“It just happens”: A qualitative analysis of unintentional tanning behaviors

Abstract

Objective:

Suntanning is a strong risk factor for skin cancer. Although intentional tanning is common among college students, their unintentional tanning is not well characterized. We aimed to examine (1) how college students conceptualized unintentional tanning, (2) how they perceived outcomes of unintentional tanning, and (3) potentially predictive factors that can be tested in future large-scale studies.

Participants:

30 Northeast US college students who reported any unintentional tanning in the past year.

Methods:

Data were collected using semi-structured interviews in November 2019 and analyzed using thematic analysis.

Results:

College students identified outdoor activities as a reason for recent unintentional tanning. A range of attitudes, positive and negative, were conveyed. Many discussed past sunburns and the circumstances surrounding them. The roles of culture and racial/ethnic background in tanning were important to many.

Conclusions:

This study adds complexity to previous understandings of college students’ tanning; implications include the development of behavioral interventions.

Introduction

Melanoma, the most serious form of skin cancer, is the third-most common cancer among US adults ages 20–49, and its incidence is rising.^1,2 Melanoma risk is modifiable through reducing excessive ultraviolet radiation (UVR) exposure, such as sunburning and tanning.³ Indoor tanning use has declined profoundly;^4,5 in contrast, outdoor tanning continues to be quite common among young people,⁶ including 25–47% of college students.⁷ For good reason then, intentional tanning, both outdoor and indoor, has been the main focus of behavioral research on tanning among college students,^{7, 8} given their risk for the development of skin cancer. However, these intentional behaviors, including outdoor and indoor tanning, may not represent the full spectrum of UVR exposure for young adults. Below, we argue that interventions encouraging young people to avoid tanning may have an unaddressed blind spot that fails to capture a significant share of tanning that occurs outdoors.

The college campus may be an ideal context for studying risky UVR exposure, as tanning and sunburn can occur in a variety of circumstances that are common for these young adults. Outdoor activities such as swimming, exercise, working, and vacationing have recently been linked with high levels of sunburn,^9,10 and in one study, particularly frequent sunburning.¹¹ College students spend a significant amount of time outdoors, including socializing, commuting, and engaging in recreational, work, or sports activities; one study documented that 88% college students spend three or more hours outside on summer days.¹² Research also finds that sunburn is reported among about half of college students and a similar proportion of young adults aged 18–24.^10,13 A tan, acquired intentionally or not, may be welcomed among young people due to positive attitudes about its appearance.¹⁴ Among a sample of northeastern college students, 72% reported unintentional tanning in the past year.¹⁰

A recent representative study found that among men, walking outdoors for transportation and leisure was associated with a higher prevalence of past-year sunburn compared to men who reported no walking.¹³ A large cohort study conducted during a summer weekend with high UVR exposure found that 7% reported sunburning as a result of deliberate tanning but nearly 14% also experienced sunburn unexpectedly without intending to get a suntan that summer (and those who reported unintended sunburn were also more likely to have worn sunscreen and to have higher levels of knowledge about sun safety).¹⁵ These results highlight an important commonality between sunburn and some tanning behaviors: underlying unintentionality. Measurement of sun protective behaviors (e.g., sunscreen use) and their associations with outdoor activities and sunburn are important, but do not address psychosocial motivations that may fall outside of intentional, planned protection strategies. Tanning that occurs unintentionally has not been well-studied and our understanding of its antecedents and the potentially complex attitudes toward it are also not well understood. As indoor tanning behavior decreases,^4,5 it is important to study motivations and intentions (or lack thereof) for outdoor tanning, including unintentional tanning.⁸

To that end, we aimed to conduct a qualitative investigation focused on unintentional tanning among college students. Unintentional tanning may be described as spending time outside and ending up with a tan, even without trying to get one – we defined it this way in our screening process and prior research.¹⁰ The construct of unintentional tanning also encompasses unintentional sun exposure not specific to tanning (i.e., sunburn, which, for some individuals, can turn into a tan). To date, this construct has been assessed using single-item, closed-ended measures (see Table 1). Only two previous qualitative studies of tanning behavior have explored unintentional tanning more comprehensively. In the first, Lupton et al. (1996) sought to understand youth attitudes about sun exposure with a focus on gender. The analysis identified one theme related to incidental tanning: participants discussed sunbathing as more feminine and were more likely to view favorably a boy’s tan that happens incidentally such as during physical activity.¹⁶ Also using qualitative methods, Shoveller et al. (2003) aimed to understand factors to explain the experience of adopting intentional tanning behavior from childhood to adolescence. The study found that adolescent participants seemed to distinctly self-categorize as incidental and/or intentional tanners, providing evidence for differing conceptualizations of tanning behavior or identities among tanners.¹⁷ The growing literature about unintentional tanning indicates that there may be distinct beliefs associated with it (i.e., that it is healthy¹⁷ or more masculine¹⁶). It has been associated with sunburns¹⁰ and rural settings.¹⁸ Yet, much remains unknown, including the psychological underpinnings of unintentional tanning, young people’s current beliefs and attitudes toward it, under what circumstances it commonly occurs, and what, if any, gender differences may exist. Further understanding of this construct will be aided by an updated, in-depth qualitative examination.

Table 1.

Known studies that include assessments of unintentional tanning

First author, year [Citation]	Study type	Term(s) used in the manuscript	Item wording in the manuscript
Lupton, et al., 1996 16	Qualitative focus group study	Incidental, unintentional (authors); not trying to tan, a tan that just happened, natural tanning (participants)	N/A
Shoveller et al, 2003 17	Qualitative interview study	Incidental tanning	The process of getting a tan while engaged in an outdoor activity other than lying out in the sun
Heckman et al., 2016 43	Randomized controlled trial	Incidental sun exposure, incidental UV exposure	Hours per week in the past month they spent in the sun not trying to get a tan (e.g., working, recreational activities)
Bowers et al., 202110	Cross-sectional survey study	Unintentional tanning	When spending time outside in the past year, how often have you ended up with a tan, even if you didn’t try to get one?
Parsons et al., 2021 44	Observational longitudinal study	Unintentional tanning	Did you end up with a tan, even if you didn’t try to get one?
Wu et al., 2022 18	Observational longitudinal dyadic study	Unintentional outdoor tanning	Ending up with a tan when one was not intending to tan
Wu et al., 2022 45	Randomized controlled trial	Outdoor unintentional tanning	End up with a tan, even if you didn’t try to get one

Note. This table refers to the results of an exhaustive but not systematic search of the literature, including terms, “unintentional,” “incidental,” “accidental,” “unplanned,” or “inadvertent” with “tanning.”

We used semi-structured interview methodology to address the research gaps described above. Using grounded theory, and targeting a high-risk group in young people, this study aims to provide clarity about unintentional tanning: what it means to young people, how and when it happens, as well as its contextual factors. Understanding how individuals define and think about this behavior will be important for developing intervention strategies to reduce sun damage, addressing behaviors that may be overlooked. Further, this research may facilitate future measurement development and observation of, and thus prevention of, unintentional tanning. While previous studies may have included unintentional tanning as one item, outcome, or theme of interest, the full focus of our study is on dissecting the construct/behavior in-depth to advance this area of tanning behavior research.

Tanning behaviors have been documented to peak during young adulthood.^19,20 While youth perspectives on different types of tanning – indoor tanning and outdoor sunbathing – are relatively well characterized,^7,21 little is known about their conceptualization of unintentional tanning. We thus asked the following research questions. First, what does unintentional tanning mean to college students, how do they define the term, and what distinctions are drawn between unintentional tanning and intentional tanning? Second, how do participants describe the outcomes of unintentional tanning? Third, what are potential factors that may elucidate the distinct descriptions and experiences of unintentional tanning?

Method

Interviews were chosen as the approach to understand unintentional tanning due to the scarcity of research that probes beyond its reported frequency, and because this methodology can produce rich, hypothesis-generating data for follow-up study. Data reported in this study represent part of a larger study about college students’ perceptions of tanning.²²

Study Participants

Participants were 30 undergraduates attending a large Northeastern university, majoring in different subjects but all enrolled in courses that offered psychology subject pool credit for voluntary research participation. The sample was diverse across gender, race, and ethnicity, similar in age, and included domestic and international students (see Table 2 for characteristics).

Table 2.

Participant Demographics (N = 30) n, %

Age
Mean (SD), Range	19.43 (2.01), 18–27
Gender
Woman	22 (73.33)
Man	8 (26.66)
Race
White	17 (56.66)
Black	2 (6.66)
East Asian	5 (16.66)
Southeast Asian	1 (3.33)
Other	14 (13.33)
Multiple Race	1 (3.33)
Ethnicity
Hispanic/Latino/a	8 (26.66)
First Language
English	16 (53.33)
Spanish	4 (13.33)
English and Spanish	2 (6.66)
English and Portuguese	1 (3.33)
English and another language	2 (6.66)
Mandarin	2 (6.66)
Cantonese	1 (3.33)
Norwegian	1 (3.33)
Bengali	1 (3.33)
Year in School
Freshman	12 (40.00)
Sophomore	12 (40.00)
Junior	4 (13.33)
Senior	1 (3.33)
Other	1 (3.33)

Recruitment and Selection

Participants were recruited online from the university subject pool in August of 2019. Several researchers had the opportunity to screen potentially interested participants (N = 439) using one short online survey consisting of all researchers’ items, approved by the Institutional Review Board. Our survey items probed about recent indoor, intentional outdoor, and unintentional tanning. The screening question pertaining to recent unintentional tanning was, “When spending time outside, how often have you ended up with a tan, even if you didn’t try to get one?” which we adapted from previous work¹⁰ to specifically address unintentionality. Two items assessed tanning motivations (to avoid tanning and to tan for appearances) to characterize the participant pool for the selection process.

Our survey items, along with demographic items included in the base subject pool survey, facilitated the study selection process. We aimed to identify eligible respondents among the 439 students, and then identify stratification groups (e.g., intentional tanners) that would enable inviting a balanced sample. Eligibility requirements were to be 18+ years old, fluent in English, and to have reported any unintentional tanning in the past year. We selected participants by first prioritizing any respondents who reported indoor tanning, because there were so few, but ultimately, none responded to invitations to participate. Without their participation, we aimed to recruit some respondents who reported intentional outdoor tanning (and some who did not). Males and older participants were prioritized for invitation (without specific quota goals) because they were underrepresented in the subject pool. As a part of the iterative data saturation evaluation process, all screening variables (tanning behaviors, attitudes, and demographics) were reviewed as invitations to the study were sent out, with the aim to attain a sample with multiple perspectives.

Recruitment was conducted iteratively by sending selected participants email invitations to participate in our in-person interview study, “Understanding Tanning Behaviors.” Invitations were sent from the doctoral student primary investigator (first author) asking for participation in an interview study about college students’ “thoughts and behaviors as they relate to tanning.” We provided information about signing up for a timeslot for the available subject pool credit. The purpose of the study was not concealed, but “unintentional tanning” was not mentioned.

Data Collection

Data were collected in-person using semi-structured interviews throughout November and December 2019. The primary investigator (female, age 27) conducted each recorded interview in-person in a psychology laboratory on campus that resembles an office space. The semi-structured individual interview format was used to ask questions of participants using the same order and phrasing of questions, and to allow for any necessary probing and expanded discussions for each question.²³ The questions were intended to invite conversation about unintentional tanning, with further probes as warranted. The interviewer used conversational language guided by pre-specified probes to ask the participant to expand on what they were saying. Interviews ranged in length from 10 to 50 minutes (M=19 minutes, SD=9 minutes). After participants were debriefed and awarded credit, recorded interviews were uploaded, labeled, and filed on a secure PC in the laboratory.

Recruitment was an ongoing process until a pre-planned assessment for data saturation was undertaken after 30 interviews were completed. It was determined that data saturation had been reached when themes were repeating rather than new ones emerging.²⁴ The Institutional Review Board of the university approved all study procedures. All participants signed an informed consent document and consented to being recorded before participation.

Analysis

The data transcription plan consisted of two parts. First, each interview file was uploaded to a transcription service program provided by NVivo, a leading qualitative data analysis software. Transcriptions were completed by an automated speech processing software program and returned to researchers in half the time of the recording itself. Transcriptions typically had about 80–90% accuracy. Therefore, a second step involved careful editing of the transcripts by trained research assistants who played back the recordings to edit any mistakes or omissions. After editing, transcripts were imported into NVivo 12 Plus for Windows for coding.²⁵ Following the guidance of Braun and Clarke (2006), the codebook was developed using emergent codes. Higher order codes were created with respect to the broader topic (e.g., “feelings about unintentional tanning”) followed by more specific secondary codes within (e.g., “does not like when it happens”). In our study, we used “codes” to refer to concepts we identified and organized in the data management software and used to calculate a coding consensus. We used “themes” to refer to the concepts that finally emerged from the process of organizing, merging, renaming, and discussing codes – these are presented below in the Results.

Analysis was completed by the first and second authors using inductive thematic content analysis²⁶ and a grounded theory approach.²⁴ Coding in NVivo was completed independently and blindly according to the codebook. Each interview was reviewed by each of the two coders. Suggestions for additional codes or changes in the organization of codes were discussed during weekly consensus meetings. Generally, if more than one participant expressed the same sentiment, it was coded in the data for consideration as a theme. Each coded selection was analyzed for consensus, calculated as 74% agreement. Disagreements were resolved by comparing the coding decision for each discrepant quote and discussing, resulting in total agreement by the conclusion of the process. Combined analysis was completed after all coding was finished and each quote was discussed. The final process of determining the delineation of themes and how they related to the Research Questions resulted from analysis and discussion of the data by the first and last authors.

Results

Quotes presented below are lightly edited to remove filler language and are labeled using Participant ID numbers. Quotes in full and additional quotes are listed in Tables 3–5.

Table 3.

Research question 1 themes and representative quotes

Research question	Theme	Exemplary quotes
What does unintentional tanning mean to college students, how do they define the term, and what distinctions are drawn between unintentional tanning and intentional tanning?	Theme 1: Outdoor Activities	“For me, when I think of unintentional tanning it’s like… when I’m just outside and I’m doing stuff. Because my dad works construction so we’re always building something around the house. It’s like, if I’m outside and we build a shed, like last year, and I got that T-shirt farmer’s tan… that’s unintentional tanning. And I golf, so I’m also wearing collared shirts with sleeves, so I also get the farmer’s tan. That’s unintentional tanning because you’re just outside doing activities, but you do tan.” (1973, woman) “When I work, I bring out orders so every order I’m going out. You know I’ll get tan from just going out like all the time.” (1924, man) “I also work at a pool over the summer so I’m in the sun like six hours a day for five, six days a week. So that’s also me tanning even though I’m not doing it on purpose.” (1963, woman) “That [unintentional tanning] did happen to me once, like I thought I was just going to be in the park for just a few minutes, but eventually I stayed there for hours just playing basketball with my friends.” (1976, man) “Going to Six Flags [amusement park] you get a pretty good tan. But it’s not in my mind that I’m trying to tan.” (1945, woman)
	Theme 2: Everyday Life	“If I’m just walking around outside, doing whatever, like walking my dog, I won’t think to put sunscreen on because like…getting color isn’t what’s on my mind.” (1947, woman) “It means going outside, and just doing everyday activities… not sitting in the sun on purpose, but just doing something you would do every day, and, you know, being tan out of it.” (1924, man)
	Theme 3: Tanning by Accident	“I think of unintentional as kind of like unconscious.” (1943, woman) “I guess when you’re doing something else, and you don’t intend to… go for that tanned look. And it just happens. You’re not looking for it.” (1968, man) “Unintentional tanning is, you’re outside, you’re not thinking about it, you’re in the sun. You don’t realize how strong the sun is until you get home and then you realize, oh I got sunburned. And it’s kind of awkward because it’s only half your arm, the other side is still pale. And then you had the weird tan lines from your tank top or t-shirt. So that’s what I feel like unintentional tanning is. You just don’t mean it. It just happens.” (1940, woman) “To me it’s like, if I’m going outside without thinking about getting a tan and then it just ends up happening. So, sometimes when it’s cloudy you don’t even realize you’re gonna get a sunburn even though you still can.” (1947, woman)
	Theme 4: Comparisons with Intentional Tanning	“Maybe if you’re just outside doing an activity like playing sports or doing yard work… that wouldn’t really be intentionally tanning. Intentional tanning to me would be like going out and like laying out.” (1919 woman) “I think in general it’s the same result but it’s a different type of attitude towards tanning itself.” (1927, woman) “At the beach, I can’t really say if it’s intentional or unintentional, because to me, I’m going to the beach for it to happen, but if it doesn’t happen it doesn’t really affect me. But if it does happen, then it’s also nice. Right so I’d say it’s intentional to some degree and also an unintentional to some degree.” (1968, man) “Before [in childhood] when you went outside it was more like, play and have fun with your friends. Now it’s also about having fun with friends but at the same time you think about getting a tan.” (1955, woman)

Table 5.

Research question 3 themes and representative quotes

Research question	Theme	Exemplary quotes
What are potential factors that may elucidate the distinct descriptions and experiences of unintentional tanning?	Theme 8: Gender	N/A
	Theme 9: Racial/Ethnic Identity and Norms	“I guess it depends on the culture you’re talking about, and I guess in America in general it’s a mix of different ones so there’s no particular right answer to it.” (1927, woman) “To protect myself not to get a tan, I think it’s about the culture. Because Asians don’t like tanned skin so I just – I look at myself in the mirror I feel like I prefer the pale skin because I feel like it just makes my face just look good.” (1969, woman) “My first initial reaction is like, ‘oh, look, I’ve gotten darker,’ which I guess I would feel negative in a way…because I just feel as if I’m already dark, and um, I don’t know, like psychologically, I just automatically think that it’s a bad thing and I associate negative characteristics with it…I think this arises from my family, like, if you tend to be darker it’s kind of seen as a more negative thing.” (1967, man) “My family comes from Dominican Republic and I’m Afro-Latino and my culture as it is, it likes to deny it’s Black ancestry. So, for me, I like to come into my Black history. I’m taking a couple of diversity courses and everything. And it’s like as my skin gets dark I can properly identify and I can show them that I support.” (1928, man) “I feel like it’s just Asian culture, especially the kind of a trend going on is all about being as white as possible. And I just don’t like it… Even in like a traditional Chinese family they don’t think being skinny and tanned is healthy. So, I’m violating all those rules [laughing] but I like it so far.” (1979, woman) “Personally, to me I feel tanning is alright, because my family’s from Latin America. So, we’re tanned. So being tanned it’s just like a natural thing.” (1965, woman)

Research Question 1

This research question aimed to understand college students’ perspectives regarding the meaning of the term unintentional tanning. Discussions related to these definitions and comparisons to intentional tanning resulted in the following five themes.

Theme 1: Outdoor Activities

A common way of defining unintentional tanning involved describing getting tanned while engaging in an outdoor activity. For those who used this language, the act of doing something outdoors – other than “laying out” or just sitting in the sun – and nonetheless getting a tan, underlies its unintentionality. Several different activities were mentioned in the context of unintentional tanning, from sports and recreation to work and childcare. Some students specifically named activities include fishing, soccer, visiting amusement parks, riding a bike, gardening, field hockey, softball, running, volleyball, jet skiing, band camp, tennis, swimming, golfing, basketball, going to the park, and attending outdoor concerts. Participant 1973 used several examples when defining unintentional tanning in her own words: “For me, when I think of unintentional tanning it’s like… when I’m just outside and I’m doing stuff…. That’s unintentional tanning because you’re just outside doing activities, but you do tan.” (See Table 3 for full quote.)

Several talked about their time spent working outdoors and getting tanned unintentionally while at summer jobs, such as serving food, working at a pool, working as a summer camp counselor or otherwise watching children, and doing construction and yard work. Some mentioned trying to protect themselves at work by using sunscreen but still experiencing tanning at times.

Others who used examples of their outdoor activities to definite unintentional tanning discussed recreational activities, such as sports. Many who used recreation in their definition emphasized that their focus was on the fun activity rather than tanning.

Theme 2: Everyday Life

Some students defined unintentional tanning as tanning that occurs during everyday life. These definitions referred to actions that make up the course of normal day-to-day life, such as walking to class. Other daily activities, such as walking the dog or competitive sports practice, were mentioned when describing unintentional tanning. Some mentioned getting tanned quickly because of their skin type. One participant said, about this everyday type of tanning, “…I won’t think to put sunscreen on because like…getting color isn’t what’s on my mind.” (Participant 1947)

Theme 3: Tanning by Accident

Another important theme involved definitions that focused more on their mindset (i.e., attitudes) and lack of intention. “Not meaning to tan on purpose,” “tanning by accident,” and “not paying attention” were components of definitions given by several participants to convey their views of unintentional tanning as accidental in nature. Participants described unintentional tanning as derived from a lack of motive, intent, or attention. A lack of explicit motivation to get a tan was emphasized, especially to distinguish from intentional tanning. To many, unintentional tanning is defined by getting tanned in specific places on their body that they did not want to be tan. Some participants emphasized that an unintentional tan may result from “not watching the time” and a “lack of awareness” was mentioned by participants in reference to the time as well as the weather or UV index.

Theme 4: Comparisons with Intentional Tanning

Some participants defined unintentional tanning by contrasting it with intentional tanning. These intentional tanning behaviors included going to the beach, “laying out” by the pool or elsewhere in the sun, and using tanning products. Some participants felt that while they can still tan if they do so unintentionally, they prefer intentional tans because they are “nicer” or better controlled. For some, intentional and unintentional tanning were thought of as overlapping due to achieving similar results, and intentionality was described ambiguously or with uncertainty. For example, “I can’t really say if it’s intentional or unintentional…” (Participant 1968; see Table 3 for full quote). In these conversations, sometimes the difference in attitude was underscored. “I think in general it’s the same result but it’s a different type of attitude towards tanning itself.” (Participant 1927) However, some participants, especially frequent intentional tanners, did not distinguish unintentional from intentional tanning.

Research Question 1 Summary

Overall, participants were able to provide their own definitions for unintentional tanning with ease, and many readily drew contrasts with intentional tanning by using examples or referring to a difference in their thinking. In Theme 1, outdoor activities and hobbies were mentioned as a central component of the definition of unintentional tanning, and in Theme 2, participants discussed routine or daily activities, describing unintentional tanning as something that happens in the background of their everyday lives. In Theme 3, intent, attitudes, not having “the main goal to get tan,” a lack of awareness and associating this with both unintentional tanning and sunburning was a cognitive dimension emphasized in the definitions. Results in Theme 4 reveal that some participants were identifying similarities and overlaps between the two types of tanning, sometimes seeing intentionality as a grey area or ambiguous, while others felt that intentional and unintentional tanning were distinct from one another.

Research Question 2

In this research question, we sought to understand outcomes that participants associated with unintentional tanning. Results found descriptions of outcomes that were both physical (i.e., how tanned they might get when it is unintentional) and emotional (i.e., how they feel about it).

Theme 5: Positive and Negative Feelings About Unintentional Tanning

While there was no single consensus view, sentiments can be summarized as either strongly positive, somewhat positive, or negative. Those who felt very positively about unintentional tanning said that they enjoy the outcome of being tanned, think that they look better with a tan, and find it exciting and welcome to be looking good, regardless of whether it was intentional or not. Others expressed more muted positive feelings about unintentional tanning; these participants expressed that they don’t mind it. One participant said, “I like that it happens but it’s not my intention” (Participant 1955). Some felt negatively about unintentional tanning experiences and the way that a tan looks on them, expressing self-criticism and regret for times that they experienced sun damage. These participants were typically not intentional tanners and many use high levels of sun protection but had still experienced tanning unintentionally.

Theme 6: Tan Lines

Tan lines were frequently mentioned as a salient outcome of unintentional tanning. This was raised by participants in several early interviews using stories and examples, thus the topic was incorporated into the interview guide. Sometimes tan lines were described neutrally or positively. However, many of participants’ stories about tan lines were told with a negative connotation or a strong negative attitude – referring to being tanned in a way that looked unusual or embarrassing. In addition to these negative feelings, descriptions of trying to “fix” or “even out” unintentional tan lines by subsequently tanning intentionally were encountered. Finally, one participant described trying to prevent, rather than fix, tan lines by either wearing more or less protective clothing.

Theme 7: Sun Damage

This theme spanned a range of content about participants’ experiences of and attitudes about sun protection and sun damage in the context of unintentional sun exposure. Sunburn was described as a frequent outcome of unintentional tanning for some. Many participants associated unintentional tanning with a lack of sun protection, because their exposure to the sun was unexpected or unplanned. Similarly, some felt that unintentional tanning is the type of tanning that gives them the best tan, or a bad sunburn, because of unexpectedness or unpreparedness; the use of sun protection strategies to prevent sunburn, mostly applying sunscreen, were described as used for trips to the beach and other intentional tanning behaviors rather than as a daily routine to prevent unintentional tanning.

RQ2 Results Summary

Results from Theme 5 show that the sample of participants had both positive and negative attitudes about unintentional tanning, with many falling somewhere in between, describing that they don’t mind it. Discussions of tan lines as a physical outcome of unintentional tanning made up Theme 6. Many expressed a dislike for unintentional tan lines because of their appearance, describing attempts to “fix” them with more tanning, while others see tan lines as a positive representation of their time spent outdoors. In Theme 7, participants described varying attitudes and experiences about the relationship between their use of sun protection behaviors, outcomes such as sunburn, and the intentionality of their tanning. Many participants associate unintentional tanning with the absence of sun protection as they use sun protection when intentionally tanning (e.g., bringing sunscreen to the beach). While some felt that unintentional tanning leads to sunburn due to a lack of preparedness and protection, others said that they get more sun damage when they are intentionally tanning.

Research Question 3

Our next question aimed to understand factors that may distinguish experiences with unintentional tanning. Below we describe the activities and experiences that were important to participants’ lives and their understandings of unintentional tanning, as well as themes related to self-identity, including multi-cultural expectations and experiences.

Theme 8: Gender

Gender norms did not explicitly arise during the interviews, and what participants had to say about unintentional tanning did not seem to differ by gender. The types of outdoor activities that participants engaged were similar across gender – for example, both women and men described working at children’s summer camps, working on construction projects, playing sports, and spending time outdoors with their friends (see Theme 1). The tanning outcomes were expressed in similar ways, as well; both men and women described the occurrence of unintentional tanning during their activities, and similar feelings about it – ranging from enjoying it, to not minding it, to disliking it (see Theme 5) – with these varying sentiments expressed across gender. For example, one female participant said, “I enjoy the way I look tan.” (Participant 1966) and similarly, one male participant said, “I love getting a tan” (Participant 1928). Women in the study mentioned bathing suits more often when asked about unintentional tanning, such as when discussing tan lines (see Theme 6). Both men and women used the term “farmer’s tan.” Overall, discussions with the young men and women about unintentional tanning were nearly undistinguishable by gender, with similar definitions, experiences, and feelings about it; quotes from each gender were used throughout this Results section.

Theme 9: Racial/Ethnic Identity and Norms

As participants in the study represented a racially diverse college student population, several distinct areas of discussion surrounding culture and racial/ethnic identity naturally arose when discussing unintentional tanning. In discussions with participants about the extent to which they like or dislike unintentional tanning, and whether they actively try to avoid it or not, experiences within Asian culture and families were raised. Particularly, several participants discussed their own or their family’s preferences for lighter skin and sun protection as a beauty standard. One participant (1967) described feeling negatively about getting tanned unintentionally because he perceives negative attitudes in his family and culture about darker skin color (see Table 5).

In contrast, some participants who described perceiving preferences for lighter skin within their culture personally felt compelled to oppose this view. One participant wanted to tan his skin, intentionally and unintentionally, as much as possible (Participant 1928). Another participant enjoyed the way she looks with tanned skin and described feeling discordant with her culture, in which tanning is “stigmatized” and viewed as “not pretty.” (Participant 1979)

Finally, several participants of Hispanic, Latino/a, or Portuguese descent mentioned their ethnicity in terms of their skin type and its propensity to tan easily and unintentionally. For example, one participant said, “Personally, to me I feel tanning is alright, because my family’s from Latin America. So, we’re tanned. So being tanned it’s just like a natural thing.” (Participant 1965)

RQ3 Results Summary

Seeking to understand potential moderators of unintentional tanning among young people, findings from Theme 8 indicate few gender differences across unintentional tanning definitions, descriptions of outcomes, or attitudes. In Theme 9, we found that cultural and racial/ethnic attitudes and norms can influence unintentional tanning attitudes and behaviors. While some described embracing unintentional tanning and a darker skin tone as a part of their cultural identity, others discussed a culturally influenced preference for lighter skin and displeasure with the occurrence of unintentional tanning.

Discussion

The purpose of this study was to describe a diverse sample of college students’ definitions, experiences, and beliefs about unintentional tanning, a topic that has not been recently explored in-depth. Recent quantitative research shows that unintentional tanning is commonly reported by young and middle-aged adults^10,18 yet the term had been vaguely defined and seldomly measured, with participants’ perspectives relatively unknown. Using qualitative methodology, our study explored how college students conceptualize unintentional tanning and perceive its outcomes. Participants usually highlighted the accidental nature of unintentional tanning as central to the definition, but there were several small but meaningful distinctions in the ways they chose to describe it – by using examples, emphasizing their attitude about it, or focusing on the results of an unintentional tan. Importantly, unintentional tanning was described by a diverse group of college students as a nearly universal experience that, for many, resembles risk behaviors (i.e., intentional outdoor tanning and sunburn) in its physical and emotional outcomes. This novel data has implications for theory, methodology and measurement, and on-campus skin cancer prevention interventions.

Theoretical Implications

One central theoretical question is whether unintentional tanning is a way of describing skin type, is a behavior, an accidental occurrence, or some mix of these elements. The intention-behavior gap indicates that intending to perform a health behavior, such as using sun protection, may not necessarily lead to doing so;²⁷ indeed, several participants described scenarios where they accidentally incurred sun damage through unplanned or changing circumstances despite their better intentions or plans to use sun protection. In contrast, it also seems that for some, unintentional tanning may be something that happens willingly. Some study participants described being open to and willing to have tanning occur (more passive phrasing than “going tanning”); they “don’t mind it.” This finding suggests that the Prototype-Willingness Model (PWM) of adolescent health risk behavior may be useful for further investigation.²⁸

Research using the PWM indicates that behavioral willingness is an important component of young people’s risky health behaviors, and in some cases, a stronger predictor of risk behavior than behavioral intentions.²⁹ The model posits that many do not specifically plan to engage in an unhealthy behavior, but often do so anyway due to their attitudes, willingness, and the opportunities they encounter in social situations. A robust literature demonstrates that willingness is a strong predictor of adolescent and adult cigarette, alcohol, and substance use behavior, and other less frequently studied behaviors including sun protection.³⁰ This theory appears to be echoed in our data. College students go outside for myriad reasons and encounter opportunities to passively tan while socializing, working, or recreating. Interviews revealed that much of the time, indifference about this happening seemed to account for many examples and stories about students’ recent unintentional tans. Few participants had a strong disposition toward tanning that prevented this. Although further study is needed on the topic of unintentional tanning, the PWM has been used to develop successful interventions for indoor tanning³¹ and predict going to the beach without sunscreen.³² The present study establishes that college students distinguish tanning that happens on purpose from unintentional tanning that happens willingly, showing promise for future studies that utilize the PWM in this area.

Habit theory,³³ also from psychology, may additionally be important to consider for the interpretation of this study’s findings and development of future interventions. The automaticity³⁴ of spending time outdoors without sun protection or forethought may explain frequent unintentional tanning among some. In our study, some participants described tanning as an inevitable, “normal” part of their and their families’ daily lives or the US culture, while others described having a daily sunscreen routine. Routines that do not include using sun protection regularly may explain much unintentional tanning. Habits, willingness, and behavioral intentions may altogether be important predictors of unintentional tanning as seems to be the case in previous research on physical activity.³⁵

Methodological Implications

The findings from this study draw attention to the diversity of unintentional tanning attitudes and behaviors among college students, and the need to measure this. Our sample consisted of young women and men with various lifestyles and racial/ethnic identities. Assessment of tanning behaviors in the field, including college student studies, often does not include measurement of unintentional tanning – the construct has been assessed primarily using a single closed-ended item. While these items, seen in Table 1, appear to be face valid, no scale currently exists to assess the construct. Nationally representative health surveys of US adults and adolescents have measured indoor tanning, sun exposure, sun protection, sunburn, and more recently, intentional outdoor tanning, but there are not yet reliable scales available for unintentional tanning. One recent nationally representative survey asked what participants were doing when they were last sunburned in the past year – more reported swimming (37%) or working outside (29%) than sunbathing (19%)³⁶ – this item and emerging ones like it can provide important data about specific contexts for harmful sun exposure in national samples. By probing undergraduates for their own definitions of unintentional tanning, our study findings provide the first foundation from which to build and validate survey items on this topic (an endeavor in progress by authors of this study). The development of such a measure could start to tease apart the aspects of unintentional tanning that are largely related to skin type, i.e., having skin that tans or burns readily³⁷, and those aspects that are more motivational, or related to unexpected situations or willingness to tan.

Intervention Implications

Findings reveal compelling reasons to consider unintentional tanning in developing behavioral interventions. In recounting previous experiences with unintentional tanning, some students in our study brought up the topic of sunburn and how it can occur in similar circumstances to unintentional tanning. A study in New Zealand reported that about 14% of respondents aged 15–69 with a recent sunburn were not intending to tan and were more likely to use sunscreen.¹⁵ This finding supports our qualitative data in which some students referred to the times when they were most sunburned as the times that they did not have tanning on their mind. Others said that they sunburn while trying to tan intentionally. Indeed, our previous survey research found that both intentional and unintentional tanning were associated with recent sunburn among college students.¹⁰ Sunburn has a dose-response relationship to melanoma throughout the lifespan and it is important to prevent.³⁸ Although our qualitative research cannot determine how common unintentional tanning is on the college campus, our previous research found that 44% of college students reported unintentional outdoor tanning only, and 25% reported both unintentional and intentional outdoor tanning.¹⁰ Thus, unintentional tanning seems relevant for both intentional tanners and non-intentional tanners alike, and intervention development can benefit from the insights presented here about students’ perceptions of these risk behaviors. Indeed, if interventions are exclusively focused on addressing tanning that is pursued intentionally, they may overlook significant portions of skin cancer risk behavior.

Unintentional tanning may be an important factor to incorporate into the design of sun protection-focused interventions; assessing sun protection behavior but not unintentional tanning may lead to important latent psychosocial factors being missed. Interventions focusing on UVR exposure among young people may be most efficacious when addressing motivations and intentions (e.g., Heckman et al., 2017 ³⁹). This approach can be enhanced by applying findings of the present study; unintentional tanning attitudes and perceptions of low risk appear to be subtle and complex barriers to the use of sun protection. For some participants in our study and in other research¹⁵ sun protection behaviors coincide with unintentional sun exposure, suggesting a potential for interventions to target more effective use (e.g., re-applying sunscreen throughout the day), and for those less likely to use sun protection, emphasize that all outdoor activities can be risky, regardless of any intention to tan. Targeting unintentional tanning attitudes may provide a complementary benefit to intervention designs that focus on this behavior.

Several unintentional tanning situations described by the students in our study revolved around social activities, such as playing sports or attending outdoor events with friends. Cultural norms were also important components of the discussions, with participants perceiving societal or familial norms around tanning in general. Skin cancer interventions targeting young people may consider dyadic and other novel social relationships interventions, and models such as the PWM that account for norms, to address these factors. Social network analysis may also be appropriate; this methodology is increasingly being used to inform health behavior change interventions.⁴⁰ Unintentional tanning may also be addressed using multiple health behavior change interventions⁴¹ that simultaneously target outdoor physical activity which is beneficial to health but should be balanced to reduce UVR damage. Participants in our study engaged in an impressive array of outdoor activities, which sheds light on the many different opportunities to attempt interventions at the levels of sports teams, workplaces, and on college campuses.

Strengths and Limitations

There are several strengths and limitations to the study. We interviewed a sample of 4-year college undergraduate students in the northeast US, a purposive sample that does not represent all college students; at the same time, this was a hypothesis-generating study, and findings were not intended to be generalized to all college students. Other areas of the country have different levels of UVR exposure throughout the year which may lead to different findings about unintentional tanning behaviors. Our study was strengthened by the diversity of the sample by gender, race, and ethnicity. Also, established methods, reporting standards,⁴² and formal fellowship training in qualitative research informed study development and implementation; the approach makes a novel contribution to the literature by obtaining an in-depth understanding of tanning perceptions.

Conclusions

Results from this study provide a foundation from which skin cancer prevention theory, measurement, and interventions can build. Unintentional tanning, previously undefined or thought of interchangeably with skin type, was often described by college students as a tan that occurs under a variety of common circumstances including everyday activities, and as a subconscious behavior they do not think about until after the damage is done – in the form of sunburns, tan lines, and tans that are a sign of pride, excitement, indifference, or regret. Among some, namely intentional tanners, unintentional tanning seemed to blur together with tanning on purpose, depending on their attitudes. Further research should investigate the role of gender in all types of tanning, as we encountered little difference in unintentional tanning behaviors among women and men in the study, and culture, as participants described norms around tanning and skin color. Although intentional tanning can be narrowed down to occur during specific activities and circumstances like sunbathing in the backyard or going to the beach, the risk of unintentional tanning among college students appears more complex and requires further study.

Table 4.

Research question 2 themes and representative quotes

Research question	Theme	Exemplary quotes
How do participants describe the outcomes of unintentional tanning?	Theme 5: Positive and Negative Feelings About Unintentional Tanning	“Yeah. Sometimes I get a little excited… I like when I look tan. It can be a little fun because if you’re tan it’s a good summer, you know.” (1963, woman) “I like that it happens but it’s not my intention.” (1955, woman) “I don’t really mind it to be honest. I mean people say it looks good on me, but I don’t really notice the difference. (Interviewer: It’s not something that you deliberately seek?) No not really. No.” (1918, woman) “I just get so frustrated ‘cause I’m like, this is damaging my skin even more, like I should’ve been prepared or at least took something in my bag.” (1965, woman) “I feel so bad. You know in my opinion I feel like I prefer pale skin.” (1969, woman)
	Theme 6: Tan Lines	“I worked at a camp over the summer so I was always out in the sun so I would get home and I would have a mean farmer’s tan. I’ll take my shirt off [laughing] my whole chest is light brown my arms and legs are like dark brown.” (1928, man) “I don’t mind tan lines. My jersey is usually short sleeve. But I don’t really mind them, especially in the summer it’s cool to have a tan.” (1970, woman) “I got the worst tan lines from this bathing suit. And it was so horrible because I didn’t mean to tan that part of my body, but it just happened. And then I was stuck with these tan lines. I was like, well. And anytime I wore a dress or a certain shirt that was more open you could see it, and it just looked so bad. And I was like, I have to go to the beach and fix this, I have to fix my tan lines.” (1974, woman) “Sometimes – I know I shouldn’t but – I try to even out my tan lines. Because from work like the one-piece [bathing suit] my stomach is always like crazy white, and everything has a big contrast.” (1963, woman) “[On the dance team] it was kind of a thing – even my director would tell us before [competitions], ‘watch the tan lines! I don’t want to see a big white stripe across your back when you’re in your costume’ – for if you had an open back costume or whatever. So, I had to wear a shirt… going to the beach and tanning or whatever I’d try to wear strapless, or they try to make sure you take the straps off before you tan…. I had to think about what costumes I’m wearing.” (1925, woman)
	Theme 7: Sun Damage	“I feel like unintentional tanning, for me, usually starts out with a burn because I’m not thinking about it, and I wouldn’t put on sunscreen. And then it usually will fade to a tan.” (1947, woman) “Because I have no intent – because of the no intention of tanning, I don’t put any sunblock, SPF, or sometimes some makeup products also have that as well, I don’t really try to use those or take it. Even like sunglasses or anything like that. And I could probably go out somewhere, come back, and I’m red, sunburnt, I could be tanned. And I could be like, damn I could’ve protected myself, but I wasn’t expecting to go out and get tanned.” (1965, woman) “I think that unintentional tanning is actually when you get the worst burn in my mind because you’re really, really not thinking about it, and sometimes you may not even be aware that you’re in direct sun, and you’re definitely burning really bad, until you get home and it’s like really painful.” (1945, woman) “If I was intentionally tanning, I would definitely have sunblock on. It might not be a lot, but it would still be there... because I know that when I’m laying down, I’m just trying to get as much of the sun’s rays as I can, and I know that they’re not safe.” (1921, man) “If you try, you’re either gonna get a tan or you’re gonna get a sunburn or something… At least with my personal experience, I feel I tan better if I tried. But if I don’t try, I still get a tan. It’s just not as good as if I did try.” (1924, man)