This article was downloaded by: [Temple University Libraries]On: 18 November 2014, At: 22:04Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Evidence-Based Social WorkPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/webs20

Inoculation Theory: A Framework for theReduction of Skin CancerJonathan Matusitz PhD a & Gerald-Mark Breen ba Nicholson School of Communication, University of Central Florida ,Orlando, Florida, USAb Department of Public Affairs , University of Central Florida ,Orlando, Florida, USAPublished online: 03 Jun 2010.

To cite this article: Jonathan Matusitz PhD & Gerald-Mark Breen (2010) Inoculation Theory: AFramework for the Reduction of Skin Cancer, Journal of Evidence-Based Social Work, 7:3, 219-234,DOI: 10.1080/19371910902911172

To link to this article: http://dx.doi.org/10.1080/19371910902911172

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Journal of Evidence-Based Social Work, 7:219–234, 2010

Copyright © Taylor & Francis Group, LLC

ISSN: 1543-3714 print/1543-3722 online

DOI: 10.1080/19371910902911172

Inoculation Theory:A Framework for the Reduction of Skin Cancer

JONATHAN MATUSITZNicholson School of Communication, University of Central Florida,

Orlando, Florida, USA

GERALD-MARK BREENDepartment of Public Affairs, University of Central Florida,

Orlando, Florida, USA

This paper analyzes skin cancer in detail and explains how

inoculation theory, which demonstrates how attitudes can be

strengthened and made resistant to counter-attitudinal persuasive

messages, is a unique method for specifically targeting and confer-

ring resistance to unprotected and excessive ultraviolet exposure

to people of all ages. As many previous efforts to reduce exposure

to ultraviolet rays have had minimal impact, inoculation theory is

appropriate in this context because the theory has been successful

in other health campaigns and may increase the efficacy of skin

cancer interventions. In justifying the need for this analysis, we

illustrate the prevalence and detrimental impact of skin cancer to

clarify the seriousness of the disease and how people oftentimes

fail to adequately shield themselves. This conceptual analysis

not only has the potential to be applied in rendering subjects

resistant to engaging in unprotected (and/or excessive) sunbathing

and artificial tanning, but it also represents an addition to the

disciplinary domains of health communication and social policy

and offers clues for further exploration in this area.

KEYWORDS Attitude, communication, health, inoculation the-

ory, prevention, skin cancer

This research was, in part, supported by the National Institute of Nursing Research, NIH,

under research grant number 1R01 NR008226-01A1.

Address correspondence to Jonathan Matusitz, PhD, Nicholson School of Communication,University of Central Florida at Serminole State College, Partnership Center (UP 3009),

100 Weldon Blvd., Sanford, FL 32773. E-mail: matusitz@gmail.com

219

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

220 J. Matusitz and G.-M. Breen

INTRODUCTION

This paper analyzes skin cancer in detail and explains how inoculationtheory is a unique method for specifically targeting and conferring resis-tance to unprotected and excessive ultraviolet (UV) exposure via sunbathingand artificial tanning to people of all ages. Inoculation theory demonstrateshow attitudes can be strengthened and made resistant to counter-attitudinalpersuasive messages. As many previous efforts to reduce exposure to UVrays have had minimal impact (i.e., Ringborg, Brandberg, Breitbart, & Grein-ert, 2006)—which is one of the primary reasons for skin cancer’s status asa dangerous disease in the United States (Geller et al., 2004; NCCDPHP,2005)—the authors propose and conceptually analyze inoculation theory, aconstruct that has been successful in other health campaigns (i.e., Comp-ton & Pfau, 2004) and that may increase the efficacy of skin cancer inter-ventions. In justifying the need for this analysis, the authors illustrate theprevalence and detrimental impact of skin cancer to clarify the serious-ness of the disease and how people oftentimes fail to adequately shieldthemselves. Also examined are three primary national interventions (thatis, the Centers for Disease Control and Prevention, the Federal Council onSkin Cancer Prevention, and the U.S. Preventive Services Task Force, etc.)that have otherwise failed in their efforts to minimize dangerous ultravioletexposure.

Through this in-depth discussion of inoculation theory, the assertion ismade that this conceptual analysis not only has the potential to be appliedin rendering subjects resistant to engaging in unprotected (and/or excessive)sunbathing and artificial tanning, but it also represents a vital addition to thedisciplinary domains of health communication and social policy and offersclues for further exploration in this area.

SKIN CANCER: ITS PREVALENCE, DETRIMENTAL

IMPACT, AND MAIN CAUSES

Although heart disease is the number one ‘‘killer’’ in the United States (Essel-styn, 2007; Geller et al., 2004), skin cancer has also claimed the lives of manypeople. Despite the fact that widespread attitudes exist that acknowledge theconsequences of unprotected and excessive sun exposure, in addition to ar-tificial tanning (Oliveria, Christos, Marghoob, & Halpern, 2001), many peoplestill choose to neglect this serious risk by exposing themselves to damagingUV rays (Geller et al., 2002; Nouri, 2007; Po-lin, 2007). The prevalence ofthis disease, its main causes, and its detrimental impact will be discussed indetail. As such, the authors provide the foreground by which the argumentis made on how inoculation can minimize the risks and prevalence of this

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 221

disease. In short, and is demonstrated later, inoculation can achieve this endby significantly strengthening existing attitudes about the dangers of UV.This reinforcement of attitude will offer people the ability to be mindfullyprotected against UV rays.

The Prevalence of Skin Cancer and Its Main Causes

Skin cancer cases worldwide are rising rapidly (Geller et al., 2004; Nouri,2007); human fatalities resulting from this disease are on an upsurge ( Je-mal, Devesa, Hartge, & Tucker, 2001; Po-lin, 2007). Besides excessive andunprotected sun exposure—both of which primarily contribute to the riseof melanoma cases—artificial tanning is a major contributor to the increasednumber of skin cancer cases (Glanz, Saraiya, & Briss, 2003; Swerdlow &Weinstock, 1998; Young, 2004). Although the yearly increase in skin cancerrates differs between populations, previous estimates suggest that between3–7% of fair-skinned Caucasians acquire skin cancer each year (Diepgen &Mahler, 2002). In addition, Egan (2005) predicted that the numbers of skincancer cases will double every 10 to 20 years.

Invasive melanoma, a potentially deadly form of skin cancer, strikesmore than 50,000 Americans annually (Davis, 2007; Po-lin, 2007). The ac-quisition rate of cutaneous malignant melanoma, also a deadly form of skincancer, has significantly increased in all Caucasian demographics in the last20 years (Burton, Coates, & Hersey, 1993; Glanz, Saraiya, & Briss, 2003;Nouri, 2007). Since the fatality rate is growing with invasive melanoma, thistype of skin cancer represents a rising public health and social concern.

Nonmelanoma skin cancers (NMSCs) represent almost 40% of all cancersand are globally regarded as a ‘‘world epidemic’’ (Glanz, Saraiya, & Briss,2003; Nouri, 2007). Basal cell carcinoma represents approximately 75% to80% of all NMSC cases. Squamous cell carcinoma also comprises 20% ofNMSCs. Additionally, more than half of middle-aged fair-skinned personsliving in hot, sunny geographical areas have Actinic Keratosis, premalignantcondition of scaly or crusty skin patches.

All three of these forms of skin cancer usually present themselves onsun-exposed surfaces on the skin, including the face, ears, neck, lips, andbacks of the hands (Po-lin, 2007). Since these cancers typically appear onchronically sun-exposed areas of the skin, especially the head and neck(Glanz, Saraiya, & Briss, 2003; Po-lin, 2007), as well as in geographical areasthat have high sunshine levels, it makes sense to argue that unprotected andexcessive sun exposure, as well as artificial tanning, are largely to blame(Garbe, McLeod, & Buettner, 2000; Glanz, Saraiya, & Briss, 2003; Scrivener,Grosshans, & Cribier, 2002). Clearly, with the increase of skin cancer casesin the United States and in other countries, a results-driven strategy must beemployed quickly to reduce this epidemic.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

222 J. Matusitz and G.-M. Breen

Skin Cancer’s Impact on the Skin and the

Body as a Whole

Because sunlight emits ultraviolet rays that deform the genetic fabric of skincells, and since tanning booths also release UV rays that can injure skinand render malignant cell mutations, it is understandable why excessiveexposure to UV is the primary contributor to skin cancer (Diepgen & Mahler,2002; Geller et al., 2004; International Agency for Research on Cancer, 2006).Although skin cancer is virulent, it is superficially visible and, therefore,readily detectable. If treated in its early stages, it is generally curable. How-ever, as the point was made earlier, it progresses very rapidly (Geller et al.,2004; Nouri, 2007). If left untreated long enough, it can contaminate otherareas of the skin and can permeate throughout the skeletal and nervoussystems, causing systemic infection. Once this occurs, melanoma becomesvery difficult to treat and cure (Glanz, Saraiya, & Briss, 2003). Moreover,since there are several types of skin cancer (e.g., basal cell carcinoma,squamous cell carcinoma, etc.), this class of diseases can affect people in amultitude of ways, ranging from unsightly disfigurements to death (Young,2004).

After the preceding clarification of the deleterious effects of skin cancer,the authors explain, in the next section, how previous and current programsand skin cancer prevention campaigns that aim to prevent such behaviorhave had limited success. Due to these shortcomings, a new approach toskin cancer prevention is needed and is, thus, suggested.

THE FAILURE OF PREVIOUS OR CURRENT PROGRAMS

AND THE NEED FOR STRONGER AND MORE

EFFECTIVE TECHNIQUES

Although a handful of skin cancer prevention campaigns in the UnitedStates have been successful, such as the one published by Saraiya et al.(2004) in the American Journal of Preventive Medicine, numerous othercampaigns to significantly reduce new skin cancer cases, including healthinterventions and awareness programs, have failed. As such, considerableenergy should be invested in finding a better solution to these rampantproblems in our society. In this section, the authors describe the threeprimary health intervention and awareness programs (via the Centers forDisease Control and Prevention, the Federal Council on Skin Cancer Pre-vention, and the U.S. Preventative Services Task Force). Although these pro-grams have consumed significant resources, they have yielded little benefit interms of reducing this national and international plague: skin cancer (Glanz,Saraiya, & Briss, 2003; NCCDPHP, 2005; Ringborg et al., 2006; Saraiya et al.,2003).

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 223

Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC), in association withthe Division of Cancer Prevention and Control and the National Centerfor Chronic Disease Prevention and Health Promotion, offers leadershipand support for national and local campaigns to minimize sickness andfatalities induced by skin cancer (Glanz, Saraiya, & Briss, 2003; NCCDPHP,2005). While these campaigns typically consist of several approaches andtechniques, CDC’s main goals are education and prevention. The first ap-proach CDC has employed is a report that is published regularly and entitled‘‘Guidelines for School Programs to Prevent Skin Cancer’’ (which is found inthe CDC’s Morbidity and Mortality Research and Recommendations Report).Although this publication disseminates information about the significanceof minimizing UV exposure during early childhood and adolescence, itsforemost intention is to aid state and local education agencies and schoolsincrease their role in reducing dangerous sun exposure (NCCDPHP, 2005).CDC works together with such state and local organizations to reduce dan-gerous UV radiation exposure. The organization also provides recommen-dations targeted at establishing policies that cut down contact with UVradiation, (a) keeping and promoting an environment that upholds sun-safety practices, offering health education courses to students, (b) engagingstudents’ families, (c) educating healthcare professionals, and (d) evaluatingschool skin cancer prevention programs (Glanz, Saraiya, & Briss, 2003; NC-CDPHP, 2005). Despite such significant and widespread efforts to minimizeexposure to UV radiation, there have been insignificant and limited effects onthe targeted populations. This evidence can be seen in the statistics (Glanz,Saraiya, & Briss, 2003).

The Federal Council on Skin Cancer Prevention

The Federal Council on Skin Cancer Prevention (FCSKC) is another organi-zation whose goal is to help reduce this global health epidemic. Specifically,FCSKC is designed to promote sun-protection behaviors among federal em-ployees, their families, and agency constituents (Glanz, Saraiya, & Briss, 2003;NCCDPHP, 2005). Interestingly, although the organization mentioned in theprevious paragraph (that is, CDC) is an active member of FCSKC, FCSKC initself is a campaign promoter to target awareness and reduction of UV radi-ation exposure (NCCDPHP, 2005). Through FCSKC and its online resources,the U.S. Environmental Protection Agency offers relevant services, includingits UV Index (also known as the Global Solar UV Index). This UV Indexincludes and distributes (via online or mail) UV Index forecasts for 58 U.S.cities from the National Weather Service. This service also provides Internetusers with the ability to check UV forecasts by ZIP code from the EPA Website. Hence, FCSKC is a conduit through which the EPA can announce the

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

224 J. Matusitz and G.-M. Breen

Global Solar UV Index (for one, this promotes standardization of reportingwithin the United States) and provide recognition and comprehension of theUV Index for United States residents (NCCDPHP, 2005). Such services maymake some U.S. residents aware of the UV levels at a certain time, but theydo not seem to have a significant influence in reducing new cases of skincancer.

U.S. Preventive Services Task Force

The Task Force on Community Preventive Services (TFCPS) systematicallyevaluates the relative efficacy of various community interventions, all ofwhich are aimed at minimizing exposure to ultraviolet light and increaseprotective behaviors (Glanz, Saraiya, & Briss, 2003; Saraiya et al., 2003).Following their close investigation of recent interventions, they concludedthat two specific types of interventions—both of which were based onimprovements in sun protective behavior (i.e., using protective clothing suchas long-sleeved clothing and hats)—rendered the greatest level of successin primary schools and recreational/tourism sites: educational and policyapproaches (Saraiya et al., 2003). They also concluded that more researchneeds to be done on a range of other population-based interventions. Hence,they recommended that research in several areas need to be further exploredto increase significant reduction in UV radiation exposure in certain groups:childcare centers, secondary schools and colleges, recreational or tourismsites for children, and workplaces (Saraiya et al., 2003). Furthermore, Saraiyaet al. (2003) suggested that stronger interventions need to be conductedin healthcare settings, targeted at both providers and children’s parents orcaregivers. Unfortunately, despite all the efforts and considerable resourcesdedicated by the TFCPS to minimize dangerous UV radiation exposure, therehas been little progression in terms of substantially reducing new cases ofskin cancer. These failed efforts represent another hint that more puissantstrategies need to be explored.

Although those powerful, governmentally funded/sponsored organiza-tions (and vast resources) dedicate themselves to the prevention and/orreduction of this global epidemic, they are faced with outcomes that are farfrom being successful. Let us face it: those three main organizations designedto attack behavior contributive to skin cancer are otherwise failing. With thisrealization in mind, the authors offer a curious alternative and a potentiallymore efficacious tool with a proven track record in health-related contexts:inoculation theory. Inoculation theory is important for two valid reasons.First, the theory can provide strong insights into the complex persuasionprocess of skin cancer prevention campaigns. Second, not a single bit ofattention has been given to the potential of inoculation to confer resistanceto behavior that contributes to such a serious health-related danger facingUnited States residents.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 225

INOCULATION THEORY:

A THEORETICAL AND PRACTICAL FRAMEWORK

FOR THE REDUCTION OF SKIN CANCER

In this section, the authors describe inoculation theory in detail. As such,they examine the theory in terms of its conceptual assumptions, based on itstwo elements (threat and refutational preemption) and its three stages (thewarning, the weak attack, and the active defending), and explain its applica-tions in relevant health contexts. The main objective here is to legitimize thetheory’s capacity and utility to be applied in cases where researchers desireresistance to influence in health and social situations, and to show that thistheory serves as an ideal tool for largely reducing risky behavior contributiveto skin cancer. Examples of how inoculation works in reducing skin cancercases are also offered.

INOCULATION THEORY: DESCRIPTION

Inoculation theory, as technically applied in the social sciences, was firstproposed by McGuire (1961) to demonstrate how attitudes could be strength-ened and made resistant to counter-attitudinal persuasive messages (An &Pfau, 2004; McGuire, 1964; Miller, 2002). Interestingly, the etymology ofinoculation refers to the intentional introduction of a pathogen or antigeninto a live organism to produce antibodies (Matusitz & Breen, 2005; McGuire,1964), which reasonably mirrors what the theory represents in the socialsciences context; a kind of mental immunization process against external,attitudinal influences that are usually undesired to individuals who seek tobe and remain morally or ethically appropriate.

McGuire and subsequent researchers (An & Pfau, 2004; Compton &Pfau, 2004; Godbold & Pfau, 2000; Matusitz & Breen, 2005; McGuire, 1964;Pfau & Van Bockern, 1994; Pfau et al., 2001; Szabo & Pfau, 2001; Wan &Pfau, 2001) continued this exploration into inoculation and determined thatexisting attitudes could be protected against counter-attitudinal influences orattacks. Through these discoveries and empirically grounded validations, in-oculation researchers concluded that if peoples’ attitudes could be inoculatedagainst persuasive messages delivered to them by some external source (e.g.,models, friends, advertisements, etc.), then inoculation merited placement asa highly feasible method. This method would solidify existing attitudes torender people impervious to persuasive communication, even before suchmessages presented themselves to the inoculated receivers (Compton & Pfau,2004; Pfau, 1992; Szabo & Pfau, 2001). Through recent assertions by re-searchers (An & Pfau, 2004; Compton & Pfau, 2004), inoculation methodicallyinstills information in receivers prior to persuasive communication. As such,it can be logically predicted that the information will reinforce attitudinal re-

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

226 J. Matusitz and G.-M. Breen

sistance to later counter-attitudinal attacks (An & Pfau, 2004; Borchers, 2001;Pfau, 1992, 1995; Szabo & Pfau, 2001). Inoculation also suggests that throughthe administration of low doses of contrasting perspectives (Compton & Pfau,2004; Miller, 2002), inoculated subjects can become further immunized. Thus,their responses to discordant perspectives (or attacks) become more greatlyminimized (McGuire, 1964), leading to an increasingly protective attitudinalshield.

Inoculation theory has proven successful in a variety of contexts. Fromlooking at the long history of inoculation (Compton & Pfau, 2004; McGuire,1961), it has been both theoretically and empirically examined in a plethoraof important contexts, particularly in the health communication domain.Some health-related inoculation studies include its use in alcohol consump-tion prevention (Godbold & Pfau, 2000), smoking prevention (Pfau & VanBockern, 1994; Szabo & Pfau, 2001), as well as other general contexts suchas commercial advertising (Pfau, 1992), political campaign issues (Pfau &Burgoon, 1988), and public relations issues (Wan & Pfau, 2001). Althoughthis list is not exhaustive and only represents a small portion of successfulinoculation studies, it does indicate that a substantial amount of research hasalready been conducted on inoculation theory and its meaningful impacton inducing resistance to counter-attitudinal attacks, persuasion, and riskybehavior.

So how can it be demonstrated that inoculation applies in the proposedhealth-related context? It might be as simple as the idea that the admin-istration of low doses of contrasting perspectives vis-à-vis sunbathing orexposure to UV rays can be done by convincing individuals that they shouldbe more acquainted with skin cancer. For example, inoculation researcherscan compel them to read books on the subject matter, show them shockingpictures of patients with severe cases of skin cancer, address the more imme-diate effects of sun exposure, for example, wrinkled, sagging, dry skin (Cho,2003). Researchers—and policy makers—can also give them protection tipssuch as seeking shade in the middle of the day, so that they can strengthentheir attitudes toward ultraviolet rays and be inoculated against counter-attitudinal persuasive messages delivered to them by external sources suchas close friends (i.e., ‘‘You’re too white to go to the prom next week. Get asun tan, whether it is at the beach or at the tanning salon’’). The goal is toinstill information in individuals prior to persuasive communication. Basedon the prediction of inoculation theory, the individuals would be immunizedand, every time the sun is out, they would protect themselves by wearingsunscreen, wearing a hat, and so on.

In the same train of thought, social influence to visit beaches and otheroutdoor locations will be agreed to only under the conditions that suchprotective wear and ointments are used. Moreover, artificial tanning may beerased from one’s interest in spite of the cosmetic and/or social desirabilityof darkened skin in Caucasian males and females (Young, 2004). In effect,

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 227

inoculation can produce in people a high level of awareness and actionthat will cause them to eliminate close to all dangerous UV exposure fromtheir lives. This absence or significant reduction of ultraviolet exposure mayconsiderably decrease new cases of skin cancer.

Attitude in Inoculation

Attitude represents a key concept that is acutely embedded in the model ofinoculation theory (An & Pfau, 2004; Compton & Pfau, 2004; Godbold & Pfau,2000; Pfau, 1992, 1995). Because of the importance and relevance of attitudewithin inoculation’s framework, definitions of what attitude is and how itis typically characterized are essential in this address. According to Ajzen(1988), and Fiske and Taylor (1991), attitude is defined as the collectionof opinions about a specific circumstance. Considering how keenly tiedattitudes are in the process of inoculation, humans are the ideal subjectsfor undergoing inoculation treatments. These administrations can increasethe resistance of their attitudes so that they can refuse counter-attitudinalcommunications (An & Pfau, 2004; Compton & Pfau, 2004; Pfau, 1992, 1995;Pfau & Van Bockern, 1994).

To relate this information to the focus of this study, attitudes can bearmed to avoid any level of dangerous UV exposure, as when contact withthe sun or artificial tanning becomes optional. Motivating counter-attitudinalattitudes among individuals is important for controlling the incidence of skincancer because unprotected sun exposure augments their risk of developingskin cancer considerably (Cho, 2003). When inoculation researchers employpowerful messages (i.e., that people [particularly fair-skinned] can get burnedeven on a cloudy day, etc.) in order to convince individuals of the potentialdanger posed by UV exposure, the resistance of those individuals’ attitudescan increase towards the danger they are facing. By the same token, theirattitude will be consistent with the direction of message recommendations todecrease their risk (Cho, 2003). If those individuals realize that the harmfulconsequences of skin cancer are serious and that they are able to take sun-protective preventions easily, the researchers’ messages will produce positiveeffects of attitudinal change (Cho, 2003).

Threat and Refutational Preemption

It is important to know that inoculation has two important elements: threatand refutational preemption. According to Pfau (1992, 1995), these ele-ments must cascade in order to render resistance to later counter-attitudinalmessages. Pfau and Burgoon (1988) defined threat as a perception of anupcoming counter-attitudinal attack. The threat element is important becausenot only does it have the capacity to ‘‘trigger the receiver’s motivation tobolster attitudes and gives inoculation its distinctive power’’ (Pfau, 1995,

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

228 J. Matusitz and G.-M. Breen

p. 101), it also has the ability to stimulate resistance to differing persuasivemessages that occur over time (Compton & Pfau, 2004; Matusitz & Breen,2005; Pfau, 1992, 1995). In the context of UV exposure, a threat could involvean approaching person—either in a video presentation (Pfau & Van Bockern,1994) or in real life—whom the inoculated individual perceives to be ready toinfluence or persuade him or her into entering dangerous UV environments(either with or without protective wear or cream). As such, this threat wouldreinforce the inoculated attitude so that refusal or ‘‘resistance’’ to enter intothat environment would be prepared (once the counter-attitudinal attack, orpersuasion, takes place).

The second element, refutational preemption, is characterized as poten-tial attacks to existing attitudes that are initially addressed and preemptedsoon after (Godbold & Pfau, 2000; Pfau, 1995). To clarify this, when aninoculated individual is presented with a counter-attitudinal persuasion, thatindividual must disregard the counter-attitudinal message in order for in-oculation to take effect and maintain or keep intact the original attitude(Pfau & Van Bockern, 1994). For example, the person who was previ-ously prepared to communicate the counter-attitudinal attack to influencethe inoculated individual to engage in risky UV exposure then carries outthe attempted persuasion. In effect, and as predicted through inoculation’sproduction, the inoculated receiver should immediately reject the influencein order to maintain the safe attitude and resist such dangerous health-relatedbehavior.

Certainly, these two elements (threat and refutational preemption) areessential components in the inoculative process. They provide the meansby which inoculation can render attitudinal protection from unwanted orharmful influences. In this case, this inoculative frame or platform may offerutility in the context of UV, or health-related, behavior and protection.

The Three Stages of Inoculation

There are also three stages of inoculation treatments. These include thewarning, the weak attack, and the active defending (Miller, 2002; Pfau et al.,2001). These stages represent the finer elements in the inoculative process,or, in clearer terms, the underpinnings for threat and refutational preemption.The warning takes place when the individual receiving inoculation is told thatthere will be an upcoming counter-attitudinal argument. The purpose of thiswarning is to prepare the individual for the (upcoming counter-attitudinal)attack (Pfau, 1992, 1995). In this analysis, the individual would be warnedthat they will receive counter-attitudinal persuasive messages (i.e., from afriend, a classmate, etc.) about UV rays or sunbathing.

The weak attack takes place when the individual receiving inoculationis lightly challenged. The goal here is to allow the individual to immediatelyreject the attack and do so with minimal effort (Godbold & Pfau, 2000; Pfau

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 229

& Van Bockern, 1994). Going back to this analysis, the individual is lightlychallenged by, say, that close friend mentioned earlier (i.e., ‘‘You’re too whiteto go to the prom next week. Get a sun tan, whether it is at the beach orat the tanning salon,’’ ‘‘Don’t wear sunscreen because it is too greasy,’’ or‘‘Don’t wear long-sleeve shirts or wide-brimmed hats because they do notlook fashionable’’ [Koh, 1991]). The active defending stage stipulates thatthe individual must protect his or her attitude with active cognitive exertion,thereby resisting persuasion and retaining and sustaining the initial attitude(Compton & Pfau, 2004; McGuire, 1964; Pfau, 1995). So, the individual inthe study would protect his or her attitude by immunizing him- or herself(i.e., through self-protection such as sunscreen and/or a hat).

What the authors have shown is that the two elements and three stagesof inoculation theory can be used as a puissant strategy in persuasive resis-tance. They first enable people to be influenced by persuasive attacks andthen promptly induce them to think about rebuttals (Pfau, 1992, 1995; Miller,2002). The usual result is that the inoculated subjects, when confronted withthese counter-attitudinal arguments in the future, will be apt to ignore suchcounter-attitudinal arguments because their inoculated attitudes cognitivelyresist them (Compton & Pfau, 2004; Miller, 2002; Pfau & Burgoon, 1988; Pfauet al., 2001).

Timing as a Key Component in Inoculation

Inoculation theorists have also pointed out that timing is a delicate factor thatcontributes to the efficacy of inoculation treatments (McGuire, 1961; McGuire& Papageorgis, 1961; Pfau, 1995). Specifically, subsequent inoculation treat-ments—or attacks—are usually administered in a timely fashion in order toavoid enervation of strengthened attitudes. Given the effects incorrect timingcan have on the outcome of inoculation, it is important that correct timingbe identified and implemented in inoculation studies. In addition, since paststudies have pinpointed or determined appropriate timing sequences for in-oculation treatments (Compton & Pfau, 2004; McGuire, 1964), deriving thesemethodologies and procedures is the most reliable way to execute futurestudies using inoculation. As such, the authors believe that it is appropriatethat this method be utilized in a campaign to inoculate against behavior thatpromotes skin cancer.

Ensuring Active Participation in Inoculation Treatments

Applying inoculation treatments in laboratory settings may prove difficultif the subjects oppose inoculation or are passive in receiving treatment(Godbold & Pfau, 2000; McGuire, 1964; Pfau, 1992). As such, this aspectof inoculation requires special consideration for researchers, especially acampaign as sensitive as the one that seeks to prevent dangerous behavior

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

230 J. Matusitz and G.-M. Breen

that contributes to melanoma. If subjects are resistant to the inoculation mes-sages, or if the subjects are indifferent to the treatment, then the inoculationeffort may fail or achieve minimal effects. Hence, researchers always needto attract the attention and interest of the subjects in order to prime themfor inoculation. One way to achieve active participation from subjects isfor the researchers to inform the subjects before their active participationbenefits them. In doing so, the treatments will protect them from dangerousactivities. Through this perceived reward, subjects will be apt to devote theirenergies to the inoculation treatment (Compton & Pfau, 2004). As a result,the treatment should render inoculation, thus creating mindsets that avoidharmful exposure to ultraviolet rays.

The Need for Credible Inoculators

Other issues that may arise in such a laboratory setting have to do withwhether the subjects perceive their sources as credible, expert, and reliable.In two studies conducted by Tannenbaum, Macaulay, and Norris (1966),source credibility was examined as the basis for inoculation. If subjectsquestion the character of the inoculator, and if this distrust causes the subjectsto resist the treatment itself, then the inoculation attempt will probably fail(Compton & Pfau, 2004; Eagly & Chaiken, 1993). Hence, source credibilityis an important factor to effective inoculation, and requires special consid-eration by researchers. One way to achieve source credibility could involvetraining the researchers to identify with and cater to their subjects in orderto establish a connection. Plus, researchers should be selected based onstrict personality criteria (Cialdini, 1993). For instance, typical personalitycharacteristics that inoculators should have include extroversion, agreeable-ness, amiability, and kindness, all of which are features likely to presentthe inoculator in a positive, and thus, a credible light. Additionally, theinoculators need to appear knowledgeable in their subject. In this way,the inoculators will appear confident in their activities and will transmita comforting perception to the subjects that they are qualified to practiceinoculation administrations. Once this bond is established, subjects shouldbe more inclined to trust the researchers conducting the inoculation treat-ments.

DISCUSSION

Given the tenets and assumptions of inoculation theory, this analysis has thepower to convince future researchers to apply it in order to make humansmore resistant to engaging in unprotected exposure to UV rays and, hope-fully, reduce skin cancer. As has been seen, the global threat of skin cancerin this day and age and many previously failed policy efforts to eliminate

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 231

risky behavior like sunbathing without sunscreen or artificial tanning givecredence to inoculation theory as a viable policy implementation. Applyingthe theory can eliminate the barriers that prevent individuals from adoptingpreventive attitudes (i.e., not wearing sunscreen because it makes the skinlooks too greasy). By administrating low doses of contrasting perspectivestoward sunbathing or exposure to UV rays, individuals can strengthen theirattitudes vis-à-vis this danger and be inoculated against counter-attitudinalpersuasive messages delivered to them by external sources such as closefriends.

Besides, the two elements of inoculation theory (threat and refutationalpreemption) and its three stages (warning, weak attack, and active defend-ing) can be used as an effective strategy in persuasive resistance. The theory’sassumptions not only enable humans to be influenced by persuasive attacks;they also methodically induce them to think about rebuttals (Pfau, 1992,1995; Miller, 2002). The goal will always be the same: to make subjects‘‘inoculated’’ and, when confronted with counter-attitudinal arguments inthe future, to render them fully apt to ignore counter-attitudinal argumentsthanks to their immunized attitudes that have made them more cognitivelyresistant (Pfau & Burgoon, 1988; Pfau et al., 2001).

As scholars in health communication and social policy, the authors feelit is imperative that inoculation theory be explored as a method by whichskin cancer prevention can be attained (or, at the very least, significantlyminimized). It was clearly described that inoculation theory rests on a num-ber of principles and assumptions which have been empirically proven inhealth-related and other important contexts (i.e., An & Pfau, 2004; Pfau,1992; Szabo & Pfau, 2001; Wan & Pfau, 2001). These successes have beendisplayed in numerous journals of the health communication, public affairs,and social policy domains. Yet, despite inoculation theory’s application intopics such as the prevention of smoking and drinking (see Godbold & Pfau,2000; Pfau & Van Bockern, 1994), not a single analysis has been conductedto date regarding how inoculation can confer resistance to behavior thatcontributes to skin cancer, a serious health and social danger facing theUnited States. For this reason, the authors contend that inoculation theoryshould be seriously considered as a means through which this critical goalcan be achieved.

In line with these contentions, the threat of skin cancer is serious;therefore, suggesting an established communication theory to prevent itseems more than appropriate. It has been shown that skin cancer is arampant problem facing this country (i.e., Nouri, 2007). New cases—and thedamaging impacts that it causes—are rising quickly. Through this conceptualanalysis, inoculation theory may serve to remedy this malady in our society.It is a human issue. Its power and ability to yield significant health-relatedeffects (not to mention gigantic improvement for our national health status)deserves such appointment.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

232 J. Matusitz and G.-M. Breen

REFERENCES

Ajzen, I. (1988). Attitudes, personality and behavior. Milton-Keynes, England: OpenUniversity Press.

An, C., & Pfau, M. (2004). The efficacy of inoculation in televised political debates.Journal of Communication, 54(3), 421–437.

Borchers, T. A. (2001). Persuasion in the media age. New York: McGraw-Hill Press.Burton, R. C., Coates, M. S., & Hersey, P. (1993). An analysis of melanoma epidemic.

International Journal of Cancer, 55, 765–770.Cho, H. (2003). Communicating risk without creating unintended effects. American

Journal of Health Studies, 18(2), 1–7.Cialdini, R. (1993). Influence: The psychology of persuasion. New York: William

Morrow.Compton, J. A., & Pfau, M. (2004). Use of inoculation to foster resistance to credit

card marketing targeting college students. Journal of Applied Communication

Research, 32(4), 343–365.Davis, D. W. (2007). Anti-angiogenic cancer therapy. Boca Raton, FL: CRC Press.Diepgen, T. L., & Mahler, V. (2002). The epidemiology of skin cancer. British Journal

of Dermatology, 146, 1–6.Eagly, A., & Chaiken, S. (1993). The psychology of attitudes. Orlando, FL: Harcourt

Brace Jovanovich.Egan, T. (2005). Skin cancer: Current and emerging trends in detection and treat-

ment. New York: Rosen Central.Esselstyn, C. B. (2007). Prevent and reverse heart disease. New York: Avery Pub-

lishing.Fiske, S. T., & Taylor, S. E. (1991). Social cognition. New York: McGraw Hill.Garbe, C., McLeod, G. R., & Buettner, P. G. (2000). Time trends of cutaneous

melanoma in Queensland, Australia and Central Europe. Cancer, 89, 1269–1278.

Geller, A. C., Miller, D. R., Annas, G. D., Demierre, M. F., Gilchrest, B. A., & Koh,H. K. (2002). Melanoma incidence and mortality among US Whites: 1969–1999.Journal of the American Medical Association, 288, 1719–1720.

Geller, A. C., O’Riordan, D. L., Oliveria, S. A., Valvo, S., Teich, M., & Halpern,A. C. (2004). Overcoming obstacles to skin cancer examinations and preventioncounseling for high-risk patients: Results of a national survey of primary carephysicians. Journal of the American Board of Family Practice, 17(6), 416–423.

Glanz, K., Saraiya, M., & Briss, P. A. (2003). Impact of intervention strategies toreduce UVR exposure. In D. Hill, J. M. Elwood, & D. English (Eds.), Prevention

of skin cancer (pp. 58–82). New York: Kluwer Academic Publishers.Godbold, L. C., & Pfau, M. (2000). Conferring resistance to peer pressure among ado-

lescents: Using inoculation theory to discourage alcohol use. Communication

Research, 27, 411–437.International Agency for Research on Cancer (2006). Exposure to artificial UV radi-

ation and skin cancer: IARC working group reports. Lyons, France: IARC.Jemal, A., Devesa, S. S., Hartge, P., & Tucker, M. A. (2001). Recent trends in cuta-

neous melanoma incidence among whites in the United States. Journal of the

National Cancer Institute, 93, 678–683.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

Inoculation and Skin Cancer 233

Koh, H. K. (1991). Cutaneous melanoma. New England Journal of Medicine, 325,171–182.

Matusitz, J., & Breen, G. M. (2005). Prevention of sexual harassment in the medicalsetting: Applying inoculation theory. Journal of Health and Social Policy, 21(2),53–71.

McGuire, W. (1961). Resistance to persuasion conferred by active and passive priorrefutation of the same and alternative counterarguments. Journal of Abnormal

and Social Psychology, 63, 326–332.McGuire, W. J. (1964). Inducing resistance to persuasion. In L. Berkowitz (Ed.).

Advances in experimental social psychology (pp. 192–229). New York: McGraw-Hill.

McGuire, W. J., & Papageorgis, D. (1961). The relative efficacy of various typesof prior belief-defense in producing immunity against persuasion. Journal of

Abnormal Social Psychology, 62, 327–337.Miller, K. (2002). Communication theories: Perspectives, processes, and contexts.

New York: McGraw-Hill.National Center for Chronic Disease Prevention and Health Promotion. (2005). Chronic

disease–19th National Conference (2005)–overview. Retrieved April 20, 2007,from http://www.cdc.gov/nccdphp/conference/overview.htm

Nouri, K. (2007). Skin cancer. Boston: McGraw-Hill.Oliveria, S. A., Christos, P. J., Marghoob, A. A., & Halpern, A. C. (2001). Skin can-

cer screening and prevention in the primary care setting: National ambulatorymedical care survey 1997. Journal of General Internal Medicine, 16, 297–301.

Pfau, M. (1992). The potential of inoculation in promoting resistance to the effective-ness of comparative advertising messages. Communication Quarterly, 40(1),26–44.

Pfau, M. (1995). Designing messages for behavioral inoculation. In E. Maibach & R. L.Parrott (Eds.). Designing health messages: Approaches from communication

theory and public health practice (pp. 99–113). Thousand Oaks, CA: SagePublications.

Pfau, M., & Burgoon, M. (1988). Inoculation in political campaign communication.Human Communication Research, 15(1), 91–111.

Pfau, M., & Van Bockern, S. (1994). The persistence of inoculation in conferringresistance to smoking initiation among adolescents: The second year. Human

Communication Research, 20, 413–430.Pfau, M., Szabo, E. A., Anderson, J., Morrill, J., Zubric, J., & Wan, H. H. (2001). The

role and impact of affect in the process of resistance to persuasion. Human

Communication Research, 27, 216–252.Po-lin, S. (2007). Skin cancer: The biology of cancer. New York: Chelsea House

Publishers.Ringborg, U., Brandberg, Y., Breitbart, E., & Greinert, R. (2006). Skin cancer pre-

vention. New York: Informa Healthcare.Saraiya, M., Glanz, K., Briss, P., Nichols, P., White, C., & Das, D. (2003). Preventing

skin cancer: Findings of the task force of community preventative services onreducing exposure to ultraviolet light. Morbidity and Mortality Weekly Report,

52(15), 1–12.Saraiya, M., Glanz, K., Briss, P. A., Nichols, P., White, C., Das, D., Smith, S. J., Tannor,

B., Hutchinson, A. B., Wilson, K. M., Gandhi, N., Lee, N. C., Rimer, B., Coates,

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014

234 J. Matusitz and G.-M. Breen

R. C., Kerner, J. F., Hiatt, R. A., Buffler, P., & Rochester, P. (2004). Interven-tions to prevent skin cancer by reducing exposure to ultraviolet radiation: Asystematic review. American Journal of Preventive Medicine, 27(5), 422–466.

Scrivener, Y., Grosshans, E., & Cribier, B. (2002). Variations of basal cell carcino-mas according to gender, age, location and histopathological subtype. British

Journal of Dermatology, 147, 41–47.Swerdlow, A. J., & Weinstock, M. A. (1998). Do tanning lamps cause melanoma? An

epidemiological assessment. Journal of the American Academy of Dermatology,

38, 89–98.Szabo, E. A., & Pfau, M. (2001). Nuances in inoculation: Theory and applications.

In J. P. Dillard & M. Pfau (Eds.), The persuasion handbook: Developments in

theory and practice (pp. 233–258). Thousand Oaks, CA: Sage Publications.Tannenbaum, P. H., Macaulay, J. R., & Norris, E. L. (1966). Principle of congruity

and reduction of persuasion. Journal of Personality and Social Psychology, 2,233–238.

Wan, H.-H., & Pfau, M. (2001, May). Inoculation: A promising proactive approach

in crisis communication. Paper presented at the annual meeting of the Inter-national Communication Association, Washington, DC.

Young, A. R. (2004). Tanning devices: Fast track to skin cancer? Pigment Cell Re-

search, 17, 2–9.

Dow

nloa

ded

by [

Tem

ple

Uni

vers

ity L

ibra

ries

] at

22:

04 1

8 N

ovem

ber

2014