Skin cancer continues to be a growing public health concern worldwide as its incidence climbs at an increasing rate (Jemal et al., 2009). According to Skin Cancer Foundation statistics, each year in the US more people are diagnosed with skin cancer than all other cancers combined (Skin Cancer Foundation, 2018). Similar to how Western body-shape ideals presented in the global media influence appearance-related behaviors around the globe (i.e., dieting and exercising), the social and cultural influences of universal tanned attractiveness are particularly salient to engaging in body-tanning behaviors (Cafri, Thompson, Roehrig et al., 2006; Yoo & Kim, 2014). Appearance-focused intervention strategies were suggested as effective for skin cancer prevention and education (Gibbons, Gerrard, Lane, Mahler, & Kulik, 2005; Hillhouse & Turrisi, 2002), and recent skin cancer interventions have had an emphasis on the damaging effect of exposure to ultraviolet (UV) rays on appearance. Even though these appearance-focused intervention efforts have proven effective in deterring harmful UV exposure, there is a limitation, in that the efforts fail to address individuals’ intention to quit tanning from the broader sociocultural perspectives and appearance-related concerns, which may include physical fitness and skin aging. For example, researchers have reported that skin-aging concern increased individuals sun-protection intention (Cafri, Thompson, Roehrig et al., 2006), but there has not yet been any research conducted in which it has been confirmed that skin-aging concern will influence intention to quit tanning behaviors. By identifying the social and cultural factors leading to body-tanning behaviors, educators and prevention strategists can target the skin cancer prevention of young people.

Research on understanding the behavioral motivations that influence body-tanning behaviors has primarily been focused on sun-protection behaviors and UV-induced exposure, which has a direct link to skin cancer development. Tanning-bed use is associated with an increased risk of developing skin cancer, but knowledge about body-tanning risks is not sufficient to alter attitudes toward tanning-bed use (Hillhouse & Turrisi, 2002). Skin cancer prevention strategies should be developed by understanding all tanning methods. Even though sunless tanning products may not cause skin cancer (Fu, Dusza, & Halpern, 2004), having a tanned appearance using tanning products may perpetuate the belief that tanned skin is ideal and attractive.

It has been suggested that understanding what are the factors that influence health decision making has the potential to decrease risky behavior such as tanning-bed use (Greene & Brinn, 2003). Although the desire to be attractive has been identified as a primary motivation for body-tanning behavior (Cafri, Thompson, Roehrig et al., 2006; Yoo & Kim, 2014), individuals have many reasons for tanning their skin. Greene and Brinn (2003) reported that susceptibility to the influence of others and motivation to make a good impressions on others strongly predicted the intention to use a tanning bed. Additional motives for tanning include that it makes people feel better about themselves, that the lack of a tan is unattractive, that tanned skin looks healthier, and that friends and the media influence the idea that a tan is attractive (Dennis, Lowe, & Snetselaar, 2009).

It is important to examine the variables that influence individuals’ intentions to quit tanning in the context of all three methods (i.e., outdoor tanning, indoor tanning bed, and sunless tanning), and how these intentions might be utilized for understanding tanning behaviors and for developing skin cancer prevention strategies. Skin cancer has emerged as a major threat to public health in the United States (Jemal et al., 2009). Therefore, it is important to understand the specific motives that influence individuals’ intentions to quit tanning and the relationship of these to actual tanning behaviors. The focus of skin cancer prevention strategies should be on attitudinal changes toward body tanning.

Literature Review and Development of Hypotheses

From a historical review it has been found that tanning first became fashionable in the 1920s or 1930s (Martin et al., 2009). It has been suggested that body-tanning deterrents, in which the focus is solely on health issues—such as skin cancer—and without a major focus on appearance-related issues, may not be effective (Heckman, Wilson, & Ingersoll, 2009). Frequent mass media portrayals of tanned fashion models account, in part, for the popularity of tanned bodies in North American culture (Cafri, Thompson, Roehrig et al., 2006).

Historically, the public have associated individuals with tanned skin with good health (Keesling & Friedman, 1987). A person who obtains tanned skin often perceives himself or herself as having physical strength and an active lifestyle (Koblenzer, 1998; Mawn & Fleischer, 1993). A certain amount of exposure to the sun helps the body to produce vitamin D (Keesling & Friedman, 1987). In addition, Dougherty, McDermott, and Hawkins (1988) found that individuals experience therapeutic benefits by using sunbeds, such as feeling well, being in a good mood, and looking healthy. Individuals with tanned skin elicit a more positive impression than do persons without a tan (Broadstock, Borland, & Gason, 1992; Miller, Ashton, McHoskey, & Gimbel, 1990).

Tanning Methods and Differences in the Effect of Tanning

People can achieve a tan by three different methods: exposure to the sun, using beds in tanning salons, and by using tanning cosmetic products (Reilly & Rudd, 2008). Shoveller, Lovato, Young, and Moffat (2003) found that the motivation to obtain a suntan is influenced by observing siblings, friends, and others who are tanned, as well as by receiving positive feedback about their tanned appearance. The use of indoor tanning is becoming increasingly popular among younger populations (Hamlet & Kennedy, 2004). An examination of the use of tanning beds and attitudes toward tanning of adolescents aged 14 to 16 years revealed that they perceived that they looked healthy and became more attractive and confident from using tanning beds. In addition, the market for sunless tanning products has grown because of greater public awareness of skin cancer that has resulted from exposure to UV rays (Fu et al., 2004). Consumers in the US spend approximately $86 million per year in the pursuit of a sunless tan, accounting for 50% of global self-tanning sales. Even though the primary concern about using sunless tanning products is that the tan would not look very natural (Yoo & Kim, 2012), there is another concern that means precautions should be taken, especially for spray tanning, because sunless tanning products can create skin irritation and dryness (Brundage, 2010).

Perceived Attractiveness of Tanning and Motivation

The aesthetic effect of tanning on appearance has been consistently identified as the primary reason for UV ray exposure (Cafri, Thompson, Roehrig et al., 2006; Yoo & Kim, 2014). Tanned skin is an important part of appearance in terms of developing one’s identity and self-expression, especially for young adults in individualistic cultures (Yoo & Hur, 2012). Many young adults have reported that they perceive that a tanned body is much more attractive than an untanned one (Boldeman et al., 2001; Knight, Kirincich, Farmer, & Hood, 2002; Monfrecola, Fabbrocini, Posteraro, & Pini, 2000; O’Riordan et al., 2006). Body tanning has been a popular appearance-enhancing method in the United States, in that a tanned complexion is considered more attractive than a pale one (Cafri, Thompson, & Jacobsen, 2006). Therefore, the following hypothesis was established:
Hypothesis 1: Perceived attractiveness from tanning will have a negative influence on the intention to quit tanning.

Media Influences of Tanning as an Ideal

Fashion magazine contents in which a tan is promoted as an ideal skin tone have been identified as a significant influence on the tanning behaviors of individuals in the United States (Gallagher & Lee, 2006). Individuals who viewed magazine advertisements using models with tanned skin rated them more highly in terms of the overall attractiveness of a tanned appearance than those who viewed neutral stimuli, suggesting that the mass media can influence people to make more positive evaluations of a tanned appearance (Mahler, Beckerley, & Vogel, 2010). When having tanned skin is endorsed by celebrities this provides a point of social comparison for young adults to strive to achieve the same look. Although not all individuals find sociocultural standards important, many base the physical appearance they wish to achieve on these standards. Therefore, the following hypothesis was established:
Hypothesis 2: Media portrayals of tanned skin as the ideal complexion will have a negative influence on the intention to quit tanning.

Family and Friend Influences

According to Friedkin and Cook (1990), group interactions influence behavior; as a result, social tanning is identified as a source of tanning motivation, and is an important factor in inducing people to engage in body-tanning behaviors (Dennis et al., 2009). Attitudes toward physical appearance are related to the family structure and familial opinions about appearance (Sinton & Birch, 2006; Tester & Gleaves, 2005). In past research, the role of parents has been addressed with respect to indoor-tanning-bed use only by examining the relationship between parental knowledge of indoor tanning risks, and the frequency of parents’ indoor-tanning-bed use (Demko, Borawski, Debanne, Cooper, & Stange, 2003). However, levels of parental knowledge concerning risks are not related to their children’s tanning-bed use (Magee, Poorsattar, Seidel, & Hornung, 2007). In addition, peer crowd identification is significantly associated with body image concerns and indoor artificial UV-induced tanning-bed use (Stapleton, Turrisi, & Hillhouse, 2008). Image-conscious individuals may consider body tanning as the norm when their peers comment positively about their tanned skin. Accordingly, family and peers may present body tanning as a norm that influences the individual’s intentions to quit tanning. Considering the importance of socialization of body image concerns, the following hypothesis was established:
Hypothesis 3: Family/friend influences will have a negative influence on the intention to quit tanning.

Perceived Physical Fitness

A tanned appearance has been linked to good health. Fiala, Kopp, and Günther (1997) found that people who often visit tanning salons have a stronger sense of physical and mental well-being due to their visits. Findings reported in research have shown that frequent tanning-bed use is associated with the individual being highly concerned about his or her body weight and with other weight-related behaviors, such as dieting to lose weight, and using laxatives and vomiting to control weight (Blashill & Traeger, 2013). Overweight adolescents tend to engage in body tanning more frequently than their peers do because they perceive that having tanned skin creates an appearance of looking slim (O’Riordan et al., 2006). On the contrary, Yoo and Kim (2012) found that adolescents who were underweight or average weight were more likely to engage in outdoor tanning from the sun compared to overweight adolescents. However, little is known about the relationship between perceived physical fitness and a tanned appearance as regards to intention to quit tanning. We believed that if people are physically fit, they are less likely to engage in tanning because they would not need tanned skin to look fit. Therefore, the following hypothesis was established:
Hypothesis 4: The perception that tanning is related to physical fitness will have a negative influence on the intention to quit tanning.

Skin-Aging Concerns

Assessing the perception of skin aging has important implications because the overall appearance of skin, even when minimally flawed, can have a profound effect on one’s body-image perception (Gupta & Gupta, 2013). Skin dissatisfaction contributes to significant morbidity in people who have dermatologic disorders and is often their primary consideration in deciding whether to proceed with certain cosmetic procedures. In addition, skin-aging concerns in individuals may deter them from seeking UV exposure because there is a strong correlation between UV exposure and skin damage (Heckman et al., 2009). Therefore, we judged that it would be important to assess whether skin-aging concerns have a significant role with respect to individuals’ intentions to quit tanning. Therefore, the following hypothesis was established:
Hypothesis 5: Concerns about skin aging will have a positive influence on the intention to quit tanning.

The Intention to Quit Tanning and Its Relationship With Tanning Behaviors

An individual’s behavior is a result of personal motivation toward adopting the behavior (Ajzen, 2005). Individuals try to enhance their self-image and are willing to take health risks to modify their appearance when they believe that their actions will bring about positive social outcomes. The factors influencing and interacting with the decision to engage in UV-induced tanning have been identified in a previous study, in that intentions and perceived behavioral control predict indoor-tanning-bed use (Hillhouse, Turrisi, & Kastner, 2000). These intentions are influenced by attitudes an individual has toward tanning behaviors. Therefore, we formed a hypothesis to test whether the intent to quit has a direct link to actual body-tanning behaviors.
Hypothesis 6: The intention to quit tanning will significantly reduce body-tanning behaviors.

The Variables That Motivate Tanning Behaviors via Intention to Quit Tanning

As a new strategy, the theory of planned behavior was adopted to develop new health promotion strategies for prevention of health issues caused by tanning (Ajzen, 2005; Hillhouse et al., 2000). In the theory of planned behavior, it is posited that an individual’s behavior is a function of personal motivation toward adoption of the behavior. We applied this theory to examine the perceptions the individual holds about what significant others believe they should do regarding adoption of tanning behaviors. Sunbathing and having prolonged exposure to sunlight are personal choices that the individual can control himself or herself. However, tanning behavior is a phenomenon for which the individual takes social and cultural influences into consideration. In other words, tanning is a behavior that is difficult for the individual to control when a tanned appearance is idealized, popularized, and influenced by members of the group to which one belongs. Therefore, the following hypothesis was established:
Hypothesis 7: The influences of media, family, and friends, perceived physical fitness, perceived attractiveness of tanning, and concerns for skin aging will influence body-tanning behaviors via intention to quit tanning.

Method

Data Collection

After obtaining approval from the Institutional Review Board of the university, we contacted the instructors of courses in the Family and Consumer Sciences Department at a university located in central Texas, USA, to distribute an online survey using their course websites. The participants were contacted via a weblink to an online survey and were asked to consent to join the study. A consent form was provided on the webpage, on which we also gave information about the survey and the nature of the study. Participants read the information on the form then gave their consent via clicking on an “agree” or “disagree” button.

Participants

We received 385 usable responses that we entered for the data analysis after eliminating incomplete responses. The majority of participants were Caucasian (79.7%; n = 307), followed by African American (8.8%; n = 34), Asian (6.0%; n = 23), multiracial (3.4%; n = 13), and Hispanic American (2.1%; n = 8). Of the participants, 89.1% were women and 10.6% were men, with an average age of 20.55 years (SD = 9.7).

Instrument Development

Items to assess perceived attractiveness of tanning, media and family/friends influence, perception of physical fitness, and concern about skin aging were all measured on a 5-point rating scale (1 = strongly disagree, 5 = strongly agree) developed by Cafri, Thompson, Roehrig et al. (2006).

Perceived attractiveness of tanning. Example items from the five we used include: “I tan because it makes me more attractive,” “Having a tan gives me more sex appeal,” and “I tan because it makes me look better.” The internal consistency of perceived tanning attractiveness in this study was α = .946, with a higher score denoting higher perceived attractiveness of tanning.

Media influence. We used six items to assess media influence. Example items include “I wish I had a tan like the celebrities on TV,” and “I want to be as tanned as people in magazines.” The internal consistency in this study was α = .961, with a higher score denoting higher media influence.

Family/friend influence. We used five items to assess family/friend influence. Example items are “I would like to be tanned because my friends say it is attractive,” and “I want to tan because people in my family think it makes my skin look nicer.” The reported internal consistency in this study was α = .922, with a higher score denoting higher family/friend influence.

Perceived physical fitness. We included six items to assess perceived physical fitness as a result of tanning. Example items are “The more tanned I am, the more physically fit I look,” and “I tan because it helps me look in shape.” The internal consistency of physical fitness in this study was α = .936, with a higher score denoting higher perceived physical fitness from tanning.

Skin-aging concerns. The four items on skin-aging concerns as a result of tanning were “I don’t tan because it will age my skin quicker,” “I am hesitant to tan because it will wrinkle my skin,” “I am concerned about getting blemished skin as a result of tanning,” and “I don’t tan as much as I would like because I am worried about premature skin aging.” The internal consistency in this study was α = .880, with a higher score denoting increased concern about skin aging as a result of tanning.

Intention to quit tanning. The survey included three items to assess the intention to quit tanning, which were modified from Ajzen’s (2005) generalized intention (e.g., “I intend to quit tanning.”). Items are measured on a 5-point rating scale (1 = strongly disagree, 5 = strongly agree) with a higher score denoting stronger intention to quit tanning. The internal consistency in this study was α = .952.

Tanning behavior. We developed four items on body-tanning behaviors and these were also measured on a 5-point rating scale (1 = strongly disagree, 5 = strongly agree). The items are “I suntan outdoors (lying in the sun) regularly,” “I use indoor tanning (a tanning bed/lamp) regularly,” “I use tanning spray (at tanning salons) regularly,” and “I use tanning products (tanning lotion, tanning pills) regularly.” The internal consistency in this study was α = .754, with a higher score denoting more frequent tanning behaviors. Last, demographic variables included participants’ gender, age, and ethnicity.

Control variables

We controlled for the respondents’ ethnicity because tanning is prevalent among Caucasian populations (Gillen & Markey, 2012). Caucasians were coded as 1 and all other ethnicities were coded as 0.

Results

Preliminary Data Analyses

An exploratory factor analysis with the maximum likelihood method and Varimax rotation was performed. Items that showed poor psychometric properties (< 0.40 factor loading) were dropped. One item from perceived attractiveness, two items from family/friend influence, and one item from tanning behavior were dropped. A minimum eigenvalue of 1.0 was used to determine the number of factors. From the analysis we extracted five tanning motivation factors: perceived attractiveness of tanning, influence of media, influence of family/friends, perceived physical fitness, and skin-aging concerns. These five factors accounted for 81.659% of the total variance in tanning motivation. The Cronbach alphas for all items were above .754, which showed acceptable reliability (Nunnally & Bernstein, 1994).

Measurement Model

Using AMOS 18, we performed confirmatory factor analysis (CFA) to further assess the suitability of each of the factors in the research structural model for measurement. Results for all items were above .60. (Anderson & Gerbing, 1988). Therefore, the final model consisted of 27 items, including 22 items to assess the five tanning motivations, two items to measure the intention to quit tanning, and three items to measure tanning behaviors. Although the CFA model had a significant chi-square value (χ² = 874.851, df = 329, p < .001), other fit indices for normed fit (NFI), comparative fit (CFI), incremental fit (IFI), and root mean square error of approximation (RMSEA) provided evidence for the sound psychometric properties of the seven constructs used in this study (NFI = .92, CFI = .95, IFI = .95, RMSEA = .06).

Testing Hypotheses

Table 1 shows the results of the structural model. We performed a latent structural equation modeling analysis with maximum likelihood estimation to test the significance of the parameters in the structural model. We also used bootstrapping, and 1,000 usable bootstrap samples were obtained. The structural equation model also indicated that the proposed model had a significant chi-square value (χ² = 1058.79, df = 356, p < .001), but other model fit indices indicated an acceptable model fit to the data (NFI = .91, CFI = .93, IFI = .94, RMSEA = .072). The results of the hypotheses testing are also presented in Figure 1.

H1, predicting the negative influence of perceived attractiveness of tanning on the intention to quit tanning, was supported. Participants who believed tanning gave them an attractive appearance tended to have less intention to quit tanning than did those who did not believe this. The influence of media and of family/friends, and the motivation of perceived physical fitness on the intention to quit tanning were not statistically significant (H2, H3, and H4, respectively). In H5 we predicted that skin-aging concerns would positively influence the intention to quit tanning; the result was statistically significant. Therefore, H5 was supported. Participants who were more concerned than others were about skin aging tended to have a stronger intention to quit tanning. There was also a negative relationship between the intention to quit tanning and tanning behaviors, which supported H6.

Participants who had a stronger intention to quit tanning tended to have a lower score for tanning behaviors. As perceived attractiveness from tanning (.072) and skin aging concern (-.069) showed a statistically significant indirect effect on tanning behaviors, the intention to quit was a partial mediator between these two influencing variables and body-tanning behaviors. The 95% confidence interval (CI) of indirect effect of perceived attractiveness of tanning was between .009 and .073. The CI of indirect effect of influence of media was between -.007 and .029. The CI of indirect effect of influence of family/friends was between -.044 to .008. The CI of indirect effect of perceived physical fitness was between -.041 and .009. Last, the CI of indirect effect of skin-aging concern was between -.083 and -.014. Therefore, H7, that perceived attractiveness of tanning, influence of media/family/friends, perceived physical fitness, and concerns about skin aging would all influence body-tanning behaviors via intention to quit tanning, was partially supported. The results set out in Table 2 demonstrate a decomposition of the total effect into direct and indirect effects.

Discussion

The results support the notion that individuals’ intention to quit tanning is positively influenced by skin-aging concerns and negatively influenced by positive motivation toward perceived attractiveness from tanning. These findings suggest that appearance-based motivation would be the variable with the greatest influence on individuals in regard to engaging in tanning behaviors. We were interested that our results show that young adults are concerned with skin damage as a result of tanning, although they use methods to tan their skin to achieve the particular outcome of a tanned appearance. Communicating the long-term negative consequences of tanning, such as skin aging, would be an important deterrent for those young adults who are at risk of exposing themselves to UV rays.

Social factors (the media, peers, family) have consistently been identified as significant influences on body-tanning attitudes (Yoo & Kim, 2015), and tanning behaviors (Cafri, Thompson, Roehrig et al., 2006; Yoo & Kim, 2015). However, the influences of media, family, and friends on the intention to quit tanning were not found to be significant in our study. This suggests that people are preoccupied with their appearance, and that conforming to the ideal appearance is embedded in U.S. culture. In addition, perceived physical fitness was not a significant element in deciding participants’ intention to quit tanning. This finding is in contrast to the previous findings that overweight individuals of both sexes were less likely than their peers were to engage in outdoor tanning (Yoo & Kim, 2012). Individuals who exhibit strong physical fitness are already invested in their appearance and may engage in tanning in addition to physical exercise to achieve body fitness (Yoo, 2017).

Our findings provide important implications for skin cancer prevention campaigns. We recommend that a range of the damaging effects of tanning on appearance should be emphasized as a new intervention strategy to curtail UV exposure. Consequently, in our study we confirmed that the accompanying negative appearance-related outcome of tanning (i.e., skin damage) can be considered as an effective skin cancer prevention strategy. It is important that health practitioners emphasize adverse effects of tanning on appearance and develop a diverse range of possibilities for interventions and prevention programs. Instead of trying to promote the message of body tanning as an unhealthy behavior, promoting untanned healthy bodies as a positive healthy image can serve as an effective approach to decreasing skin cancer incidence. Additionally, compensatory alternatives to UV exposure, such as fashion guidance to accentuate healthy body form and shape, should be promoted to boost a positive body image, and to reduce the likelihood of engaging in risky tanning behaviors.

There are several limitations to consider in generalizing our findings. First, we relied on self-reports, which may limit the validity of the data. In addition, rigorous sampling methods would strengthen the results. Participants were recruited using a convenience sampling method in one geographic location. Second, we performed a cross-sectional analysis and it would be desirable to carry out a longitudinal analysis using the same participants as the unit of analysis. Despite the limitations, our findings further support the growing literature in which the efficacy of appearance-related variables that influence body-tanning behaviors are affirmed.

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Seahee Lee, Ewha Womans University, A-3801 Hyundai Superville, Seocho-Dong, Seocho-Ku, Seoul, Republic of Korea. Email: [email protected]