Skin deep: coverage of skin cancer and recreational tanning in Canadian women's magazines (2000-2012).

McWhirter, Jennifer E. ; Hoffman-Goetz, Laurie

Skin cancer is the most common type of cancer among Canadians. (1) It is such a significant and growing public health problem that the Canadian Cancer Society made skin cancer a special focus of the 2014 annual cancer statistics report, (1) with 6,500 new cases of melanoma (1,050 deaths) and 76,100 cases of non-melanoma (440 deaths) skin cancers estimated. Both the incidence of, and mortality from, melanoma--the most dangerous type of skin cancer--have increased significantly in Canada over the past 25 years. Indeed, the incidence of melanoma among Canadian women is 13.0 per 100,000 and has risen by 1.5% per year from 1986 to 2010.1 In 2004, the cost of skin cancer care in Canada was $532 million; by 2031, this is expected to increase to $922 million per year. (2)

Ultraviolet (UV) radiation exposure is the most important cause of melanoma and non-melanoma skin cancers. (3) In Canada, UV radiation accounts for 90% of melanoma cases. (4) Sources of UV radiation include the sun (most commonly) and indoor tanning equipment. The World Health Organization recognizes UV exposure--both from the sun and indoor tanning beds-as carcinogenic. (5) Intermittent intense sun exposure, history of sunburn, susceptible phenotype (light hair, skin or eyes), indoor tanning bed use, and multiple or atypical moles are associated with melanoma. (6)

National surveys suggest that the sun behaviours of Canadians may increase their risk of skin cancer. More Canadians are taking winter vacations in sunny locales, spending more time in the sun while vacationing or doing leisure activities, and fewer Canadians report wearing protective clothing or hats. (7) Artificial UV exposure is also a public health problem. Over 25% of Canadian women ages 16 to 24 years, and 15% of women ages 25 to 44, use indoor tanning equipment. (7) There are over 5,000 tanning salons in Canada, (8) far more than the number of McDonald's (1,400) and Tim Hortons (3,000) restaurants. (9,10)

The mass media, including print magazines, are an important source of information about skin cancer for the public. (11) Previous research on cancer coverage in Canadian magazines has focused on cervical cancer, (12) breast cancer, (13) and, more broadly, on attention to different cancer types. (14) Investigating media coverage of cancer, including skin cancer, is supported by theory. According to Agenda Setting Theory, the media is persuasive toward influencing public and policy agendas: the more frequent and prominent the media coverage of an issue is, the more important audiences will believe this issue to be. (15) It is, thus, important to investigate the frequency and nature of skin cancer and tanning coverage as a way of understanding the contribution of media effects on skin cancer behaviours by the public.

Despite the growing incidence of skin cancer and the importance of media to position health issues on the policy agenda and influence the public's health knowledge, attitudes and behaviours, there has been no published research on the coverage of skin cancer and tanning in Canadian mass media. In an effort to address this surprising research gap, we examined 13 years of skin cancer and tanning content (both article text and accompanying images) in six popular Canadian women's magazines, with a focus on risk factors, UV protection and exposure behaviours, and early detection or screening information. We also assessed magazine reporting on skin cancer and tanning in Canadian compared to American (US) women's magazines because US magazines have considerable reach in Canada. (16) We hypothesized there would be no jurisdictional differences in reporting given the increased incidence of skin cancer among both countries, (17) similarities in each country's approach to indoor tanning restrictions, (18) and general cultural similarities.

METHODS_

Using directed content analysis as our qualitative methodology, we examined coverage of skin cancer and recreational tanning in six popular Canadian women's magazines from 2000 to 2012: Canadian Living, Chatelaine, Homemakers, FASHION, ELLE Canada, and Flare (2012 circulation rates: approximately 127,000 to 512,000). Although the focus of this study was on Canadian magazines, we also included six popular US women's magazines to serve as a comparison group: Good Housekeeping, Family Circle, Ladies' Home Journal, Glamour, ELLE US, and Vogue (2012 circulation rates: approximately 1.1 to 4.4 million).

We used electronic databases (Canadian Periodical Index, Reader's Guide to Periodical Literature, LexisNexis, Factivia, and ProQuest Research Library) and relevant search terms (skin cancer, melanoma, basal cell carcinoma, squamous cell carcinoma, tan*, indoor tan*, outdoor tan*, suntan*, sunburn, sunscreen, sunblock) to search the magazines for skin cancer and tanning content. Those magazines not indexed electronically were searched manually using the table of contents. A comprehensive list of the potential articles on skin cancer and tanning was created, which noted the title of the article, the periodical in which it was published, the date of publication, and the relevant page numbers (when available). Using this list, one researcher collected the data 1) by using electronic databases, 2) manually by visiting libraries (e.g., Toronto Reference Library), and 3) by co-ordinating with the university inter-library loan specialist to facilitate the collection of data from other libraries (e.g., Vancouver Public Library).

We determined whether articles focused on skin cancer and tanning by examining the title, byline, introductory paragraph, and amount of space (>75%) devoted to the issues. To examine the nature of skin cancer and tanning coverage, we coded articles and their accompanying images for the presence or absence of variables related to mentioning specific risk factors for skin cancer, promoting UV protection and exposure avoidance behaviours, and encouraging early detection through self or physician-led skin examination. These variables are listed in Table 1 and were operationalized in a codebook developed by the researchers based on information from the Canadian and American academies of dermatology and cancer societies. A description of these variables appears in Table 1. For each article and image, the variables were coded as being present (1) or absent (0), and this information was entered into a spreadsheet in SPSS v 21. NVivo 10 software was used to capture quotes and create image descriptions for each variable. The reading grade level for text of each article was determined using an online SMOG (simplified measure of gobbledygook) calculator. (19)

One researcher coded all articles and images for the study. To ensure reliability of coding and reduce bias, a sample of articles (n = 32) and images (n = 53) were independently coded by a second researcher. Each researcher kept separate notes on variables where descriptions or images were ambiguous and on other questions or concerns that arose during coding. After independently coding the sample of data, the results were compared: inter-coder reliability was very good with kappa scores ranging from 0.83 to 1.00. Discrepancies in coding were resolved through discussion until consensus was reached; to address discrepancies, the codebook was revised to include more detailed descriptions and examples.

We used SPSS v 21 for descriptive statistics to summarize the volume and nature of skin cancer and tanning coverage in Canadian women's magazines. We used chi-square and Fisher's exact tests to compare the presence of variables by content type (text vs. images) and country (Canada vs. US). Statistical results with p < 0.05 were considered statistically significant.

RESULTS

There were 154 articles (containing 221 images) published on skin cancer or tanning in six popular Canadian women's magazines between 2000 and 2012. Data retrieval was high (98.7%); just two articles could not be obtained. The number of articles published per year fluctuated considerably, ranging from 4 (in 2001) to 18 (in 2004) (Figure 1). The average number of articles published per year between 2000 and 2012 was 11.85 (SD = 4.67). There was no linear trend for the volume of articles published over time (Figure 1).

Articles came from Canadian Living (n = 21, 13.6%), Chatelaine (n = 24,15.6%), Homemakers (n = 12, 7.8%), FASHION(n = 32, 20.8%), ELLE Canada (n = 18, 11.7%) and Flare (n = 47, 30.5%). About 80% of articles were published between May and July (May, 6.5%; June, 55.2%; July, 18.8%).

Articles were accompanied by 0 to 6 images (M = 1.46, SD = 0.99). Articles were between 0.25 and 5 pages in length (M = 1.29, SD = 1.13) and ranged from 40 to 1967 words (M = 519.05, SD = 418.60). The average reading grade level of the articles as calculated using SMOG was high and at post-graduate levels (M = 16.34, SD = 1.79).

The number and percent of all articles reporting and images depicting skin cancer risk factors, UV behaviours, and early detection variables in Canadian women's magazines are presented in Table 2. Table 2 also presents chi-square tests (or Fisher's exact tests) for comparisons between how text vs. images conveyed these variables. Table 3 provides representative example quotes and image descriptions to illustrate each of the variables.

The most common skin cancer risk factor reported on was UV exposure (39% of articles). Light skin, moles, personal or family history, and sunburns were infrequently reported as risk factors: less than 12% of articles mentioned them. Although there was limited coverage in text about skin cancer risk factors, they were nevertheless more frequently described in text than depicted in images (p < 0.01 for all risk factor variables).

With regard to UV behaviours, the most frequently conveyed variables were sunscreen use, self-tanners, and the suntanned look. Nearly 72% of articles promoted sunscreen use, but little content promoted other means of UV radiation protection, including seeking shade (7%), wearing a hat (12%), or wearing protective clothing (14%). Articles that encouraged UV avoidance--avoiding the sun (16%) or indoor tanning (15%)--were in the minority. In fact, there were more articles (41%) and images (53%) that promoted the suntanned look as attractive compared to those that discouraged indoor tanning or sun exposure.

Text tended to have more messages about the importance of UV protection and avoidance compared to images: images more frequently promoted the tanned look as attractive, while text more frequently encouraged the use of self-tanners and sunscreens and discouraged indoor tanning more often than images.

Few articles (<11%), and even fewer images (<2%), focused on early detection (skin self-examination, physician-led skin examination, ABCD criteria) for skin cancer. For all three early detection variables, they were significantly more likely to be conveyed through article text than through images (Table 2).

For country comparisons, six US women's magazines with similar topic focus and target audience were selected. There were a total of 332 articles about skin cancer and tanning between the two sets of magazines, but 8 were missing (2 Canadian, 6 US);the remaining comparison analyses were based on 324 articles (n = 152 Canadian articles;n = 172 US articles) and 531 accompanying images (n = 221 Canadian images;n = 310 US images). There was no statistically significant difference for the number of skin cancer and tanning articles published in the 6 Canadian (n = 154) vs. the 6 US (n = 178) women's magazines ([chi square] = 1.74, df = 1, p = 0.188) over the study timeframe. The jurisdictional comparisons by variable are summarized below and presented in detail in Table 4.

US magazine article content was more likely to convey light skin (images), moles (text and images), and history of skin cancer (text) as risk factors. There were no significant differences in reporting frequency between the two countries for UV exposure or sunburns as risk factors for skin cancer.

For UV behaviours, text and images in Canadian magazines were more likely to promote the tanned look than those in US magazines. Images in US magazines more often promoted solar UV avoidance (18%) compared to images in Canadian magazines (11%). Articles in Canadian magazines were more likely to promote indoor tanning (3%) compared to US magazines (0%). Articles in US magazines were more likely to promote hat use (20% vs. 12%), but images in Canadian magazines were more likely to promote sunscreen use (27% vs. 18%) (Table 4).

Regarding early detection variables, a greater proportion of articles encouraged physician-led skin examination (US = 24%; Canada = 11%) and a greater proportion of both articles (US = 22%; Canada = 11%) and images (US = 8%; Canada = 1%) encouraged skin self-examination in the US compared to Canadian magazines.

DISCUSSION

Overall, while there was considerable focus on UV exposure as a risk factor for skin cancer and the importance of sunscreen use in Canadian women's magazine content on skin cancer and tanning, other risk factors, other prevention and protection behaviours, and screening information received little attention. When these findings are considered in light of the fact that skin cancer usually receives less media coverage than other cancers, (20) the concern is amplified. The lack of informative content on skin cancer and tanning in Canadian magazines may both help to explain and also reflect the general lack of knowledge about skin protection among the population.

UV exposure is the most important risk factor for skin cancer, so it is positive that it is reported on most frequently in this media channel; however, risk is heavily modified by other variables (susceptible phenotype, personal or family history, history and severity of sunburns, and numerous or abnormal moles) which were mentioned infrequently. This may have been because magazine journalists and editors are aware that UV exposure is the most important risk factor for the disease or because it is a modifiable risk factor that can be readily changed (whereas family history, susceptible phenotype, etc., are not). Images did little to convey information about risk factors. Although UV exposure as a risk factor was frequently messaged in the magazines, this emphasis was only reflected in terms of UV protection and not UV avoidance behaviours.

As with risk factors, there was one stand-out UV behavioural variable that was encouraged most frequently in articles: sunscreen use. It is encouraging that so many articles promoted sunscreen use; however, when this is considered in the context that approximately half of the content also promoted the tanned look as attractive, it becomes less clear that this message is entirely positive. About 30% of articles in Canadian women's magazines also promoted self-tanners--more than those discouraging indoor tanning behaviours. This may suggest, perhaps not surprisingly given the role beauty product advertising plays in magazine operation and publication, that the UV behaviours encouraged in magazines are product-related. The lack of information about UV protection behaviours (other than sunscreen) in popular magazines may partly contribute to the lack of sun safety awareness and sun protective behaviours among Canadians. (7)

Images generally did not promote prevention behaviours: compared to text, they were more likely to convey the tanned look as attractive, and less likely to encourage sunscreen use. That images stressed the tanned beauty ideal potentially has an even greater impact on the 'take-home' message for the readership of these women's magazines as the readability of article texts was at the post-graduate level. With such high reading grade levels, readers tend to focus even more on images. The promotion of the tanned look as attractive has been reported elsewhere in Australian magazine content, (21) but we were particularly concerned that even in images accompanying Canadian articles about skin cancer and tanning, this beauty ideal was present. Approximately 77% of Canadian adults report that an important reason for using tanning equipment is to look better and 29% of Canadian women try to tan from the sun or tanning equipment. (7) These attitudes and behaviours may be encouraged by Canadian media content promoting the tanned look as normative and desirable;images are important drivers of these behaviours. (22)

Given the rising incidence of melanoma and the known carcinogenic nature of UV radiation from indoor tanning devices, a number of provinces now restrict youth under 19 years of age from using tanning beds, including: British Columbia, Ontario, Quebec, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador. (8) Health Canada recently strengthened warnings on the devices about the dangers of indoor tanning through changes to the Radiation Emitting Devices Act, (23) and the Canadian Cancer Society and Canadian Dermatology Association advise against the use of these devices. (24,25) Despite these health policies and efforts to dissuade users, fewer than 15% of articles in the magazines included in our study discouraged indoor tanning bed use. The public health push limiting and discouraging artificial tanning device use appears not to be reflected in Canadian women's magazine content on skin cancer and tanning. The Canadian Cancer Society indicates that greater efforts are needed to encourage UV avoidance, from both the sun and tanning beds. (1) The results of this study add further support to this recommendation.

There was very limited focus on early detection and screening for skin cancer in Canadian women's magazines. Early detection has been associated with better prognosis, (26) and screening for skin cancer, including skin self-examination and physician check-ups, is encouraged for those at high risk of skin cancer. (27) Early detection information was infrequently conveyed through text, and even less so, in images. In fact, just one image in six Canadian women's magazines over a 13-year timeframe depicted the visual ABCD* criteria-images which are necessary to promote frequent and accurate skin self-examination. (28) It is unclear how Canadians might gain access to seeing such images, or even know to seek them out, if they are not depicted in the mass media. For example, at the time of writing, the Canadian Cancer Society did not provide visual examples of skin lesions on its website, (29) although it does encourage skin self-examination. This is exacerbated by the fact that there are relatively few dermatologists serving the Canadian population, and family medicine programs provide limited training in dermatology. (30)

There were significant differences in the way Canadian and US women's magazines covered the issues of skin cancer and tanning. Aside from the topic of sunscreen use, which was featured more often in Canadian magazines, US magazines were generally more informative with regard to skin cancer and tanning: they reported on a wider variety of risk factors and UV protection behaviours and more often encouraged UV avoidance and early detection and screening. The reasons for the transnational variation in popular women's magazines between the two countries are not clear from our data. We suggest that differences in health care systems (31) and the personal responsibility that a private health care system in the US puts on individuals for their own health (32) may be possible factors. Variations in coverage and emphasis could also relate to the warmer and sunnier climate in many parts of the US compared to Canada. Canadian magazines more often conveyed the tanned look as attractive, which may reflect the 'tan' being rather exotic in Canada because of climate or because Canadians seek leisure time in warm, sunny climates. (7)

Limitations

Our research did not investigate skin cancer and tanning coverage in Canadian men's magazines. Determining media messages around skin cancer and tanning targeted towards men is an important area for future research, especially given that men over 50 have a higher incidence of melanoma skin cancer compared to women. (1) It is also a limitation that the magazines in our study target adult women while it is adolescent girls who most often use tanning beds and to whom the tanning bed restrictions apply. There were no Canadian men's or girls' magazines published consecutively during the study timeframe, so we restricted the focus to women's magazines. Our study focused on print magazine coverage, but many Canadians turn to other print media (e.g., newspapers), online sources (e.g., websites), and social media (e.g., Twitter) for health information. Future research should investigate reporting of skin cancer and tanning in these types of mass media outlets. Our study focused only on English-language magazines and it will be important to examine the coverage of French-language Canadian women's magazines with regard to skin cancer and tanning, in light of possible differences in normative beauty ideals.

Had the research been guided by other media communication theories, our results might have been interpreted differently. For example, active audience theory (33) suggests that readers are actively involved with making meaning from the information they receive from magazines. A reader who recently had a friend diagnosed with melanoma may attend more to early detection information, while a reader who has suffered a sunburn may be more influenced by content around sunscreen use. How audiences interpret media messages (passively, actively, or a combination of both) around these public health issues will be important to address in future research.

CONCLUSION

Over a decade of Canadian women's magazine reporting on skin cancer and tanning has focused on UV exposure as a risk factor and sunscreen use as a protection behaviour; however, little attention was given to other risk factors, other UV protection or avoidance behaviours, and information about early detection. Images promoted the tanned look and rarely depicted skin cancer risk factors, prevention behaviours, or early detection. With the exception of sunscreen use, US magazine content, in comparison with Canadian content, tended to be more informative about skin cancer and tanning. Taken together, the results of our study indicate that some skin cancer-related information is reported fairly frequently, but there is considerable room for improvement in the way Canadian women's magazines cover this public health issue. Our results strongly support the recommendation of the Canadian Cancer Society that there is a great need for "clear and consistent sun safety messages for the public." (1) Public health engagement with Canadian mass media may facilitate the promotion of effective skin cancer and UV protection and avoidance messaging.

Jennifer E. McWhirter, PhD, Laurie Hoffman-Goetz, PhD, MPH

* Asymmetry, border irregularity, colour, diameter.

Authors' Affiliation

School of Public Health and Health Systems, University of Waterloo, Waterloo, ON Correspondence: Laurie Hoffman-Goetz, PhD, Faculty of Applied Health Sciences, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue W, Waterloo, ON N2L 3G1, Tel: 519-888-4567, ext. 33098, E-mail: lhgoetz@uwaterloo.ca

Acknowledgements: This work was supported by grants from the Canadian Institutes of Health Research (Jennifer McWhirter) and the Social Sciences and Humanities Research Council of Canada (Laurie Hoffman-Goetz). The authors thank Ted Harms and the Inter-library Loan department at the University of Waterloo for help with coordinating data collection.

Conflict of Interest: None to declare.

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Received: September 15, 2014 Accepted: March 21, 2015 Table 1. Codebook of variables of interest Variable Text description Image description Risk factors UV exposure Mention of UV Depiction of someone exposure (solar or who has had skin artificial) as risk cancer being exposed factor for skin to UV radiation cancer (e.g., UV (e.g., depiction of rays from the sun someone diagnosed cause skin cancer) with skin cancer outdoors in the sun) Light skin, Mention of having Depiction of person hair or eyes susceptible who has had skin phenotype cancer with (light-coloured susceptible hair, skin or eyes) phenotype (e.g., a as risk factor for scar from skin skin cancer (e.g., cancer treatment on people with very the body of a person fair skin are more with fair skin) prone to skin cancer) Moles Mention of increased Depiction of risk of skin cancer numerous or abnormal with abnormal moles moles (e.g., images or more than 50 of abnormal-looking moles (e.g., people moles or image of a with many moles are person with a large more likely to get number of moles on skin cancer) their skin) History of Mention of personal Depiction of skin cancer or family history of recurrence of skin skin cancer as a cancer or of family risk factor (e.g., members affected by having had skin skin cancer (e.g., cancer before, or image of siblings having a relative both diagnosed with with skin cancer, skin cancer) raises the chances you will get skin cancer) Sunburns Mention of sunburn Depiction of someone as risk factor for with sunburn (i.e., skin cancer (e.g., red, blistered, or sunburns increase peeling skin), with the chances you will some connection to get skin cancer) skin cancer UV behaviours Tanned look Promotes tanned Depiction of a ideal or having a person with tanned tanned look (e.g., a skin (i.e., image of tan is beautiful, person depicted in a sexy, or favourable way who healthy-looking) appears to have skin darkened by UV exposure) Self-tanners Promotes use of Depiction of self-tanners self-tanner, of (lotions or sprays someone applying applied topically to self-tanner, or produce appearance having a self-tan of suntan) (e.g., (for images of skin, try a sunless tanner there must be to fake a healthy evidence the tan is glow) from a self-tanner) Solar UV Promotes sun Depiction of a avoidance avoidance (e.g., person either not avoid the sun during exposed to the sun certain times of or without suntan day) (e.g., depiction of a pale person indoors) Discourages Information Negative depiction indoor discouraging the of indoor tanning tanning behaviour (e.g., it (e.g., picture of a is dangerous, should tanning bed with an be avoided, can "x" over it) cause deleterious health effects) Encourages Information Positive depiction indoor tanning encouraging the of someone indoor behaviour (e.g., tanning (e.g., it's good for you attractive, because it provides healthy-looking vitamin D, prevents person in a tanning sunburns, provides bed) an attractive suntan, feels good) Promotes shade Promotes seeking Depiction of someone shade to avoid UV seeking shade (e.g., exposure (e.g., image of model bring a beach sitting under the umbrella to provide shade of a tree on protective shade) the beach) Promotes hats Promotes wearing a Depiction of a hat hat to protect the or of someone face from UV wearing a hat (e.g., exposure (e.g., a image of person wide-brimmed hat wearing a will shield your wide-brimmed hat) face from the sun) Promotes Promotes use of Depiction of clothes protective clothing protective clothing (e.g., protect your or of someone skin from the sun wearing protective with long sleeves clothing (e.g., long and long pants) sleeved t-shirt, long pants) Promotes Promotes use of Depiction of sunscreen sunscreen (e.g., use sunscreen or sunscreen daily, sunscreen sunscreen can application (e.g., prevent skin cancer image of a bottle of and skin aging) sunscreen, image of sunscreen being rubbed into skin) SPF level (30+) Promotes SPF level Depiction of of 30 or higher sunscreen labelled Early detection (e.g., use sunscreen with SPF 30 or with an SPF of at higher (e.g., image least 30) of bottle of sunscreen with SPF 30 on label) ABCD criteria Mention or Depiction of moles description of the that exhibit the ABCD* criteria ABCD criteria (e.g., (e.g., use the ABCD image of moles, each criteria to look for depicting one of the early signs of skin criteria) cancer) Skin self- Promotes skin Depiction of someone examination self-checking for conducting a skin skin cancer (e.g., self-exam or example conduct a skin images of dangerous self-exam once per mole characteristics month, skin to look for (e.g., self-examination is image of a person important for looking at a mole on detecting skin their skin) cancer early) Physician Promotes seeking a Depiction of someone skin physician to do a having a examination skin examination for physician-led skin skin cancer (e.g., examination those at high risk conducted (e.g., should see their image of a doctor doctor for a skin looking at a mole on examination) patient's skin) * ABCD = asymmetry, border irregularity, colour, diameter. Table 2. Skin cancer and tanning content in Canadian women's magazines from 2000 to 2012 Text Image Variable % (n/152) % (n/221) Risk factors UV exposure 38.8% (59) 0.0% (0) Light skin, hair or eyes 11.2% (17) 3.2% (7) Moles (>50 or abnormal) 7.2% (11) 1.4% (3) History of skin cancer 5.3% (8) 0.0% (0) Sunburns 10.5% (16) 0.0% (0) UV behaviours Promotes tanned look 41.4% (63) 53.4% (118) Promotes self-tanners 33.6% (51) 20.8% (46) Promotes solar UV avoidance 16.4% (25) 11.3% (25) Discourages indoor tanning 14.5% (22) 0.9% (2) Promotes indoor tanning 3.3% (5) 0.9% (2) Promotes shade 6.6% (10) 7.7% (17) Promotes hats 11.8% (18) 8.6% (19) Promotes clothes 13.8% (21) 10.0% (22) Promotes sunscreen 71.7% (109) 27.1% (60) SPF level (30+) ([dagger]) 59.1% (55) 86.0% (37) Early detection Skin self-examination 10.5% (16) 1.4% (3) Physician-led skin examination 10.5% (16) 0.5% (1) ABCD criteria 3.9% (6) 0.5% (1) [chi square] (df = 1) or Variable Fisher's exact, p value Risk factors UV exposure 101.90, p <0.0001 * Light skin, hair or eyes 9.61, p = 0.002 * Moles (>50 or abnormal) 8.62, p = 0.003 * History of skin cancer Fisher's exact, p = 0.001 * Sunburns 24.31, p < 0.0001 * UV behaviours Promotes tanned look 5.25, p = 0.023 * Promotes self-tanners 7.59, p = 0.006 * Promotes solar UV avoidance 2.05, p = 0.153 Discourages indoor tanning 27.54, p <0.0001 * Promotes indoor tanning Fisher's exact, p = 0.126 Promotes shade 0.17, p = 0.683 Promotes hats 1.06, p = 0.303 Promotes clothes 1.32, p = 0.251 Promotes sunscreen 72.17, p <0.0001 * SPF level (30+) 9.73, p = 0.002 * ([dagger]) Early detection Skin self-examination 15.66, p <0.0001 * Physician-led skin examination 21.01, p <0.0001 * ABCD criteria Fisher's exact, p = 0.020 * n/a = not available; ABCD = asymmetry, border irregularity, colour, diameter. * Statistically significant. Articles or images not mentioning or depicting a specific SPF level were excluded from these analyses. Table 3. Example quotes and image descriptions in Canadian women's magazines from 2000 to 2012 Variable Example quote Example image description Risk factors UV exposure "Excessive exposure n/a (depiction of to UV rays before someone who has had the age of 18 is a skin cancer being risk factor, as is exposed to UV frequent sunbathing radiation) or visits to tanning salons." (Canadian Living, No Safe Tan, August 2002) Light skin, "...other risk Photographic hair or eyes factors include portrait of a having fair or blonde-haired, freckled skin, light fair-skinned young coloured eyes, lots woman in a of moles, using fashionable dress tanning beds or and heels, who is a having a family melanoma survivor. history of the (Flare, Sun Smart, disease." (Canadian June 2008) Living, Skin Cancer, July 2007) Moles "With her Circular photographs platinum-blond of five abnormal locks, green eyes (cancerous) moles. and fair skin (Chatelaine, Spot sprinkled with It, July 2009) moles, Stephanie Gionet, 23, knew she was at high risk for skin cancer." (Flare, Sun Smart, June 2008) History of skin "Be especially n/a (depiction of cancer careful if you have recurrence of skin one or more of these cancer or of family risk factors: a members affected by family history of skin cancer) melanoma or other skin cancer." (Chatelaine, 9 Suncare Secrets, June 2010) Sunburns "Numerous burns can n/a (depiction of also lead to someone with leathery, blotchy sunburn, with some and yellowing skin connection to skin and up your chance cancer) of developing skin cancer." (Homemakers, Hat Tricks, June 2004) UV behaviours Tanned look "Then fashion diva Large photograph of Coco Chanel turned an attractive, the tan into a blond-haired, darkly status symbol, and tanned model wearing suddenly everyone a fashion-forward wanted to be a posh white bathing suit. golden girl." (ELLE (FASHION, Bronze Canada, Ray of Ambition, June 2006) Light, June 2005) Self-tanners "'Spray-on tanning Photograph of six is a confidence different builder because self-tanning everyone feels products (lotions, better with a tan.'" sprays and wipes). (ELLE Canada, Sunny (ELLE Canada, Gold Side Up, June 2004) Standard, April 2005) Solar UV "Stay out of the sun Photographic avoidance during peak hours portrait of a model (11 am to 2 pm)." with very pale, (FASHION, Skin Care youthful skin for Bad Girls, June pictured in indoor 2004) lighting. (FASHION, Total Protection, January 2005) Discourages "75%: the increase Photograph of an indoor tanning in your risk of attractive young melanoma if you woman in a tanning start using indoor bed with the words tanning beds before "cancer is skin 35." (Flare, Health deep" printed over News, June 2012) the photograph. (Canadian Living, Skin Deep, February 2004) Encourages "I can attest that Photograph of an indoor tanning soaking up the rays attractive young feels woman in a tanning intoxicating--I bed. (Canadian craved the warmth, Living, Skin Cancer the glow, and the IQ August 2010) tranquil escape from reality. [...] feeling refreshed with a sun-kissed glow and a major confidence kick." (Flare, Confessions of a Former Tanoholic, June 2011) Promotes shade "... the CDA Photograph of a recommends that you model on a sandy seek shade and beach standing under minimize the amount a large palm tree of time you spend frond, which is outdoors between 11 providing shade. am and 4 pm." (ELLE Canada, Ray (Canadian Living, No Ban, June 2006) Safe Tan, August 2002) Promotes hats "Wear a hat to help Photograph of woman prevent sun spots." outside, sitting on (Flare, Health: You a dock wearing a sun Ask, October 2004) hat, tank top, and long pants. (ELLE Canada, Shore Thing, July 2002) Promotes "If you have to be Photograph of a clothes out in the sun, wear model in a tropical long-sleeved shirts, location, on a long pants, a beach, wearing a red wide-brimmed hat." wrap dress with long (Canadian Living, No sleeves. (Flare, Safe Tan, August 21st Century Sun, 2002) May 2000) Promotes "'If you plan on Photograph of a sunscreen being in the sun, we red-haired woman recommend spreading generously applying at least two sunscreen to her tablespoons of SPF bare shoulders. 15 over your entire (Canadian Living, body.'" (ELLE Here Comes the Sun, Canada, Ray Ban, June 2010) June 2006) SPF level (30+) "Use at least a Full-page photograph broad-spectrum SPF of bottles of face 30 (the minimum and body sunscreens, recommended by the each with a minimum Canadian Dermatology SPF 30 marked on the Association)." bottle. (FASHION, (Flare, Screen Test, Protection Plan, June 2012) June 2010) Early detection ABCD criteria "You might be Photographs of five familiar with the moles, each ABCDs of melanoma: exhibiting one of Asymmetry, Borders, the criteria: Colour and Diameter. asymmetry, border Now doctors have irregularity, added an E (for colour, diameter, Evolving) [.]" evolution. (Canadian Living, (Chatelaine, Spot Summer Skin: What to It, July 2009) Watch, June 2005) Skin self- "In addition to Illustration of examination routine self-checks, woman looking at she regularly sees a photographs of her dermatologist." own moles as (Flare, Sun Smart, baseline images for June 2008) performing a skin self-exam. (Chatelaine, Picture Yourself, July 2004) Physician skin "'Avoiding the sun, An illustrated examination wearing sunscreen pathway combining and seeing your text and image doctor for early showing the steps detection are still from a skin-check your best with a doctor, to strategies.'" (ELLE biopsy, to Canada, Java Jolt, diagnosis, and September 2010) treatment. (Chatelaine, Mole Survivor, June 2006) n/a = not available; ABCD = asymmetry, border irregularity, colour, diameter. Table 4. Comparison of skin cancer and tanning content in Canadian vs. US women's magazines from 2000 to 2012 Content Canadian US type Text % (n/152) % (n/172) Variable Image % (n/221) % (n/310) Risk factors UV exposure Text 38.8% (59) 39.0% (67) Image 0.0% (0) 1.3% (4) Light skin, hair, eyes Text 11.2% (17) 17.4% (30) Image 3.2% (7) 13.5% (42) Moles (>50 or abnormal) Text 7.2% (11) 17.4% (30) Image 1.4% (3) 6.8% (21) History of skin cancer Text 5.3% (8) 13.4% (23) Image 0.0% (0) 0.0% (0) Sunburns Text 10.5% (16) 12.2% (21) Image 0.0% (0) 0.0% (0) UV behaviours Promotes tanned look Text 41.4% (63) 29.1% (50) Image 53.4% (118) 39.0% (121) Promotes self-tanners Text 33.6% (51) 29.7% (51) Image 20.8% (46) 18.1% (56) Promotes solar Text 16.4% (25) 16.9% (29) UV avoidance Image 11.3% (25) 17.7% (55) Discourages indoor Text 14.5% (22) 12.8% (22) tanning Image 0.9% (2) 0.3% (1) Promotes indoor Text 3.3% (5) 0.0% (0) tanning Image 0.9% (2) 1.6% (5) Promotes shade Text 6.6% (10) 12.8% (22) Image 7.7% (17) 8.7% (27) Promotes hats Text 11.8% (18) 20.3% (35) Image 8.6% (19) 11.6% (36) Promotes clothes Text 13.8% (21) 15.7% (27) Image 10.0% (22) 7.7% (24) Promotes sunscreen Text 71.7% (109) 61.6% (106) Image 27.1% (60) 17.7% (55) SPF level (30+) Text 59.1% (55) 52.6% (41) ([dagger]) Image 86.0% (37) 71.1% (69) Early detection ABCD criteria Text 3.9% (6) 9.3% (16) Image 0.5% (1) 2.5% (7) Skin self-examination Text 10.5% (16) 22.1% (38) Image 1.4% (3) 7.7% (24) Physician-led Text 10.5% (16) 23.8% (41) skin examination Image 0.5% (1) 1.0% (3) Content [chi square] or type Fisher's exact, p value Text Variable Image Risk factors UV exposure Text 0.00, df = 1, p = 0.980 Image Fisher's exact, p = 0.145 Light skin, hair, eyes Text 2.55, df = 1, p = 0.110 Image 16.60, df = 1, p < 0.0001 * Moles (>50 or abnormal) Text 7.60, df = 1, p = 0.006 * Image 8.77, df = 1, p = 0.003 * History of skin cancer Text 6.13, df = 1, p = 0.013 Image n/a Sunburns Text 0.23, df = 1, p = 0.635 Image n/a UV behaviours Promotes tanned look Text 5.44, df = 1, p = 0.020 * Image 10.75, df = 1, p = 0.001 * Promotes self-tanners Text 0.57, df = 1, p = 0.450 Image 0.63, df = 1, p = 0.428 Promotes solar Text 0.01, df = 1, p = 0.921 UV avoidance Image 4.17, df = 1, p = 0.041 * Discourages indoor Text 0.20, df = 1, p = 0.659 tanning Image Fisher's exact, p = 0.573 Promotes indoor Text Fisher's exact, p = 0.022 * tanning Image Fisher's exact, p = 0.705 Promotes shade Text 3.50, df = 1, p = 0.061 Image 0.18, df = 1, p = 0.675 Promotes hats Text 4.27, df = 1, p = 0.039 * Image 1.26, df = 1, p = 0.312 Promotes clothes Text 0.23, df = 1, p = 0.634 Image 0.80, df = 1, p = 0.372 Promotes sunscreen Text 3.68, df = 1, p = 0.055 Image 6.73, df = 1, p = 0.009 * SPF level (30+) Text 0.75, df = 1, p = 0.388 ([dagger]) Image 2.90, df = 1, p = 0.089 Early detection ABCD criteria Text 3.66, df = 1, p = 0.056 Image Fisher's exact, p = 0.146 Skin self-examination Text 7.77, df = 1, p = 0.005 * Image 10.90, df = 1, p = 0.001 * Physician-led Text 9.86, df = 1, p = 0.002 * skin examination Image Fisher's exact, p = 0.645 n/a = not available; ABCD = asymmetry, border irregularity, colour, diameter. * Statistically significant. ([dagger]) Articles or images not mentioning or depicting a specific SPF level were excluded from these analyses. Figure 1. Skin cancer and tanning articles published per year (2000-2012) in six Canadian women's magazines Year Number of articles 2000 7 2001 4 2002 9 2003 16 2004 18 2005 14 2006 16 2007 14 2008 7 2009 15 2010 17 2011 10 2012 7