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Using behavioral economics to promote healthy behavior toward sun exposure in adolescents and young adults
Preventive Medicine 81 (2015) 184–188
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Using behavioral economics to promote healthy behavior toward sun exposure in adolescents and young adults Maria T. García-Romero a,⁎, Alan C. Geller b,c, Ichiro Kawachi b a b c
Department of Dermatology, National Institute of Pediatrics, Mexico City, Mexico Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, United States Melanoma Epidemiology, Massachusetts General Hospital, Boston, MA, United States
a r t i c l e
i n f o
a b s t r a c t Skin cancer represents an important public health problem, and it is associated with ultraviolet radiation exposure, particularly at early ages. Unhealthy sun exposure and intentional tanning continue to be the trend among young people. Multiple interventions to raise awareness of the risks of sun exposure have been implemented, without necessarily translating into decreased unhealthy behaviors or skin cancer incidence rates. Behavioral economics adds a set of concepts and tools to potentially boost the efficacy of existing approaches to decrease unhealthy sun exposure. This paper reviews public health interventions that have been based in behavioral economics concepts and their results, and provides examples of new and creative ways physicians and health professionals can actively apply insights from behavioral economics to counsel teenagers and young adults about skin cancer prevention. © 2015 Elsevier Inc. All rights reserved.
Available online 9 September 2015 Keywords: Behavioral economics Skin cancer Skin neoplasms Ultraviolet rays Adolescents
Contents A role for behavioral economics? . . . Bounded rationality . . . . . . . . . Status quo bias and default options Anchoring heuristic . . . . . . . Framing effects . . . . . . . . . Bounded willpower . . . . . . . . . Social influence and norms . . . . . . Conclusions . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . References . . . . . . . . . . . . .
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Skin cancer, both melanoma and non-melanoma (NMSC), represents an important public health problem.(US Department of Health and Human Services, 2015) Approximately 3.5 million cases of NMSC and more than 70,000 cases of melanoma are diagnosed annually in the United States alone (76,100 projected for 2014)(Siegel et al., 2014; SEER, 2014), and the incidence rates have risen in the past 2 decades (Guy et al., 2014; Lazovich et al., 2012). Even though mortality is not high for NMSC, the mortality rates for melanoma are 2.7 per 100 000(SEER, 2014) and the costs of treating and palliating these ⁎ Corresponding author at: Department of Dermatology, National Institute of Pediatrics, Insurgentes Sur 3700c, Colonia Insurgentes Cuicuilco, Mexico D.F. 04530, Mexico. E-mail address: [email protected] (M.T. García-Romero).
http://dx.doi.org/10.1016/j.ypmed.2015.08.025 0091-7435/© 2015 Elsevier Inc. All rights reserved.
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patients are estimated at US$17 billion annually (Guy et al., 2014). In the past decades, multiple interventions have been implemented to raise awareness of the risks of sun exposure and tanning; and while people may have general awareness of these risk, unhealthy sun exposure and intentional tanning continue to be the trend particularly among young people (US Department of Health and Human Services, 2015; Schwebel, 2014; Robinson et al., 1997; Kyle et al., 2014; Heckman et al., 2011) and thus the incidence rate of skin cancer continues to rise throughout Europe and the United States (Guy et al., 2014; Morris et al., 2014). Adolescents and young adults have the lowest protection rates of all age groups, receiving large amounts of intentional and unintentional exposure to UV (Heckman et al., 2011), often driven by the motivation to meet cultural ideas of attractiveness,
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which involve tanned skin (US Department of Health and Human Services, 2015; Morris et al., 2014; Heckman et al., 2014). A systematic review of interventions implemented in individuals of all ages and in multiple settings concluded that education and policy approaches encouraging sun-protective behavior were effective, particularly when implemented in primary schools and in recreational or tourism settings (Saraiya et al., 2004). The Community Preventive Services Task Force has recently reviewed several community-wide interventions in multiple settings in the US—child-care centers, healthcare settings and providers, high-schools and colleges, outdoor occupational settings, outdoor recreational and tourism settings, and primary and middle schools—and found them to be effective in reducing exposure to UV radiation and improving sun protection behavior, albeit with limitations (Saraiya et al., 2004; Force CPST, 2015). Regarding tanning, there are two broad categories of prevention strategies: strategies that influence behaviors at the structural level (i.e. through the imposition of laws and regulations) and strategies that target persuasion and behavioral change. Changes in policy have proven effective for decreasing indoor tanning. For example, laws restricting the use of tanning beds either through age, parental permission requirement, or systems access, have been shown to effectively reduce indoor tanning rates among female high school students (Guy et al., 2014). Because they cannot easily be regulated, outdoor tanning and unhealthy levels of sun exposure will continue to pose a challenge. Hence, there is a role for more interventions to motivate behavioral change. Physicians who take care of and counsel adolescents and young adults must focus on increasing sun protection through the use of sunscreen, shading, protective clothing and hats; as well as decreasing intentional tanning (both outdoor and indoor). This is not just a matter of providing adequate information, but being able to communicate effectively and leveraging novel strategies to nudge people's behaviors in healthy directions (Force CPST, 2015; Buller et al., 2000). How can this be done? The purpose of this paper is to review interventions that have been based in behavioral economics concepts and their results, and explore new and creative ways physicians and health professionals can actively apply these insights when counseling teenagers and young adults regarding sun protection and the risk of skin cancer. A role for behavioral economics? Daniel Kahneman, who received the 2002 Nobel Prize in Economics, is one of the pioneers in the field of behavioral economics. He describes two separate cognitive systems that control our judgments and choices: intuition (system 1) and reasoning (system 2). The thought processes in system 2 are identified with what we usually think of when we speak of the “reasoning brain”, i.e. the processes are reflective, deliberate and effortful. However dual process theory posits that our actions are simultaneously determined by the operation of system 1, in which thought processes are intuitive, fast, automatic and emotionally charged (Kahneman, 2011). Research indicates that intuition (system 1) is the part of our brain which really governs most of our routine daily thoughts and actions (with some monitoring by reasoning or system 2). The advertisement industry has long understood this and appeals to system 1 help to sell products. By contrast, we as physicians appeal solely to system 2 most of the time. A good example is the tobacco industry, which has for decades convinced people that smoking is fun and sociable (system 1); while physicians try to convince them that smoking poses many risks to health and causes lung cancer (system 2). Recently, the public health approach has been to target system 1 and counter-market with the same type of youth-focused messages as the industry, like the truth® campaign which has proven to be effective at promoting changes in attitudes, beliefs and intentions of young adults (Richardson et al., 2010). Public health has just begun to leverage behavioral economics principles to nudge people's behaviors toward healthier habits. Medical
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specialists who have a role in counseling teenagers and young adults about healthy behaviors toward sun exposure could learn from these concepts and apply them with our patients. Our patients, particularly teenagers, are unlikely to be influenced by being lectured about the risks of skin cancer (system 2) (Bränström et al., 2001), but they are moved by ads showing images of tanned people enjoying a summer vacation (system 1); and thus disregard the risk. Behavioral economics is a rapidly growing field with potentially tremendous relevance for public health. It assumes—as do standard economic models—that markets and incentives shape people's behavior. However, it departs from the standard economic model in assuming that people often do not act rationally, i.e. they do not always behave in their long-term self-interest. It offers a tool-kit of concepts by which to understand human decision-making, as well as influence behaviors. It emphasizes three human behavioral traits that affect how we make decisions: bounded rationality, bounded willpower, and social influence (Thorgeirsson and Kawachi, 2013). Bounded rationality The concept of bounded rationality describes how human capabilities to process information are limited, and can lead to errors that cause unhealthy behavior (Thorgeirsson and Kawachi, 2013). Many times people use rules of thumb or heuristics (mental shortcuts) to make decisions and are influenced by how simple or easy a decision is (Thorgeirsson and Kawachi, 2013; Rice, 2013). Three key concepts related to bounded rationality that are relevant to development and implementation of interventions designed to prevent skin cancer are now described in turn: 1) status quo bias; 2) anchoring heuristic; and 3) framing effects. Status quo bias and default options Status quo bias refers to the fact that people disproportionally prefer the status quo to changing their routines; and healthier behavior can be promoted through the use of “default options”, such as showing healthier food options as default in a restaurant menu or making a fruit the default dessert of a kid meal (Thorgeirsson and Kawachi, 2013). Another great example is the high rates of organ donation in states or countries where the default option is to be a donor and people have to opt-out of it (Rice, 2013). If in outdoor areas the default option were the use of sunscreen or shade structures instead of being the option that takes more effort, more people would apply or use it. Building shade structures to be used as a default is an excellent return-for investment intervention with a one-time investment (plus maintenance costs) and an extended, self-sustainable useful period. Dobbinson et al. established a new status quo in secondary schools by building tables and seats with built-in shade that greatly reduced students' exposure to UV radiation (Dobbinson et al., 2014; Dobbinson et al., 2009). Another possible intervention would be to get all municipal swimming pools or beach facilities to install sunscreen dispensers just as they do antibacterial gel dispensers or soap in the changing rooms and restrooms. A randomized trial of a skin cancer prevention program (Pool Cool) that included providing sunscreen and shade showed significant positive changes in sun-protection habits and a decrease in the number of sunburns in 28 pools in Hawaii and Massachusetts (Glanz et al., 2002). Most recently, the Boston City Council will soon vote on the provision of sunscreen dispensers at the more than 200 city-wide parks. Anchoring heuristic Another interesting behavioral economics concept related to default options is anchoring, which refers to the fact that people's choices are frequently biased toward some initial value, such as the size of a dinner
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plate or drink glasses (where decreasing the size of these containers leads to lower intake) (Force CPST, 2015). There is the issue of whether people are applying a large enough quantity of sunscreen to actually receive the advertised sun protection factor (SPF); there is often a significant mismatch between labeled and delivered SPF (Neale et al., 2002). Anchoring could be of use to change people's conception of how much sunscreen they should apply to get its benefits, such as the recommendation to use a shot glass worth of sunscreen with each application, applying a quarter-sized amount for each part: face, neck, back, front, arm and leg; or providing a measuring device with the sunscreen bottle. Alternatively, sunscreen bottles could have a dispenser that pumps a pre-set default amount (i.e. 5 g) and a very graphic explanation of the average number of pumps needed for each body part shown on the bottle. Framing effects According to Rothman & Salovey, people respond differentially to messages depending on whether they are framed as potential gains or losses, even if it is the same information. An example of a gain-framed message is “If you follow the Surgeon General's recommendations, you will increase your chances of living a long, healthy life.” In contrast, a loss-framed message might state, “If you do not follow the Surgeon General's recommendations, you will increase your chances of dying early” (Detweiler et al., 1999). Loss-framed messages are more effective for disease detection behaviors (e.g. cancer screening), whilst gain-frames tend to be more effective for promoting preventive behaviors. While there is debate about the size of these effects, there is some evidence to support the notion that gain-framed messages are more effective for sunscreen use. Detweiler et al. compared the effectiveness of 4 differently framed messages (2 highlighting gains, 2 highlighting losses) to persuade 217 beach-goers to obtain and use sunscreen. Those who read either of the 2 gain-framed brochures were more likely to request sunscreen, expressed intent to use sunscreen, and repeatedly applied sunscreen with a sun protection factor of 15 or higher while at the beach; compared to those who read either of the 2 loss-framed brochures (Detweiler et al., 1999). Other studies have focused on the intensity of the language used to give sun safety information and advice, finding that health professionals can obtain better compliance by using highly intense language to frame conclusions and recommendations about sun protection and the risk of skin cancer (Buller et al., 2000). Framing can also change misconceptions about sunscreens and their perceived undesirable cosmetic characteristics by focusing on gain-framed messages. Young people, particularly males, are often of the opinion that sunscreen is greasy, uncomfortable and too scented. We can look to address this belief by focusing on formulas and brands that do not have these characteristics. Similarly, some young female patients are concerned about sunscreen clogging pores; we should identify these fears and emphasize the existence of non-comedogenic as well as tinted formulations that can replace additional application of make-up (Morris et al., 2014).
preventive behaviors (Thorgeirsson and Kawachi, 2013; Rice, 2013). This well describes young people's attitudes toward tanning, disregarding the future costs (of skin cancer) in favor of looking good today. Robinson et al. interviewed 658 teenagers about the dangers of sun exposure as well as their behavior toward it. A high percentage (85%) of the sample had sufficient knowledge of the risks of sun exposure as well as sun-protection methods, yet only half of teens admitted to using sunscreen a few times each summer and 3–4 sunburns per year were reported even in the high-risk phototype patients (Robinson et al., 1997). Anecdotically, teenagers and young people tend to believe skin cancer is a problem of the elderly, and thus sun protection and avoidance becomes a problem of intertemporal choice. One important point to make when we counsel young patients is that melanoma is among the 4 most common cancers in young adults in the 20 to 29 year-old age range, the 2nd most common cancer in females. Likewise, in 30–39 and 40–49 year-old females it is the 3rd and 4th most common cancer respectively, but in males it is the 2nd (SEER, 2014). Hence, we should make sure our patients understand that many of the risks of sun exposure including skin cancer and early signs of aging are faced in the not too distant future. The concept of intertemporal choice also suggests that we could be more persuasive by bringing the costs of behavior closer to the present, i.e. mentioning the downside of tanning behaviors that occur sooner rather than later (such as sun-burn, wrinkles, UV damage and a cosmetically-worse appearance); and focusing on these may turn out to be more effective than education about the risks of cancer. For example, instead of showing frightening pictures of skin cancer, a more persuasive and salient message might be to show visual images of the immediate risks of tanning such as photos of highlighted UV damage to tanning-booth users—see Fig. 1. Mahler et al. examined the efficacy of UV photographs for increasing sun protection intentions and behaviors of young adults and found that it resulted in significantly stronger intentions and behaviors (Mahler et al., 2005; Mahler et al., 2007; Mahler et al., 2003). By bringing the “cost” of tanning nearer to the present, it helps to overcome the mismatch between the fact that the benefit of tanning happens today (fashionable appearance) while the cost of the behavior (skin cancer) falls far into the future. For young people in particular it may be more effective to appeal to the immediate downsides of tanning such as burning, dyspigmentation and dryness.
Bounded willpower The concept of bounded willpower refers to the fact that even if people have the intention to behave a certain way, this does not always translate into changing a behavior. The concept of intertemporal choice refers to situations in which the costs and benefits of a behavior are separated across time. Whenever a decision has this characteristic, people are likely to fall prey to temptation (i.e. succumbing to instant gratification rather than investing for the future) or procrastination (i.e. putting off a chore for later—such as applying sunscreen—before running down to the beach). People generally place a higher premium on consumption in the present than in the future; a tendency that often works against the adoption of
Fig. 1. SunSense campaign in Australia showing ultraviolet enhanced photographs of wellknown and popular personalities.
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Commitment contracts are another behavioral economics tool to help people overcome problems of intertemporal choice. They refer to interventions that help participants pre-commit themselves to future healthy behavior. The strategy relies on the observation that our rational self (system 2) is usually willing to pre-commit ourselves to a future course of action when we may be feeling the influence of temptation in a “hot” state. For example, some people are willing to sign up for a deposit contract in which they set aside a sum of money each month toward the goal of stopping smoking or losing a certain amount of weight by a set date (Thorgeirsson and Kawachi, 2013; Rice, 2013). If they have not achieved their goal by the pre-determined date, then they forfeit their deposit. This type of pre-commitment has been shown to boost the success of smoking cessation and weight loss interventions (Force CPST, 2015; Kahneman, 2011). Reward-based programs are another type of commitment contracts, and have been associated with higher abstinence rates than deposit-based programs (Halpern et al., 2015). Future research should identify pre-commitments that teens and young adults may be likely to agree to for reducing adverse UV exposure. Social influence and norms People do not perform behaviors in a vacuum. Often our behavior is influenced by others (whom we aspire to emulate), and collective norms can powerfully influence individual behavior. Indeed changing social norms have been the basis of some of the most successful interventions in public health. One example is the success of tobacco-free indoor laws, which are largely self-enforcing (Thorgeirsson and Kawachi, 2013). There are important implications of social norms for sun exposure and tanning. Many decades ago, among high socioeconomic status groups, the social norm was to avoid the sun (to signal to the rest of the world that they did not have to perform manual labor outdoors). Later, as outdoor labor declined and manual workers shifted to stuffy indoor sweatshops, the social norm flipped so that it became fashionable to look tanned. Accordingly, an intervention target is to change the social norm back toward a more healthy set of behaviors toward sun exposure. The perception of peer behavior and attitudes has a great impact on adolescents and young adults, both positive and negative (Hoerster et al., 2007). Adolescents who have friends who tan are significantly more likely to engage in indoor tanning (Geller et al., 2002). Interventions that capitalize on the impact of peers have found an increase in sun protective behaviors, such as using ¨sun teams¨ of students who lead peer-education activities regarding sun protection (Olson et al., 2007). Australia is the country with the highest rates of skin cancer in the world, and thus, has been a pioneer in many of the public health interventions to promote healthy sun exposure habits. One of these interventions is a comprehensive life-course intervention including a media campaign called SunSmart that started in 1988, which incorporated an animated friendly character that promoted structural change in schools, workplaces and swimming pools. This campaign has been shown to increase the population's sun-protective behaviors and decrease sunburns by half, not only through educating and raising awareness, but by keeping sun protection on the agenda for the wider community (Lazovich et al., 2012; Dobbinson et al., 2008; Emmons and Colditz, 1999; Giles-Corti et al., 2004), and thus, slowly changing the norm. Such efforts have now led to the population-wide ban of tanning beds across all of Australia as of January 1, 2015. In broad terms, Australia has been successful in enforcing the norm: a complete stranger feels within their right to gently remind parents who are not putting sunscreen on their kids, just as they would if they saw children riding a car without a seatbelt, or left in a hot parking lot with the windows up. There can be no stronger proof that the norm exists and is enforced every day. However, there is a risk that without commitment
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to significant on-going investment, the norm can change and things could slip backward again; particularly the SunSmart campaign has experienced modest challenges in recent years in terms of behavioral compliance (Turner et al., 2014). Existing gender differences in attitudes toward sunscreen use are also an area of opportunity for strategies aimed at normative beliefs. In a recent publication, males reported positive normative beliefs from their girlfriends encouraging sunscreen use and even applying it on them. For females, these positive normative beliefs usually come from their mothers or their peers, stemming from the concern of sun exposure generating wrinkles and a worse cosmetic appearance (Abroms et al., 2003). We can take advantage of these roles, and the impact that peers can have with one another's health behaviors, by reminding and advising our patients to make sure their friends or significant others are protecting themselves from the sun. Perhaps the most valuable intervention we can strive to make is to develop health messages that make sun protection the norm. A good place to start would be getting opinion leaders to stop promoting the tanned look and instead promote healthy sun exposure habits. In the case of adolescents, opinion leaders could be Hollywood popular artists making appearances showing their natural skin color, thus giving the message that this is “cool” and tanning is “not cool”; similar to the denormalizing of smoking that was central to the major counteradvertising campaigns. Conclusions Existing public health approaches toward healthy sun behaviors are valuable– e.g. public education, existing regulations on indoor tanning—and they have proven effective when broadly implemented. By taking advantage of insights into how people really behave and translating these into policy interventions, behavioral economics adds a set of concepts and tools to potentially boost the efficacy of existing approaches. As physicians and advocacy organizations try to promote healthy sun behavior and reduce intentional tanning, we need to actively apply these insights when we mount our campaigns and counsel teenagers and young adults. Conflict of interest Maria T. García-Romero has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. Alan C. Geller has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. Ichiro Kawachi has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. References Abroms, L., Jorgensen, C.M., Southwell, B.G., Geller, A.C., Emmons, K.M., 2003. Gender differences in young adults' beliefs about sunscreen use. Health Educ. Behav. 30 (1), 29–43. Bränström, R., Brandberg, Y., Holm, L., Sjöberg, L., Ullén, H., 2001. Beliefs, knowledge and attitudes as predictors of sunbathing habits and use of sun protection among Swedish adolescents. Eur. J. Cancer Prev. 10, 337–345. Buller, D.B., Burgoon, M., Hall, J.R., Levine, N., Taylor, A.M., Beach, B.H., et al., 2000. Using language intensity to increase the success of a family intervention to protect children from ultraviolet radiation: predictions from language expectancy theory. Prev. Med. 30 (2), 103–113. Detweiler, J.B., Bedell, B.T., Salovey, P., Pronin, E., Rothman, A.J., 1999. Message framing and sunscreen use: gain-framed messages motivate beach-goers. Health Psychol. Off. J. Div. Health Psychol., Am. Psychol. Assoc. 18 (2), 189–196. Dobbinson, S.J., Wakefield, M.A., Jamsen, K.M., Herd, N.L., Spittal, M.J., Lipscomb, J.E., et al., 2008. Weekend sun protection and sunburn in Australia trends (1987–2002) and association with SunSmart television advertising. Am. J. Prev. Med. 34 (2), 94–101. Dobbinson, S., White, V., Wakefield, M.A., Jamsen, K.M., White, V., Livingston, P.M., et al., 2009. Adolescents' use of purpose built shade in secondary schools: cluster randomised controlled trial. BMJ 338, b95.
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Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
Review
Using behavioral economics to promote healthy behavior toward sun exposure in adolescents and young adults Maria T. García-Romero a,⁎, Alan C. Geller b,c, Ichiro Kawachi b a b c
Department of Dermatology, National Institute of Pediatrics, Mexico City, Mexico Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, United States Melanoma Epidemiology, Massachusetts General Hospital, Boston, MA, United States
a r t i c l e
i n f o
a b s t r a c t Skin cancer represents an important public health problem, and it is associated with ultraviolet radiation exposure, particularly at early ages. Unhealthy sun exposure and intentional tanning continue to be the trend among young people. Multiple interventions to raise awareness of the risks of sun exposure have been implemented, without necessarily translating into decreased unhealthy behaviors or skin cancer incidence rates. Behavioral economics adds a set of concepts and tools to potentially boost the efficacy of existing approaches to decrease unhealthy sun exposure. This paper reviews public health interventions that have been based in behavioral economics concepts and their results, and provides examples of new and creative ways physicians and health professionals can actively apply insights from behavioral economics to counsel teenagers and young adults about skin cancer prevention. © 2015 Elsevier Inc. All rights reserved.
Available online 9 September 2015 Keywords: Behavioral economics Skin cancer Skin neoplasms Ultraviolet rays Adolescents
Contents A role for behavioral economics? . . . Bounded rationality . . . . . . . . . Status quo bias and default options Anchoring heuristic . . . . . . . Framing effects . . . . . . . . . Bounded willpower . . . . . . . . . Social influence and norms . . . . . . Conclusions . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . References . . . . . . . . . . . . .
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Skin cancer, both melanoma and non-melanoma (NMSC), represents an important public health problem.(US Department of Health and Human Services, 2015) Approximately 3.5 million cases of NMSC and more than 70,000 cases of melanoma are diagnosed annually in the United States alone (76,100 projected for 2014)(Siegel et al., 2014; SEER, 2014), and the incidence rates have risen in the past 2 decades (Guy et al., 2014; Lazovich et al., 2012). Even though mortality is not high for NMSC, the mortality rates for melanoma are 2.7 per 100 000(SEER, 2014) and the costs of treating and palliating these ⁎ Corresponding author at: Department of Dermatology, National Institute of Pediatrics, Insurgentes Sur 3700c, Colonia Insurgentes Cuicuilco, Mexico D.F. 04530, Mexico. E-mail address: [email protected] (M.T. García-Romero).
http://dx.doi.org/10.1016/j.ypmed.2015.08.025 0091-7435/© 2015 Elsevier Inc. All rights reserved.
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patients are estimated at US$17 billion annually (Guy et al., 2014). In the past decades, multiple interventions have been implemented to raise awareness of the risks of sun exposure and tanning; and while people may have general awareness of these risk, unhealthy sun exposure and intentional tanning continue to be the trend particularly among young people (US Department of Health and Human Services, 2015; Schwebel, 2014; Robinson et al., 1997; Kyle et al., 2014; Heckman et al., 2011) and thus the incidence rate of skin cancer continues to rise throughout Europe and the United States (Guy et al., 2014; Morris et al., 2014). Adolescents and young adults have the lowest protection rates of all age groups, receiving large amounts of intentional and unintentional exposure to UV (Heckman et al., 2011), often driven by the motivation to meet cultural ideas of attractiveness,
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which involve tanned skin (US Department of Health and Human Services, 2015; Morris et al., 2014; Heckman et al., 2014). A systematic review of interventions implemented in individuals of all ages and in multiple settings concluded that education and policy approaches encouraging sun-protective behavior were effective, particularly when implemented in primary schools and in recreational or tourism settings (Saraiya et al., 2004). The Community Preventive Services Task Force has recently reviewed several community-wide interventions in multiple settings in the US—child-care centers, healthcare settings and providers, high-schools and colleges, outdoor occupational settings, outdoor recreational and tourism settings, and primary and middle schools—and found them to be effective in reducing exposure to UV radiation and improving sun protection behavior, albeit with limitations (Saraiya et al., 2004; Force CPST, 2015). Regarding tanning, there are two broad categories of prevention strategies: strategies that influence behaviors at the structural level (i.e. through the imposition of laws and regulations) and strategies that target persuasion and behavioral change. Changes in policy have proven effective for decreasing indoor tanning. For example, laws restricting the use of tanning beds either through age, parental permission requirement, or systems access, have been shown to effectively reduce indoor tanning rates among female high school students (Guy et al., 2014). Because they cannot easily be regulated, outdoor tanning and unhealthy levels of sun exposure will continue to pose a challenge. Hence, there is a role for more interventions to motivate behavioral change. Physicians who take care of and counsel adolescents and young adults must focus on increasing sun protection through the use of sunscreen, shading, protective clothing and hats; as well as decreasing intentional tanning (both outdoor and indoor). This is not just a matter of providing adequate information, but being able to communicate effectively and leveraging novel strategies to nudge people's behaviors in healthy directions (Force CPST, 2015; Buller et al., 2000). How can this be done? The purpose of this paper is to review interventions that have been based in behavioral economics concepts and their results, and explore new and creative ways physicians and health professionals can actively apply these insights when counseling teenagers and young adults regarding sun protection and the risk of skin cancer. A role for behavioral economics? Daniel Kahneman, who received the 2002 Nobel Prize in Economics, is one of the pioneers in the field of behavioral economics. He describes two separate cognitive systems that control our judgments and choices: intuition (system 1) and reasoning (system 2). The thought processes in system 2 are identified with what we usually think of when we speak of the “reasoning brain”, i.e. the processes are reflective, deliberate and effortful. However dual process theory posits that our actions are simultaneously determined by the operation of system 1, in which thought processes are intuitive, fast, automatic and emotionally charged (Kahneman, 2011). Research indicates that intuition (system 1) is the part of our brain which really governs most of our routine daily thoughts and actions (with some monitoring by reasoning or system 2). The advertisement industry has long understood this and appeals to system 1 help to sell products. By contrast, we as physicians appeal solely to system 2 most of the time. A good example is the tobacco industry, which has for decades convinced people that smoking is fun and sociable (system 1); while physicians try to convince them that smoking poses many risks to health and causes lung cancer (system 2). Recently, the public health approach has been to target system 1 and counter-market with the same type of youth-focused messages as the industry, like the truth® campaign which has proven to be effective at promoting changes in attitudes, beliefs and intentions of young adults (Richardson et al., 2010). Public health has just begun to leverage behavioral economics principles to nudge people's behaviors toward healthier habits. Medical
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specialists who have a role in counseling teenagers and young adults about healthy behaviors toward sun exposure could learn from these concepts and apply them with our patients. Our patients, particularly teenagers, are unlikely to be influenced by being lectured about the risks of skin cancer (system 2) (Bränström et al., 2001), but they are moved by ads showing images of tanned people enjoying a summer vacation (system 1); and thus disregard the risk. Behavioral economics is a rapidly growing field with potentially tremendous relevance for public health. It assumes—as do standard economic models—that markets and incentives shape people's behavior. However, it departs from the standard economic model in assuming that people often do not act rationally, i.e. they do not always behave in their long-term self-interest. It offers a tool-kit of concepts by which to understand human decision-making, as well as influence behaviors. It emphasizes three human behavioral traits that affect how we make decisions: bounded rationality, bounded willpower, and social influence (Thorgeirsson and Kawachi, 2013). Bounded rationality The concept of bounded rationality describes how human capabilities to process information are limited, and can lead to errors that cause unhealthy behavior (Thorgeirsson and Kawachi, 2013). Many times people use rules of thumb or heuristics (mental shortcuts) to make decisions and are influenced by how simple or easy a decision is (Thorgeirsson and Kawachi, 2013; Rice, 2013). Three key concepts related to bounded rationality that are relevant to development and implementation of interventions designed to prevent skin cancer are now described in turn: 1) status quo bias; 2) anchoring heuristic; and 3) framing effects. Status quo bias and default options Status quo bias refers to the fact that people disproportionally prefer the status quo to changing their routines; and healthier behavior can be promoted through the use of “default options”, such as showing healthier food options as default in a restaurant menu or making a fruit the default dessert of a kid meal (Thorgeirsson and Kawachi, 2013). Another great example is the high rates of organ donation in states or countries where the default option is to be a donor and people have to opt-out of it (Rice, 2013). If in outdoor areas the default option were the use of sunscreen or shade structures instead of being the option that takes more effort, more people would apply or use it. Building shade structures to be used as a default is an excellent return-for investment intervention with a one-time investment (plus maintenance costs) and an extended, self-sustainable useful period. Dobbinson et al. established a new status quo in secondary schools by building tables and seats with built-in shade that greatly reduced students' exposure to UV radiation (Dobbinson et al., 2014; Dobbinson et al., 2009). Another possible intervention would be to get all municipal swimming pools or beach facilities to install sunscreen dispensers just as they do antibacterial gel dispensers or soap in the changing rooms and restrooms. A randomized trial of a skin cancer prevention program (Pool Cool) that included providing sunscreen and shade showed significant positive changes in sun-protection habits and a decrease in the number of sunburns in 28 pools in Hawaii and Massachusetts (Glanz et al., 2002). Most recently, the Boston City Council will soon vote on the provision of sunscreen dispensers at the more than 200 city-wide parks. Anchoring heuristic Another interesting behavioral economics concept related to default options is anchoring, which refers to the fact that people's choices are frequently biased toward some initial value, such as the size of a dinner
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plate or drink glasses (where decreasing the size of these containers leads to lower intake) (Force CPST, 2015). There is the issue of whether people are applying a large enough quantity of sunscreen to actually receive the advertised sun protection factor (SPF); there is often a significant mismatch between labeled and delivered SPF (Neale et al., 2002). Anchoring could be of use to change people's conception of how much sunscreen they should apply to get its benefits, such as the recommendation to use a shot glass worth of sunscreen with each application, applying a quarter-sized amount for each part: face, neck, back, front, arm and leg; or providing a measuring device with the sunscreen bottle. Alternatively, sunscreen bottles could have a dispenser that pumps a pre-set default amount (i.e. 5 g) and a very graphic explanation of the average number of pumps needed for each body part shown on the bottle. Framing effects According to Rothman & Salovey, people respond differentially to messages depending on whether they are framed as potential gains or losses, even if it is the same information. An example of a gain-framed message is “If you follow the Surgeon General's recommendations, you will increase your chances of living a long, healthy life.” In contrast, a loss-framed message might state, “If you do not follow the Surgeon General's recommendations, you will increase your chances of dying early” (Detweiler et al., 1999). Loss-framed messages are more effective for disease detection behaviors (e.g. cancer screening), whilst gain-frames tend to be more effective for promoting preventive behaviors. While there is debate about the size of these effects, there is some evidence to support the notion that gain-framed messages are more effective for sunscreen use. Detweiler et al. compared the effectiveness of 4 differently framed messages (2 highlighting gains, 2 highlighting losses) to persuade 217 beach-goers to obtain and use sunscreen. Those who read either of the 2 gain-framed brochures were more likely to request sunscreen, expressed intent to use sunscreen, and repeatedly applied sunscreen with a sun protection factor of 15 or higher while at the beach; compared to those who read either of the 2 loss-framed brochures (Detweiler et al., 1999). Other studies have focused on the intensity of the language used to give sun safety information and advice, finding that health professionals can obtain better compliance by using highly intense language to frame conclusions and recommendations about sun protection and the risk of skin cancer (Buller et al., 2000). Framing can also change misconceptions about sunscreens and their perceived undesirable cosmetic characteristics by focusing on gain-framed messages. Young people, particularly males, are often of the opinion that sunscreen is greasy, uncomfortable and too scented. We can look to address this belief by focusing on formulas and brands that do not have these characteristics. Similarly, some young female patients are concerned about sunscreen clogging pores; we should identify these fears and emphasize the existence of non-comedogenic as well as tinted formulations that can replace additional application of make-up (Morris et al., 2014).
preventive behaviors (Thorgeirsson and Kawachi, 2013; Rice, 2013). This well describes young people's attitudes toward tanning, disregarding the future costs (of skin cancer) in favor of looking good today. Robinson et al. interviewed 658 teenagers about the dangers of sun exposure as well as their behavior toward it. A high percentage (85%) of the sample had sufficient knowledge of the risks of sun exposure as well as sun-protection methods, yet only half of teens admitted to using sunscreen a few times each summer and 3–4 sunburns per year were reported even in the high-risk phototype patients (Robinson et al., 1997). Anecdotically, teenagers and young people tend to believe skin cancer is a problem of the elderly, and thus sun protection and avoidance becomes a problem of intertemporal choice. One important point to make when we counsel young patients is that melanoma is among the 4 most common cancers in young adults in the 20 to 29 year-old age range, the 2nd most common cancer in females. Likewise, in 30–39 and 40–49 year-old females it is the 3rd and 4th most common cancer respectively, but in males it is the 2nd (SEER, 2014). Hence, we should make sure our patients understand that many of the risks of sun exposure including skin cancer and early signs of aging are faced in the not too distant future. The concept of intertemporal choice also suggests that we could be more persuasive by bringing the costs of behavior closer to the present, i.e. mentioning the downside of tanning behaviors that occur sooner rather than later (such as sun-burn, wrinkles, UV damage and a cosmetically-worse appearance); and focusing on these may turn out to be more effective than education about the risks of cancer. For example, instead of showing frightening pictures of skin cancer, a more persuasive and salient message might be to show visual images of the immediate risks of tanning such as photos of highlighted UV damage to tanning-booth users—see Fig. 1. Mahler et al. examined the efficacy of UV photographs for increasing sun protection intentions and behaviors of young adults and found that it resulted in significantly stronger intentions and behaviors (Mahler et al., 2005; Mahler et al., 2007; Mahler et al., 2003). By bringing the “cost” of tanning nearer to the present, it helps to overcome the mismatch between the fact that the benefit of tanning happens today (fashionable appearance) while the cost of the behavior (skin cancer) falls far into the future. For young people in particular it may be more effective to appeal to the immediate downsides of tanning such as burning, dyspigmentation and dryness.
Bounded willpower The concept of bounded willpower refers to the fact that even if people have the intention to behave a certain way, this does not always translate into changing a behavior. The concept of intertemporal choice refers to situations in which the costs and benefits of a behavior are separated across time. Whenever a decision has this characteristic, people are likely to fall prey to temptation (i.e. succumbing to instant gratification rather than investing for the future) or procrastination (i.e. putting off a chore for later—such as applying sunscreen—before running down to the beach). People generally place a higher premium on consumption in the present than in the future; a tendency that often works against the adoption of
Fig. 1. SunSense campaign in Australia showing ultraviolet enhanced photographs of wellknown and popular personalities.
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Commitment contracts are another behavioral economics tool to help people overcome problems of intertemporal choice. They refer to interventions that help participants pre-commit themselves to future healthy behavior. The strategy relies on the observation that our rational self (system 2) is usually willing to pre-commit ourselves to a future course of action when we may be feeling the influence of temptation in a “hot” state. For example, some people are willing to sign up for a deposit contract in which they set aside a sum of money each month toward the goal of stopping smoking or losing a certain amount of weight by a set date (Thorgeirsson and Kawachi, 2013; Rice, 2013). If they have not achieved their goal by the pre-determined date, then they forfeit their deposit. This type of pre-commitment has been shown to boost the success of smoking cessation and weight loss interventions (Force CPST, 2015; Kahneman, 2011). Reward-based programs are another type of commitment contracts, and have been associated with higher abstinence rates than deposit-based programs (Halpern et al., 2015). Future research should identify pre-commitments that teens and young adults may be likely to agree to for reducing adverse UV exposure. Social influence and norms People do not perform behaviors in a vacuum. Often our behavior is influenced by others (whom we aspire to emulate), and collective norms can powerfully influence individual behavior. Indeed changing social norms have been the basis of some of the most successful interventions in public health. One example is the success of tobacco-free indoor laws, which are largely self-enforcing (Thorgeirsson and Kawachi, 2013). There are important implications of social norms for sun exposure and tanning. Many decades ago, among high socioeconomic status groups, the social norm was to avoid the sun (to signal to the rest of the world that they did not have to perform manual labor outdoors). Later, as outdoor labor declined and manual workers shifted to stuffy indoor sweatshops, the social norm flipped so that it became fashionable to look tanned. Accordingly, an intervention target is to change the social norm back toward a more healthy set of behaviors toward sun exposure. The perception of peer behavior and attitudes has a great impact on adolescents and young adults, both positive and negative (Hoerster et al., 2007). Adolescents who have friends who tan are significantly more likely to engage in indoor tanning (Geller et al., 2002). Interventions that capitalize on the impact of peers have found an increase in sun protective behaviors, such as using ¨sun teams¨ of students who lead peer-education activities regarding sun protection (Olson et al., 2007). Australia is the country with the highest rates of skin cancer in the world, and thus, has been a pioneer in many of the public health interventions to promote healthy sun exposure habits. One of these interventions is a comprehensive life-course intervention including a media campaign called SunSmart that started in 1988, which incorporated an animated friendly character that promoted structural change in schools, workplaces and swimming pools. This campaign has been shown to increase the population's sun-protective behaviors and decrease sunburns by half, not only through educating and raising awareness, but by keeping sun protection on the agenda for the wider community (Lazovich et al., 2012; Dobbinson et al., 2008; Emmons and Colditz, 1999; Giles-Corti et al., 2004), and thus, slowly changing the norm. Such efforts have now led to the population-wide ban of tanning beds across all of Australia as of January 1, 2015. In broad terms, Australia has been successful in enforcing the norm: a complete stranger feels within their right to gently remind parents who are not putting sunscreen on their kids, just as they would if they saw children riding a car without a seatbelt, or left in a hot parking lot with the windows up. There can be no stronger proof that the norm exists and is enforced every day. However, there is a risk that without commitment
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to significant on-going investment, the norm can change and things could slip backward again; particularly the SunSmart campaign has experienced modest challenges in recent years in terms of behavioral compliance (Turner et al., 2014). Existing gender differences in attitudes toward sunscreen use are also an area of opportunity for strategies aimed at normative beliefs. In a recent publication, males reported positive normative beliefs from their girlfriends encouraging sunscreen use and even applying it on them. For females, these positive normative beliefs usually come from their mothers or their peers, stemming from the concern of sun exposure generating wrinkles and a worse cosmetic appearance (Abroms et al., 2003). We can take advantage of these roles, and the impact that peers can have with one another's health behaviors, by reminding and advising our patients to make sure their friends or significant others are protecting themselves from the sun. Perhaps the most valuable intervention we can strive to make is to develop health messages that make sun protection the norm. A good place to start would be getting opinion leaders to stop promoting the tanned look and instead promote healthy sun exposure habits. In the case of adolescents, opinion leaders could be Hollywood popular artists making appearances showing their natural skin color, thus giving the message that this is “cool” and tanning is “not cool”; similar to the denormalizing of smoking that was central to the major counteradvertising campaigns. Conclusions Existing public health approaches toward healthy sun behaviors are valuable– e.g. public education, existing regulations on indoor tanning—and they have proven effective when broadly implemented. By taking advantage of insights into how people really behave and translating these into policy interventions, behavioral economics adds a set of concepts and tools to potentially boost the efficacy of existing approaches. As physicians and advocacy organizations try to promote healthy sun behavior and reduce intentional tanning, we need to actively apply these insights when we mount our campaigns and counsel teenagers and young adults. Conflict of interest Maria T. García-Romero has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. Alan C. Geller has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. Ichiro Kawachi has no conflict of interest to disclose and no financial disclosures. There were no funding sources supporting this work. References Abroms, L., Jorgensen, C.M., Southwell, B.G., Geller, A.C., Emmons, K.M., 2003. Gender differences in young adults' beliefs about sunscreen use. Health Educ. Behav. 30 (1), 29–43. Bränström, R., Brandberg, Y., Holm, L., Sjöberg, L., Ullén, H., 2001. Beliefs, knowledge and attitudes as predictors of sunbathing habits and use of sun protection among Swedish adolescents. Eur. J. Cancer Prev. 10, 337–345. Buller, D.B., Burgoon, M., Hall, J.R., Levine, N., Taylor, A.M., Beach, B.H., et al., 2000. Using language intensity to increase the success of a family intervention to protect children from ultraviolet radiation: predictions from language expectancy theory. Prev. Med. 30 (2), 103–113. Detweiler, J.B., Bedell, B.T., Salovey, P., Pronin, E., Rothman, A.J., 1999. Message framing and sunscreen use: gain-framed messages motivate beach-goers. Health Psychol. Off. J. Div. Health Psychol., Am. Psychol. Assoc. 18 (2), 189–196. Dobbinson, S.J., Wakefield, M.A., Jamsen, K.M., Herd, N.L., Spittal, M.J., Lipscomb, J.E., et al., 2008. Weekend sun protection and sunburn in Australia trends (1987–2002) and association with SunSmart television advertising. Am. J. Prev. Med. 34 (2), 94–101. Dobbinson, S., White, V., Wakefield, M.A., Jamsen, K.M., White, V., Livingston, P.M., et al., 2009. Adolescents' use of purpose built shade in secondary schools: cluster randomised controlled trial. BMJ 338, b95.
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