Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis

Adolescent indoor tanning use and unhealthy weight control behaviors

OBJECTIVE

Youth indoor tanning rates remain high despite the potential for increased melanoma risk. No previous study has assessed the prevalence of unhealthy weight control behaviors in both male and female adolescent indoor tanning users using a nationally representative survey.

METHODS

Pooled data on high school students from the 2009 and 2011 Youth Risk Behavior Survey were used (n = 26,951). Multivariate logistic regression was used to assess associations between the recent indoor tanning use and recently doing the following to lose weight: fasting for more than 24 hours; taking a pill, powder, or liquid without a doctor's consent; and vomiting or taking a laxative.

RESULTS

Pooled data showed 23.3% of females reported indoor tanning within the past year; 6.5% of males did so as well. Adjusted multivariate results show that females who indoor tan were, on average, more likely to have fasted (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), taken a pill, powder, or liquid (OR, 2.4; 95% CI, 1.9-3.0), and vomited or taken a laxative to lose weight (OR, 1.4; 95% CI, 1.1-1.7) within the past 30 days than those who did not. Males who indoor tanned within the past year were, on average, more likely to have fasted (OR, 2.3; 95% CI, 1.7-3.1), taken a pill, powder, or liquid (OR, 4.4; 95% CI, 3.3-6.0), and vomited or taken a laxative to lose weight (OR, 7.1; 95% CI, 4.4-11.4) within the past 30 days.

CONCLUSIONS

Significant associations between indoor tanning use and unhealthy weight control behaviors exist for both male and female adolescents, with a stronger association observed among males.

Melanocytes are selectively vulnerable to UVA-mediated bystander oxidative signaling

Long-wave UVA is the major component of terrestrial UV radiation and is also the predominant constituent of indoor sunlamps, both of which have been shown to increase cutaneous melanoma risk. Using a two-chamber model, we show that UVA-exposed target cells induce intercellular oxidative signaling to non-irradiated bystander cells. This UVA-mediated bystander stress is observed between all three cutaneous cell types (i.e., keratinocytes, melanocytes, and fibroblasts). Significantly, melanocytes appear to be more resistant to direct UVA effects compared with keratinocytes and fibroblasts, although melanocytes are also more susceptible to bystander oxidative signaling. The extensive intercellular flux of oxidative species has not been previously appreciated and could possibly contribute to the observed cancer risk associated with prolonged UVA exposure.

Socioeconomic status and cutaneous malignant melanoma in Northern Europe

Socioeconomic status (SES) is associated with cutaneous malignant melanoma (CMM) in Northern Europe, despite equal access to health care. SES per se is not responsible for this association, which must be ascribed to important risk factors for CMM such as intermittent ultraviolet radiation (UVR) exposure, and screening for CMM possibly owing to a greater knowledge and understanding of CMM. Our review of the literature showed that high SES is associated with increased risk of CMM, thinner tumours, increased survival and decreased mortality from CMM - the latter shown among women, and in recent studies also among men. There is evidence that high SES is associated with sun holidays, whereas low SES is associated with the use of sunbeds. Findings suggest that high SES is associated with the use of physicians and dermatologists for marks and moles, possibly owing to more knowledge and better understanding of CMM. We conclude that there has been a true increase in CMM incidence among high SES individuals in Northern Europe probably due to past intense intermittent UVR exposure, especially in connection with sun holidays. However, the increased risk of CMM and a better outcome of CMM in high SES individuals may also be conditioned by frequent recourse to physicians, which may be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Thicker CMM tumours and increased CMM mortality among low SES individuals in recent decades may reflect exposure to intermittent UVR, such as the use of sunbeds, as well as delayed diagnosis.

Perioral lesions and dermatoses

The purpose of this article is to review the common neoplasms, infections, and inflammatory dermatoses that may present around or near the mouth. Dental professionals are well positioned to evaluate perioral skin conditions, further contributing to patients' general health. This article includes a review of seborrheic keratosis, warts, actinic keratoses, actinic cheilitis, and squamous cell carcinoma, among several other perioral cutaneous lesions.

Society of Behavioral Medicine (SBM) position statement: ban indoor tanning for minors

The Society of Behavioral Medicine (SBM), an interdisciplinary professional organization focused on the science of health behavior joins the American Academy of Dermatology, the American Academy of Pediatrics, and a host of other national and international organizations in support of a total ban on indoor tanning for minors under the age of 18. According to the International Agency for Research on Cancer, artificial sources of ultraviolet radiation are in the highest category of carcinogens, joining tobacco and asbestos. Strong evidence links indoor tanning to increased risk for melanoma with repeated exposure during childhood being associated with the greatest increase in risk. Several countries and five US states have passed legislation banning indoor tanning in minors. We strongly encourage the remaining US states to do the same in an effort to protect children and prevent new cases of melanoma. SBM also strongly encourages research that explores the use of tanning beds in the home. Home-based indoor tanning has the potential to be especially dangerous given the complete absence of safety regulations. Children are currently protected from exposure to health-harming substances like tobacco and lead; thus, legislation protecting them from artificial sources of ultraviolet radiation is yet another important step forward in improving public health.

Transient receptor potential vanilloid 4 (TRPV4) is downregulated in keratinocytes in human non-melanoma skin cancer

A subgroup of the transient receptor potential (TRP) channels, including vanilloid 1 (TRPV1), TRPV2, TRPV3, TRPV4, and TRP ankyrin 1 (TRPA1), is expressed in cutaneous peptidergic somatosensory neurons, and has been found in skin non-neuronal cells, such as keratinocytes. Different cancer cells express TRPs, where they may exert either pro- or antitumorigenic roles. Expression and function of TRPs in skin cancers have been, however, poorly investigated. Here, we have studied the distribution and expression of TRPs by immunohistochemistry and messenger RNA (mRNA) in human healthy skin and human keratinocytic tumors, including intraepidermal proliferative disorders (solar keratosis (SK) and Bowen's disease), and non-melanoma skin cancer (NMSC; basal cell and squamous cell carcinomas). Similar TRPV1, TRPV2, and TRPV3 staining was found in keratinocytes from healthy and tumor tissues. TRPA1 staining was increased solely in SK samples. However, the marked TRPV4 staining and TRPV4 mRNA expression, observed in healthy or inflamed skin, was abrogated both in premalignant lesions and NMSC. In a human keratinocyte cell line (HaCaT), TRPV4 stimulation released IL-8, which in turn downregulated TRPV4 expression. Selective reduction in TRPV4 expression could represent an early biomarker of skin carcinogenesis. Whether the cytokine-dependent, autocrine pathway that results in TRPV4 downregulation contributes to NMSC mechanism remains to be determined.

The association of indoor tanning and melanoma in adults: systematic review and meta-analysis

BACKGROUND

Tanning beds are associated with increased risk of melanoma.

OBJECTIVE

We sought to update the evidence of the association of melanoma and indoor tanning focusing on frequency of use and exposure to newer tanning beds.

METHODS

We searched Scopus, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature on August 14, 2013. We included all observational studies that included patients with melanoma who had indoor tanned. Odds ratios (OR) with 95% confidence intervals (CI) were extracted and combined using generic inverse variance methods assuming a random effects model.

RESULTS

In all, 31 studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared with never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 (95% CI 1.05-1.28). Similar findings were identified in recent studies with enrollment occurring in the year 2000 onward (OR 1.22, 95% CI 1.03-1.45) and in subjects attending more than 10 tanning sessions (OR 1.34, 95% CI 1.05-1.71).

LIMITATIONS

The quality of evidence contributing to review results ranges from poor to mediocre.

CONCLUSION

Using tanning beds is associated with a subsequent melanoma diagnosis. Exposure from more than 10 tanning sessions is most strongly associated and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models.

Cutaneous melanoma

In the past decade, major advances have been made in the understanding of melanoma. New predisposition genes have been reported and key somatic events, such as BRAF mutation, directly translated into therapeutic management. Surgery for localised melanoma and regional lymph node metastases is the standard of care. Sentinel-node biopsy provides precise staging, but has not been reported to affect survival. The effect of lymph-node dissection on survival is a topic of investigation. Two distinct approaches have emerged to try to extend survival in patients with metastatic melanoma: immunomodulation with anti-CTLA4 monoclonal antibodies, and targeted therapy with BRAF inhibitors or MEK inhibitors for BRAF-mutated melanoma. The combination of BRAF inhibitors and MEK inhibitors might improve progression-free survival further and, possibly, increase overall survival. Response patterns differ substantially-anti-CTLA4 immunotherapy can induce long-term responses, but only in a few patients, whereas targeted drugs induce responses in most patients, but nearly all of them relapse because of pre-existing or acquired resistance. Thus, the long-term prognosis of metastatic melanoma remains poor. Anti-PD1 and anti-PDL1 antibodies have emerged as breakthrough drugs for melanoma that have high response rates and long durability. Biomarkers that have predictive value remain elusive in melanoma, although emerging data for adjuvant therapy indicate that interferon sensitivity is associated with ulceration of the primary melanoma. Intense investigation continues for clinical and biological markers that predict clinical benefit of immunotherapeutic drugs, such as interferon alfa or anti-CTLA4 antibodies, and the mechanisms that lead to resistance of targeted drugs.

Measurement of urinary biomarkers of parabens, benzophenone-3, and phthalates in a Belgian population

Parabens, benzophenone-3 (BP3), and phthalates are commonly used as antimicrobial conservator, UV-filter, and plasticizer, respectively, and are thought to exhibit endocrine disrupting properties. These endocrine disrupting activities have been recently assumed to lead to cutaneous malignant melanoma. Humans are exposed to these chemicals through different sources such as food, personal care products, or cosmetics. In this study, we measured urinary levels of 4 parabens, BP3, and 7 metabolites of phthalates in samples collected from 261 participants living in and around Liege (Belgium). The analyses were carried out by liquid chromatography tandem mass spectrometry (LC-MS/MS) using isotopic dilution. To the best of our knowledge, this is the first time that the urinary levels of these 3 classes of chemicals are reported for the same general population in Belgium. Most of the parabens, the BP3, and all the phthalate metabolites were detected in 82.8 to 100.0% of the samples. For most of these chemicals, the exposure patterns significantly differ not only between children and adults, but also between males and females, especially with higher concentrations of parabens and phthalate metabolites in female and children subjects, respectively.

Global cancer patterns: causes and prevention

Cancer is a global and growing, but not uniform, problem. An increasing proportion of the burden is falling on low-income and middle-income countries because of not only demographic change but also a transition in risk factors, whereby the consequences of the globalisation of economies and behaviours are adding to an existing burden of cancers of infectious origin. We argue that primary prevention is a particularly effective way to fight cancer, with between a third and a half of cancers being preventable on the basis of present knowledge of risk factors. Primary prevention has several advantages: the effectiveness could have benefits for people other than those directly targeted, avoidance of exposure to carcinogenic agents is likely to prevent other non-communicable diseases, and the cause could be removed or reduced in the long term--eg, through regulatory measures against occupational or environmental exposures (ie, the preventive effort does not need to be renewed with every generation, which is especially important when resources are in short supply). Primary prevention must therefore be prioritised as an integral part of global cancer control.

The effect of a school-based intervention on sunbed use in Danish pupils at continuation schools: a cluster-randomized controlled trial

PURPOSE

To examine the effect of an educational intervention on sunbed use and intentions and attitudes toward sunbed use in 14- to 18-year-olds at continuation schools.

METHODS

We randomized 33 continuation schools either to receive the educational intervention (n = 16) or to be controls (n = 17). Intervention schools received an e-magazine addressing the health risks of sunbed use. Information on behavior and intentions and attitudes toward sunbed use was gathered through self-administrated questionnaires before the intervention and at 6 months as a follow-up. The effect of the intervention was examined by multilevel linear regression and logistic regression.

RESULTS

Sunbed use was significantly lower at follow-up among pupils at intervention schools versus pupils at control schools (girls: odds ratio .60, 95% confidence interval .42-.86; Boys: odds ratio .58, 95% confidence interval .35-.96). The intervention had no effect on intention to use sunbeds or attitudes toward sunbed use. The analyses revealed a significant impact of school on attitudes toward sunbed; the intraclass correlation coefficient was estimated to be 6.0% and 7.8% for girls and boys, respectively.

CONCLUSIONS

The findings from the present study provide new evidence of a positive effect of an educational intervention on sunbed use among pupils aged 14-18 years at continuation schools.

International prevalence of indoor tanning: a systematic review and meta-analysis

IMPORTANCE

Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

OBJECTIVE

To summarize the international prevalence of exposure to indoor tanning.

DATA SOURCES

Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

STUDY SELECTION

Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

MAIN OUTCOMES AND MEASURES

Ever and past-year exposure to indoor tanning.

RESULTS

The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

CONCLUSIONS AND RELEVANCE

Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

Implication of ultraviolet light in the etiology of uveal melanoma: A review

Uveal melanoma is the most frequent intraocular cancer and the second most common form of melanoma. It metastasizes in half of the patients and the prognostic is poor. Although ultraviolet (UV) radiation is a proven risk factor for skin melanoma, the role of UV light in the etiology of uveal melanoma is still contradictory. We have compared epidemiological and genetic evidences of the potential role of UV radiation in uveal melanoma with data on cutaneous melanoma. Even though frequently mutated genes in skin melanoma (e.g. BRAF) differ from those found in uveal melanoma (i.e. GNAQ, GNA11), their mutation pattern bears strong similarities. Furthermore, we provide new results showing that RAC1, a gene recently found harboring UV-hallmark mutation in skin melanoma, is also mutated in uveal melanoma. This article aims to review the work done in the last decades to understand the etiology of uveal melanoma and discuss new avenues, which shed some light on the potential role of UV exposure in uveal melanoma.

Emerging trends in the epidemiology of melanoma

Cutaneous melanoma (CM) is one of the most rapidly growing cancers worldwide, with a consistent increase in incidence among white populations over the past four decades. Despite the early detection of primarily thin melanomas and the improved survival rates observed in several countries, the rate of thick melanomas has remained constant or continues to increase, especially in the older age group. Current considerations in the epidemiology of melanoma focus on the observed survival benefit of females vs. males, the contributing role of indoor tanning in melanoma risk and the diverse effect of sun exposure in the development of different types of melanoma with respect to their clinical and mutational profile. Certain well-known risk factors, such as skin, hair and eye pigmentation and melanocytic naevi have been validated in large-scale association studies, while additional lifestyle factors and iatrogenic exposures, such as immunosuppressive agents and nonsteroidal anti-inflammatory drugs are being investigated. In addition, genome-wide association studies have revealed genetic loci that underlie the genetic susceptibility of melanoma, some of which are related to known risk factors. Recently, an interesting association of melanoma with Parkinson disease has been noted, with a higher than expected frequency of melanoma in patients with Parkinson disease and vice versa. This review article provides an update in the epidemiology of cutaneous melanoma and discusses recent developments in the field.

Adolescents' reasons for tanning and appearance motives: a preliminary study

We examined adolescents' reasons for tanning and how these relate to appearance evaluation and orientation. Two hundred and sixty-four Canadian adolescents (age range 15-19 years) in grades 10, 11, and 12 completed a survey that included scales measuring their reasons for tanning, appearance evaluation, and appearance orientation. It was found that girls and boys differed on four of nine subscales measuring reasons for tanning. Girls believed more strongly than boys that tanning improved their general appearance and that friends influenced their decision to tan. Girls also expressed less concern than boys that tanning caused immediate skin damage or premature aging. The pattern of correlations between the reasons for tanning and appearance orientation was similar for girls and boys. For both, appearance reasons for tanning and sociocultural influences on tanning were positively associated with appearance orientation. Suggestions for future research with adolescents and a proposal for a guiding model are provided.

Are we seeing the effects of public awareness campaigns? A 10-year analysis of Breslow thickness at presentation of malignant melanoma in the South West of England

INTRODUCTION

The last 20 years has seen a marked improvement in skin cancer awareness campaigns. We sought to establish whether this has affected the presenting Breslow thickness of malignant melanoma in the South West.

METHOD

This is a retrospective study looking at the first presentation of melanomas from 2003 to 2011. Data was accessed using the local online melanoma database.

RESULTS

A total of 2001 new melanomas presented from 2003 to 2012 (Male:Female = 1:1.062). The average yearly number of melanomas was 200.1 (range = 138-312). The mean age was 62.5 years (range 12-99). Data was analysed using a Chi² test. For 0-1 mm melanomas, there is a significant difference in the observed versus expected values over the 10 years (p = 0.0018). There is an increasing proportion of 0-1 mm (thin) melanomas presenting year on year, with a positive linear trend. This is very statistically significant (p < 0.0001). The 1-2 mm melanomas are decreasing in proportion with a negative linear trend (p = 0.0013). The 2-4 mm are also decreasing in proportion (p = 0.0253). There is no significant change in the thick >4 mm melanomas (p = 0.1456).

CONCLUSION

The proportion of thin 0-1 mm melanomas presenting in South West England has significantly increased from 2003 to 2012. There is no significant change in the thick >4 mm melanomas. This may be a result of increased public awareness due to effective public health campaigns which has significant prognostic and financial implications.

The role of public health advocacy in achieving an outright ban on commercial tanning beds in Australia

Although many countries still face opposition to the legislation of artificial tanning beds, all Australian states and territories have announced a total ban on commercial tanning beds. A combination of epidemiological and policy-centered research, powerful personal stories, and the active advocacy of prominent academics, cancer organizations, and grassroots community campaigners contributed to the decisions to first legislate standards and then ban all commercial tanning beds. We have illustrated that incremental change can be an effective pathway to securing substantial public health reforms.

Spatial distribution of cosmetic-procedure businesses in two U.S. cities: a pilot mapping and validation study

Cosmetic procedures have proliferated rapidly over the past few decades, with over $11 billion spent on cosmetic surgeries and other minimally invasive procedures and another $2.9 billion spent on U.V. indoor tanning in 2012 in the United States alone. While research interest is increasing in tandem with the growth of the industry, methods have yet to be developed to identify and geographically locate the myriad types of businesses purveying cosmetic procedures. Geographic location of cosmetic-procedure businesses is a critical element in understanding the public health impact of this industry; however no studies we are aware of have developed valid and feasible methods for spatial analyses of these types of businesses. The aim of this pilot validation study was to establish the feasibility of identifying businesses offering surgical and minimally invasive cosmetic procedures and to characterize the spatial distribution of these businesses. We developed and tested three methods for creating a geocoded list of cosmetic-procedure businesses in Boston (MA) and Seattle (WA), USA, comparing each method on sensitivity and staff time required per confirmed cosmetic-procedure business. Methods varied substantially. Our findings represent an important step toward enabling rigorous health-linked spatial analyses of the health implications of this little-understood industry.

Tanning bed use is not associated with internal cancer risk: evidence from a large cohort study

BACKGROUND

Increased risk of skin cancer by indoor tanning has drawn public attention. However, there are arguments that tanning bed use increases vitamin D production, which may therefore prevent internal cancers.

METHODS

We followed 73,358 female nurses for 20 years (1989-2009) in the Nurses' Health Study II and investigated the frequency of tanning bed use during high school/college and at ages 25 to 35 in relation to the incidence of total cancers (excluding skin cancers). We used multivariate Cox proportional hazards models to estimate the HRs and 95% confidence intervals (CI) of total cancers and each individual major cancer with more than 100 cases.

RESULTS

During follow-up, a total of 4,271 internal cancer-related cases were diagnosed. No association was found between tanning bed use and risk of total cancers (multivariable-adjusted HR, 0.99; 95% CI, 0.95-1.04 for every 4 times/y use on average during high school/college and at ages 25-35). In addition, no association was found for the risk of any individual major cancers, such as breast cancer, thyroid cancer, colorectal cancer, non-Hodgkin lymphoma, or endometrial cancer.

CONCLUSIONS

Our data do not suggest any association between the use of tanning beds and risk of internal cancers.

IMPACT

On the basis of the strong evidence of increase in skin cancer risk and no evidence of reduction in internal cancer risk by tanning bed use, it is important to warn the public against indoor tanning.

Skin cancer prevention

Prevention signifies the avoidance of diseases. It also includes the early detection of diseases and taking measures to avoid worsening of an existing disease. Prevention is divided into primary, secondary and tertiary prevention. The prevention of skin cancer is particularly important due to the rising incidence of skin cancer in recent years. In Germany, 195.000 new cases of skin cancer, including non melanoma skin cancer and melanoma are occurring. Therefore, skin cancer is among the most common cancer diseases. Primary prevention comprises the reduction of skin cancer risk behavior, including education about the danger of UV exposure and the right way of dealing with natural and artificial UV radiation. The implementation of a systematic skin cancer screening in Germany contributes to secondary prevention. First data from the initial project in Schleswig-Holstein, Germany's most northern state, indicate for the first time that the incidence and mortality of melanoma can be reduced by secondary prevention. For tertiary prevention, the national associations recommend a risk-adapted, evidence-based follow-up for all types of skin cancer. From the perspectives of the payers and from the patients, prevention is assessed positively. Prevention can contribute to a reduction of disease burden.

Pediatricians' perspectives on indoor tanning

This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanning among adolescents, as well as their awareness of current legislation that restricts youth access to tanning beds.

Comprehensive evaluation of indoor tanning regulations: a 50-state analysis, 2012

Teenage use of indoor tanning has reached epidemic proportions. There is no federal ban on teen use; rather, it is left to each state to determine policy. We conducted a state-by-state analysis using data from each state's statutes and regulations and supplementary information from the National Conference of State Legislatures. First, we refined an earlier 35-item instrument to now include 56 items that extensively measures age bans, parental involvement, warnings/information, enforcement, and operating requirements. To grade each tanning law, we developed a uniform scoring system with a goal of providing performance data for future comparisons. As of August 2012, 13 states had no tanning facility statute or regulation for minors. In states with some regulations, teen bans are lax-nearly uniformly, most young children under the age of 14 can legally tan with or without suboptimal parental consent or accompaniment laws. Strong Food and Drug Administration involvement can simplify and unify the inconsistencies that exist among states' indoor tanning laws. Until consistent regulations are promulgated and enforced, such an instrument can provide a benchmark for state investigations into the deficiencies and progress of their laws, as well as facilitate direct comparison between states for research and educational purposes.

Sunbed use and cutaneous melanoma in Norway

Aims: Incidence rates of cutaneous melanoma (CM) in light skinned people in Norway are among the highest in the world. Sunbed use has increased in Norway since 1980. We will try to elucidate whether there is any correlation between the increase in sunbed use and the CM incidence rates, whether the increase in CM risk is similar for all age groups, and whether the possible difference between young and old persons can inform future healthcare strategies. Methods: The frequency of sunbed use by different age groups in the time period 1980–2011 and incidence rates (1980–2009) of CM at different age groups in Norway were studied. Time in minutes per day spent in front of screen of computers or TVs for boys and girls was also analysed. Results: The number of sunbed sessions per year in Norway increased throughout the entire period. The number of men and women diagnosed with CM per year, all ages combined, also increased. Sunbed use increased at a similar rate for three age groups (0–19, 20–50, and >50 years old), while the age-adjusted CM incidence rate increased only for the oldest group. Time spent in front of the screen of computers or TVs increased from 1985 to 2005 and is still increasing. Conclusions: CM incidence is decreasing while sunbed use is increasing in younger age groups. The present data indicate that more work needs to be done before one can know whether the overall health effects of sunbed exposure are positive or negative.

Preventing skin cancer through reduction of indoor tanning: current evidence

Exposure to ultraviolet radiation from indoor tanning devices (tanning beds, booths, and sun lamps) or from the sun contributes to the risk of skin cancer, including melanoma, which is the type of skin cancer responsible for most deaths. Indoor tanning is common among certain groups, especially among older adolescents and young adults, adolescent girls and young women, and non-Hispanic whites. Increased understanding of the health risks associated with indoor tanning has led to many efforts to reduce use. Most environmental and systems efforts in the U.S. (e.g., age limits or requiring parental consent/accompaniment) have occurred at the state level. At the national level, the U.S. Food and Drug Administration and the Federal Trade Commission regulate indoor tanning devices and advertising, respectively. The current paper provides a brief review of (1) the evidence on indoor tanning as a risk factor for skin cancer; (2) factors that may influence use of indoor tanning devices at the population level; and (3) various environmental and systems options available for consideration when developing strategies to reduce indoor tanning. This information provides the context and background for the companion paper in this issue of the American Journal of Preventive Medicine, which summarizes highlights from an informal expert meeting convened by the CDC in August 2012 to identify opportunities to prevent skin cancer by reducing use of indoor tanning devices.

Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Exposure to ultraviolet radiation from indoor tanning device use is associated with an increased risk of skin cancer, including risk of malignant melanoma, and is an urgent public health problem. By reducing indoor tanning, future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs. On August 20, 2012, the CDC hosted a meeting to discuss the current body of evidence on strategies to reduce indoor tanning as well as research gaps. Using the Action Model to Achieve Healthy People 2020 Overarching Goals as a framework, the current paper provides highlights on the topics that were discussed, including (1) the state of the evidence on strategies to reduce indoor tanning; (2) the tools necessary to effectively assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and (3) strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors. Although many challenges and barriers exist, a coordinated, multilevel, transdisciplinary approach has the potential to reduce indoor tanning and prevent future cases of skin cancer.

Implications of lessons learned from tobacco control for tanning bed reform

Tanning beds used according to the manufacturer’s instructions expose the user to health risks, including melanoma and other skin cancers. Applying the MPOWER model (monitor, protect, offer alternatives, warn, enforce, and raise taxes), which has been used in tobacco control, to tanning bed reform could reduce the number of people at risk of diseases associated with tanning bed use. Among the tactics available to government are restricting the use of tanning beds by people under age 18 and those with fair skin, increasing the price of tanning bed services through taxation, licensing tanning bed operators, and banning unsupervised tanning bed operations.

Effects of ultraviolet radiation, visible light, and infrared radiation on erythema and pigmentation: a review

The effects of ultraviolet radiation, visible light, and infrared radiation on cutaneous erythema, immediate pigment darkening, persistent pigment darkening, and delayed tanning are affected by a variety of factors. Some of these factors include the depth of cutaneous penetration of the specific wavelength, the individual skin type, and the absorption spectra of the different chromophores in the skin. UVB is an effective spectrum to induce erythema, which is followed by delayed tanning. UVA induces immediate pigment darkening, persistent pigment darkening, and delayed tanning. At high doses, UVA (primarily UVA2) can also induce erythema in individuals with skin types I-II. Visible light has been shown to induce erythema and a tanning response in dark skin, but not in fair skinned individuals. Infrared radiation produces erythema, which is probably a thermal effect. In this article we reviewed the available literature on the effects of ultraviolet radiation, visible light, and infrared radiation on the skin in regards to erythema and pigmentation. Much remains to be learned on the cutaneous effects of visible light and infrared radiation.

Exposure to indoor tanning in France: a population based study

Background

Tanning lamp sessions have increased in Europe in recent years. Recent epidemiological studies have confirmed a proven link between melanoma and artificial UV exposure. However, in France, little information is available to determine the exposure of the population. This article presents the results from the ‘Baromètre cancer 2010’ concerning the proportion of users exposed to artificial UV radiation in France, their characteristics and level of information on the risks associated.

Methods

A two stage random sampling telephone survey assisted by CATI system (household, individual) was performed from 3 April 2010 to 7 August 2010 on a sample of 3,359 people aged 15 to 75 years old.

Results

In 2010, 13.4% of the French population reported to have tanning lamp sessions at least once in their lifetime and 3.5% of the total population reported the use of artificial UV radiation over the last twelve months. Exposure over the last twelve months is most commonly seen among females (5.0%) and young population between 20–25 years old (9.6%). In addition, 3.5% of those under 18 years report having attended UV booths at least once during their lifetime even though they are forbidden to minors. Moreover, more than one the third of users reported more than 10 exposures within a year. The places of exposure cited most often were beauty salons (50%) and tanning centers (46%). Only 49.2% of those surveyed felt that they were well informed on the risks of cancer associated with UV booths. Furthermore, the population was found to have misconceptions about artificial UV radiation. One quarter of the population, believe that artificial UV radiation use before vacation protects the skin from sunburn.

Conclusions

This first study on artificial UV radiation exposure in France has better quantified and characterized the users. It has also defined the state of knowledge and the perception of risk by the general French population. This work will contribute to determine actions of prevention to reduce cancer risk related to artificial UV radiation.

Teens and indoor tanning: a cancer prevention opportunity for pediatricians

In October 2011, California became the first US state to ban indoor tanning for minors under age 18 years. Vermont followed in May 2012. Increasingly, scientific evidence shows that artificial tanning raises the risk of skin cancer, including melanoma, a common cancer in adolescents and young adults and the type most likely to result in death. The World Health Organization, the American Academy of Pediatrics, the American Academy of Dermatology, the American Medical Association, and other organizations strongly recommend legislation to ban minors under age 18 from indoor tanning. Several nations have banned teen tanning. Yet, tanning in salons is still a prevalent practice in the United States, especially among teen girls, where rates for the oldest teens approach 40%. There is no federal legislation to restrict minors from salon tanning. More than 60% of states have some kind of legislation regarding minors' use of tanning salons, but only California and Vermont have passed complete bans of indoor tanning for minors. The Indoor Tanning Association, an industry advocacy group, has vigorously opposed legislative efforts. Pediatricians can play key roles in counseling families and with legislative efforts. In this update, we review the prevalence of salon tanning, association with skin cancer risk, tanning addiction, the roles of the federal and state governments in regulation and legislation, and responses to arguments created by industry to oppose legislation. Preventing exposure to artificial tanning may save lives, including young lives, and is a key cancer prevention opportunity for pediatricians.

Practices of unregulated tanning facilities in Missouri: implications for statewide legislation

BACKGROUND

The incidence of skin cancer has increased in the United States, concomitant with increased UV radiation (UVR) exposure among young adults. We examined whether tanning facilities in Missouri, a state without indoor-tanning regulations, acted in accordance with the Food and Drug Administration's recommendations and consistently imparted information to potential clients about the known risks of UVR.

METHODS

We conducted a statewide telephone survey of randomly selected tanning facilities in Missouri. Each tanning facility was surveyed twice, in the morning (7 am-3 pm) and evening (3-10 pm), on different days, to determine intrasalon consistency of information provided to potential clients at different times.

RESULTS

On average, 65% of 243 tanning-facility operators would allow children as young as 10 or 12 years old to use indoor-tanning devices, 80% claimed that indoor tanning would prevent future sunburns, and 43% claimed that there were no risks associated with indoor tanning. Intrasalon inconsistencies involved allowable age of use, and UVR exposure type and duration. Morning tanning-facility employees were more likely to allow consumers to start with maximum exposure times and UV-A-emitting devices (P < .001), whereas evening employees were more likely to allow 10- or 12-year-old children to use indoor-tanning devices (P = .008).

CONCLUSIONS

Despite increasing evidence that UVR exposure in indoor-tanning devices is associated with skin cancer, ocular damage, and premature photoaging, tanning facilities in Missouri often misinformed consumers regarding these risks and lack of health benefits and inconsistently provided information about the Food and Drug Administration's guidelines for tanning devices.

Psychosocial correlates of frequent indoor tanning among adolescent boys

The aim of the current study was to assess psychosocial correlates (i.e., perceived weight, weight control strategies, substance use, and victimization) of frequent indoor tanning in adolescent boys-a group at high risk for developing skin cancer. Participants (N=7,907) were drawn from a nationally representative sample of adolescent boys attending high school in the United States. Binary logistic regression revealed that extreme weight control strategies, particularly steroid use (odds ratio=3.67) and compensatory vomiting (odds ratio=2.34), along with substance use and victimization, were significantly related to frequent indoor tanning. These results highlight the role of appearance-changing, and health-risk behaviors in the context of frequent indoor tanning. Skin cancer prevention interventions may benefit from adopting approaches that integrate the treatment of body dissatisfaction and subsequent maladaptive behaviors.