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Cancer Prevention Research Presented at ASPO

Cancer Prevention Research Presented at ASPO

Klein Buendel investigators and their collaborators presented research from two large studies at the 50th Annual Meeting of the American Society of Preventive Oncology on April 12-14 in Denver, Colorado. The theme of the conference was “50 Years of Impact: Empowering Communities Through Cancer Prevention Research.” 

*Klein Buendel authors are bolded.

ORAL PRESENTATION 1

Title: A Confederate Study of Indoor Tanning Facility Compliance with Laws

Presenter: Dr. Carolyn Heckman

Co-authors: Anna Mitarotondo, Melissa Goldstein, Rucha Janodia, Ileana Gonzalez, Dr. David Buller, Julia Berteletti

  • This submission was designated as a Best of ASPO Abstract.

Because indoor tanning is a known cause of skin cancer, state laws and federal regulations restricting indoor tanning for minors have been implemented: 22 states and the District of Columbia (DC) ban minors under age 18 from indoor tanning, 22 states have other age and parental involvement restrictions, and 6 states have no restrictions on minor access to indoor tanning. The assessed indoor tanning facility law compliance, hypothesized to be insufficient and inconsistent.

Trained and supervised pseudo-patrons called randomly selected indoor tanning facilities (indoor tanning salons, beauty salons/spas, gyms, apartment buildings) in 50 states and DC, posing as minors one year younger than the state’s permitted age to indoor tan (age 17 in states banning indoor tanning under 18) or age 16 in states with no age restriction. Using a semi-structured script, pseudo-patrons asked about scheduling an indoor tanning session, unlimited indoor tanning (contrary to FDA guidelines), risk of skin burns, and parental involvement requirements. Responses were coded, with discrepancies resolved by consensus, and summarized descriptively.

A total of 504 calls were completed to 206 indoor tanning salons, 111 gyms, 101 spas/beauty salons, and 86 apartment buildings. Overall, 55% of facilities would allow pseudo-patrons to book an appointment or “walk in” for indoor tanning, despite being underage, compared to 32% in states with under-18 bans. In states with minor restrictions, indoor tanning salons were least likely (48%) to permit minor indoor tanning and gyms, most likely to do so (56%). Twenty-six percent (26%) of staff did not ask pseudo-patrons their age, irrespective of law type. Forty-four percent (44%) of gyms/apartments did not require membership/tenancy to indoor tan. Most facilities (92%) offered unlimited indoor tanning packages or unlimited access to tanning beds when open. Only 52% of facility staff acknowledged that pseudo-patrons’ skin could be burned, when asked.

Although many states have laws restricting indoor tanning by minors, indoor tanning facilities were commonly non-compliant with age restrictions, suggesting inadequate law awareness and/or enforcement. Strategies must be identified to implement indoor tanning laws effectively and realize their benefits, including preventing skin burns, skin cancer, and other health consequences. Ongoing analyses are evaluating compliance when scheduling appointments online and by additional law provisions, state demographics, and U.S. region.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators).

POSTER 1 

Title: Correlates of Human Papillomavirus Vaccination Among a Sample of Emerging Adults Aged 18-26 Living in Rural Locations in the Western United States

Presenter: Dr. David Buller

Co-authors:  Dr. Deanna Kepka, Dr. Echo Warner, Dr. Evelinn Borrayo, Dr. Andrew Sussman, Alishia Kinsey, Dr. W. Gill Woodall, Dr. David Buller

Dr. Borrayo, Dr. Buller and Dr. Warner

Human Papillomavirus (HPV) vaccination status and correlates were examined in a sample of emerging adults living in rural locations in the western United States. Eight hundred and ten (n=810) emerging adults residing in rural areas in 17 western U.S. states were recruited from online survey panels or by social media advertising from August 2024-2025 for a randomized trial. Emerging adults reported at baseline their HPV vaccine uptake status, including number of doses received. Using logistic regression analysis, we tested the association of demographics, attitudes, health care, and social media use with HPV vaccine uptake status (0=no/don’t know; 1=vaccinated) and vaccine doses received (0=0 or 1 dose/don’t know; 1=2 or 3 doses).

Overall, 424 (52.3%) rural emerging adults reported being vaccinated for HPV and 184 (22.7%) not being vaccinated, and 202 (24.9%) did not know. Of the 424 emerging adults vaccinated, 41 emerging adults (9.7%) recalled receiving one dose, 88 (20.7%) two doses, and 101 (23.8%) three doses of the vaccine, but 194 emerging adults (45.8%) did not know. More rural emerging adults who were vaccinated were female, more educated, attended religious services less frequently, had a personal/family history of cancer, were more confident vaccines are safe, and had less constraints on getting vaccinated. More rural emerging adults with multiple vaccine doses were older, female, visited a physician for a routine health check-up more recently, were more confident that vaccines are safe, and had less constraints on getting vaccinated.

Uptake of HPV vaccination among rural emerging adults (52.3%) was slightly higher than the national rate in the 2022 National Health Interview Survey (47.4%). Emerging adults need advice on how to confirm vaccination status (such as checking with parent, physician, or vaccine registry) when promoting catch-up HPV vaccination. HPV vaccination interventions should educate on vaccine safety/ constraints, how it can reduce personal/family cancer concerns, and religious groups that support it. Medical providers should offer HPV vaccination to emerging adults during routine health check-ups. Male and less educated emerging adults would benefit from intervention.

This research from the #4Corners4Health study was supported by a grant to Klein Buendel from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Other collaborators are from the University of Arizona, the University of Colorado, the University of Utah, and Colorado State University.

POSTER 2 

Title: Associations Between Food Insecurity and Dietary Intake and Nicotine Use Among Rural Emerging Adults in the Western United States

Presenter: Dr. Megan Skiba

Co-authors:  Dr. Doug Taren, Dr. Dolores Guest, Dr. Kim Henry, Dr. Judith Gordon, Noah Chirico, Dr. Echo Warner, Alishia Kinsey, Angela Jung, Dr. Andrew Sussman, Dr. David Buller

Dr. Skiba

The purpose of the study was to evaluate the associations between food insecurity, dietary intake, and tobacco/nicotine use among emerging adults aged 18-26 years living in rural areas of the western United States. 

This analysis used baseline data from 810 rural emerging adults participating in a randomized trial evaluating a social media-delivered cancer prevention intervention. Emerging adults completed self-report surveys assessing demographics, dietary intake (NCI Dietary Screener Questionnaire), and any nicotine product use (yes/no) in the past 30 days. Dietary measures included predicted intake of fruit and vegetable (servings/day), fiber (g/day), added sugar from sugar sweetened beverages (tsp/day), and red/processed meat (frequency/week). Food insecurity was categorized as very low food secure, low food secure, and high food secure from a single item measuring worry about running out of food before having money to buy more. Associations between food insecurity and dietary intake or tobacco/nicotine use were examined using linear or logistic regression models, adjusting for significant demographic covariates. Linear trend tests assessed graded relationships across food insecurity levels.

Of emerging adults (mean age 22.7 years), 62% reported low or very low food security. Food insecurity was associated with race, sex, education, and employment and were used as model covariates. A positive linear trend was observed between food insecurity and added sugar from sugar sweetened beverages, with very low food secure emerging adults consuming an average of 13.0 tsp/day from sugar sweetened beverages. There were no significant associations between food insecurity and fruit and vegetable, fiber, or red/processed meat intake, although fruit and vegetable and fiber intake were low overall (2.3 ± 0.6 servings/day and 15.1 ± 3.4 g/day, respectively). Percent of emerging adults using nicotine was greater with increasing levels of food insecurity: 24% among those with high food security, 41% among those with low food security, and 53% among those with very low food security. Odds increased 2.5 times for each stepwise increase in food insecurity.

Experiencing food insecurity may be a determinant of cancer-preventive health behaviors in rural emerging adults. Very low food security may be an important target for interventions aimed at improving multiple cancer preventive health behaviors among rural emerging adults.

This research from the #4Corners4Health study was supported by a grant to Klein Buendel from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Other collaborators are from the University of Arizona, the University of Colorado, the University of Utah, and Colorado State University.

Evaluation of Go Sun Smart Georgia

Evaluation of Go Sun Smart Georgia

The evaluation results of a workplace sun safety research project were presented at the 18th Annual Conference on the Science of Dissemination and Implementation in Health held December 14-17, 2025, in Washington, DC. Dr. Cam Escoffery from Emory University was the presenting author. The presentation complemented the conference theme of “Realizing the Benefits of Dissemination & Implementation Science.”

African American and Hispanic workers face unique skin cancer risks and are underrepresented in sun safety intervention research. To support sun safety practice in occupational settings with racially/ethnically heterogeneous populations, we adapted an evidence-based sun safety program—Go Sun Smart Georgia (GSSG)—to better serve African American and Hispanic outdoor workers and evaluated it in local governments. Program implementation outcomes are described.

The study enrolled seven local public employers in Georgia in 2024 and randomly assigned them to intervention (3 sites) or delayed intervention (comparison) group (4 sites), stratified by government type (municipal/county) and size (≥100/<100 employees). GSSG included training of peer coaches; written audit of the employers’ sun safety policies and practices; 45-minute online employee training; and a resource website. Program materials were adapted with culturally relevant language and imagery. GSSG was delivered over a four-month period in June-October. Implementation outcomes were collected via surveys and implementation logs: GSSG delivery, worksite sun safety policy adoption or modification, skin cancer and heat illness prevention practice use and penetration, and GSSG acceptability.

Two county governments and five municipalities (3 large, 2 small) in Southwest/East Georgia participated and 48 managers and 156 outdoor workers were assessed. Compared to the comparison group, outdoor workers in the intervention worksites had higher level of information about UV and heat protective behaviors; more workers recalled receiving skin cancer and heat training; and more reported sharing sun safety information from work at home. Uptake of GSSG policy components was slow; no sites requested a policy audit, one requested a model sun safety policy. Both managers and outdoor workers rated GSSG materials highly (an average of 4.29 out of 5 stars).

The adapted GSSG was well received and improved knowledge and sharing of sun safety practices among outdoor workers. Systematic adaptation of effective interventions for novel populations is important for increasing reach and impact of evidence in sun safety interventions and addressing disparities in cancer prevention.

This research was supported by a grant (U48DP006377) from the U.S. Centers for Disease Control and Prevention to the Emory University Prevention Research Center (Dr. Alex Morshed from Emory University and Dr. David Buller from Klein Buendel, Multiple Principal Investigators). Additional authors on the poster presentation included Mary Buller, Dr. Barbara Walkosz, and Irene Adjei from Klein Buendel; and Dr. Cam Escoffery, Helen Singer, April Hermstad, and Dr. Regine Haardörfer from Emory University. 

Helps and hindrances to passing state indoor tanning laws

Helps and hindrances to passing state indoor tanning laws

Indoor tanning causes skin cancers, including potentially deadly melanoma. Indoor tanning often starts during youth, a critical time for deleterious skin damage. About half of U.S. states have enacted laws banning indoor tanning for minors under the age of 18. A multi-institutional team of researchers including Dr. David Buller and Julia Berteletti from Klein Buendel has published a paper in Translational Behavioral Medicine that reports qualitative findings from interviews with key informants involved in indoor tanning legislative efforts to identify/describe factors influencing law enactment, based on the Multiple Streams Framework (1).

Guided by expert advisors and using snowball-sampling, 64 key informants from 16 states with most recently enacted indoor tanning laws regulating minor access and states without restrictions were contacted. In virtual interviews, key informants shared their unique “story” of indoor tanning bill efforts, enactment, implementation, impact, and potential future directions, which were transcribed and qualitatively coded by trained staff.

Although key informant roles (legislators, advocates, clinicians, and melanoma survivors) and legislative processes vary by state, similar facilitators and barriers to indoor tanning bill passage were identified: personal stories, advocacy, opposition, preparation, legislator education, economic/ enforcement issues, bill stringency, political values/partisanship, and legislative process. Other factors influencing bill enaction included failed U.S. Food and Drug Administration attempts toward federally banning minor indoor tanning and competing priorities.

Despite evidence of laws’ impact on minors’ indoor tanning, policy enaction is challenging and slow. Understanding key facilitators and barriers may help advocates to advance legislation efforts. Advocating for stringent laws necessitates consideration of potential downstream effects. For example, even with policy enactment, key informants believed enforcement and compliance were likely insufficient and variable, with minors continuing to indoor tan, putting them at risk for potentially deadly skin cancer.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Authors include Dr. Carolyn Heckman, Ms. Anna Mitarotondo, Mr. Kevin Schroth, and Dr. Shawna Hudson from Rutgers University; Dr. Jerod Stapleton from the University of Kentucky; Dr. Robert Dellavalle from the University of Minnesota; Dr. Sophie Balk from the Albert Einstein College of Medicine; and Dr. David Buller and Ms. Julia Berteletti from Klein Buendel.

References

  1. Kingdon JW. Agendas, Alternatives, and Public Policies. Longman, 2003.
Analysis of Municipal Shade Policies

Analysis of Municipal Shade Policies

Shade is an essential environmental feature to prevent heat illnesses and skin cancer. A research team led by Klein Buendel has published a description of municipal shade policies in Frontiers in Public Health. Written policies related to shade from municipalities in four southwest and four northeast U.S. states were collected and analyzed.

Municipal codes, planning documents, and manuals/guidelines from 48 municipalities in eight U.S. states were coded for content related to shade by research assistants. A standardized protocol was used to assign numeric codes to each document to assess type of document, type of shade, location, resource allocation, accountability, and design standards. Results were summarized using descriptive statistics.

Three-quarters of municipalities (75.0%) had a policy document that addressed shade, including municipal codes (54.2%), planning documents (29.2%), and manuals/guidelines (12.5%). Protecting from heat (31.3%) was mentioned in policies more than protecting from ultraviolet radiation (8.3%), as was natural shade (56.3%) rather than constructed shade (25.0%). Policies prescribed several design standards, most frequently shade material, proportion of area covered, and attractiveness. Half (50.0%) of municipalities mentioned accountability for shade in the policy, but only a third (35.4%) addressed resource allocation. Regional differences were seen in policy document type, shade type, locations, design standards, and resource allocation.

Many municipalities had policies that mentioned shade, but only a minority of policies indicated that the purpose of the policy was protection from heat or ultraviolet radiation. In northeast municipalities, which can have local home rule traditions, policies on shade appeared almost entirely in municipal codes. Southwest municipalities often included policies in planning documents that may have less legal force than municipal codes.

This research was funded by Klein Buendel and a grant from the National Cancer Institute to the Rutgers Cancer Institute at Rutgers University (CA072720; Dr. Steven Libutti, Principal Investigator). Authors include Phoebe Grutter from Science Park High School, Dr. Margaret Morrissey-Basler from Providence College, Dr. Ian Buller from DLH, Dr. Carolyn Heckman from Rutgers University, and Alishia Kinsey, Taylor Sullivan, and Dr. David Buller from Klein Buendel.

Cost Analysis of an Occupational Sun Safety Intervention

Cost Analysis of an Occupational Sun Safety Intervention

Klein Buendel investigators and their collaborators have e-published the results of the cost analysis of distributing the Go Sun Smart at Work program via two different methods in the Journal of Occupational and Environmental Medicine (JOEM).

This randomized trial compared two methods (digital and in-person) for scaling up an evidence-based occupational sun protection program nationwide. The program was designed to help workplaces implement skin cancer prevention policy and training for employees who work outdoors. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022. Results of the effectiveness of the trial were published in JOEM in January 2025.

For the economic analysis reported in this companion publication, the cost of delivering the Go Sun Smart at Work program was obtained from project accounting records and manager reports. The study followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline for economic evaluation (1). The primary outcome of the economic analysis was an incremental cost-effectiveness ratio (ICER) from the perspective of the disseminating organization, although induced costs to the employer were also recorded and reported. The ICER numerator is the incremental difference between digital and in-person strategies in average program cost (C) per regional district. The denominator is the incremental difference between digital and in-person strategies in the mean number of implemented workplace sun protection actions (per regional district) (E [for effect]):

                                    ICER = (Cdigital – Cin-person) / (Edigital – Ein-person)

Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from a sun safety action not implemented under the digital strategy but implemented under the in-person strategy. In summary, the digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented program actions. Full descriptions of the research methods, results, and limitations are included in the JOEM publication.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Co-authors include Dr. Richard Meenan from Kaiser Permanente Center for Health Research; Dr. Gary Cutter from the University of Alabama in Birmingham; Dr. Kimberly Henry from Colorado State University; Dr. Sherry Pagoto from the University of Connecticut; and Mary Buller, Julia Berteletti, Irene Adjei, and Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this research project.

References

  1. Husereau D, Drummond M, Augustovski F, et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. Value Health. 202;25:3-9.

KB Research Presented at SBM – Part 1

KB Research Presented at SBM – Part 1

Dr. David Buller from Klein Buendel presented three posters at the 46th Annual Sessions and Meeting of the Society of Behavioral Medicine in San Francisco, California, March 26-29, 2025. Dr. Kayla Nuss and Ms. Julia Berteletti from Klein Buendel were co-authors on a fourth poster.

*Klein Buendel authors are bolded.

Dr. David Buller

Poster 1

Title: Economic Evaluation of Two Scalability Strategies for Nationwide Dissemination of an Occupational Sun Safety Intervention

Presenter: David Buller

Authors: Richard Meenan, David Buller, Julia Berteletti, Kimberly Henry, Mary Buller, Gary Cutter, Irene Adjei, and Noah Chirico

Americans spend many hours in work environments that contribute to health risks through hazardous job exposures. An economic evaluation of two methods for scaling up the Go Sun Smart at Work (GSS@W) evidence-based occupational sun protection program to prevent skin cancer in a nationwide transportation industry was conducted. GSS@W promoted employer adoption of sun protection policies and employee use of personal sun protection.

Cost-effectiveness analysis compared digital and in-person scalability strategies for disseminating the GSS@W program in a prospective two-group randomized trial. Regional districts (n=138) in 21 state Departments of Transportation (DOT) throughout the United States were recruited. District managers were assessed before and after scale-up and employees were posttest only. GSS@W was disseminated to managers at DOT districts either via an in-person scalability strategy with face-to-face on-site meetings and employee training or a digital scalability strategy with virtual meetings and online training. Cost of delivering GSS@W was obtained from project accounting records and manager reports on number and associated costs of implemented sun protection actions. Primary cost analysis was incremental cost-effectiveness ratio (ICER) between digital and in-person strategies, using program delivery cost as numerator and number of implemented sun protection actions as denominator. Secondary analysis summarized cost of implemented sun protection actions as reported by participating districts.

Mean implemented actions per district were 6.23 in digital and 6.53 in in-person strategy groups. Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from an action not implemented under the digital strategy but implemented under the in-person strategy. Training was the most expensive action implemented by districts under either strategy (88% of implemented action costs).

The digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented GSS@W program actions. The GSS@W intervention may be readily implemented within employers that manage large annual budgets. Cost analysis was limited by not assessing induced costs to employees and potential feedback effects that could produce contamination.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). 

Poster 2

Title: Pilot Test of a Social Media Campaign on Preventing Cancer Risk Factors for Emerging Adults in Rural Communities in the American Mountain West

Presenter: David Buller

Authors: David Buller, Andrew Sussman, Echo Warner, Alishia Kinsey, Barbara Walkosz, Judith Gordon, W. Gill Woodall, Douglas Taren, Deanna Kepka, Kimberly L. Henry, Kayla Nuss, Cindy Blair, Evelinn Borrayo, David Wetter, Meghan Skiba, Julia Berteletti, Annelise Small, Dolores Guest, and John Torres

A social media campaign on preventing six cancer risk factors – being physical inactive, eating an unhealthy diet, using nicotine products, binging alcohol, being sunburned, and being unvaccinated for human papillomavirus (HPV) – was pilot-tested with emerging adults aged 18-26 living in rural counties.

Using an integrated theoretical framework, social media posts were developed to counter the cancer risk factors. Posts covered simplicity, benefits, response efficacy/cost, self-efficacy/perceived control, risk perceptions, norms, social support/relatedness, goals/values compatibility, intrinsic/extrinsic motivation, media literacy, and communication with family/friends. Twenty-six (26) emerging adults aged 18-26 living in rural counties in Arizona, Colorado, New Mexico, and Utah received a 4-week social media feed with 64 posts delivered in a private Facebook group. Emerging adults completed pretest and posttest surveys, and engagement (views, reactions, comments) was recorded.

Participants were 85% female and 35% Hispanic, with a median age of 23. At pretest, emerging adults demonstrated cancer risk factors: 53% engaged in <150 minutes of moderate-to-vigorous physical activity weekly, 85% had low daily intake of fruits and vegetables, 35% used nicotine products, 58% binged alcohol, 65% were sunburned, and 38% were unvaccinated for HPV. The campaign feed received 1,060 views, 346 reactions and 72 comments. Of the six cancer risk factors, posts on physical activity received the most views (216 views) while those on HPV and sun safety, the least (115 views each). Posts on physical activity, nicotine products, and alcohol received the most reactions (>50 reactions each) and physical activity and diet posts received the most comments (>9 comments each).

Social media is a popular source for health information among emerging adults. A multi-risk factor social media campaign has potential to engage emerging adults with theory-based cancer prevention messaging. The campaign will be evaluated in a randomized trial in 2025.

The research is supported by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Dr. Sussman is from the University of New Mexico Comprehensive Cancer Center. Other collaborating investigators are from the University of Utah, the University of Arizona, the University of Colorado, and Colorado State University.  

Poster 3

Title: Association of Indoor Tanning State Laws and Other Contextual Factors with Burns from Indoor Tanning in a National Sample of US Young Adults

Presenter: David Buller

Authors: Carolyn Heckman, David Buller, Anna Mitarotondo, Daniel Gundersen, Marisa Tomaino, and Julia Berteletti

Indoor tanning by minors is a significant risk factor for the development of melanoma. In addition to FDA safety regulations, 46 states restrict minor indoor tanning access by minors to prevent acute (burns from UV exposure) and chronic (skin cancer) harms. This study’s purpose was to identify state policy and other contextual factors associated with burns from indoor tanning to inform state policy efforts.

The authors conducted an online, nationally representative survey of individuals aged 18-29 who indoor tanned in the last three years (N=1000). Respondents reported on indoor tanning as adults (age 18 or older) and as minors (under age 18). Stringency of state laws on indoor tanning use by minors was scored, with no laws regulating minor indoor tanning being a “0” and laws banning all minors under 18 from indoor tanning being a “10.” Generalized linear models were used to estimate the associations of policy stringency for minor use and enforcement, indoor tanning behavior, and other contextual factors with burns after indoor tanning as a minor or adult. All analyses used the sampling weights.

Eighty-eight percent (88%) of participants reported engaging in indoor tanning in multiple facility types in the last three years, including indoor tanning salons, gyms, beauty salons, homes, spas, and apartments. Stringency of indoor tanning laws in participants’ home states were coded as an average of 4 (weak) out of 10. Fifty-seven percent (57%) of participants reported burning one or more times from indoor tanning in the past three years, with 14% from their most recent indoor tanning session. Correlates of burns from indoor tanning when a minor were weaker age restrictions, greater enforcement, more binge drinking, tanning at locales other than an indoor tanning salon, more sessions, shorter sessions, and more sunburns. Correlates of burns from indoor tanning when an adult were being between 22-25 years old, lower perceived indoor tanning facility safety in their state, greater enforcement, more sessions, and more sunburns.

This is the first study to investigate the impact of the stringency and enforcement of age restrictions in state indoor tanning law on burns both for indoor tanning before and after age 18, in a representative national sample. Burns were very common in the context of weak laws in many states, yet harmful burns after indoor tanning during childhood appeared to be lower in states with stronger age restrictions. Enforcing weak laws or inadequate safety regulations/compliance appears to have little impact on indoor tanning or burns in minors or adults. Thus, increasing stringency of state indoor tanning laws for all facility types may ultimately decrease acute harm and subsequent skin cancer rates.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators).

Poster 4

Title: Social Comparison as a Behavior Change Technique in Digital Interventions: Users’ Perceptions of Leaderboards to Promote Physical Activity Motivation and Behavior

Presenters: Raj Harsora and Danielle Arigo from Rowan University

Authors: Raj Harsora, Emmanuel Lapitan, Giada Benasi, Amanda Folk, Laura König, Kayla Nuss, Julia Berteletti, Kyle R. Haggerty, and Danielle Arigo

Physical activity leaderboards are a common feature in digital health tools; they display users ranked physical activity behavior from highest to lowest, leveraging social comparison to boost motivation. However, some users find them motivating while others find them aversive. It is not clear how users interpret information from a leaderboard, or for whom or under what circumstances leaderboards might be effective.

To examine these nuances, we surveyed 1,676 adults in the United States and Europe (52% women). Of those who use physical activity apps, 8% indicated that their app has a leaderboard; 70% of these users did not participate in the leaderboard and expressed dislike of this feature for its emphasis on competition, unnecessary pressure, and potential “failure.” The remaining 30% reported using the leaderboard for 2 to 24 months because it kept them motivated by showing their success, particularly as they compared to others at the “same skill level.” After viewing a leaderboard with their own rank depicted, 63% of all respondents (1,504 adults) perceived themselves as doing well with physical activity. In a separate response, however, 51% perceived themselves as doing poorly. These perceptions differed by rank but also showed meaningful heterogeneity for the same rank. Across ranks, 74% of respondents endorsed motivation to engage in physical activity though 26% did not. Physical activity motivation did not differ by rank and was not associated with perceiving oneself as doing poorly but was positively associated with perceiving oneself as doing well; the latter was strongest for those ranked 3rd of 6.

Finally, physical activity motivation in response to the leaderboard did not differ by gender but was higher among those with stronger (vs. weaker) general tendencies to respond positively and negatively to comparison opportunities; the latter did not differ by rank. Findings show that responses to physical activity leaderboards vary widely and aren’t based solely on rank or individual difference characteristics. Further, some people who believe they dislike leaderboards still find them motivating, and it is unclear how leaderboards affect physical activity behavior in daily life. Additional investigation is warranted to identify for whom and under what circumstances leaderboards are most likely to lead to benefits for physical activity.

This research was funded by an NIH Director’s New Innovator Award to Rowan University (DP2HL173857; Danielle Arigo, Principal Investigator).

Analysis of Indoor Tanning Legislation in the United States

Analysis of Indoor Tanning Legislation in the United States

Dr. David Buller, Klein Buendel Director of Research, and a national team of scientists, physicians, and attorneys, have published an article in the American Journal of Public Health that describes the progression, content, and stringency of state legislation regulating indoor tanning in the United States.

Skin cancer is a highly prevalent, potentially deadly, and expensive disease. Indoor tanning is a well-established cause of melanoma and keratinocyte (non-melanoma) carcinomas. In the most recent estimates, nearly 6% of adolescents and 5% of adults indoor tan. Most individuals begin indoor tanning as adolescents or young adults. Stringent state indoor tanning laws that include age bans for minors instead of just parental consent are associated with less indoor tanning.

For this study, trained research assistants used legal mapping methods to collect and code legislative bills on indoor tanning introduced in U.S. states, the District of Columbia, and Puerto Rico. The research aimed to (1) describe the progression of state indoor tanning legislation (enacted or failed); (2) detail the content and stringency of bills with special attention to whether bills banned indoor tanning by minors (individuals aged younger than 18 years (under-18 ban); and (3) explore the potential impact of political party affiliation of state government leadership when bills were proposed.

Between 1992 and 2023, 184 bills were introduced in 49 of 50 states and the District of Columbia (56 laws were enacted, and 126 bills failed). An under-18 ban was enacted in 22 states and the District of Columbia. Analyses calculated composite scores on the stringency of age restrictions and of warnings, operator requirements, and enforcement. The research team evaluated associations of the political party of the legislative sponsor and legislature majority. Specific methods, coding protocols, statistical analyses, results, conclusions, limitations, and public health implications are detailed in the American Journal of Public Health paper.

In many states, it took several years and proposed bills before a law on indoor tanning was enacted. Enacted bills were more stringent than failed bills. Party affiliation of the bill sponsor and legislature majority combined to affect bill passage and age restrictions. Increasing support for stringent regulations on indoor tanning is evident and may motivate other states or the federal government to prohibit minors from using indoor tanning facilities in an effort to improve health and prevent death.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Paper authors include Dr. Carolyn Heckman, Ms. Anna Mitarotondo, and Mr. Kevin Schroth from Rutgers University; Mr. Alan Geller from Harvard University; Dr. Jerod Stapleton from the University of Kentucky; Ms. Samantha Guild from the AIM at Melanoma Foundation in Texas; Dr. Jeffrey Gershenwald from the MD Andersen Cancer Center at the University of Texas; Dr. Robert Dellavalle from the University of Minnesota; Dr. Sherry Pagoto from the University of Connecticut; and Dr. David Buller, Ms. Julia Berteletti and Ms. Irene Adjei from Klein Buendel.

Recruitment Challenges for Project SHINE

Recruitment Challenges for Project SHINE

Dr. David Buller, Klein Buendel Director of Research, is part of a multiple institution research team that published a paper on recruitment challenges for Project SHINE. The research team is led by Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute. The paper entitled, “Challenges and lessons learned in recruiting participants for school-based disease prevention programs during COVID-19,” was published in Contemporary Clinical Trials.

Schools provide an ideal setting for delivery of disease prevention programs due to the ability to deliver health education and counseling, including health behavior interventions, to large numbers of students. However, the remote and hybrid learning models that arose during the COVID-19 pandemic created obstacles to these efforts. The Contemporary Clinical Trials paper provides insights on collaborating with schools to deliver disease prevention programming during the height of the COVID-19 pandemic, and in subsequent years. The authors illustrate recruitment and engagement strategies by drawing upon their research experiences engaging high schools in a school-based cancer prevention trial focused on sun safety.

Delivery of a cluster-randomized trial of a school-based skin cancer prevention program was initiated in the spring of 2020 at the onset of the COVID-19 pandemic in the United States. The authors present multilevel evaluation data on strategies used to reach schools remotely and share lessons learned that may inform similar approaches moving forward during times of crises.

Although the COVID-19 pandemic interrupted school-based recruitment for this trial, enrollment improved one year later and did not appear to differ between rural and urban schools. Recruitment strategies and trial-related procedures were modified to address new challenges brought about by the pandemic. Despite the COVID-19 crisis altering classrooms, disease prevention programming can continue to be offered within schools, given close community partnerships and new adaptations to the ways in which such programming and research are conducted.

This research is sponsored by the National Cancer Institute (Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, Principal Investigator). Dr. David Buller from Klein Buendel is a Co-Investigator.

Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies

Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies

Klein Buendel investigators and their collaborators have published the results of the Go Sun Smart at Work project in the Journal of Occupational and Environmental Medicine. This research compared two methods for scaling up an evidence-based occupational sun protection program nationwide. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022 in 1:2 ratio. Managers completed pretest and posttest surveys and employees completed posttest surveys. Due to the COVID-19 pandemic, only posttest measures were analyzed (from 255 managers and 1387 employees).

After scale-up, more employees reported training and communication at workplaces in in-person rather than digital strategy. There were no differences in managers’ reports of sun protection training, communication, or actions by scalability method. Overall, occupational sun protection was implemented during program scale-up and employees recalled training/communication more in the in-person than digital strategy. A full description of methods, analyses, and results can be found in the Journal of Occupational and Environmental Medicine publication.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Collaborators include Dr. Richard Meenan from Kaiser Permanente Center for Health Research, Dr. Gary Cutter from the University of Alabama in Birmingham, Dr. Kimberly Henry from Colorado State University, and Ms. Mary Buller, Ms. Julia Berteletti, Ms. Alishia Kinsey, Ms. Irene Adjei, and Mr. Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this project.

6th International Conference on UV and Skin Cancer Prevention: Posters

6th International Conference on UV and Skin Cancer Prevention: Posters

Klein Buendel research investigators and staff presented three posters on their skin cancer prevention research at the 6th International Conference on UV and Skin Cancer Prevention in Brisbane, Queensland, Australia, September 10-13, 2024.

Poster 1 – This poster won a BEST POSTER AWARD at the conference.

Title: Narrative Synthesis of Skin Cancer Prevention Interventions for Samples with High Proportions of Participants with Skin of Color in a Systematic Review

Presenter: Irene Adjei, BS

Authors: David Buller, PhD; Alexandra Morshed, PhD; Radhika Agarwal, MPH; Irene Adjei, BS; Shenita Peterson, MPH; Cam Escoffery, PhD; Mary Buller, MA; Barbara Walkosz, PhD; Kayla Anderson, MPH

While melanoma and keratinocyte skin cancers are very prevalent in light-skinned non-Hispanic (NH) White adults in the United States, rates of skin cancer may be increasing in Hispanics, African Americans present with thicker lesions, and both Hispanics and African Americans have higher skin cancer mortality rates than NH Whites. Ethnic minority adults may have lower knowledge and risk perceptions, practice sun protection infrequently and for reasons other than skin cancer, have less access to dermatologists, and receive fewer skin exams than NH Whites. As part of a project adapting an evidence-based occupational program to be more equitable by including lower-risk African American and Hispanic worker populations, investigators conducted a systematic literature review of 25 behavioral skin cancer prevention interventions. Investigators extracted information from 10 studies (2014-2022) that evaluated interventions in samples with 20% Hispanic and/or African American participants. Interventions were delivered in eight clinical and two community settings through verbal (for example, a community health worker), printed, visual (for example, videos/photographs), and e-messages. Adaptations for individuals with skin of color included incorporating culturally relevant images, culturally appropriate language (including Spanish translation), and testimonials, informed by diverse research staff and interested individuals. Seven studies evaluated interventions in randomized controlled trials, two in non-randomized experimental designs, and one in a cohort study, with interventions primarily showing improvements in knowledge, perceived risk, and reported sun protection. To be effective with lower-risk populations, skin cancer prevention interventions should incorporate cultural tailoring of images, language, and testimonials. This research was funded by a grant from the Centers for Disease Control and Prevention (U48DP006377; Alexandra Morshed and David Buller, Multiple Principal Investigators).

Poster 2

Title: Feasibility of Using Location-Based Data through the Strava App to Provide Tailored Sun Protection Advice to Outdoor Exercisers

Presenter: Alishia Kinsey, BS

Authors: Alishia Kinsey, BS; Julia Berteletti, MSW; David Buller, PhD; Chuck Anderson, PhD; Kimberly Henry, PhD

Individuals who engage in more physical activity have a higher prevalence of sunburn, and melanoma is positively associated with physical activity. This study was designed to determine the feasibility of using Strava, a popular exercise tracking app, to promote sun protection tailored to individuals who engage regularly in outdoor physical activity. To provide tailored sun protection advice, investigators connected through the Strava Application Programming Interface (API) to collect retrospective activity data from users who consented and authorized collection of data from the past two years. Despite robust recruitment efforts, only 78 Strava users provided this authorization. From these users, 16,669 outdoor activity events were accessed. Of those activities, 46.1% occurred during high UV (between 10 am and 4 pm) for at least 30 minutes. Using predictive modeling, time outdoors for more than one hour during high UV was predicted by day of week (more likely occurs on weekends) or proximity to a high UV event (less likely occurs the day after a previous high UV event). While Strava users are active and prone to overexposure to the sun, privacy settings in the Strava app, which became more restrictive during the study, and users’ resistance to share their data were substantial barriers to employing the app to deliver tailored advice on sun safety. It may be possible to predict when exercisers would be outside during high UV periods if periodicity of individuals’ exercise bouts are known (information that users might be willing to disclose in a mobile app without sharing location data). This research was funded by a grant from the National Cancer Institute (CA241637; Dr. David Buller and Ms. Julia Berteletti, Multiple Principal Investigators).

Poster 3

Title: Gender Differences in the Sun Safety Practices of Tattoo Studio Clients

Presenter: Mary Buller, MA

Authors: Barbara Walkosz, PhD; Mary Buller, MA; David Buller, PhD; Robert Dellavalle, MPH, MD

Melanoma is the one of the most common cancers among young adults and low rates of sun protection are elevated in this group. Approximately 225 million people worldwide have tattoos and 40% of adults ages 18-29 have at least one tattoo. The Sun Safety Ink! program trained tattoo artists to promote full-body comprehensive sun protection to clients to compliment standard aftercare instructions that recommend sun protection for new tattoos. Thirty-seven tattoo studios participated. At pretest, 861 clients completed an online survey and self-reported sun protection on a 5-point scale as: apply sunscreen SPF 15+ on face (aftershave, face lotion, or make-up); apply sunscreen SPF 30+ exposed skin areas; reapply sunscreen; apply sunscreen lip balm; wear any hat; wear wide-brimmed hat; wear sunglasses; stay mostly in the shade; wear protective clothing; watch skin for sunburn or tanning. Women were significantly more likely to apply sunscreen of SPF 15+ on the face, apply sunscreen of SPF 30+ to exposed skin, reapply sunscreen every two hours, limit time in the sun, and watch their skin for signs of sunburn. Men were significantly more likely to wear any hat and a brimmed hat. Strategies are needed to promote specific sun protection practices for men and women as these reported practices have remained persistent. This research was funded by a grant from the National Cancer Institute (CA206569; Barbara Walkosz and Robert Dellavalle, Multiple Principal Investigators).

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Klein Buendel investigators and staff were collaborators on two additional skin cancer prevention research posters at the UV and Skin Cancer Prevention conference.

Poster 4

Title: Indoor Tanning Facility Regulation Compliance in the United States Remains Suboptimal: A Confederate Study

Presenter: Carolyn Heckman, PhD

Authors: Carolyn Heckman, PhD; Anna Mitarotondo; Melissa Goldstein, MS; Rucha Janodia; Ileana Gonzalez; Julia Berteletti, MSW; David Buller, PhD

In the United States, indoor tanning is regulated by the Food and Drug Administration (FDA) and individual state legislation. Twenty-two states and the District of Columbia ban minors under age 18 from indoor tanning, 22 have varying age restrictions and parental involvement requirements, and six have no age restrictions. This study assesses law compliance of indoor tanning facilities, hypothesized to be insufficient and inconsistent. Trained female staff pseudo-patrons called indoor tanning facilities (such as indoor tanning salons, beauty salons/spas, gyms, apartments) posing as minors one year younger than the state’s permitted age to tan (for example, 17 in a state banning indoor tanning under age 18). Pseudo-patrons asked about unlimited indoor tanning packages (contrary to FDA recommendations), sunburns, and whether they were permitted to indoor tan. One hundred and twelve (112) calls were completed across 15 states. Twenty-one percent of facility staff did not ask pseudo-patrons for their age, and 41% told pseudo-patrons they could indoor tan despite being underage. Forty-one percent (41%) of gyms/apartments did not require pseudo-patrons to be a member/tenant to indoor tan. Eight-one percent (81%) of facilities offered unlimited indoor tanning packages or unlimited access during open hours, and 29% of staff did not admit to pseudo-patrons that they could be sunburned from indoor tanning. Although many state laws restricting indoor tanning have been passed in the United States, and indoor tanning has decreased, facilities continue to be non-compliant with restrictions for minors, putting children at risk of sunburns and skin cancer. Further analyses will evaluate compliance by type of facility, law stringency, and U.S. region. This research was supported by a grant from the National Cancer Institute (CA244370; Carolyn Heckman and David Buller, Multiple Principal Investigators).

Poster 5

Title: Adolescents’ Perceived Threat and Perceived Efficacy in Relation to Skin Cancer: Associations with Tanning, Sunburns, and Sun Protection

Presenter: Tammy Stump, PhD

Authors: Tammy Stump, PhD; Jennifer Hay, PhD; Kenneth Tercyak, PhD; David Buller, PhD; Douglas Grossman PhD, MD; Jacob Jensen, PhD; Jincheng Shen, PhD; Yelena Wu, PhD

According to the Extended Parallel Process Model (EPPM), health promotion programs are optimally successful when they heighten the perceived threat of a medical condition while also enhancing perceived efficacy for offsetting that threat. For skin cancer prevention, the authors developed a school-based intervention based on EPPM constructs. The program was designed to both enhance perceived threat of skin cancer (such as susceptibility, severity) and perceived efficacy for sun protection (such as self-efficacy, response efficacy). In advance of the intervention, 2,199 participants (52% female) at 36 Utah high schools completed a baseline survey, which was analyzed as an initial test of the conceptual model underlying the intervention approach. Within a series of linear regression models, all four EPPM constructs were simultaneously entered as independent variables. Self-reported sun protection, tanning (intentional, outdoor, and unintentional), and sunburns served as dependent variables. In these models, self-efficacy significantly predicted all outcomes. Response efficacy for sun protection was associated with greater weekend sun protection. Susceptibility to skin cancer was significantly associated with all outcomes except indoor tanning. Severity of skin cancer was significantly associated with sun protection use only. In sum, self-efficacy was the strongest predictor of outcomes whereas perceived severity of skin cancer had a small effect, and only on one outcome. Overall, these findings suggest that by targeting EPPM constructs, the intervention is likely to have an effect on adolescents’ tanning, sunburns, and sun protection behaviors. This research is sponsored by the National Cancer Institute (Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, Principal Investigator).