Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates

Who uses sunbeds? A systematic literature review of risk groups in developed countries

Skin cancer is caused by ultraviolet radiation (UVR). Indoor tanning is a totally avoidable risk behaviour. This review addresses the specific characteristics of sunbed users and the differences in motivation and risk perception compared with non-users. This review is based solely on empirical original articles. Based on literature searches with widely used reference databases ('PubMed', 'OVID', 'Social Citation Index', 'ERIC--Educational Resources Information Center', 'Web of Science' and the 'International Bibliography of the Social Sciences'), we included studies from developed nations with a publication date between 1 January 2000 and 12 August 2008. All studies were selected, classified and coded simultaneously by both authors on a blinded basis. All searches were performed on 13 and 14 August 2008. In accordance with the QUOROM and the MOOSE Statements, we identified 16 original studies. The typical sunbed user is female, between 17 and 30 years old, and tends to live a comparatively unhealthy lifestyle: Users smoke cigarettes and drink alcohol more frequently and eat less healthy food than non-users. Users are characterized by a lack of knowledge about health risks of UVR, and prompted by the frequent use of sunbeds by friends or family members and the experience of positive emotions and relaxation by indoor tanning. This review is the first systematic review on risk groups among sunbed users that has been published in a scientific journal. There is still a lack of information among users, particularly among young people regarding the safety of solariums.

'My friends love to tan': examining sensation seeking and the mediating role of association with friends who use tanning beds on tanning bed use intentions

This paper explored how sensation seeking contributes to the likelihood of tanning bed use intentions both directly and indirectly through the way it shapes interaction with peers who use tanning beds and attitudes toward tanning bed. Eight hundred and ninety six (n = 896) male and female college students were recruited for the study. Measured variables included sensation seeking, association with friends who use tanning beds, attitudes toward tanning and tanning bed use intentions. Structural equation modeling was performed to test the hypotheses. In general, results supported the proposed hypotheses and documented that sensation seeking is indirectly associated with tanning bed use intentions through the mediation of association with peers who use tanning beds and attitudes toward tanning. The article discusses theoretical and methodological implications of the findings demonstrating the pathways of influence of sensation seeking on tanning bed use intentions.

Adolescent attitudes towards tanning: does age matter?

Adolescents seem to be obsessed with tanning. One third of both adolescents and adults report sunbathing. On average, about 20% of adolescents report ever-using of artificial UV tanning devices with 15% currently using them. Tanning attitudes appear similar for adolescents and adults. The top three reasons for tanning included beliefs that a tan makes them more comfortable socializing with friends, looks better and is attractive. The top reason for using artificial UV tanning devices is also aesthetics, followed by relaxation. Other reasons for using artificial UV tanning devices include vacation preparation and to gain a protective base. Attitudes related to appearance that result in more frequent tanning may be difficult to change.

Youth access to artificial UV radiation exposure: practices of 3647 US indoor tanning facilities

OBJECTIVE

To assess indoor tanning facility practices in a sample of facilities in 116 cities representing all 50 states.

DESIGN

Cross-sectional study.

SETTING

United States.

PARTICIPANTS

Employees of 3647 indoor tanning facilities were contacted by telephone. Data collectors (ie, confederates) posed as prospective, fair-skinned, 15-year-old female customers who had never tanned before.

MAIN OUTCOME MEASURES

Confederates asked respondents about their facility's practices related to parental consent, parental accompaniment, and allowable tanning session frequency.

RESULTS

Approximately 87% of the facilities required parental consent, 14% required parental accompaniment, 5% said they would not allow the confederate to tan owing to her age, and 71% would allow tanning every day the first week of indoor tanning. In Wisconsin, which bans indoor tanning among those younger than 16 years, 70% of facilities would not allow the confederate to tan. Multivariate analyses indicated that facilities in states with a youth access law were significantly more likely to require parental consent (P <.001) and parental accompaniment (P <.001) than those in states without a youth access law. Law was not significantly related to allowable tanning frequency (P = .81). Conclusion We recommend that additional states pass youth access legislation, preferably in the form of bans.

Older women and suntanning: the negotiation of health and appearance risks

This paper examines older women's experiences and perceptions of sunbathing, sun avoidance, and suntanned appearances. Using data from in-depth interviews with 36 women aged 71 to 94, we elucidate the motivations behind the women's sunbathing practices. Specifically, we explore how the women responded to the health and appearance risks associated with exposure to and avoidance of ultraviolet radiation as well as extant feminine beauty norms. The majority of women put their experiences of sunbathing in an emergent historical context. Although most of the women suggested that suntanned appearances were indicative of health and beauty, sunbathers tended to downplay their health risks by distancing themselves from those they considered to be most at risk, namely tanning bed users and individuals who acquired overly dark suntans. Sunbathers also emphasised the benefits of sun exposure for adequate vitamin D absorption. In contrast, the women who did not suntan tended to have experienced negative health and appearance consequences from their past sunbathing practices. Thus, these women emphasised the importance of future health over immediate appearance dividends. We discuss our findings in relation to the extant research on suntanning and the literature pertaining to health, risk, and beauty work.

The benefits and risks of ultraviolet tanning and its alternatives: the role of prudent sun exposure

Sunlight- and indoor ultraviolet (UV)-induced tanning is a common behavior, especially among adolescents, young adults, and individuals who have lighter skin. Excessive sun exposure is associated with several health risks, including the acceleration of skin aging and the promotion of skin cancers. Several health benefits of UV exposure include vitamin D production and improved mood. This article analyzes these health risks and benefits and discusses pertinent issues surrounding indoor tanning, the role of sunless tanning products, and prudent sun exposure.

Lifestyle Interventions in the Prevention and Treatment of Cancer

Despite evidence that cancer death rates in the United States are declining, the absolute number of new cancers and cancer deaths continues to increase, and there is clear evidence that certain human behaviors are influencing these increases. The 4 major factors of lifestyle that continue to be causally related to certain cancers—tobacco use, an unhealthy diet, inadequate exercise, and excessive exposure to ultraviolet radiation—are each independently important in their effects on the genetic and molecular processes that result in the malignant transformation of human cells. There is both irrefutable and otherwise strong evidence that 4 common cancers that occur in the United States—lung cancer, colon/rectal cancer, breast cancer, and prostate cancer—and a less common cancer, malignant melanoma, have etiologic factors that are lifestyle based and therefore controllable through alterations in human behavior. These cancers and the evidence that lifestyle is important in the causation and/or prevention of the disease are the subjects of this review.

Tanning behavior of London-area youth

BACKGROUND

The World Health Organization recommends that tanning parlors not be used by individuals under age 18 years. The impact of self-tanners on tanning parlor and sunscreen use by Canadian teens is unknown.

OBJECTIVE

To determine teens' use of, knowledge of, attitudes toward, and behavior regarding tanning parlors, self-tanning products, and sunscreen.

METHODS

Self-report questionnaire of grade 10 students in Thames Valley district, Ontario.

RESULTS

Indoor tanning parlors were used by 14%, self-tanners by 28%, and sunscreen daily or most days by 36%. Use was more common in females. There was a strong association between parental and child use of tanning parlors and use of self-tanners. Sixty-two percent believe that self-tanners give adequate photoprotection.

CONCLUSIONS

Further education is required to address teen tanning parlor use, infrequent sunscreen use, and lack of knowledge about the safety of tanning parlors and self-tanning products.

Tanning salons in Santiago, Chile: the knowledge of the staff in charge and the quality of information provided to potential clients before and after a new regulatory law

INTRODUCTION

In recent years, the use of artificial tanning devices has become very popular in Chile. In April, 2007, a new law was established to regulate the non-medical use of tanning beds and tanning booths. The aim of this study was to evaluate the level and quality of information provided by tanning salon staff to clients before deciding on using the services. This information was collected before and 6 months after the law was enacted by researchers visiting tanning salons posing as potential clients.

METHODS

Using a previously designed questionnaire, 24 tanning salons in Santiago, Chile, were evaluated by researchers acting as potential customers without experience with artificial tanning devices. Employees were questioned using a hidden questionnaire before and 6 months after enactment of the law.

RESULTS

Before the law, 25% of the establishments gave spontaneous information about the risks of using tanning beds, which increased to 45.8% after enactment of the law. Clients never received written information, either before or after enactment of the law. On both evaluations, more than 1/3 of the employees affirmed that there were no risks in using tanning beds. Before enactment of the law, only 12.5% of the tanning salons required the use of goggles, while after the law, this increased to 25% (P=NS). Only two establishments required that clients sign an informed consent form after enactment of the law.

DISCUSSION

The level of knowledge among employees in tanning salons was very low and the quality of the information they provided to the clients was very poor. It was important to legislate on ultraviolet tanning services, but at present, the impact of the law has been very limited.

Indoor tanning use among adolescents in the US, 1998 to 2004

BACKGROUND

A recent meta-analysis found that indoor tanning use before the age of 35 years increases the risk of melanoma, supporting policies to restrict indoor tanning use among adolescents. The objectives of the current study were to provide a national assessment of prevalence and trends of indoor tanning use among US adolescents, to examine changes in the prevalence of indoor tanning use from 1998 to 2004 in relation to state policies on minors' access, and to assess the prevalence of burns, rashes, and infections among users.

METHODS

Two cross-sectional population-based surveys of US youths ages 11 to 18 years and their parents/guardians conducted in 1998 (N=1196) and 2004 (N=1613) used identical questions to assess use of indoor tanning and correlates of this behavior.

RESULTS

The prevalence of indoor tanning use by adolescents within the past year changed little from 1998 to 2004 (10% to 11%). In states with policies regarding minors' access to indoor tanning, the prevalence stayed the same or decreased from 1998 to 2004, whereas it increased in states without such policies. Neither trend was found to be statistically significant. Youth tanning attitudes, parental indoor tanning use, and parents' permission were strongly associated with youth use of indoor tanning. Fifty-eight percent of users reported burns from indoor tanning.

CONCLUSIONS

The presence of state legislation restricting minors' access to indoor tanning appears to have limited effectiveness, perhaps because most states' policies permit use with parental consent. Multipronged approaches are needed to reduce indoor tanning use in youths.

The benefits and risks of ultraviolet tanning and its alternatives: the role of prudent sun exposure

Sunlight- and indoor ultraviolet (UV)-induced tanning is a common behavior, especially among adolescents, young adults, and individuals who have lighter skin. Excessive sun exposure is associated with several health risks, including the acceleration of skin aging and the promotion of skin cancers. Several health benefits of UV exposure include vitamin D production and improved mood. This article analyzes these health risks and benefits and discusses pertinent issues surrounding indoor tanning, the role of sunless tanning products, and prudent sun exposure.

Density of indoor tanning facilities in 116 large U.S. cities

BACKGROUND

U.S. adolescents and young adults are using indoor tanning at high rates, even though it has been linked to both melanoma and squamous cell cancer. Because the availability of commercial indoor tanning facilities may influence use, data are needed on the number and density of such facilities.

METHODS

In March 2006, commercial indoor tanning facilities in 116 large U.S. cities were identified, and the number and density (per 100,000 population) were computed for each city. Bivariate and multivariate analyses conducted in 2008 tested the association between tanning-facility density and selected geographic, climatologic, demographic, and legislative variables.

RESULTS

Mean facility number and density across cities were 41.8 (SD=30.8) and 11.8 (SD=6.0), respectively. In multivariate analysis, cities with higher percentages of whites and lower ultraviolet (UV)index scores had significantly higher facility densities than those with lower percentages of whites and higher UV index scores.

CONCLUSIONS

These data indicate that commercial indoor tanning is widely available in the urban U.S., and this availability may help explain the high usage of indoor tanning.

The impact of an appearance-based educational intervention on adolescent intention to use sunscreen

During adolescence, there is a steady decline in the use of sun protection and increased use of indoor tanning lights. Previous health education efforts have changed knowledge but not these behaviors. Middle school students (n=113) received a single educational class that included personal viewing of skin changes visible under ultraviolet (UV) filtered light. Pre-/post-surveys assessed past, current and future intent to use sunscreen, as well as sun benefit and sun risk attitudes. Prior to the session, 42% were sunscreen non-users and 21% were consistent users. At post-test, one-third of students who had not previously intended to use sunscreen in the next month now intended to use it. Among students who had seen skin damage, 59% reported intention to use sunscreen in the next month versus 35% who did not see skin changes (P = 0.04). Viewing sun damage was an independent predictor of intent to use sunscreen in the next month (OR 2.9, P = 0.04), as was older age (OR 2.6, P = 0.04) and previous consistent sunscreen use (OR 6.1, P = 0.004). A brief educational intervention that emphasizes risk-to-appearance and personalizes the risks of UV exposure has the potential to influence early adolescent sun protection. Long-term studies of this approach are needed.

Indoor tanning and problem behavior

OBJECTIVE

The authors examined factors predicting college students' use of tanning beds.

PARTICIPANTS AND METHODS

Undergraduate students (N = 745) at a large Northeastern university participated in the study by answering a survey measuring tanning behavior and other psychosocial variables, including sensation seeking, self-esteem, tanning image beliefs, and friends' tanning bed use.

RESULTS

All 3 systems from problem behavior theory predicted past tanning bed use and intention to use tanning beds. The authors observed a positive association between sensation seeking and intention to use tanning beds. Tanning image beliefs were positively associated with both past tanning behavior and intention to use tanning beds.

CONCLUSIONS

Interventions focusing on friend and acquaintance social network influences may be more effective than health-risk campaigns in reducing tanning bed use.

Weekend sun protection and sunburn in Australia trends (1987-2002) and association with SunSmart television advertising

BACKGROUND

The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed.

METHODS

In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation.

RESULTS

Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997-1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39-0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun.

CONCLUSIONS

The general improvement in sun-protective behaviors over time highlight that a population's sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a population's sun-protective behaviors.

Multiple skin cancer risk behaviors in the U.S. population

BACKGROUND

The incidence of all types of skin cancer has increased over the past 3 decades in the United States. Increased skin cancer risk is associated with exposure to ultraviolet radiation. This study examined the age-stratified prevalence and correlates of multiple skin cancer risk behaviors (infrequent use of sun-protective clothing, staying in the sun when outside on a sunny day, infrequent use of sunscreen, indoor tanning, and receiving a sunburn) among U.S. adults.

METHODS

28,235 adults participating in the 2005 National Health Interview Survey (NHIS) answered questions regarding sun-protection behaviors, indoor tanning in the past year, and sunburns in the past year. Examined correlates included geographic location, demographics, healthcare access, BMI, physical activity, smoking, alcohol use, melanoma family history, perceived cancer risk, skin sensitivity to the sun, and receipt of a total skin exam.

RESULTS

The most commonly reported skin cancer risk behaviors were infrequent use of sun-protective clothing and infrequent use of sunscreen. The majority of individuals reported multiple skin cancer risk behaviors. Although significant correlates varied according to age, individuals reporting more risk behaviors were more likely younger, residing in the Midwest, male, non-Hispanic white, less-educated, smokers, risky drinkers, and had skin that was less sun-sensitive.

CONCLUSIONS

The majority of the U.S. population engage in multiple skin cancer risk behaviors. A comprehensive approach to skin cancer prevention requires attention to multiple skin cancer risk behaviors that are common in the U.S. population.

The influence of parents and peers on adolescent indoor tanning behavior: findings from a multi-city sample

BACKGROUND

Indoor tanning is common among adolescents.

OBJECTIVE

Our purpose was to examine the influence of parents and peers on adolescent indoor tanning.

METHODS

Telephone interviews were conducted with 5274 teen-parent pairs in the 100 largest US cities. Random coefficient regression analyses were conducted to examine the relationship between parental and peer factors and adolescent indoor tanning.

RESULTS

Teens' report of whether their parents allow them to tan indoors was the strongest predictor (adjusted odds ratio [aOR]: 5.6), whereas parents' modeling (aOR: 1.2), attitudes (aOR: 1.1), and concern about teen tanning (aOR: 1.9) were significantly but less strongly associated. Teens thinking most of their peers like to be tan (aOR: 1.7) and perceived percentage of peers who tan indoors (aOR: 1.0) also were significantly associated.

LIMITATIONS

The cross-sectional design was a limitation of this study.

CONCLUSION

Interventions targeting adolescent indoor tanning should address both family- and peer-related factors.

Australian adolescents' sun protection behavior: who are we kidding?

PURPOSE

To examine the influence of tan preference and skin type on sun protection behaviors of Australian adolescents.

METHODS

The Australian Secondary School Alcohol and Drug Questionnaires were conducted in 1993, 1996, 1999 and 2002 among randomly selected students aged 12--17. Schools were randomly selected from each education sector in each state. The self-administered questionnaire contained questions about tan preferences, skin type and usual SunSmart behavior (use of sunscreen, hats and covering clothing).

RESULTS

The routine use of SunSmart behavior was low in all survey years. There was a significant decrease over time in the proportion of students who practiced SunSmart behavior, with prevalence rates lower in 2002 than in any other survey year (males: p<0.01 and females: p<0.01). As desire for a tan increased, routine practice of SunSmart behaviors decreased. Across the four survey periods, male (p<0.01) and female (p<0.01) students who preferred no tan were significantly more likely to practice SunSmart behavior than students who preferred any sort of tan. Across the four survey years, male (p<0.01) and female (p<0.01) students with skin that 'just burns' were most likely to routinely practice SunSmart behavior.

CONCLUSIONS

Sun protection practices among adolescents have continued to decline significantly over time. Future educational programs require an innovative approach to modify adolescent behaviors in relation to sun exposure and sun protection.

Tanning device usage: what are parents thinking?

Tanning device usage is prevalent among adolescents. Few studies have assessed the role of parental influence on children's use of indoor tanning facilities. Our objective was to determine if children's tanning device usage is affected by parental knowledge of risks of indoor tanning or by parental tanning practices. A survey was administered to 160 parents of 328 children at a general pediatrics clinic and 204 parents of 367 children at a pediatric dermatology clinic (parents n=364, children n=695). Over half of all parents and 17% of all teenagers queried had previously used tanning devices. The level of parental knowledge did not predict tanning device usage by their children. However, parental tanning device usage was associated with increased usage by children (p<0.05). Children began using tanning devices on average more than 4 years earlier than their parents. Most parents (69%) never wanted their children to use tanning devices, but only 15% of parents had discussed them with their children. Therefore, health providers can provide an important service by initiating discussions about tanning devices. Additional measures, including legislation requiring parental consent for indoor tanning, are needed to reduce tanning device usage by minors.

Melanoma in Children and Teenagers: An Analysis of Patients From the National Cancer Data Base

Purpose

This study examines the demographics, presentation, and outcomes of children and teenagers with melanoma using a US hospital-based oncology database.

Patients and Methods

Data from the National Cancer Data Base from 1985 through 2003 were examined for demographics, presentation, and survival of patients aged 1 to 19 years, as well as a comparison group of patients aged 20 to 24 years. Two-sided linear and Pearson χ2 tests were calculated to examine associations. Proportions were compared using two-sided z tests. Five-year overall observed survival was evaluated using the Kaplan-Meier method and the log-rank test. Cox proportional hazards regression was used to estimate risk of mortality.

Results

Of 3,158 patients aged 1 to 19 years, 96.3% had cutaneous melanoma, 3.0% had ocular melanoma, and 0.7% had an unknown primary tumor. Cutaneous melanoma in patients aged 1 to 19 years was more common in girls (55.5%) and patients older than 10 years (90.5%). The demographics and presentation of cutaneous melanoma were age related; younger children were significantly more likely to be nonwhite and male and more likely to present with a head and neck primary tumors and with regional or distant metastases (linear χ2, P < .001 for sex, race, and extent of disease). Poorer survival was associated with higher stage and younger age. In contrast to patients aged 20 to 24 years, survival was not related to thickness in patients aged 1 to 19 years with localized invasive melanoma.

Conclusion

Melanoma in children and teenagers differs from melanoma in young adults in demographics, presentation, and survival. Further investigation is warranted to elucidate possible biologic correlates of the unique aspects of melanoma in children and teenagers.

The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

Exposure to solar ultraviolet (UV) radiation is a known cause of skin cancer. Sunbed use represents an increasingly frequent source of artificial UV exposure in light-skinned populations. To assess the available evidence of the association between sunbed use and cutaneous malignant melanoma (melanoma) and other skin cancers, a systematic review of the literature till March 2006 on epidemiological and biological studies on sunbed use was performed in Pubmed, ISI Web of Science, Embase, Pascal, Cochrane library, Lilacs and Medcarib. Search for keywords in the title and in the abstract was done systematically and supplemented by manual searches. Only case-control, cohort or cross-sectional studies were selected. Data were abstracted by means of a standardized data-collection protocol. Based on 19 informative studies, ever-use of sunbeds was positively associated with melanoma (summary relative risk, 1.15; 95% CI, 1.00-1.31), although there was no consistent evidence of a dose-response relationship. First exposure to sunbeds before 35 years of age significantly increased the risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% CI, 1.35-2.26). The summary relative risk of 3 studies of squamous cell carcinoma showed an increased risk. For basal cell carcinoma, the studies did not support an association. The evidence does not support a protective effect of the use of sunbeds against damage to the skin from subsequent sun exposure. Young adults should be discouraged from using indoor tanning equipment and restricted access to sunbeds by minors should be strongly considered.

Prevalence of sunless tanning product use and related behaviors among adults in the United States: Results from a national survey

Little is known about the use of sunless tanning products in the United States. This report describes the prevalence and correlates of sunless tanning use, comparing exclusive sunless tanners, exclusive indoor tanners, both sunless and indoor tanners, and non-tanners with respect to sociodemographic and sun protection behaviors.

Measuring the stringency of states' indoor tanning regulations: instrument development and outcomes

OBJECTIVES

We sought to describe the development of an instrument to quantify the stringency of state indoor tanning legislation in the United States, and the instrument's psychometric properties. The instrument was then used to rate the stringency of state laws.

METHODS

A 35-item instrument was developed. An overall stringency measure and 9 stringency subscales were developed, including one measuring minors' access to indoor tanning. Stringency measures showed good internal consistency and interrater reliability.

RESULTS

In all, 55% of the 50 states and the District of Columbia had any indoor tanning law, and 41% had any law addressing minors' access. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island had high overall stringency scores, and Texas and New Hampshire were the most restrictive with regard to minors' access.

LIMITATIONS

Measurement of actual enforcement of the laws was not included in this study.

CONCLUSIONS

The instrument appears to be an easy-to-use, reliable, and valid methodology. Application of the instrument to actual laws showed that, in general, state laws are relatively weak, although there was considerable variability by state.

Internet advertising of artificial tanning in Australia

Artificial tanning, defined as deliberate exposure to ultraviolet rays produced by artificial tanning devices, is a new and emerging public health issue in Australia and globally. Epidemiological research suggests that artificial tanning may contribute to the incidence of melanoma, nonmelanoma skin cancer as well as other health problems. Given that Australia has a high incidence of skin cancer, we have undertaken a study to explore how artificial tanning has been promoted to its users. The aim was to analyze the completeness and accuracy of information about artificial tanning. A content analysis of web sites of tanning salons and distributors of tanning equipment in Australia was conducted. A total of 22 web sites were analyzed. None of the solarium operators or distributors of equipment provided full information about the risks of artificial tanning. Fifty-nine percent of web advertisements had no information and 41% provided only partial information regarding the risks of artificial tanning. Pictures with the image of bronze-tanned bodies, predominantly women, were used by all web advertisers. In light of the success of sun-safety campaigns in Australia, the findings of future epidemiological research on the prevalence of artificial tanning and sociological and anthropological research on why people utilize artificial tanning should be a basis for developing effective targeted health promotion on the elimination of artificial tanning in the country.

SunSafe in the Middle School Years: a community-wide intervention to change early-adolescent sun protection

OBJECTIVE

Rising rates of skin cancer associated with early-life sun exposure make it important to improve adolescent sun-protection practices. Our study objective was to determine if a multicomponent community-wide intervention could alter the decline in sun protection that begins in early adolescence.

METHODS

A randomized, controlled trial was conducted in 10 communities to assess the impact of the SunSafe in the Middle School Years program. The intervention sought to (1) educate and activate adults and peers to role model and actively promote sun-protection practices and (2) create a pro-sun protection community environment. It targeted school personnel, athletic coaches, lifeguards, and clinicians and enlisted teens as peer advocates. Annual observations of cross-sectional samples of teens at community beach/pool sites were used to assess the impact of 1 and 2 years of intervention exposure compared to grade-matched controls. The outcome was percent of body surface protected by sunscreen, clothing, or shade.

RESULTS

Observers determined the sun protection level of 1927 adolescents entering 6th to 8th grades. After 2 years of intervention exposure, adolescents at the beach/pool in intervention communities were significantly better protected than those in control communities. Over 2 years, the percent of body surface area protected declined by 23% in the control arm but only 8% in intervention arm. After intervention, the average percent of body surface protected at intervention sites (66.1%) was significantly greater than control sites (56.8%). Teens in intervention communities reported sun-protection advice from more adult sources, were more likely to use sunscreen, and applied it more thoroughly than control-site teens.

CONCLUSIONS

Our multicomponent model addressing adolescent sun protection shows the power of engaging teens and adults from across the community as role models and educators. This new ecological approach shows promise in changing adolescent sun protection behaviors and reducing skin cancer risks.

Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States)

OBJECTIVE

To examine the association between tanning bed use and weight concerns, health risk behaviors, and peer influence.

METHODS

The Growing Up Today Study (GUTS) is an ongoing prospective cohort study of adolescents established in 1996. In 1999, a total of 6,373 adolescent females ages 12-18 (offspring of participants in the Nurses Health Study 2) completed the survey.

RESULTS

Almost nine percent (8.6%) of the adolescent girls had used a tanning bed 1-9 times and an additional 5.4% had used tanning beds at least 10 times in the past year (frequent users). Logistic regression models revealed that frequent tanning bed use was associated with being highly concerned about weight (OR = 1.5, 95%CI = 1.1, 2.0), frequently dieting to lose weight (OR = 1.5, 95%CI = 1.1, 2.0), using laxatives or vomiting to control weight (OR = 3.6; 95%CI = 2.2-5.8), having friends who placed a lot of importance on being thin (OR = 2.6; 95%CI = 1.3-5.1), smoking cigarettes (OR=1.7, 95%CI = 1.1, 2.6), binge drinking (OR = 2.1, 95%CI = 1.3, 3.1), using recreational drugs (OR = 3.0; 95%CI = 2.4, 3.8), and trying to look like females in the media (sometimes/pretty much: OR = 1.3, 95%CI = 1.0, 1.8).

CONCLUSION

Frequent tanning bed use among adolescent females is associated with a range of health risk behaviors. This effect may be mediated by peer influence and a desire to look like other females in the media. Multi-pronged approaches, particularly those that target attitudes of young females, are needed to combat increased use of tanning beds.

An investigation of appearance motives for tanning: The development and evaluation of the Physical Appearance Reasons For Tanning Scale (PARTS) and its relation to sunbathing and indoor tanning intentions

Motives for UV exposure have been shown to be related to appearance concerns, yet little research has examined specific tan appearance attitudes. Given this lacuna, Study 1 involved the identification of six factors among college female tanners: general attractiveness, media influence, family/friends influence, physical fitness appearance, acne reasons, and skin aging concerns. In Study 2, a separate sample of college female tanners were used to validate a higher order factor model, which demonstrated acceptable fit. Additionally, the factors converged in the expected directions, with the general attractiveness and skin aging concerns being the best correlate of UV exposure and sun-protection intentions. The relevance of these findings to skin cancer prevention is discussed.

Motives of Belgian Adolescents for Using Sunscreen: The Role of Action Plans

The first objective of this study was to analyze the differences between adolescents who use sunscreen frequently and those who do not. The second objective was to explore the importance of specific action plans when planning sunscreen use. Data was gathered among 602 Belgian secondary school students. Frequent and infrequent users of sunscreen were compared on several determinants related with sunscreen use, and a regression analysis on sunscreen use was done. Frequent users of sunscreen measures had significantly higher scores on attitudes, social influence, self-efficacy, some awareness factors, intention, and action plans. The integrated model for exploring motivational and behavioral change (I-Change model) explained 57% of the total variance of using sunscreen every 2 hours. Frequent sunscreen use was most strongly predicted by action plans, followed by positive intentions to use sunscreen, wearing protective clothing, seeking shade, attitude toward sunscreen use, education, social influence, and exposure to the sun. Our results suggest that skin cancer prevention programs aimed at promoting sunscreen use need to emphasize the advantages of sunscreen to infrequent users and to increase feelings of self-efficacy. Moreover, support by friends and parents should be stimulated. Finally, developing specific action plans for the use of sunscreen should be promoted to more effectively translate general intentions into actual sunscreen use.

The challenge of intentional tanning in teens and young adults

Changing UV exposure in adolescents and young adults has the potential to prevent years of excess exposure and subsequent skin cancer. Initial expectations were that an individual or media campaign informational approach would change this behavior. It is being recognized that current efforts have failed. Changing UV behaviors is challenging and has much in common with changing other health risk behaviors. The tanning industry benefits from recruiting new participants in this risky behavior. Research is just beginning to show some promising approaches, and will benefit from our experience attempting to change other risky behaviors.

Do adolescent indoor tanners exhibit dependency?

BACKGROUND

Indoor tanning is a common adolescent risk behavior that has been hypothesized to be motivated and maintained by the mood-altering effects of ultraviolet light.

OBJECTIVE

Our purpose was to explore heretofore anecdotal reports that indoor tanning leads to dependency.

METHODS

A telephone interview was conducted among 1275 adolescents, ages 14 to 17 years. Self-reported difficulty in quitting indoor tanning was assessed among 267 adolescents (20.9% of total) who tanned indoors more than once in the previous year in relation to age of initiation, frequency of use, and positive or negative consequences of the practice.

RESULTS

Difficulty in quitting was more likely with younger age at initiation (age 13 years or younger vs ages 16 to 17; odds ratio = 4.3, 95% confidence interval 1.3-14.7) and higher frequency of use (P = .009), even after accounting for positive or negative consequences of indoor tanning and other demographic characteristics.

LIMITATIONS

This was a cross-sectional study design with a limited outcome measure.

CONCLUSION

Although preliminary, our findings for age at initiation and frequency of use in relation to difficulty in quitting indoor tanning are consistent with other potentially addictive behaviors taken up during adolescence.

Sun-protective behavior among high-school and collegiate athletes in Los Angeles, CA

OBJECTIVES

To evaluate the use, knowledge, and perceptions of sun-protective behavior (SPB), among young athletes in Southern California.

DESIGN

Cross-sectional survey, assessing various measures of SPB, sun exposure, attitudes, and knowledge.

SETTING AND PARTICIPANTS

A total of 1006 students from 2 public high schools and 1 public university in the Los Angeles area volunteered. Athlete volunteers were recruited during sports preparticipation examinations. Nonathlete controls were recruited from physical education classes (high school) and from an introductory lecture class (university).

MAIN OUTCOME MEASURES

Use of SPB during sports and nonsports activities, sun exposure, sun-protection knowledge, and attitudes. Results from athletes were compared with those from controls at each site.

RESULTS

Overall rates of SPB were low. During nonsports activities, university athletes had higher rates of sunscreen (37.7% vs. 32.3%, P = 0.03) and hat use (34.7% vs. 17%, P < 0.001) than did controls. However, university athletes had lower rates of use of long shirts (27.9% vs. 39.8%, P < 0.001), long pants (38.8% vs. 63%, P < 0.002), and had higher total sun exposure (16.1 vs. 10.1 h/wk, P < 0.001). Similar results were seen among the high-school subjects. Despite having good knowledge of the potential dangers of ultraviolet radiation exposure, approximately 1 in 5 subjects overall had experienced a blistering sunburn within the past year.

CONCLUSIONS

Young athletes in the Los Angeles area reported low rates of SPB, high levels of ultraviolet radiation exposure, and high rates of sunburns, despite knowing the risks of sun exposure. Specific educational and behavioral interventions should be directed toward improving SPB in this high-risk group.

Controversies in the public health approach to keratinocyte carcinomas

Keratinocyte carcinomas are very common cancers in fair-skinned populations throughout the world. The term 'keratinocyte carcinoma' includes basal and squamous cell carcinoma of the skin, but not other cancers that may be included under the more ambiguous term 'nonmelanoma skin cancer'. Incidence and mortality are important for assessing impact and recent research suggests that these cancers are increasing in incidence in young adults. There is evidence to suggest that this trend may be due, in part, to the popularity of ultraviolet exposures in commercial tanning facilities. Mortality from keratinocyte carcinoma reveals distinct patterns suggestive of an important role of human papilloma virus infection. Ultimately, our aim is to reduce mortality and morbidity from these cancers, and to that end several large-scale trials of public health interventions have been conducted that may help point the way forward.

Sun protection practices among offspring of women with personal or family history of skin cancer

OBJECTIVE

Family history of skin cancer is an important determinant of skin cancer risk for offspring. No previous study of the effect of personal or family history of skin cancer on the sun protection behaviors of the offspring has been published.

METHODS

A retrospective study was conducted of the sun protection behaviors of the adolescent participants in the Growing Up Today Study (GUTS), who were offspring of mothers from the Nurses Health Study II. Adolescents' surveys were matched with their mothers' reports of a personal or family history of skin cancer and compared with adolescents whose mothers did not report a personal or family history of skin cancer. The outcome measures were (1) occurrence of frequent sunburns during the past summer, (2) use of a tanning bed during the past year, and (3) routine use of sunscreen. Frequent sunburns were defined as the report of > or = 3 sunburns during the past summer. We compared those who reported having used a tanning bed in the past year at least once with those who reported no tanning bed use in the past year. Routine use of sunscreen was defined as a respondent who replied that he or she "always" or "often" used sunscreen with sun protection factor of 15 or more when he or she was outside for > 15 minutes on a sunny day during the past summer. General estimating equations were used to calculate odds ratios and 95% confidence intervals adjusted for gender, age, color of untanned skin, and number of friends who were tanned. We also conducted an additional analysis restricted to children whose mothers had received a diagnosis of skin cancer in which we assessed sun protection behaviors according to the child's age and mother's age at the time of the mother's diagnosis and the number of years that had passed since the diagnosis of the mother's skin cancer.

RESULTS

In 1999, 9943 children reported their sun protection behaviors; 8697 of their mothers had not received a diagnosis of skin cancer or reported a family history of melanoma, 463 participants' mothers had received a diagnosis of skin cancer, and 783 participants' mothers reported a family history of melanoma. Between 1989 and 1999, 371 mothers of GUTS participants received a diagnosis of skin cancer: melanoma (n = 44), squamous cell (n = 39), and basal cell cancer (n = 311); 23 mothers received a diagnosis of > 1 type of skin cancer. Because GUTS includes siblings from the same family, the 371 mothers with skin cancer had 463 offspring in GUTS. Offspring of mothers with skin cancer were slightly more likely to report frequent sunburns in the past year compared with those with neither maternal diagnosis nor family history (39% vs 36%). Tanning bed use was not significantly different among those with either a maternal diagnosis of skin cancer or family history of melanoma as compared with nonaffected adolescents (8% vs 9% vs 10%). Sunscreen use among offspring of mothers with skin cancer was higher than among those whose mothers had a family history of melanoma or mothers with no personal history of skin cancer (42% vs 33% vs 34%). Tan-promoting attitudes were also similar across all groups. Only 25% thought that a natural skin color was most attractive, and on average, 25% in each group agreed that it was worth burning to get a tan. Children of mothers who had received a diagnosis > 2 years in the past were less likely to use sunscreen, more likely to sunburn, and more likely to use tanning beds than children of mothers with a more recent diagnosis, although the results did not reach statistical significance.

CONCLUSION

Frequent sunburns, suboptimal sunscreen use, and high rates of tanning bed use are commonplace even among the children of health professionals who are at risk for developing skin cancer themselves as a result of personal or family history. With new information on family risk, pediatricians can use the potential of a teachable moment to ensure optimal sun protection for children who are at risk.

A randomized intervention study of sun protection promotion in well-child care

BACKGROUND

This study evaluated the behavioral impact of a skin cancer prevention program in which health care providers delivered advice and materials to parents of infants over a 3-year period from 1998 to 2001.

METHODS

Fourteen offices of a large managed care organization in Colorado were randomly assigned to the intervention or control groups. 728 infants and their parents were recruited within 6 months of birth. At intervention offices, health care providers attended orientation sessions, prompts for delivering sun protection advice were placed in medical records, and parents received sun protection packets at each well-child visit between 2 and 36 months of age.

RESULTS

Based on provider self-report and exit interviews of parents, providers in the intervention group delivered approximately twice as much sun protection advice as providers in the control group. Annual telephone interviews of parents indicated small but statistically significant differences in parent sun protection practices favoring the intervention. Skin exams revealed no significant differences in tanning, freckling, or number of nevi. Behavioral differences between groups appeared to grow over the 3 years of follow-up.

CONCLUSIONS

This intervention strategy was successful in increasing the delivery of sun protection advice by health care providers and resulted in changes in parents' behaviors. While the behavioral effect was probably not strong enough to reduce risk for skin cancer, the effect may increase as children age and have more opportunities for overexposure to the sun.

Comparing two methods of measuring legislation compliance among indoor tanning facilities

BACKGROUND

Accurate measurement of compliance by tanning facilities to indoor tanning legislation is important.

OBJECTIVE

This study compared a telephone-based measurement procedure with a face-to-face visit.

METHODS

Indoor tanning facilities (N = 115) in San Diego County, California, were contacted by two adolescents posing as prospective customers using each method. Two compliance variables were assessed: number of times one can tan during 1 week and written parental consent for minors.

RESULTS

Facility compliance with the frequency variable by face-to-face and telephone was 25.5% and 17.5%, respectively. These rates for the parental consent variable were 73.3% and 80.8%, respectively. Percent agreement between data collection methods was 71.3% for compliance with the frequency recommendation and 76.3% for parental consent regulation. Although traditional statistical tests indicated poor concordance, an alternative test indicated good concordance.

LIMITATIONS

Levels of concordance for the confederates differed.

CONCLUSION

Telephone assessment of compliance is fairly comparable with the more labor-intensive, face-to-face assessment.

The indoor UV tanning industry: A review of skin cancer risk, health benefit claims, and regulation

BACKGROUND

Nearly 30 million people tan indoors in the United States annually, including 2.3 million adolescents. Despite increased evidence on the dangers of artificial UV radiation, the popularity of indoor tanning is growing.

OBJECTIVES

We aim to assess the following 3 entities: (1) the association of indoor tanning with skin cancer; (2) statements regarding the health benefits of indoor tanning, especially regarding the production of vitamin D; and (3) current regulation of the tanning industry in the United States.

METHODS

We conducted a narrative review of the literature.

RESULTS

Indoor tanning poses great risks. Studies support the role of artificial UV radiation in cutaneous carcinogenesis. Despite claims by the tanning industry, artificial tanning is not a safe or necessary way to increase systemic vitamin D levels. The National Institutes of Health and the World Health Organization have acknowledged the risks of indoor tanning. Nonetheless, regulations limiting tanning in the United States are surprisingly sparse.

LIMITATIONS

Systematic review of the literature was not performed.

CONCLUSIONS

Health care providers must increase efforts to warn and educate the public and government about the dangers of UV radiation.

Sun protective behaviors and sunburn experiences in parents of youth ages 11 to 18

BACKGROUND

Recent studies suggest that parental sun protective behaviors and communication influence their adolescents. However, there is limited information on sun protection for parents of adolescents.

METHODS

A telephone-based, nationally representative prevalence study of sun exposure among youth, aged 11-18, and their parents living in households was conducted in 1998. Separate, independent responses were collected. Weighted prevalence estimates and 95% confidence intervals were estimated and presented for parents only (n = 1187).

RESULTS

Approximately one-third of parents planned activities to avoid the sun and used sunscreen. Among parents who used sunscreen, 70% applied it while at the beach or pool, but not as often during other outdoor activities. Almost one-third of parents were participating in water or non-water recreational activities during their most serious sunburn. Differences in sun protection and sunburn experiences were observed by age, gender, sun sensitivity, race and ethnicity, and educational attainment.

CONCLUSIONS

Parents have adopted sun protection habits, but have not surpassed national sun-protection goals. Combined use of sun protection behaviors may reduce sunburn prevalence and number of incident skin cancers. These data may be useful for developing or enhancing current sun protection programs for effective sun protection that include parents and their adolescents.

Indoor UV tanning operator opinion regarding youth access: an electronic survey

BACKGROUND

Adolescents frequently use indoor tanning facilities, but little is known about tanning facility operator opinions regarding this use. Objective To assess indoor tanning operator attitudes and stated practices regarding youth access.

METHODS

We electronically surveyed 89 indoor tanning facilities and 130 spas with active e-mail addresses.

RESULTS

The survey response rate was 21% for both indoor tanning facilities (19/89) and spas (27/130). Most tanning operators (92%) felt that a client can be too young to receive indoor tanning, and most felt that written parental permission should be required (80%). Most facilities required adult accompaniment (92%), and most operators had discouraged a customer from receiving indoor tanning based on age (77%). The reported age of the youngest patron receiving indoor tanning ranged from 5 to 21 years.

CONCLUSION

Our sample of indoor tanning facility operators believed that minimum age and parental consent regulations for indoor tanning should be required.

Solaria compliance in an unregulated environment: the Australian experience

This study aimed to explore compliance with international recommendations on solaria use in a unregulated setting. Simulated customers visited 176 solaria operating in Australia and two face-to-face visits and one telephone contact were made for each establishment. From the survey, establishments compliant with the recommendations ranged from: 1.1% refusing access to the customer with skin type I; 9.7% recommending to the customer with skin type I against solaria use and up to 87.5% assessing skin type and recommending eye protection. Few (15.9%) were compliant with more than 10 of the 13 recommendations. Establishment type and number of sunbeds were significantly associated with compliance. This study has shown that a much higher level of compliance with recommendations, particularly those excluding higher-risk groups, is required to reduce the harm associated with use of solaria. While new legislation may be useful, other harm minimisation strategies including mandatory staff training and taxation should be considered.

Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners

BACKGROUND

Investigations into tanners' reasons for tanning have focused primarily on the perception of improved appearance. Reported relaxing effects of tanning suggest the possibility of a physiologic effect of UV that drives tanning behavior.

OBJECTIVE

We sought to determine if there is a physiologic reinforcing effect of UV exposure, separate from appearance motivation, that may contribute to tanning behavior.

METHODS

We determined the reinforcing effect of UV light in a series of controlled, blinded, repeated-choice trials of UV carefully designed to separate as cleanly as possible reinforcing effects of UV exposure from other factors including perceived benefits of having a tan. A total of 14 young adults who used tanning beds regularly were exposed to otherwise identical UV and non-UV tanning bed stimuli on Mondays and Wednesdays for 6 weeks. On Fridays, participants had concurrent access to the two beds. The primary dependent variable was the percentage of choice sessions during which more UV than non-UV tanning was chosen.

RESULTS

In all, 12 participants chose additional tanning exposure on Fridays and, of these, 11 consistently used the UV bed for that exposure. Of the total 41 occasions when participants chose to tan on Friday, 39 sessions (95%) were for the UV bed and only two for the non-UV bed. A more relaxed and less tense mood was reported after UV exposure compared with after non-UV exposure (P=.008 and P=.002, respectively).

DISCUSSION

When exposed to UV and non-UV under blinded conditions, frequent tanners can distinguish the two conditions and undertake further UV exposure, indicating that UV is a reinforcing stimulus. The relaxing and reinforcing effects of UV exposure contribute to tanning behavior in frequent tanners and should be explored in greater detail.

Indoor tanning by adolescents: prevalence, practices and policies

Despite known acute and chronic health effects from the use of indoor tanning, including the potential for all forms of skin cancer, the practice is popular in the United States (US) and Europe. A review of the scientific literature that examines adolescents and indoor tanning use was undertaken, summarising what is known about prevalence and practices among adolescents, characteristics associated with adolescent use, and policies that regulate adolescent access to indoor tanning facilities. The prevalence of indoor tanning is consistently found to be higher among girls than boys and to increase with age in both Europe and the US. An examination of other demographic characteristics, skin cancer risk factors, knowledge, attitudes and social factors points to higher prevalence of the behaviour among adolescents with positive attitudes towards tans and whose friends or parents also tan indoors. Adolescent access to indoor tanning is rarely regulated in the US or Europe, and where regulations exist, business compliance is low. In addition, businesses actively market their product to adolescents as they organise to limit further regulations prohibiting adolescent access. Pricing, licensure, advertising restrictions and media campaigns, in combination with adolescent-targeted interventions, are possible strategies that could be tested for their effectiveness to reduce adolescent indoor tanning use. Harm reduction policies, such as eye protection, that reduce risk for adolescents who choose to tan indoors, are also important.

Maternal/female caregiver influences on adolescent indoor tanning

PURPOSE

To identify aspects of maternal/female caregiver (MFC) influences on adolescents' indoor tanning, including modeling, cognitions (MFC knowledge and attitudes about indoor tanning), and gatekeeping/monitoring (MFC permissiveness and concern) of indoor tanning.

METHODS

A telephone survey of adolescents aged 14-17 years and their female parent/caregiver in Minnesota and Massachusetts was conducted in 2000-2001 (n = 1284 matched pairs). Logistic regression was used to obtain odds ratios for relationships between measures of MFC influence and teens' indoor tanning practices, adjusting for demographic and sun sensitivity differences.

RESULTS

Separately, each of the five MFC influence variables was significantly associated with adolescents' indoor tanning practices. In a multivariate model, significant independent contributors were parents' behavior, parents' concern about their children's indoor tanning practices, and MFC permissiveness of teen indoor tanning. Using a combined summed scale of the 5 influence factors, there was a monotonically increasing likelihood of tanning with each incremental scale increase: (in comparison to none, 1 factor aOR = 4.1, 95% CI: 1.3, 12.8; any 2 factors aOR = 8.3, 95% CI: 2.8, 24.6; any 3 factors aOR = 14.3, 95% CI = 4.9, 41.8; any 4 factors aOR = 30.5, 95% CI: 10.3, 90.3; all 5 factors aOR = 66.0, 95% CI: 20.0, 217.6).

CONCLUSIONS

Mothers/female caregivers may be a powerful influence on their teenagers' indoor tanning use, and are an important target for future health promotion efforts to discourage youth indoor tanning.

What influences university students' intentions to practice safe sun exposure behaviors?

PURPOSE

To apply Protection Motivation Theory to examine adolescents' intentions to perform safe sun exposure behaviors.

METHODS

A total of 239 students (aged 18 to 22 years) from two British universities were recruited to the study. The majority of participants were white (68%), 29% were classified as Asian, and the remaining 3% were Afro-Caribbean. Participants completed a questionnaire comprising items examining the components of Protection Motivation Theory. Intention to perform safe sun exposure behaviors was examined by asking participants to indicate their agreement with five statements about future sun exposure behaviors.

RESULTS

Hierarchical multiple regression analysis revealed that the threat appraisal components of Protection Motivation Theory were stronger predictors of intention to perform safe sun exposure behaviors (accounting for 15% of the variance) than the coping appraisal components (accounting for 3% of the variance). However, previous performance of similar behaviors emerged as the strongest overall predictor of intention to perform safe sun exposure behaviors (beta = -.514, p < .01), followed by perceived vulnerability to developing skin cancer (beta = .232, p < .01) and practicing skin and naevi self examination behaviors (beta = -.172, p < .01).

CONCLUSIONS

The results suggest that a strategic sun protection education campaign is necessary with the aim of encouraging adaptive sun behaviors by emphasizing the risk of skin cancer associated with sunburn.