Creating the first indoor tan-free skin smart college campus.

Given the prevalence and risk associated with indoor tanning among college students, university campuses constitute a prime target for skin cancer prevention. This report identifies the successes and challenges faced in promoting a campus-wide tan-free policy through the National Council on Skin Cancer Prevention (NCSCP) Indoor Tan-Free Skin Smart Campus Initiative. Beginning in February 2016, we communicated with university faculty or staff members who have participated in skin cancer prevention via education, clinical care, or research at 20 universities regarding the steps to adopt the tan-free policy. One campus, East Tennessee State University (ETSU), successfully fulfilled all criteria and implemented the policy change to become the first US Indoor Tan-Free Skin Smart Campus. The greatest challenge faced in recruiting campuses was gaining administrative support. Reported reasons for not adopting the policy change included wanting to wait for other schools to join first and not seeing it as a top priority. Despite the importance of improving skin cancer awareness and decreasing tanning among university students, we faced several challenges in promoting campus-wide policy change. We identify a need for research on effective ways to disseminate university health policies and increased involvement of healthcare providers in policy-related work.

Introduction

In 2014, the US Surgeon General's Call to Action to Prevent Skin Cancer included reducing indoor tanning as one of five strategic goals (The Surgeon General's Call to Action to Prevent Skin Cancer, 2014). Colleges constitute a prime target for skin cancer prevention because a) those between the ages of 18 and 29 comprise the majority of adults who tan indoors (Guy et al., 2014), b) many colleges allow campus ID and cash card use at tanning salons, and c) tanning salons cluster on or near college campuses (Boyers et al., 2014, Demko et al., 2003, Pagoto et al., 2015, Mayer et al., 2011).

Several studies have identified the benefits of intervening at a policy level in order to promote effective change (The Surgeon General's Call to Action to Prevent Skin Cancer,, Frieden, 2010, Glanz et al., 2002). Authors in the Morbidity and Mortality Weekly Report's (MMWR) Guidelines for School Programs to Prevent Skin Cancer suggested that policy changes affect all persons in a population, rather than just motivated individuals (Glanz et al., 2002). The importance of policy change was also echoed in the Surgeon General's Call to Action (The Surgeon General's Call to Action to Prevent Skin Cancer, 2014).

In response to the US Surgeon General Call to Action, the National Council on Skin Cancer Prevention established the Indoor Tan-Free Skin Smart Campus (SSC) Initiative in January 2015, modeled after the National Tobacco Free College Campus Initiative. In this study, we discuss the process of implementing a campus-wide policy in the inaugural campus, as well as some of the challenges faced in creating policy change on other campuses.

Materials and methods

In February 2016, the SSC team began actively recruiting schools to participate. Letters were emailed to university faculty or staff who have participated in skin cancer prevention via education, clinical care, or research at 20 schools. The letter invited the contact to collaborate on facilitating policy adoption at their university and often resulted in discussions about the initiative and how to facilitate adoption. In order to join, universities were required to 1) prohibit indoor tanning on campus, 2) prohibit tanning salons from being off-campus merchants on university-affiliated debit cards, 3) discontinue website referrals of students to off-campus housing that offers indoor tanning, and 4) provide educational material about skin cancer prevention to students. To facilitate adoption, we developed levels of recognition that allow universities that meet some, but not all, criteria to participate (Fig. 1).

Fig. 1

Requirements for achieving Platinum, Gold, and Silver level recognition through the Skin Smart Campus Initiative. Platinum level recognition is equivalent to being a Skin Smart Campus. Developed in March 2016 in Washington D.C.

*In addition to prohibiting indoor tanning devices on campus or in university-affiliated buildings, the Skin Smart Campus must fulfill the following 3 criteria: 1) The university does NOT list any off-campus housing that includes indoor tanning as an amenity on the university's off-campus housing listings website. 2) The university does NOT permit any indoor tanning salon to be included as a university-affiliated debit card merchant. 3) The university provides access to educational programming (e.g., educational website) focusing on the risks of UV exposure and skin cancer prevention practices to students, faculty and staff at all times.

Results and discussion

In August 2016, East Tennessee State University (ETSU) was the first campus to adopt the policy. Initial contact with this university was made in March 2016 (five months prior to policy adoption). The process entailed faculty in the College of Public Health proposing the policy draft to the Divisions of Student Affairs and Health Affairs, who facilitated it being presented to the Interim University Council (IUC). The policy draft was then opened to a 30-day campus-wide online comment period open to anyone with a university-administered e-mail address, including students, faculty, and staff. Mixed reactions were expressed including support from two people with a family history of skin cancer and resistance from four faculty and staff who requested clarification on advertising and sales restrictions and the nature (voluntary vs. mandatory) of the educational component of the policy. At the following IUC meeting, members were presented with the results of the public comment period and subsequent modifications to the policy draft. These changes included: 1) Specifying that the university would not list any off-campus housing offering indoor tanning as an amenity on the off-campus housing webpage and 2) Clarifying that the restriction on the use of university-affiliated debit cards would occur at tanning salons only. Faculty and student advocates spoke in strong support of the revised policy at that meeting. The IUC unanimously voted to adopt the policy in July 2016. IUC members later shared that student support was instrumental to their decision.

While the inauguration of ETSU as the first Indoor Tan-Free Skin Smart campus marks a significant milestone, garnering support from university administrators has proven challenging. While the majority of our contacts (75%) at the 20 universities expressed interest in the initiative to the level of discussing the initiative with administrators at the institution, the only campus to reach adoption was ETSU. In three cases, administrators reported that indoor tanning was not a campus priority. In two cases, administrators stated they would only sign after other campuses had joined. In five cases, administrators failed to respond after initial discussions regarding the initiative. A second campus is in the process of achieving compliance in preparation to adopt the policy. Furthermore, the policy change ultimately involves several key components including campus housing, university debit cards, and student education. Any areas requiring special focus or investigation are identified and addressed. This requires the collaboration and involvement of all parties involved.

Conclusions

The success at ETSU serves as a model for future campuses. Strong advocates, including faculty and students in the College of Public Health at ETSU persistently drove the policy forward through multiple rounds of consideration. As part of the initiative, faculty in the College of Public Health created engaging and informative educational modules to inform students on skin cancer prevention. Organization and perseverance ultimately allowed for the ETSU's nationally acclaimed success.

Key stakeholders including university administrators and parents should be informed about the increasing prevalence of skin cancer among young adults and the potential for universities to play a role in prevention. Data showing student support for the policy might allay administrator's concerns that students would react negatively or that the policy could negatively impact enrollment. A recent study of the Tobacco Free Initiative found no impact on student enrollment (Miller et al., 2015). Research on dissemination and implementation strategies for university health policies is needed. We solicited skin cancer prevention advocates because they would seem to have the most investment in the topic. However, such individuals have competing demands and may or may not have influence on the university administration. Tobacco-free campus efforts have involved organizing committees, engaging student groups, generating publicity, and targeting board of trustee members with messages that resonate with their mission (e.g., financial, student retention) (Glassman et al., 2011). Academics and healthcare professionals may have an important role in impacting skin cancer related policies at their affiliated universities (Pederson et al., 2016). As has been the case for tobacco-free policies on university campuses, advocacy at the faculty, student, and administrative levels is essential to policy adoption.

Funding/support

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

The authors of this paper have no conflicts of interest to declare.

Financial disclosure

The authors report no financial disclosures.