This mixed methods study included social media content analysis and qualitative interviews. Content analysis was conducted on the social media platform Facebook between the dates May 1, 2015 and April 30, 2016. This data collection received an exemption for observation of public information from the Seattle Children’s institutional review board (15506 exempt).

Participant interviews were conducted after content analysis was complete in order to include observations from content analysis in the interview. These data were collected between May 8, 2017 and July 7, 2017. This data collection was approved by the Seattle Children’s institutional review board (15710).

Of a total of 147 indoor tanning business Facebook pages that were evaluated across 50 states, 3 businesses closed prior to coding initiation. This sample of indoor tanning business Facebook pages yielded 4956 posts. Among 8 health misinformation topics identified, the most common were posts promoting misinformation about Vitamin D (n=73, 1.3%). This misinformation typically focused on tanning as a safe and healthy way to get Vitamin D. The American Academy of Dermatology notes that tanning beds are not a safe way to get Vitamin D given the cancer risk [27]. Furthermore, since bulbs in tanning beds mostly emit UVA light, vitamin D can only be generated via UVB light. Thus, tanning beds do not provide sufficient exposure to create adequate doses of Vitamin D [27]. An example post was

Most indoor tanning businesses that displayed misinformation about Vitamin D did so infrequently. Many businesses had only 1 Vitamin D–related post within the 1-year sample, though 3 businesses had 5 or more of this category of posts.

A second category was misinformation about tanning as a medical treatment (n=31 posts, 0.6%), for example,

Some of these posts were consistent with described inaccuracies in an investigative report provided to the US House of Representatives. These inaccuracies mainly center on promoting tanning as having health benefits or as a health treatment, there is no evidence to support tanning as a safe health treatment for illness including mental illness, inflammatory diseases, sleep problems or pain disorders [28]. Most businesses that displayed misinformation about tanning as a medical treatment had only 1 of these posts within the 1-year sample; there were no businesses with more than 3 posts of this type in the 1-year sample.

Another category of misinformation was promoting misinformation about the benefits of a “base tan” (n=29 posts, 0.5%) The posts often argued that a base tan would prevent sunburn or was a protective measure to take prior to a vacation. There is no evidence that a base tan is protective against sunburn or against cancer risks from sun exposure [27]. Most tanning businesses displayed only 1 of these posts in the 1-year sample, and many were posted in late winter, prior to spring break season. Table 1 displays the 8 categories of health misinformation, and Table 2 displays example social media posts.

A total of 46 interviews were conducted (age: mean 20 years, SD 2) and 26 states were represented in our sample. Among our participants, 45 (97.8%) used Facebook, and 20 (43.5%) followed an indoor tanning salon on social media. Most participants (38/46, 82.6%) mentioned viewing indoor tanning salon posts on social media to find out about sales or special offers; fewer (3/46, 6.5%) noted that they learned tips related to tanning from these posts.

Approximately half (21/46, 45.5%) of participants acknowledged that indoor tanning businesses likely used social media to “draw people in” and influence tanning behavior. Some participants who followed tanning businesses on social media specifically noted that social media posts may normalize tanning behaviors or “promote tanning benefits.” Table 3 includes the most common topics that participants described viewing on indoor tanning salons’ social media pages.

Just over half (25/46, 54.3%) of participants expressed that social media influenced their friends, or people in general, to go tanning more often, and 52.2% (24/46) mentioned that social media influenced them personally to tan more. Some participants (4/46, 8.7%) stated that posts on social media by indoor tanning salons led them to see tanning as safer than the sun or the business as trustworthy.

As Vitamin D was the most common category of social media misinformation posts, we asked participants whether they had seen indoor tanning businesses post on social media about Vitamin D. Approximately half (20/46, 43%) of participants reported seeing social media posts from tanning salons about Vitamin D:

Among those participants, approximately half (25/46, 54%) believed it was safe to get Vitamin D from indoor tanning stating, for example,

This mixed methods study included social media content analysis and qualitative participant interviews. We found an overall low frequency of social media posts promoting health misinformation (range 0.5%-1.5%); however, many (20/46,43.5%) of our participants actively followed tanning businesses on social media, and participants commonly reported remembering misinformation posts such as those promoting tanning as a safe way to get Vitamin D.

Our first finding was that social media posts related to health misinformation were uncommon. Most of the content posted by tanning businesses was related to other topics, such as deals or sales as described by our participants. These findings are consistent with a previous study examining hashtags related to tanning that found that most tanning salon posts were related to price reductions [29]. We found that the most common category of misinformation—indoor tanning as a safe way to get Vitamin D—comprised less than 2% of posts recorded across the year. It is important to clarify that our data did not represent that UV tanning could provide Vitamin D, but that posts described UV tanning as a safe way to achieve Vitamin D, which identifies these statements as clear misinformation as there is no evidence that the body can achieve adequate Vitamin D levels safely (given cancer risks) or adequately [27]. Furthermore, in many categories of health misinformation, most tanning businesses displayed only 1 post in that category across our 1-year evaluation period. Given these findings, it is even more striking that many participants reported recalling these posts. This finding suggests that these health misinformation posts, while uncommon, were memorable and may have been influential. Our findings from participant comments clearly support that the practice of following social media tanning businesses contributed to reminders to participants to go tanning, through deals and specials, and reminders about motivations to tan. It is also important to note that a social media platform is interactive, whereby users and businesses can interact bidirectionally. Thus, while the frequency of these health misinformation posts displayed by tanning businesses was uncommon, these posts can be shared or distributed across an individual’s own social media.

Our second finding was that, among our purposeful sample focused on those who engage in indoor tanning as well as social media, participants commonly engaged with social media related to tanning. As nearly half (20/46, 43.5%) participants followed a tanning business on social media, this supports the potential reach and influence that tanning salons have among young social media users. Participants described that indoor tanning salons’ social media pages provided them reminders, nudges, and information about special deals and sales. Participants described the influence of tanning-related social media on their own tanning attitudes, as well as on their behaviors. This finding suggests that, of the approximately 10% of young White females who continue to engage in indoor tanning, social media may be a viable platform to reach this at-risk population with education or intervention approaches.

Our study is not without limitations. This study focused on tanning businesses that were present on Facebook, and we did not examine other platforms such as Snapchat or Instagram. We were interested in how popular tanning businesses utilized social media to engage with customers. Thus, our purposeful sampling strategy prioritized selection of tanning businesses that were popular on social media (ie, by number of followers). We excluded tanning salon chains that extended across states, which allowed us to focus on individual businesses within states. However, tanning salons within chains may reach more viewers compared to individual businesses. Furthermore, our Facebook data were from 2015; however, the role of Facebook as a platform to connect to businesses remains relevant today, and no new laws or regulations governing tanning business content on social media have arisen since that time. Finally, our qualitative interviews were purposeful in order to target the at-risk population for indoor tanning, thus evaluating external validity of our sample was not appropriate for this study.

Despite these limitations, our study has implications in the area of health misinformation. While the overall reduction in indoor tanning behaviors among women and adolescents [6,7] is a public health triumph, a significant at-risk group of White young women remain engaged in this health risk behavior [8,9]. Our study findings suggest that some of these women who tan are also connected to indoor tanning salons on social media. While misinformation may not be common or a significant motivator for adolescent and young adult tanning, social media connections between businesses and adolescents and young adults are very common and may provide ongoing engagement with and encouragement of tanning behavior, that is, this social media connection may foster ongoing relationships with tanning businesses and behavioral nudges to go tanning through deals and reminders about motivations to tan.

An initial strategy to prevent adolescents from following these businesses on social media may be to consider requiring age-gating for indoor tanning businesses. Age-gating would block access to indoor tanning social media pages for youth under age 18. The age-gating approach is currently used by alcohol companies on social media, and youth are supportive of applying this restriction to other businesses on social media [30]. Additional strategies may include creating regulations about health misinformation directed at indoor tanning businesses, similar to strategies used to limit health misinformation about tobacco and marijuana. Finally, strategies to reach at-risk women may include placing targeted educational campaigns on social media, similar to the Facebook advertisements that we used to recruit for this study, which were successful in identifying the population at risk for consequences of indoor tanning.

Our study focused on health misinformation messages shared on social media by tanning salons. However, the implications of our findings may contribute to a critical conversation about how health misinformation shared via social media may reach vulnerable populations and potential prevention strategies. First, age-gating may present a valid approach to limit youth access to content from businesses based on minimum age limits, such as alcohol, tobacco, e-cigarettes, marijuana, and tanning. Second, regulations that clearly define allowable messages on any medium (print, online, or social media) are critical to consider. Enhancing efforts around surveillance of social media would be an important part of such regulations. It is possible that funds from tax revenues related to these sale of these products could support regular and ongoing monitoring of industry compliance. Challenges to monitoring social media content include its potentially ephemeral nature, as well as the ability in social media to target content behaviorally, geographically, and temporally. While surveillance may not capture all businesses that post misinformation, for example, many of the businesses that posted Vitamin D misinformation did so only once during our data collection time period. However, ongoing surveillance may be likely to identify businesses that repeatedly post misinformation. For example, we found that 1 tanning business displayed 13 posts promoting misinformation about benefits of a base tan. Finally, our study illustrates that it is possible to create a sampling strategy to evaluate posts over time and to develop a codebook to identify content and achieve interrater reliability for such content. The content and keywords identified in this study may inform other social media surveillance methods using machine learning or automated text analysis for more widespread evaluation. It is also possible that partnering with adolescents and young adults who are often at the forefront of the learning curve for digital media may lead to creative prevention approaches.