the pro- many individuals had a negative attitude toward sunless vided sunscreen sample and/or to purchase sunscreen. tanning lotion. For example, several individuals re- These findings are consistent with the only previ- marked that they would never use sunless tanning lotion ously published empirical investigation of the UV pho- because, among other reasons, they had heard that it does tographic intervention.15 However, in contrast to that not look natural, it would turn their skin orange, and it study, the present participants had no idea that they would would leave a “streaked” appearance. Because only 37% be contacted for follow-up, thus rendering implausible of the participants tried the sunless tanning lotion sample, the notion that anticipation of reporting sun protection most did not have the chance to develop positive atti- behaviors, rather than the intervention, was responsible tudes toward it as an alternative method of obtaining a tan. for the increased sun protection behaviors. It may be necessary to debunk the myths of sunless tan- Consistent with the findings of Mahler et al,15 partici- ning lotion or to develop methods of inducing participants who were shown their UV photographs shared the pants to try it to foster the development of positive atti- information learned about UV radiation effects and sun tudes toward this alternative. protection with more family members and friends than This experiment has several methodologic strengths. did controls. It is important to note that participants A novel technique for reducing skin cancer risk was evalu- viewed their UV photographs for only a few minutes and ated with a population that is prone to high rates of in- were not allowed to take the photographs with them. It cidental sun exposure (Southern California college stu- is conceivable that if individuals were given the photo- dents). Baseline sun exposure and sun protection graphs, the impact would be enhanced. That is, occa- behaviors, along with relevant demographic character- sionally reviewing such a photograph might remind in- istics, were assessed and statistically controlled in the dividuals of their accrued sun damage and help to analyses, when appropriate. The experiment included the maintain higher levels of motivation for engaging in sun assessment of several health-risk and health-behavior per- protection. In addition, the photograph might become ceptions that have been linked with varying degrees of the focal point of sun protection discussions with friends success to achieving risk modification in other health do- and family and thereby have more far-reaching benefi- mains. Finally, and perhaps most importantly, this ex- cial effects. periment went beyond immediate behavioral intentions We also found that several perceptions regarding pho- by assessing reported sun exposure and protection be- toaging and sun protection were altered as a result of re- haviors during the month following the intervention in ceiving the photoaging information and viewing the UV a “surprise” telephone follow-up. photograph. Specifically, those who received the inter- However, it is important to note that the experiment vention, relative to controls, came to view themselves as involved a relatively small sample size (particularly with more susceptible to photoaging, became more con- respect to the subgroup that received the intervention and vinced of the efficacy of sunscreen as a method of pre- used the sunless tanning lotion sample), thus limiting sta- venting photoaging, and developed greater confidence tistical power. Also, the follow-up period was only 1 in their ability to use sunscreen regularly. The finding month, thus precluding determination of the longer- that such perceptions were altered by the intervention term effects of the intervention. In addition, because all is important given that most models of health behavior findings are based on self-reports, it is not possible to rule (eg, Health Belief Model,33 Precaution Adoption Pro- out response bias. However, it should be noted that pre- cess,34 Protection Motivation Theory35) argue that it is vious work has demonstrated significant associations be- the alteration of just such perceptions that is necessary tween self-reported and actual sun protection behav- to produce changes in health-risk behaviors. Thus, it is ior,5,36-38 and all participants were sensitized to the issues possible that the effect of the UV photographic interven- being investigated. That is, even participants in the con- tion on sun protection intentions and behaviors was me- trol group completed all of the measures and were de- diated by these perceptions. However, it is also worth not- briefed regarding the general purpose of the study after ing that, consistent with the existing health-risk literature, the initial session in the laboratory. If the findings were the effects of the intervention on intentions and risk per- due simply to demand, one would expect across-the-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 board differences between the intervention and control groups rather than the pattern observed. Nonetheless, it Editor’s Note: Whereas most dermatologists rec- would be desirable for future work to use more objec- ommend avoidance of UV exposure and the use of tive behavioral measures of sun exposure (eg, a spectro- sun protective clothing and sunscreens, the effi- photometer).20 One difficulty of a spectrophotometer in cacy of educational interventions for skin cancer the present context, however, is that it cannot distin- prevention and their effect on sun exposure be- guish skin color that is the result of UV exposure vs sun- havior have not been well studied. Several ran- less tanning lotion. Finally, participants were all South- domized controlled trials of educational interven- ern California college students, potentially limiting tions have, however, been performed, including generalizability to other populations or to other regions interventions administered in schools, the work- of the country. place, the community, and at beaches. Outcome Ultraviolet-filtered photography is used both com- measures have included use of sunscreens, use of mercially and by many practicing dermatologists.26 protective clothing, avoidance of midday sun, or However, to date there has been only 1 published number of sunburns. The state of the art of skin empirical study examining its effect on behavior.15 The cancer prevention is well summarized by Weston. present results, in concert with the findings of Mahler (Weston R. Prevention of skin cancer. In: Wil- et al,15 indicate that this intervention can significantly liams HC, Bigby M, Diepgen T, Herxheimer A, Naldi impact self-reported behaviors. Assuming that future L, Rzany B. Evidence-Based Dermatology. London, work confirms the efficacy of the intervention using England: BMJ Books; 2003:273-284.) A system- more objective indicators of behavior, this appearance- atic review is underway to assess the effect of edu- based intervention can have important practical appli- cational programs to promote awareness of skin cations. Ultraviolet instant cameras are readily available, cancer and sun-protective behavior. (Naldi L, relatively inexpensive, and simple to operate. In fact, Buzzetti R, Cecchi C, et al. Educational Pro- with the model used in this experiment, individuals grammes for Skin Cancer Prevention [Protocol]. Ox- could easily take their own photographs (alleviating the ford, England: The Cochrane Database of System- need to assign staff time to take photographs). Thus, it atic Reviews Volume 4; 2004). seems plausible that this intervention could be offered at most dermatology offices, student health clinics, and Michael E. Bigby, MD physicians’ offices. In addition, it is likely that the endorsement by a physician or nurse of sunless tanning lotion as a safe and effective alternative to UV exposure would induce more individuals to try it. Based on the trends observed Diego County Inc, La Jolla, Calif; and Coppertone Inc, in this experiment with the small percentage of partici- Kenilworth, NJ, who donated the sunless tanning lotion pants who tried the sunless tanning lotion, this might and sunscreen samples. lead to additional sun protection behaviors. Of course, it would be important for clinicians to encourage the REFERENCES regular use of sunscreen and to explain that a tan achieved with sunless tanning lotion does not provide 1. American Cancer Society. Cancer Facts and Figures. 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