Prevalence of Indoor Tanning and Association With Sunburn Among Youth in the United States

A photoaging smartphone application to promote sun safety behaviors among youth in late childhood and adolescence

BACKGROUND

Ultraviolet (UV)-exposure behaviors can directly impact an individual's skin cancer risk, with many habits formed during childhood and adolescence. We explored the utility of a photoaging smartphone application to motivate youth to improve sun safety practices.

METHODS

Participants completed a preintervention survey to gather baseline sun safety perceptions and behaviors. Participants then used a photoaging mobile application to view the projected effects of chronic UV exposure on participants' self-face image over time, followed by a postintervention survey to assess motivation to engage in future sun safety practices.

RESULTS

The study sample included 87 participants (median [interquartile (IQR)] age, 14 [11-16] years). Most participants were White (50.6%) and reported skin type that burns a little and tans easily (42.5%). Preintervention sun exposure behaviors among participants revealed that 33 (37.9%) mostly or always used sunscreen on a sunny day, 48 (55.2%) experienced at least one sunburn over the past year, 26 (30.6%) engaged in outdoor sunbathing at least once during the past year, and zero (0%) used indoor tanning beds. Non-skin of color (18 [41.9%], p = .02) and older (24 [41.4%], p = .007) participants more often agreed they felt better with a tan. Most participants agreed the intervention increased their motivation to practice sun-protective behaviors (wear sunscreen, 74 [85.1%]; wear hats, 64 [74.4%]; avoid indoor tanning, 73 [83.9%]; avoid outdoor tanning, 68 [79%]).

CONCLUSION

The findings of this cross-sectional study suggest that a photoaging smartphone application may serve as a useful tool to promote sun safety behaviors from a young age.

A prospective cohort study exploring the joint influence of sunlight exposure and tanning bed use on basal cell carcinoma, squamous cell carcinoma, and melanoma risk

Exposure to solar ultraviolet (UV) radiation and use of UV-emitting tanning devices are known risk factors for skin cancer. Few studies have explored the interaction between these risk factors, namely how the risk of skin cancer increases among those who both have been exposed to high levels of natural sunlight and regularly use tanning beds. Nurses' Health Study II followed 116,430 women, aged 25-42, from 1991 to 2011. Cumulative average UV exposure was based on participants' residences at follow-up periods. History of severe sunburn during ages 15-20 was used as a proxy for early-life sunlight exposure. Tanning bed use in early life data was collected. Participants reported melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) diagnoses. We built multivariable Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of skin cancer associated with joint effects of sunlight exposure and tanning bed use. Participants with high sunlight exposure and tanning bed use during high school/college had an increased risk of BCC (HR = 1.53, 95% CI 1.37-1.71, Pinteraction=0.01; vs. low sun exposure and no tanning bed use). Participants with a history of severe sunburns and tanning bed use during high school/college were at increased risk of BCC (HR = 1.62, 95% CI 1.47-1.79, Pinteraction=0.02; vs. no sunburns and no tanning bed use). No significant interactions were found between sunlight exposure and tanning bed use on SCC and melanoma risk. We found significant interactions between sunlight exposure and tanning bed use on the risk of BCC.

Protocol for a cluster-randomized trial of a school-based skin cancer preventive intervention for adolescents

BACKGROUND

Adolescents infrequently use sun protection and engage in intentional tanning more frequently compared to other age groups, leading to increased ultraviolet radiation (UVR) exposure that heightens skin cancer risk across the lifespan. High schools are therefore an ideal setting for offering skin cancer preventive interventions. Yet, there are limited UVR protection interventions for high school students, especially those that are personalized, tested using randomized designs, and include long-term outcome assessment to determine the durability of intervention effects.

METHOD

The Sun-safe Habits Intervention and Education (SHINE) cluster-randomized trial will test a novel, personalized intervention that targets high school adolescents' sun protection and tanning behaviors, and tracks their outcomes for up to one year following intervention. Enrolled high schools will be randomized to receive either the personalized SHINE intervention, which includes facial UVR photographs and sun protection action planning, or standard education using publicly available materials. Students in both conditions will receive information about skin cancer, sun protection, and skin self-examination. Outcome variables will include students' sun protection and tanning behaviors and sunburn occurrence. Potential moderators (e.g., race/ethnicity) and mediators (e.g., self-efficacy) will also be assessed and tested.

CONCLUSIONS

This trial examines the efficacy of a personalized intervention targeting sun protection and tanning of high school students. The project will lead to new scientific understanding of the theoretical mechanisms underlying outcomes and moderators of the intervention effects, which will inform future intervention tailoring to meet the needs of vulnerable subgroups.

A Prospective Cohort Study Exploring the Joint Influence of Sunlight Exposure and Tanning Bed Use on Basal Cell Carcinoma, Squamous Cell Carcinoma, and Melanoma Risk

Exposure to solar ultraviolet (UV) radiation and use of UV-emitting tanning devices are known risk factors for skin cancer. Few studies have explored the interaction between these risk factors, namely how the risk of skin cancer increases among those who both have been exposed to high levels of natural sunlight and regularly use tanning beds. Nurses' Health Study II followed 116,430 women, aged 25-42, from 1991 to 2011. Cumulative average UV exposure was based on participants' residences at follow-up periods. History of severe sunburn during ages 15-20 was used as a proxy for early-life sunlight exposure. Tanning bed use in early life data was collected. Participants reported melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) diagnoses. We built multivariable Cox regression models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of skin cancer associated with joint effects of sunlight exposure and tanning bed use. Participants with high sunlight exposure and tanning bed use during high school/college had an increased risk of BCC (HR=1.53, CI 1.37-1.71, P interaction =0.01; vs. low UV exposure and no tanning bed use). Participants with a history of severe sunburns and tanning bed use during high school/college were at increased risk of BCC (HR=1.62, CI 1.47-1.79, P interaction =0.02; vs. no sunburns and no tanning bed use). No significant interactions were found between sunlight exposure and tanning bed use on SCC and melanoma risk. We found significant interactions between sunlight exposure and tanning bed use on the risk of BCC.

Association of sun-seeking behaviors with indoor tanning behavior in US white females during high school/college in Nurses' Health Study II

BACKGROUND

Frequent exposure to ultraviolet light has more detrimental and longer-term effects on the skin in early life than in adulthood. Teenagers with strong sun-seeking behaviors may be more likely to use an indoor tanning bed than those who seek less sun. We aimed to examine associations between sun-seeking behaviors and indoor tanning behavior during high school/college in US females.

METHODS

In this cross-sectional study, we used data from The Nurses' Health Study II, a large prospective cohort of US female nurses. We included a total of 81,746 white females who provided responses on the average annual frequency of indoor tanning during high school/college. Our study exposures were number of times/week spent outdoors in a swimsuit and percentage of time wearing sunscreen at the pool/beach as a teenager, weekly hours spent outdoors in direct sunlight during the daytime during high school/college, and number of severe sunburns that blistered between ages 15-20 years. The main outcome was annual frequency of indoor tanning bed usage during high school/college.

RESULTS

In multivariable-adjusted logistic regression, we demonstrated positive associations between sun-seeking behaviors and indoor tanning use. Specifically, teenagers who spent 7 times/week outdoors in a swimsuit (adjusted odds ratio [aOR], 95% confidence interval [CI] for daily vs. <1/week: 2.68, 1.76-4.09) were more likely to use indoor tanning beds ≥ 12 times/year. Teenagers with ≥ 10 sunburns (aOR, 95% CI for ≥ 10 vs. never: 2.18, 1.53-3.10) were more likely to use indoor tanning beds ≥ 12 times/year. Also, teenagers/undergraduates who spent ≥ 5 h/week outdoors in direct sunlight (aOR, 95% CI for ≥ 5 h/week vs. <1 h/week: 2.18, 1.39-3.44) were more likely to use indoor tanning ≥ 12 times/year. However, there was not a significant association between average usage of sunscreen at the pool/beach and average usage of indoor tanning beds. Multivariable-adjusted linear regression models also showed similar results.

CONCLUSIONS

Teenagers who spent more time outdoors in a swimsuit/direct sunlight or got more sunburns tended to use indoor tanning more frequently. These findings provide evidence that teenagers with stronger sun-seeking behaviors may have more exposure to artificial ultraviolet radiation as well.

Association of sun-seeking behaviors with indoor tanning habit in US females

Background

Frequent exposure to ultraviolet light in early life has more detrimental and long-term effects on skin than in adulthood. Teenagers with strong sun-seeking behaviors may be more likely to use an indoor tanning bed than those who seek less sun, probably due to addictiveness of ultraviolet exposure. We aimed to examine associations between sun exposure behaviors and average annual indoor tanning usage frequency during high school/college in US females.

Methods

In this cross-sectional study, we used data from The Nurses' Health Study II, a large prospective cohort of US female nurses. We included a total of 81,746 white females who answered the average annual frequency of indoor tanning during high school/college. Our study exposures were average weekly time spent outdoors in a swimsuit and average percentage of time of wearing sunscreen at the pool or beach during their teenage years, average weekly hours spent outdoors in direct sunlight in daytime during high school/college, and the number of severe sunburns which blistered between ages 15-20. Main outcomes was average annual frequency of indoor tanning bed usage during high school/college.

Results

In multivariable-adjusted logistic regression, we demonstrated positive associations between the sun exposure behaviors and the indoor tanning habit. Specifically, teenagers who spent daily outdoors in a swimsuit (adjusted odds ratio [aOR], 95% confidence interval [CI] for daily vs. <1/week: 2.68, 1.76-4.09) or who had ≥ 10 sunburns that blistered (aOR, 95% CI for ≥ 10 vs. never: 2.18, 1.53-3.10) were more likely to use indoor tanning beds ≥ 12 times/year. Also, teenagers/undergraduates who spent ≥ 5hours/week outdoors in direct sunlight during daytime used indoor tanning ≥ 12 times/year (aOR, 95% CI: 2.18, 1.39-3.44) than those who spent < 1/week. However, there was not a significant association between average uses of sunscreen at the pool/beach and indoor tanning bed. Multivariable-adjusted linear regression models also showed similar results.

Conclusions

Teenagers who spent more time outdoors or got more sunburns tended to use indoor tanning more frequently. These findings provide evidence that teenagers with strong sun-seeking behaviors may have excessive exposure to artificial ultraviolet radiation as well.

Validity of a Self-Assessment Skin Tone Palette Compared to a Colorimeter for Characterizing Skin Color for Skin Cancer Research

Our goal is to determine whether our objective 9-point Self-Assessment Skin Tone Palette (SASTP) is correlated with a colorimeter’s assessment of a melanin index, so that Hispanic and Black people can be included in skin cancer research where scales were developed for White populations. Subjects were asked to self-identify their skin tones using the SASTP. This study assessed the criterion validity of the SASTP by measuring a range of skin colors compared to a melanin index reported from a colorimeter for the upper-inner arm (non-sun-exposed skin color), and the outer forearm (sun-exposed). Among 188 non-artificial tanners, 50% were White, 30% were Hispanic or White-Hispanic, and 20% were other racial categories. Meanwhile, 70% were female (30% male) and 81% were age 18–29 (19% age 30+). The mean melanin of the upper-inner arm decreased with lighter skin color and stronger tendency to burn. The SASTP in comparison to melanin index values was correlated for both the upper-inner arm (r = 0.81, p < 0.001) and the outer forearm (r = 0.77, p < 0.001). The SASTP provides a 9-point scale that can be considered as an alternative, less expensive method that is comparable to the objective colorimeter melanin index, which may be useful in studies on skin cancer among White, non-White, and Hispanic peoples.

Epidemiology of Melanoma

Melanoma accounts for 1.7% of global cancer diagnoses and is the fifth most common cancer in the US. Melanoma incidence is rising in developed, predominantly fair-skinned countries, growing over 320% in the US since 1975. However, US mortality has fallen almost 30% over the past decade with the approval of 10 new targeted or immunotherapy agents since 2011. Mutations in the signaling-protein BRAF, present in half of cases, are targeted with oral BRAF/MEK inhibitor combinations, while checkpoint inhibitors are used to restore immunosurveillance likely inactivated by UV radiation. Although the overall 5-year survival has risen to 93.3% in the US, survival for stage IV disease remains only 29.8%. Melanoma is most common in white, older men, with an average age of diagnosis of 65. Outdoor UV exposure without protection is the main risk factor, although indoor tanning beds, immunosuppression, family history and rare congenital diseases, moles, and obesity contribute to the disease. Primary prevention initiatives in Australia implemented since 1988, such as education on sun-protection, have increased sun-screen usage and curbed melanoma incidence, which peaked in Australia in 2005. In the US, melanoma incidence is not projected to peak until 2022-2026. Fewer than 40% of Americans report practicing adequate protection (sun avoidance from 10 a.m.-4 p.m. and regular application of broad-spectrum sunscreen with an SPF > 30). A 2-4-fold return on investment is predicted for a US sun-protection education initiative. Lesion-directed skin screening programs, especially for those at risk, have also cost-efficiently reduced melanoma mortality.

Etiologies of Melanoma Development and Prevention Measures: A Review of the Current Evidence

Simple Summary

Melanoma constitutes a major public health risk, with the rates of diagnosis increasing on a yearly basis. Monitoring for risk factors and preventing dangerous behaviors that increase melanoma risk, such as tanning, are important measures for melanoma prevention. Additionally, assessing the effectiveness of various methods to prevent sun exposure and sunburns—which can lead to melanoma—is important to help identify ways to reduce the development of melanoma. We summarize the recent evidence regarding the heritable and behavioral risks underlying melanoma, as well as the current methods used to reduce the risk of developing melanoma and to improve the diagnosis of this disease.

Abstract

(1) Melanoma is the most aggressive dermatologic malignancy, with an estimated 106,110 new cases to be diagnosed in 2021. The annual incidence rates continue to climb, which underscores the critical importance of improving the methods to prevent this disease. The interventions to assist with melanoma prevention vary and typically include measures such as UV avoidance and the use of protective clothing, sunscreen, and other chemopreventive agents. However, the evidence is mixed surrounding the use of these and other interventions. This review discusses the heritable etiologies underlying melanoma development before delving into the data surrounding the preventive methods highlighted above. (2) A comprehensive literature review was performed to identify the clinical trials, observational studies, and meta-analyses pertinent to melanoma prevention and incidence. Online resources were queried to identify epidemiologic and clinical trial information. (3) Evidence exists to support population-wide screening programs, the proper use of sunscreen, and community-targeted measures in the prevention of melanoma. Clinical evidence for the majority of the proposed preventive chemotherapeutics is presently minimal but continues to evolve. (4) Further study of these chemotherapeutics, as well as improvement of techniques in artificial intelligence and imaging techniques for melanoma screening, is warranted for continued improvement of melanoma prevention.

Correlates Between Physical Activity and Sunburn Prevalence Among a Nationally Representative Sample of US High School Students, 2015-2017

BACKGROUND

Physical activity is associated with greater odds of sunburn in adults, increasing harmful sun exposure and skin cancer risk. The authors sought to investigate parallel associations between sunburn and physical activity among US high school students.

METHODS

The authors examined pooled cross-sectional data from the 2015 and 2017 Youth Risk Behavior Survey. A nationally representative sample of 21,894 US high school students who responded to the sunburn question was included.

RESULTS

Prevalence of sunburn was 56.6% between 2015 and 2017. Sunburn prevalence was higher in physically active students (88.3%; 95% confidence interval [CI], 86.7%-90.0%; P < .0001) and student athletes (63.0%; 95% CI, 59.4%-66.7%; P < .0001). Among male students who were vigorously physically active (≥5 d) or on ≥3 teams, the odds of sunburn were 2.33 (95% CI, 1.81-3.00; P < .0001) and 2.52 (95% CI, 1.96-3.23; P < .0001), respectively. Among female students who were vigorously physically active (≥5 d) or on ≥3 teams, the odds of sunburn were 1.65 (95% CI, 1.36-2.02; P < .0001) and 2.92 (95% CI, 2.07-4.13; P < .0001), respectively.

CONCLUSIONS

Many US high school students are affected by sunburn, and the odds of sunburn are elevated during physical activity and team sports participation. Efforts are needed to improve sun safety regulations, education, and resources for youth during school and physical activity.

Sun Exposure, Tanning Behaviors, and Sunburn: Examining Activities Associated With Harmful Ultraviolet Radiation Exposures in College Students

Understanding the behaviors that lead to sunburn is an important objective toward developing intervention strategies to reduce risk for skin cancers. Our cross-sectional study surveyed 400 college students aged 18 and older at a public state university in the northeastern US in 2018 to assess tanning behaviors, outdoor activities, sun protection, and sunburn over the past year. Sunburn was exceedingly common; over half reported one or more sunburns in the past 12 months. Outdoor intentional and unintentional tanning were also common. Male sex, White race, sun sensitive skin type, and outdoor intentional and unintentional tanning were independently associated with increased odds of sunburn. Water and non-water sports, sunbathing, and vacations were also associated with sunburn. These results indicate that tanning and outdoor activities such as sports are important behaviors on which to focus for sunburn prevention among college students. Understanding the behaviors that are associated with sunburn provides useful opportunities to prevent skin cancer among young people.

The State of Melanoma: Emergent Challenges and Opportunities

Five years ago, the Melanoma Research Foundation (MRF) conducted an assessment of the challenges and opportunities facing the melanoma research community and patients with melanoma. Since then, remarkable progress has been made on both the basic and clinical research fronts. However, the incidence, recurrence, and death rates for melanoma remain unacceptably high and significant challenges remain. Hence, the MRF Scientific Advisory Council and Breakthrough Consortium, a group that includes clinicians and scientists, reconvened to facilitate intensive discussions on thematic areas essential to melanoma researchers and patients alike, prevention, detection, diagnosis, metastatic dormancy and progression, response and resistance to targeted and immune-based therapy, and the clinical consequences of COVID-19 for patients with melanoma and providers. These extensive discussions helped to crystalize our understanding of the challenges and opportunities facing the broader melanoma community today. In this report, we discuss the progress made since the last MRF assessment, comment on what remains to be overcome, and offer recommendations for the best path forward.

Attitudes and practice among dermatologists regarding indoor tanning

The aim of this study was to explore dermatologists' practices and attitudes related to educating and counseling their adolescent patients about indoor tanning. An online survey was carried out with a convenience sample of 100 dermatologists. Findings indicated that the majority of the dermatologists are actively engaged in discussing tanning bed use and sun protection with their adolescent patients. Most expressed positive attitudes toward educating patients on the risks of tanning bed use. Limited time was the most commonly reported barrier for the lack of discussion regarding indoor tanning. Of note, more than half of the dermatologists (65%) had patients suffering from tanning addiction. For tanning-addicted patients, dermatologists can encourage lifestyle changes, the use of sunless tanning products, and referrals when the patient's needs extend beyond the scope of the dermatologist.

Prevalence of Indoor Tanning Among U.S. High School Students from 2009 to 2017

Indoor tanning exposes users to high levels of ultraviolet radiation, increasing skin cancer risk. The risk is greatest for those who begin indoor tanning at a young age. The objective of this study was to assess changes in indoor tanning prevalence over time among U.S. high school students, by sex, age, and race/ethnicity. We used cross-sectional data from the 2009, 2011, 2013, 2015, and 2017 national Youth Risk Behavior Survey to examine changes in indoor tanning prevalence from 2009 to 2017 and from 2015 to 2017. From 2009 to 2017 indoor tanning declined overall (15.6 to 5.6%; p < 0.001), across all age groups, and among white (37.4 to 10.1%; p < 0.001) and Hispanic (10.5 to 3.0%; p < 0.001) female students, and white (7.0 to 2.8%; p < 0.001) and Hispanic (5.8 to 3.4%; p < 0.001) male students. From 2015 to 2017, indoor tanning declined overall (7.3 to 5.6%; p = 0.04) and among white (15.2 to 10.1%; p = 0.03) and Hispanic (5.8 to 3.0%; p = 0.02) female students, and 16-year-old students (7.2 to 4.7%; p = 0.03). Indoor tanning has continued to decrease, particularly among white and Hispanic female students, dropping well below the Healthy People 2020 target for adolescents. However, continued efforts are needed to further reduce and sustain reductions in adolescent indoor tanning and address remaining research gaps.

The high costs of cheap tanning: pricing and promotional practices of indoor tanning facilities in six cities in the United States

Few studies have investigated pricing and promotional practices used by the indoor tanning industry, despite their potential to promote indoor UV tanning-a well-established risk factor for melanoma skin cancer. Posing as potential customers, we telephoned 94 indoor tanning businesses in six United States (U.S.) cities and requested pricing information. The price of a single tanning session ranged from $0 to $23, and was lower at facilities that offered indoor tanning as a secondary service (mean $4.82 and free in 35%) than at tanning salons (mean $16.45). Session prices in salons could be as low as $1.50 with daily use of an unlimited monthly plan. Free indoor tanning, monthly packages, and memberships encourage increased use. Policies that limit free indoor tanning or that restrict pricing and advertising for indoor tanning exist in several places in the U.S. and Europe. Future research should evaluate whether those policies are effective in reducing indoor tanning.

Indoor tanning and poor mental health among adolescents in New York City (2015)

This study explored relationships between mental health and indoor tanning among high school students in New York City using 2015 data from the Youth Risk Behavior Surveillance System. Those more likely to use indoor tanning were females (odds ratio = 6.26, 95% confidence interval = 6.08–6.45) and non-Hispanic White (odds ratio = 1.10, 95% confidence interval = 1.06–1.14). Being bullied on school property (odds ratio = 1.30, 95% confidence interval = 1.25–1.34), having attempted suicide (odds ratio = 2.08, 95% confidence interval = 1.99–2.18), and having sought counseling (odds ratio = 1.22, 95% confidence interval = 1.18–1.26) were significantly associated with indoor tanning. This study indicates that engaging in indoor tanning is associated with a number of mental health factors.

A blueprint for the primary prevention of cancer: Targeting established, modifiable risk factors

In the United States, it is estimated that more than 1.7 million people will be diagnosed with cancer, and more than 600,000 will die of the disease in 2018. The financial costs associated with cancer risk factors and cancer care are enormous. To substantially reduce both the number of individuals diagnosed with and dying from cancer and the costs associated with cancer each year in the United States, government and industry and the public health, medical, and scientific communities must work together to develop, invest in, and implement comprehensive cancer control goals and strategies at the national level and expand ongoing initiatives at the state and local levels. This report is the second in a series of articles in this journal that, together, describe trends in cancer rates and the scientific evidence on cancer prevention, early detection, treatment, and survivorship to inform the identification of priorities for a comprehensive cancer control plan. Herein, we focus on existing evidence about established, modifiable risk factors for cancer, including prevalence estimates and the cancer burden due to each risk factor in the United States, and established primary prevention recommendations and interventions to reduce exposure to each risk factor.

Prevalence and correlates of intentional outdoor and indoor tanning among adolescents in the United States: Findings from the FLASHE survey

A body of research has focused on adolescents' indoor tanning behaviors but relatively little is known about the prevalence of adolescents' intentional outdoor tanning (time spent outdoors to get a tan). The present study used data from the National Cancer Institute's 2014 Family Life, Activity, Sun, Health and Eating (FLASHE) cross-sectional survey to examine the prevalence and correlates of intentional outdoor and indoor tanning among adolescents in the United States. Both unadjusted (bivariate) and adjusted (multi-variate) logistic regressions were performed to test the associations between demographic variables, time spent on media (e.g., using computers), emotional status and outdoor or indoor tanning. The overall prevalence of frequent outdoor tanning among adolescents in the U.S. was 15.6% (95% CI 13.8-17.4%) and the rate of indoor tanning in the past 12 months was 3% (95% CI 2.2-3.9). The adjusted odds of intentional outdoor tanning were significantly higher among girls (AOR 2.39, 95% CI 1.75-3.27), Non-Hispanic Whites (AOR 2.85, 95% CI 1.99-4.07), and those who spent more time on cell phones (AOR 1.40, 95% CI 1.25-1.57). The adjusted odds of indoor tanning were significantly higher among those who spent more time on computers (AOR 1.38, 95% CI 1.09-1.74) and cell phones (AOR 1.49, 95% CI 1.19-1.87). This study provides evidence for the relationship between media use and tanning behaviors among adolescents.

State Indoor Tanning Laws and Prevalence of Indoor Tanning Among US High School Students, 2009-2015

OBJECTIVES

To examine the association between state indoor tanning laws and indoor tanning behavior using nationally representative samples of US high school students younger than 18 years.

METHODS

We combined data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveys (n = 41 313) to analyze the association between 2 types of state indoor tanning laws (age restriction and parental permission) and the prevalence of indoor tanning during the 12 months before the survey, adjusting for age, race/ethnicity, and survey year, and stratified by gender.

RESULTS

Age restriction laws were associated with a 47% (P < .001) lower indoor tanning prevalence among female high school students. Parental permission laws were not found to be associated with indoor tanning prevalence among either female or male high school students.

CONCLUSIONS

Age restriction laws could contribute to less indoor tanning, particularly among female high school students. Such reductions may reduce the health and economic burden of skin cancer.

Prevalence of Tanning Addiction and Behavioral Health Conditions among Ethnically and Racially Diverse Adolescents

Evidence indicates that tanning may be addictive and is associated with other behavioral health conditions. Few studies have examined tanning addiction among adolescents. We performed a cross-sectional study to explore the relationship between tanning addiction, substance use, and psychological conditions among a racially and ethnically diverse adolescent population. Tanning addiction was assessed using the modified CAGE measure among 11th grade students in Los Angeles (N = 2,637; response rate 78%). Overall, 7.02% of the sample met tanning addiction criteria. Tanning addiction was significantly associated with past 30-day smoking and marijuana use, problem substance use, depression, panic disorder, obsessive-compulsive disorder, and bipolar disorder in regression models. After controlling for all significant substance use and psychological variables, we found that problem marijuana use and obsessive-compulsive disorder remained significantly associated with tanning addiction (odds ratio = 2.06 [95% confidence interval = 1.03-4.09] and odds ratio = 2.54 [95% confidence interval = 1.73-3.72], respectively.) Tanning addiction was also significantly associated with multiple problem substance use and behavioral health conditions. Our findings indicate an appreciable prevalence of tanning addiction among ethnically and racially diverse adolescents and suggest the importance of addressing tanning addiction in the context of comorbid behavioral conditions to reduce this high-risk behavior among diverse youth.

Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States

Contemporary information on the fraction of cancers that potentially could be prevented is useful for priority setting in cancer prevention and control. Herein, the authors estimate the proportion and number of invasive cancer cases and deaths, overall (excluding nonmelanoma skin cancers) and for 26 cancer types, in adults aged 30 years and older in the United States in 2014, that were attributable to major, potentially modifiable exposures (cigarette smoking; secondhand smoke; excess body weight; alcohol intake; consumption of red and processed meat; low consumption of fruits/vegetables, dietary fiber, and dietary calcium; physical inactivity; ultraviolet radiation; and 6 cancer-associated infections). The numbers of cancer cases were obtained from the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute; the numbers of deaths were obtained from the CDC; risk factor prevalence estimates were obtained from nationally representative surveys; and associated relative risks of cancer were obtained from published, large-scale pooled analyses or meta-analyses. In the United States in 2014, an estimated 42.0% of all incident cancers (659,640 of 1570,975 cancers, excluding nonmelanoma skin cancers) and 45.1% of cancer deaths (265,150 of 587,521 deaths) were attributable to evaluated risk factors. Cigarette smoking accounted for the highest proportion of cancer cases (19.0%; 298,970 cases) and deaths (28.8%; 169,180 deaths), followed by excess body weight (7.8% and 6.5%, respectively) and alcohol intake (5.6% and 4.0%, respectively). Lung cancer had the highest number of cancers (184,970 cases) and deaths (132,960 deaths) attributable to evaluated risk factors, followed by colorectal cancer (76,910 cases and 28,290 deaths). These results, however, may underestimate the overall proportion of cancers attributable to modifiable factors, because the impact of all established risk factors could not be quantified, and many likely modifiable risk factors are not yet firmly established as causal. Nevertheless, these findings underscore the vast potential for reducing cancer morbidity and mortality through broad and equitable implementation of known preventive measures. CA Cancer J Clin 2018;68:31-54. © 2017 American Cancer Society.

Counseling on Sun Protection and Indoor Tanning

BACKGROUND

The US Preventive Services Task Force recommends clinical counseling for individuals ages 10 to 24 years to decrease skin cancer risk.

METHODS

A national, random sample of US American Academy of Pediatrics members practicing primary care in 2002 (response rate 55%) and 2015 (response rate 43%). Surveys explored attitudes and experiences regarding sun protection counseling; indoor tanning questions were added in 2015. χ² tests compared demographics and counseling responses across years, and multivariable logistic regression models examined counseling predictors.

RESULTS

More pediatricians in 2015 (34%) than in 2002 (23%) reported discussing sun protection during recent summer months with ≥75% of patients. This pattern held across all patient age groups (each P <.001). Female and suburban pediatricians counseled more; those in the South and West counseled less. More pediatricians in 2015 than in 2002 named time as a barrier. Sun protection ranked lowest among preventive topics in both years. In 2015, approximately one-third of pediatricians reported discussing indoor tanning at least once with 10 to 13 year-old patients; approximately half discussed this with older adolescents. Most (70%) did not know if their states had laws on minors' indoor tanning access; those stating they knew whether a law existed counseled more.

CONCLUSIONS

Although improved, sun protection counseling rates remain low. Indoor tanning counseling can be improved. Because early-life exposure to UV radiation increases risk and clinician counseling can positively impact prevention behaviors, pediatricians have an important role in skin cancer prevention; counseling may save lives. Time constraints remain a barrier.

Tanning and Teens: Is Indoor Exposure the Tip of the Iceberg?

Because of recent state regulations and the reduced availability of free-standing tanning salons, indoor tanning (IT) prevalence is beginning to decline. This may lead to unintended consequences, such as increases in outdoor intentional tanning. We advance a series of research directions to track and intervene to address all forms of intentional tanning. First, we advocate for enforcement of IT regulation and encourage collection of data on tanning salon compliance and alternative IT strategies. Second, we suggest questions about outdoor and IT should be included in national surveys. Third, we need to understand the potentially complex patterns of indoor and outdoor tanning that may exist among those who tan. Fourth, research examining changing motivations for intentional tanning is needed. Finally, IT intervention studies should include outdoor tanning as an outcome to examine the effect of interventions on these related risk behaviors. These advances will ensure the development of novel interventions to address intentional tanning through multiple routes, and to avoid any unintended negative consequence of IT regulation. The promising downward direction of IT use in the United States should now lead the public health field to sharpen its focus on outdoor tanning. Cancer Epidemiol Biomarkers Prev; 26(8); 1170-4. ©2017 AACR.

Epidemiology of Keratinocyte Carcinoma

Purpose of the review

To provide a synopsis of recent research advances in the epidemiology of keratinocyte carcinoma (KC), with a focus on indoor tanning and known risk factors for other forms of cancer such as cigarette smoking and alcohol drinking.

Recent findings

The evidence is strong enough to infer that use of UVR-emitting indoor tanning devices cause KC. Epidemiologic studies of cigarette smoking, alcohol drinking, and menopausal hormone therapy all show some suggestion for increased risk of KC but the evidence is not yet strong enough to determine if there is a true etiologic role. Body mass index is clearly inversely associated with KC risk but this is more likely to be due to lower UVR exposure in overweight and obese individuals than it is due to a true etiologic role.

Summary

The epidemic of KC continues unabated, and the causal role of indoor tanning is contributing to this unfavorable trend in KC incidence rates. Advances in understanding the etiology of KC should not divert attention away from the fact that the primary public health strategy to prevent KC is known: minimize population exposure to UVR from the sun and from UVR-emitting indoor tanning devices, particularly among those with sun-sensitive phenotypes.