Introduction
Studies have documented the use of skin fairness products, sometimes referred to as “skin whitening products,” “skin bleaching products,” “depigmenting agents,” in Africa, Europe, North America, and Asia, with prevalence of use ranging from 27 to 77% among community samples (1). Skin fairness products include whitening and skin-lightening creams, face washes, deodorants, and lotions. This industry is one of the fastest growing segments of the global beauty industry, particularly in Asia and Africa, with marketing forecasters predicting it will be worth an estimated $US 31.2 billion by 2024 (2). Historically marketed to women, companies have recently expanded their offerings to include products designed and marketed specifically for men. Advertisements and packaging overtly claim that products will make consumers’ skin fairer and more even-toned, while product names and the use of well-known models and actors in advertisements imply that they will enhance consumers’ cultural capital via improvements in attractiveness, youthfulness, confidence, and success (3, 4). Cultural capital refers to social and cultural assets (e.g., education, style of speech and dress, intellect, and appearance) that can enhance an individual’s social mobility in stratified societies (5).
The widespread use of skin fairness products is increasingly recognized as a public health, environmental justice, and social justice issue due to the deleterious health side effects and the potential reinforcement of racial and social inequalities (6, 7). Despite this, empirical research into skin fairness product use is limited to prevalence and medical side effect investigations, especially among samples in Asia (1). This is particularly the case for research conducted in India, one of the fastest growing markets with an annual spend of $US 450 million on skin fairness products (8). Recognizing the social and public health implications of fairness product use, this study presents an examination of women’s and men’s use of skin fairness products, and their beliefs about fairness in a metropolitan area in India.
The relevance of skin fairness products to public health is highlighted by the scope of the industry, the widespread use of these products, and the potential health risks associated with their use. The type and extent of side effects depends on the nature and concentration of product ingredients (9). While some cosmetic products are associated with lower risk, other products contain highly active and potentially dangerous ingredients, such as hydroquinone, mercury, and bleaching agents such as hydrogen peroxide (10, 11). Agarwal et al. (12) tested 23 skin fairness face creams available in India and found that almost 50% of these creams (n = 11) contained steroids that can be harmful to skin. A subsequent study found that levels of mercury in many popular face creams are increasing over time (13).
Side effects of skin fairness products containing hydroquinone, steroids, or mercury can include irritation, inflammation, thinning of skin, scarring, abnormalities among newborn babies if used during pregnancy and breast-feeding, and kidney, liver, or nerve damage (14, 15). Skin-bleaching agents also increase susceptibility to infections including bacteria, fungus, parasites, and viruses (16). Some countries (e.g., Ghana, Ivory Coast, Nigeria, South Africa, and Zimbabwe) have banned the import of fairness products that contain hydroquinone and mercury (17). Nevertheless, many countries, including the two biggest markets, India and China, do not have regulations on ingredients contained within these products. The widespread use of skin fairness products presents a growing public health concern, particularly in Asia.
In several Asian countries and cultures, white or fair skin is perceived to be more attractive and desirable due to its social advantages for marital and career prospects (1, 18). This is particularly relevant in Asian countries, including India, Japan, Korea, China, and Thailand, where skin fairness has been understood to be a cultural marker of class, wealth, and social status for centuries (1). The advertising industry in particular, is argued to play a significant role in reinforcing and capitalizing on stereotypical notions of caste, age, race, and beauty. Shankar et al. (19) assert that the advertising of fairness products is akin to “disease mongering,” not necessarily creating a market where there is not one, but playing on people’s insecurities about appearance and making huge profits from them. A content analysis of advertisements for skin-related products in women’s magazines in India, Japan, Korea, and Hong Kong found that “good skin” was depicted as “smooth, young, pore-less, line-free, bright, transparent, white, full and fine” and advert narratives suggested enhanced cultural capital through the use of products advertised to achieve fairer skin (4). Thus, fairer skin may be assumed to improve career and marital prospects and increase cultural capital in societies that value fair skin.
India presents a particularly interesting case example due to its large market share in the skin fairness industry and its ancient cultural notions of beauty and fairness, which have strong ties with caste and community biases, whereby fairer skin is preferred (20). In India, the market was liberalized toward the end of the twentieth century, which led to a surge in the availability of fairness products. At present, there are many fairness creams, face washes, and lotions for men and women widely available, including products marketed by local and international brands. The skin fairness industry currently represents 50% of India’s entire skincare market, with estimates of its worth varying between $US 450–535 million (8, 21).
Indian consumers are led to believe that fairer skin will provide them with higher status, and advertisements serve to reinforce this notion (21, 22). Phillips (23) describes the societal equation of fairness with beauty and the accompanying negative connotation of lack of beauty associated with darker skin color in India. She also discussed the associated moral and behavioral qualities linked with skin color, highlighting the far-reaching impact fair skin may have on an individual’s life and cultural capital within the Indian context. Individuals with darker skin in India are often assumed to be blue-collar or manual workers, required to spend time outdoors where their skin becomes darker. Furthermore, darker skin color has been associated with adverse moral and behavioral qualities (4, 23). These factors are compounded by two centuries of colonial “white” rule (20). Consequently, there are strong ties between caste, economic class, marital prospects, occupation status, colonialism, and skin color in India.
Although theoretical critiques have examined the marketing and use of skin fairness products in India, empirical quantitative research on skin fairness product use, and the social and psychological factors driving this is sparse. Most quantitative studies [e.g., Ref. (24)] investigating the prevalence of, and reasons for, using skin fairness products have been conducted in Sub-Saharan Africa (1). Nonetheless, a few studies indicate that use of these products is prevalent and associated with social disadvantage and poor health correlates among Indian consumers. Indian women and men were included in a 26-country study that investigated the prevalence and correlates of using skin fairness products among undergraduate students (16). In their study, the authors found that 18.9% of 799 Indian undergraduate students sampled reported using skin fairness products, and their use was associated with depression, risky sexual behaviors, lack of personal control, and low social support. Furthermore, a recent experimental online study found that women in India who were primed temporarily to feel disempowered were likely to indicate a stronger preference for medically risky skin fairness products (i.e., those containing more active and potentially harmful ingredients) as compared to less risky cosmetic products, in addition to finding the products more relevant and useful (25).
To inform future research, advocacy, and public health intervention efforts, the current study was undertaken to explore the use and non-use of skin fairness products in a large, educated, community sample of women and men in Mumbai, India. Among self-identified current users and non-users, reasons for use or non-use were assessed and beliefs about the benefits of skin fairness were also explored. Gender differences in reasons for and against using fairness products were also explored. Given that beauty products have historically been marketed to women and that women tend to be more likely to be judged on the basis of their appearance, experience worse body image, and have less social capital than men (4, 7), it was hypothesized that women would be more likely to report use of skin fairness products than men and would be more likely to endorse the importance of skin fairness for attractiveness and cultural capital than men.
Beliefs about Fairness
Current Users
To understand the extent to which users endorsed beliefs that being fair is more attractive (“body image and attractiveness” subscale), that their family and friends perceived fairness as desirable and better for cultural capital (“family and peer influence” subscale), and they had “a desire to look fair like media and celebrities” (“media and celebrity influence” subscale), the frequencies with which women and men reported subscale means of 4 or above (i.e., they endorsed “agree” or “strongly agree” for the subscales) were examined (see Table Table22 for mean subscale scores). Women and men most strongly endorsed family and peer ideas about fairness being desirable with 26.7 and 33.4%, respectively, either agreeing or strongly agreeing with subscale statements on average. This was followed by a desire to look fair like people shown in the media and celebrities where 25.1 and 28.1% of women and men, respectively, agreed to strongly agreed on average to these statements. Finally, 25.4% of men and 13.2% of women agreed to strongly agreed on average to statements endorsing beliefs that being fair is more attractive.
Analyses of covariance with Bonferroni corrections were conducted to determine if there was a significant difference in the extent to which women and men currently using fairness products endorsed different beliefs. Men were significantly more likely to endorse ideas about fairness being more attractive, F(1, 744) = 6.91, p < 0.01, and they were significantly more likely to endorse family and peer influences, F(1, 742) = 11.75, p < 0.01. However, there was no difference between women and men in the extent to which they reported a desire to look as fair as people depicted in the media and celebrities, F(1, 740) = 1.72, p = NS.
Non-Users
Women and men not currently using fairness products most strongly endorsed concerns about product efficacy and side effects as reasons for not using fairness products, followed by socioeconomic factors. To elaborate, 29.6% of men and 39.2% of women on average agreed or strongly agreed with items included in the product efficacy and side effects subscale. Meanwhile, 11.7% of men and 10.3% of women on average agreed or strongly agreed with items included in the socioeconomic reasons subscale. Women were significantly more likely than men to endorse concerns about side effects and product efficacy, t(1,277) = −3.785, p < 0.001, while men were significantly more likely to endorse socioeconomic reasons for not currently using fairness products than women, t(1,247) = 3.24 p < 0.01. See Table Table33 for the mean subscale scores for women and men for reasons for not using skin fairness products.
Reasons for Use
When current users were asked “who or what prompted you to start using fairness products,” almost half (44.6%) responded “Media/TV/Advertisements” prompted their use, while 20.6% reported that “Friends,” “Family” (16.4%), “Other/Self” (9.5%), and “Health Professionals” (1.3%) prompted their first use of fairness products (see Table Table4).4). There were no significant differences in the source of prompts among women and men
Side Effects
A substantial minority of current users (17%; n = 128) reported adverse side effects after the use of fairness products, with 3.1% having sought help from a health professional. Women were significantly more likely to report having experienced side effects than men, t(279) = −2.96, p < 0.01.
Age
There was no significant difference in age between current users (M = 24.73, SD = 9.12) and non-users (M = 24.67, SD = 9.03), t(1,990) = 0.128, p = NS. There was also no difference in age between women (M = 25.34, SD = 10.11) and men who were non-users (M = 24.87, SD = 10.40), t(1,263) = −0.814, p = NS. Among current users, however, the men sampled (M = 23.70, SD = 8.57) were significantly younger than the women sampled (M = 25.18, SD = 9.31), t(400) = −2.06, p < 0.05. Consequently, age was controlled for in the analyses comparing beliefs about fairness between women and men. Among current users, the mean age of initiating use of fairness products was 18.56 years (SD = 6.08, range = 10–57). There was no significant difference in the age of starting use of fairness products by gender t(713) = −1.35, p = NS.
Results
Use of Skin Fairness Products
Frequency
Of the total sample (N = 1,992), 1,084 (54.4%) participants had used fairness products within their lifetime and 901 (45.2%) had never used fairness products. Lifetime use data was missing for seven participants. There was a significant association between gender and lifetime use of fairness products,
Of the total sample, 754 (37.9%) participants had used fairness products within the past 30 days (i.e., were deemed current users) and 1,238 (62.1%) had not (i.e., were deemed non-users). Among current users, 32.7% (n = 355) reported using fairness products every day or more than once a day. There was a significant association between gender and current use of fairness products,
Procedure
Participants were asked to complete the questionnaire in one setting after obtaining consent, either in their homes, workplaces, or in their classrooms. In accordance with ethical guidelines governing research in India, it was not necessary to obtain approval for the study from an ethical review board, especially as the study did not involve data collection with vulnerable participants and had no funding source. Nevertheless, all the procedures followed in the study complied with the guidelines laid down by ethics bodies in India. The participants were informed that the study was an exploratory investigation of the use of fairness products in India and that they would be asked to complete a questionnaire on their reasons for use or lack of use of fairness products. Participants were given information on the purpose of the study. They were informed that there would be no compensation for taking part in the study and that there were no known risks to participating. They were also informed that participation was voluntary. No identifying information was collected from the participants, as such the questionnaires were anonymous and the risk of data protection issues was minimized. Once verbal consent was obtained, participants were provided with a paper version of the questionnaire and were asked to complete it in the presence of a research assistant. The questionnaires were administered in English. One large educational institution provided the researchers with permission to collect data in their classrooms. Data from the community sample (other than the educational institution) were collected from apartment complexes where the researchers were provided with permission to collect data. Certain companies also provided permission to collect data from their employees.
Measures
Participants completed a self-report questionnaire in their home, classroom, or workplace.
Demographics
Participants self-reported their gender, age, and occupation within the questionnaire.
Use of Skin Fairness Products
Participants were asked if they had ever used skin fairness products in their lifetime (“How often in your lifetime have you used fairness products?”). The response format was 0 = “Not at all,” 1 = “Less than one month,” 2 = “1–3 months,” 3 = “4–6 months,” 4 = “more than six months.” They were also asked about their frequency of use in the last 30 days (“On how many occasions in the past thirty days have you used fairness products?”). The response format for this question was 0 = “Not at all,” 1 = “1–2 times a week,” 2 = “3–4 times a week,” 3 = “Everyday,” 4 = “More than once a day.” For subsequent analyses, non-users were defined as those who reported that they had used fairness products “Not at all” in the last 30 days. Current users were defined as those who reported any use of fairness products in the past 30 days.
For current users, further items asked the respondents about who had introduced them to fairness products (open-ended response format), the age at which they first started using fairness products, and their main reason for using fairness products (open-ended response format). They were also asked if they had experienced any adverse side effects after using fairness creams and whether they had consulted a health professional either before or after use (“Yes” or “No” response formats).
Abstract
The use of skin fairness products that frequently contain toxic ingredients is associated with significant adverse health side effects. Due to the high prevalence of use in Asian and African countries, skin fairness product use is recognized as a growing public health concern. The multi-million-dollar skin fairness product industry has also been criticized for perpetuating racism and social inequalities by reinforcing beliefs about the benefits of skin fairness for cultural capital. No quantitative studies have assessed people’s beliefs about fairness and reasons for using or not using these products in India, one of the largest global markets for skin fairness products. The current study explored skin fairness product use among 1,992 women and men aged 16–60 years in the city of Mumbai, India using a self-report questionnaire. A total of 37.6% of the sample reported currently using skin fairness products, with women being two times more likely to use these products. Among current users, 17% reported past experiences of adverse side effects, and “Media/TV/Adverts” were the most common prompts for using fairness products, followed by “Friends” and “Family.” Men were significantly more likely than women to endorse beliefs about fairness being more attractive and were more likely to perceive family and peers as viewing fairness as beneficial for cultural capital. There were no differences between women and men currently using products in their desire to look as fair as media celebrities. Among non-users, women were significantly more likely than men to report concerns about product efficacy and side effects as reasons for non-use, while men were significantly more likely to report socioeconomic reasons for non-use. Implications of these findings are discussed in light of growing public health concerns about the use of fairness products, and potential for advocacy and public health interventions to address the use of skin fairness products.
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