摘要：Objectives. We investigated the impact of indoor tanning device warnings that communicate the risks associated with indoor tanning (i.e., loss framed) or the benefits of avoiding indoor tanning (i.e., gain framed). Methods. A convenience sample of non-Hispanic White women aged 18 to 30 years who tanned indoors at least once in the past year (n = 682) participated in a within-subjects experiment. Participants completed baseline measures and reported indoor tanning intentions and intentions to quit indoor tanning in response to 5 warning messages in random order. A text-only control warning was based on Food and Drug Administration–required warnings for indoor tanning devices. Experimental warnings included graphic content and were either gain or loss framed. Results. In multivariable analyses, gain-framed warnings did not differ from the control warning on women’s intentions to tan indoors, but they prompted stronger intentions to quit than the control message. Loss-framed warnings significantly reduced intentions to tan indoors and increased intentions to quit indoor tanning compared with control and gain-framed warnings. Conclusions. The public health impact of indoor tanning device warnings can be enhanced by incorporating graphic content and leveraging gain- and loss-framed messaging. Skin cancer is the most common malignancy in the United States, where approximately 3.5 million cases of nonmelanoma skin cancer and 75 000 cases of melanoma are diagnosed each year. 1,2 Although most skin cancers are preventable by reducing ultraviolet radiation exposure, their incidence is increasing. 3–6 An estimated 9000 deaths occur each year as a result of melanoma, 2 and the costs of skin cancer treatment exceed $8 billion annually. 7 Indoor tanning is major concern for skin cancer prevention. 4,8 Approximately 380 000 skin cancer cases are attributable to indoor tanning annually in the United States. 9 Recent meta-analyses have indicated that indoor tanning increases lifetime risks of nonmelanoma skin cancer by 29% to 67% and melanoma by approximately 20%. 10,11 Among US adults, the prevalence of indoor tanning is highest among young adult, non-Hispanic White women, with nearly 30% tanning each year and 15% tanning 10 or more times each year. 12,13 Indoor tanning before age 30 years and tanning more frequently further increase lifetime skin cancer risks, 10,11,14,15 and tanning at a young age is associated with early-onset skin cancer. 16 As in other areas of public health, policies are advocated as part of a comprehensive approach to skin cancer prevention. 4,17 Until recently, the US Food and Drug Administration (FDA) regulated indoor tanning devices as class I medical devices presenting minimal risks and largely exempt from premarket controls. 18 In part because of advocacy for tighter regulations, 17 the FDA recently published a new rule changing indoor tanning devices to class II devices with additional premarket controls and revised labeling requirements. Now, indoor tanning devices are required to display a text-only warning reading “Attention: This sunlamp product should not be used on persons under the age of 18 years.” 19 Consumer-facing information for indoor tanning devices is also required to include several contraindication and warning statements. 19 Unfortunately, the required warnings do not reflect evidence for skin cancer prevention messaging 20,21 and are inconsistent with warnings for other FDA-regulated products with associated health risks, such as tobacco. 22 The FDA’s strategic plan for regulatory science emphasizes designing evidence-based public health messages to empower consumers to make healthy decisions about regulated products. 23 The public health impact of indoor tanning device warnings could be enhanced through additional research to determine how to best promote preventive behavior. Under federal rulemaking procedures, the FDA could issue new labeling requirements based on the available evidence, and this evidence could also inform state and local policies on indoor tanning. Unlike warnings for tobacco, 24 little published research is available on how to design indoor tanning warnings to enhance their public health impact. According to prospect theory, framing health messages in terms of the costs of engaging in risky behavior (i.e., loss framed) or the benefits of avoiding risky behavior (i.e., gain framed) differentially affects behavioral outcomes. 25,26 The message-framing concept draws from fundamental tenets of behavioral economics and communication science that postulate that health messages can be crafted around gains or losses to shape perceptions and motivate behavior. 25 Although recent reviews have indicated that loss-framed skin cancer prevention messages can promote behavior change, 20,21 2 meta-analyses drew different conclusions regarding gain- and loss-framed skin cancer prevention messages, 27,28 and no study has tested message-framing effects for indoor tanning warnings. Research has also consistently demonstrated that graphic warnings incorporating imagery to depict the health risks of tobacco use are more effective for promoting behavior change than text-only warnings because they more effectively attract attention, evoke an emotional response, and affect perceived risks and attitudes toward tobacco use. 24,29–32 Although the available evidence on skin cancer prevention messages has suggested that graphic messages can promote preventive behaviors, 20,21 no study has investigated the effects of graphic content for indoor tanning warnings. Given the theoretical support and empirical evidence indicating that gain- and loss-framed messages incorporating graphic imagery may be important to prevent and reduce indoor tanning, we examined the impact of these message features on indoor tanning intentions and intentions to quit indoor tanning in a convenience sample of young adult women. We compared gain- and loss-framed warnings with graphic imagery with a text-only warning, such as those required by the FDA. We focused on young adult women because of the high prevalence of indoor tanning in this population and evidence that indoor tanning early in life further increases skin cancer risks. 10,11 This makes young adult women a priority population for public health skin cancer prevention efforts. We hypothesized that graphic, loss-framed messages conveying the health risks associated with indoor tanning would produce the greatest impact.
