Saturday, December 18, 2010

The Tanning Tax: A Critique and Re-invention – Amanda Wilson

I. Introduction

According to the World Health Organization (WHO), one in every three cancers diagnosed worldwide is skin cancer (1). ‘Some 132,000 cases of malignant melanoma and over two million cases of other skin cancers occur worldwide each year (1).’ Melanoma is the most common and most deadly form of skin cancer in the U.S. with over 69,000 diagnoses and 9,000 deaths in 2009 (2). According to the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) cancer registry, the age-adjusted incidence rate of melanoma from 2002 through 2006 was 25.0 per 100,000 for men and 15.8 per 100,000 for women (3).’ Melanoma is the second most common cancer among women 20-29 years old and is one of few cancers with known risk factors (4).

Some of the risk factors for melanoma are uncontrollable, such as having a fair complexion, family history, or multiple or atypical moles, while others are controllable (4). Excessive and/or unprotected exposure to ultraviolet (UV) radiation, occupational exposures to coal tar, pitch, creosote, arsenic compounds, or radium, and severe childhood sunburns are avoidable risk factors (4). Multiple studies have shown that having ever used a tanning bed is associated with an increased risk of melanoma and that first exposure to sun beds before the age of 35 significantly increases risk of cancer (5). Another study has shown that risk of melanoma jumps by 75% in people who used tanning beds in their teens and 20s (6). This is particularly alarming because nearly 30 million people, including 2.3 million adolescents, use tanning beds yearly in the U.S. (7). Robinson et al. showed that indoor tanning behavior increased from 1% in 1988 to 27% in 2007 and is likely to continue to rise (8).

The increased risk of skin cancer and its association with use of indoor tanning especially among those in their teens has been known for many years. Many states have taken initial steps to prevent skin cancer from sun beds by placing restrictions on minors. Most states require parental permission for those under the age of 18 (9). This does not seem to prevent those under 18 from increasing their risk for skin cancer because parents give their permission. The Food and Drug Administration (FDA) has been considering many precautionary steps as well, including changing the medical device class in which tanning beds are currently classified (6). Tanning beds are currently considered Class I medical devices which puts them in a category with low risk products such as bandages and tongue depressors (6). The FDA has proposed that by increasing tanning bed classification to class II, the FDA would be able to better regulate tanning beds by requiring manufactures to submit information about new tanning machines before they reach the market (6).

As of July 2010, the Obama administration implemented a 10% tax on indoor tanning (10). The tax does not pertain to tanning lotions and spray tans (11). The tax pertains to electronic tanning products that use at least one ultraviolet lamp with wavelength between 200 and 400 nanometers (11). This tax serves a dual role in that it is expected to decrease tanning use which will decrease incidence rates of skin cancer but it is also one of the ways money will be raised to fund the Health Care Reform Bill (12). The tax is expected to raise $2.7 billion over ten years (13). The tanning tax is similar to the tobacco tax in that the increased cost of the product is predicted to deter people from taking part in the behavior (14). The smoking tax is based on the Health Belief Model and the belief that people behavior rationally (14). As will be shown below, this is not the best approach to a tanning intervention because people often do not behave rationally. Other proponents of the tax argue that tanning is a good source of the vitamin D people need to stay healthy and feeling good (15).

While the tanning tax may be an excellent way for the government to raise money to fund the Health Care Reform Bill, it may not be the best way to decrease the rates of melanoma. Most proponents of the tax are tanning business owners and workers (11). Business owners fear they will lose business and workers fear their job is at risk if the tanning tax does its job in persuading people to stop visiting the tanning salon (11). If the tanning tax is evaluated through a social and behavioral aspect, it is apparent that there are many flaws in this intervention’s approach. The tanning tax does not incorporate the Tripartite Theory of Body Image or the ownership tanners feel about their behavior and relies too heavily on the assumptions of the Health Belief Model in its approach to decrease use of indoor tanning.

II. Critique 1: The Tripartite Theory of Body Image

In order to change tanning behavior it is important to understand why people tan. The Tripartite Theory of Body Image claims people tan for appearance reasons that are influenced by multiple sources (16). The theory that states there are three primary sources for developing appearance ideals (peers, parents, and media) that affect body image either directly or indirectly via internalization of the ideals (16). In the past, this model has been applied to eating disorders. The risk of an eating disorder can be evaluated by determining how aware a person is of the ideals promoted by their peer, parents, and the media opposed to the degree in which a person internalizes the ideals mediates the relationship to body image (16). In a discussion about the theory Cafri et al. stated that ‘the distinction between awareness and internalization can also be thought of as the difference between passive endorsement of a thin ideal versus incorporation of this ideal into one’s sense of self through more active cognitions/attitudes (16).’ The Tripartite Theory of Body Image has also been linked to tanning by Hillhouse et al. who has identified a significant relationship between appearance motives and intentions/behaviors to UV exposure (17).

The media has been shown to have strong affects on body image, specifically tanned skin (18). Tan skin was not always ideal or promoted in the media. In the early part of 20th century pale skin was considered a mark of beauty, wealth, and refinement and those with tanned skin were looked down upon as workers and laborers (19). It wasn’t until the 1920’s when tan skin was exemplified in magazines and instead of bleaching creams, tanning creams and bronzers were advertised (19). The famous designer Coco Chanel is thought to have played a large part in the transformation from pale to tan when she accidentally got sunburned while visiting the French Rivera (20). While her tan was an accident, Coco’s fans liked the look and adopted it themselves (20). Tan skin is still viewed as aesthetically pleasing today and the appearance of a tan is highly valued among most young adults as shown by Robinson et al. in the article Indoor Tanning Knowledge, Attitudes, and Behavior Among Young Adults From 1988-2007. This study reported that from 1994-2007 there was a 12% increase in the belief that people looked better with a tan (8).

The government’s intervention of melanoma using the tanning tax fails to incorporate the effect the media has on tanning behavior and the fact that appearance plays a major role in one’s decision to tan. As shown above, people don’t tan because it is cheap they tan because the media portrays tan skin as healthy skin. The Tripartite Theory of Body Image applies to tanning because tanning behavior is affected by how aware a person is of the media portrayals of tans and how much they internalize the ideas the media portrays.

III. Critique II: The Health Belief Model and Rational Behavior

The Health Belief Model assumes rational behavior (21). According to the Health Belief Model, individuals adopt a protective behavior to the extent that they perceive themselves to be susceptible, perceive the outcome to be severe, consider the benefits of the behavior to be protective against the threat, and believe that barriers to the protective behavior can be overcome (21). This description implies that that a rational individual would associate tanning with a high risk of skin cancer, as well as perceive the severity of cancer associated with tanning as high and discontinue tanning (16). However, this is not the trend in the U.S. .. While it is has been known for many years that tanning causes skin cancer, tanning rates have increase over the past 10 years (8). Studies have shown that indoor tanning users are more knowledgeable about the skin cancer risks of tanning compared to non-tanners (22). These studies show that the tanning tax has failed to take into account the fact that people do not behave rationally and while tanners know the cancer risks they continue to tan anyway. If people are not willing to stop tanning because of the high risk of cancer, they are not likely to stop because it costs 10% more.

As stated above, individuals adopt a protective behavior based upon beliefs that barriers to the protective behavior can be overcome (21). Many tanning business owners have stated that the cost of the tax will be passed on to the consumers (13). Tanning monthly packages cost anywhere between $15 to $100 depending on the type of tanning bed and facility (23) . If a 10% is applied to $100, and extra $10 will be charged. The extra $10 is meant to create a barrier to tanning behavior, but if an individual is willing to spend $100/month on tanning and are already aware of the skin cancer risks, they will most likely view the extra $10 as a barrier that can be overcome.

The Health Belief Model also assumes that behavior is controlled (21). The tanning tax fails to recognize that individuals may be addicted to tanning and lack self control in going tanning regardless of price. Addicts often do not think about the implications their current behavior will have on their future (24). The tax assumes that an addict is in control and that if faced with higher prices they would decrease sun bed use because of its future ramifications.

When the government decided to use the tanning tax to decrease sun bed use, it most likely followed the assumptions of the Health Belief Model. The rational behavior assumption would lead one to believe that if the skin cancer risks of tanning were known, tanning would decrease. However, studies show this is not the case. There has been increasing knowledge about the risks of skin cancer over the past 10 years, especially among tanners, but there has also been an increase in the usage of tanning. The government also failed to recognize that people may tan because of an addiction and that addicts often do not have control over their actions as the Health Belief Model assumes. The tanning tax also violates the barrier assumption of the Health Belief Model. The tax is meant to serve as a barrier to tanning, but realistically a 10% increase may not be enough of a barrier to decrease tanning behavior.

IV. Critique III Ownership of Behavior and Tanning Addiction

Kourosh et al. report in their article Tanning as a Behavioral Addiction that those tanners who persist in tanning behavior despite a recognized physical harm resemble persons with substance dependence (25). Over 70% of tanners surveyed by Kourosh et al. fit the Diagnostic and Statistical Manual-IV (DSM-IV) criteria for a substance abuse or dependence disorder (25). This study also found that the three most common reasons endorsed by 100 frequent indoor tanners were to look good (90%), feel good (69%), and relaxation (56%) (25). According to Kourosh et al. the latter of the two reasons suggest a subjective response possibly mediated by rewarding processes (25). A similar study by Harrington et al. found that 41% of subjects surveyed met criteria consistent with a ‘tanning addictive disorder’, and an additional 33% met criteria for problematic tanning behavior based on the modified CAGE criteria or sub threshold criteria on the modified DSM-IV criteria (26). Female gender and early age of onset were also associated with meeting tanning addiction criteria (26).

As in smoking addiction, tanners may feel ownership of their addiction and are not willing to give it up without receiving something of greater benefit that is important to them in exchange (27). The tanning tax fails to provide something of greater benefit that is important to tanners that will deter them from tanning. Because the tanning tax does not take into account the ownership that people feel over the decisions they make, especially those pertaining to personal habits, it drastically underestimates the fact that people might be willing to pay more for a behavior they do not wish to give up.

V. Conclusion of Critiques

Implementation of a tanning tax is a good first start in reducing tanning behavior and ultimately reducing melanoma rates. To a person unfamiliar with the Tripartite Theory of Body Image, the Health Belief Model, and the ownership of behavior addicts feel, the tanning tax may appear to be a successful intervention. After reviewing each of the theories, it is apparent that the tax fails to incorporate the Tripartite Theory which exemplifies the link between the media and appearance reasons for tanning, and it may have placed too much emphasis on the assumptions of the Health Belief Model. The model assumes that people behave rationally, are in control of their behavior, and will reduce behavior when a barrier is placed in front of them. Each of these assumptions has been proven wrong above. The tax also failed to recognize the ownership addicts feel about their personal behaviors and underestimates the fact that people might be willing to pay more for a behavior they do not wish to give up.

VI. Revised intervention

The following intervention will preserve the idea of using a tax to create revenue for the Health Care Reform Bill and decreasing the usage of indoor tanning. The new intervention also places additional restrictions on tanning in order to encompass the social and behavioral theories discussed above.

It is important for the government to raise money for the Health Care Reform Bill in order to secure health for the country in the future. Because of the potential tax revenue in the tanning industry, taxes in the tanning industry should not be discontinued. Instead of taxing the tanning salons which often defer the cost to the customers, the new intervention proposes that tax revenue be created by taxing advertisements for tanning and tanning products. The link between tanning and the media has been shown in the Tripartite Theory of Body Image and in multiple studies (16). If the way the media portrays tan skin and the use of tanning products can be changed, tanning behavior will likely change.

Because people do not behave rationally, campaigns that target skin cancer awareness are not likely to be effective. Placing stricter regulations on the tanning industry is a better attempt at reducing sun bed use. The new intervention proposes that the ability for parents to give permission for children under 18 years of age to tan be revoked. Because young adult females are at the most risk for skin cancer and are the most frequent users of sun beds, placing restrictions on this population’s use will surely decrease rates of melanoma. This intervention also places stricter regulations on how long and how often those 18 years of age and older can use a sun bed. These restrictions are meant to serve as a barrier to tanning.

The final part of the new intervention is a campaign target to tanning business owners to not only have more spray tan options than ultraviolet light options, but to use techniques that make spray tanning more relaxing than the tanning bed option. This segment of the intervention is aimed at creating something of greater benefit that is important to sun bed users in order to overcome the ownership tanning addicts feel toward their behavior.

VII. Defense of Intervention I

By applying a tax to the advertising of tanning and tanning products, this intervention is targeting the source of the problem. The Tripartite Theory of Body Image shows that tanning behavior is affected by how aware a person is of the media portrayal of tans and how much they internalize the ideas the media portrays (16). By decreasing the amount of tanning in the media, there will be less of a chance for an individual to internalize the ideas of beauty and health the media associates with tan skin.

The aim of the tax is not only to raise money for the Health Care Reform Bill, but also to decrease the amount of tanning in the media. Changing the way the media portrays being tan will have a large effect on the number of people that tan for appearance reasons. This has already been exemplified with Coco Chanel and her accidental tan (18). Celebrities have a tremendous affect on cultural trends. Using celebrities in the media that promote natural skin tones instead of tan skin is another way to change the usage of tanning beds. A limitation of passing the tax to the media is that a tax may not serve as a barrier to advertising. Most companies will have the extra money available to spend on the tax, which is why other restrictions on tanning must be put in place.

VIII. Defense of Intervention II

As shown previously in this paper, the tanning tax wrongfully assumes people behave rationally (4). Studies have shown that while tanners are aware of the cancer risks and cancer knowledge has grown over the past decade, the usage of sun beds has increased also increased (28). This violates the assumption of the Health Belief Model because the model assumes that an individual’s behavior will change if the risks are known. This is the reason the new intervention should not focus on campaigns that increase the awareness of the risk of skin cancer associated with tanning.

Instead the new intervention focuses on creating barriers to tanning. The Health Belief Model assumes that individuals adopt a protective behavior based upon beliefs that barriers to the protective behavior can be overcome (21). While a tanning tax does not create a significant enough barrier to convince individuals to discontinue tanning, restrictions on age, duration, and number of uses should create sufficient barriers to those at the most risk.

Most states will allow children under the age of 18 to use indoor tanning if they have parental permission (9). The new interventions will override this ruling and completely restrict those under the age of 18 from using indoor tanning. This will serve to protect a vulnerable population from skin cancer, because studies show that the young are more likely to develop melanoma (8). It may take time for this part of the intervention to be viewed as successful. The likely effect will occur in later generations because the behaviors you adopt when you are young are likely to continue into adulthood. If the intervention can successfully stop individuals from starting the behavior, there will be fewer people utilizing the behavior when they reach adulthood.

IX. Defense of Intervention III

Nolan and Feldman state in their article Ultraviolet Tanning Addiction that ‘efforts to reduce tanning behavior need to account for the interplay between physiologic effects of tanning and psychological drives behind tanning behavior (29).’ We have already discussed that the media can be used to change the appearance reasons people tan, but we have not discussed how to change the addictive behavior people experience when tanning.

As stated previously, tanners may feel ownership of their addiction and are not willing to give it up without receiving something of greater benefit that is important to them (27). The tanning tax fails to provide something of greater benefit that is important to tanners that will deter them from tanning. Feeling good and relaxation play a large part in why people use indoor tanning frequently (26). It is necessary for the new intervention to provide an alternative way for frequent tanners to feel good and relax, qualities that are important to them. By encouraging tanning business owners to invest in techniques that create a relaxing spray tan experience; those that use the ultraviolet beds will have something of greater benefit to experience than skin cancer.

X. Conclusion

Both the rate of melanoma and the number of people utilizing ultraviolet tanning has increased over the past decade. In order to raise money for the Health Reform Bill and to reduce the number of individuals using tanning services and therefore decrease the rates melanoma, the Obama administration has applied a 10% tax to indoor tanning service. This intervention may seem appropriate on the surface, but after careful review of the reasons people tan and the assumptions of social and behavioral theories, it is clear that this intervention has many flaws. The tax does not incorporate the appearance reasons people tan and the effect the media has on appearance beliefs, the fact that people do not behave rationally, people do not always have control over their behavior, a 10% increase may not be enough of a barrier to convince individuals not to tan, or the ownership individuals, especially addicts, feel toward their personal behaviors.

Using these flaws, a new intervention is suggested that will keep the idea of the tax because the tanning industry has the potential to create large revenue toward the Health Care Reform Bill and adds more restrictions to tanning in order to incorporate the needed barriers to indoor tanning. The new intervention will only be successful if tanning business owners are willing to cooperate. If business owners do not strictly follow the restrictions but in place, the intervention will be close to useless.


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