Tanning habits and sunburn in a Swedish population age 13-50 years

A systematic review on traditional, ayurvedic, and herbal approaches to treat solar erythema

Solar erythema is a kind of radiation burn that strikes living tissue, such as skin, that arises from overexposure to UV radiation often from the sun. Ordinary symptoms of solar erythema include reddish skin, specifically warm to touch, overall tiredness, hurting, and mild whirl. Sunscreen contains SPF value, which measures how much ultraviolet radiation is needed to cause sunburn on sunscreen-applied skin, which is proportional to the quantity of solar energy needed to cause sunburn on unprotected skin. Between 30 and 50 SPF value is sufficient to protect from sunburn, especially for the people who are more sensitive to sunburn. Sunscreen also protects from sun damage including dark spots and discoloration and helps to keep skin smooth, spotless, and more even. Chemical-based sunscreen is widely used because it effectively protects the skin from sun damage, but it clogs pores and can be problematic for sensitive skin as it can cause itching or stinging of the skin and pus in the hair follicles. On the other hand, herbal sunscreen absorbs light preferentially over the range of 280-320 mm without causing any harm to the skin and eyes. Ayurveda rejuvenates dull skin by regaining the skin's natural glow and radiance. This review concludes the damaging and harmful effects of UV rays, along with various traditional, ayurvedic, and herbal approaches to treat solar erythema naturally.

An Epidemiological Update on Indoor Tanning and the Risk of Skin Cancers

Indoor tanning (sunbeds, solarium) uses artificial ultraviolet radiation (UVR) to stimulate cosmetic tanning of the skin. Indoor tanning has been officially classified as a human carcinogen in 2009 by the International Agency for Research on Cancer of the World Health Organization (WHO). The differences in the prevalence of sunbed use across countries and over the years highlight underlying legislative, climatic, and cultural differences. Indoor tanning-seeking behaviors may be driven by motivations for an appealing appearance, largely influenced by gender and age, and several misconceptions that a prevacation tan safeguards the skin, that sunbeds can be used to treat acne or to increase vitamin D, or that tanning is a healthy habit. This review provides an epidemiological update on the prevalence of sunbed use, who tends to use sunbeds and why, and details the current evidence on the association of sunbeds with skin cancers, including cutaneous melanoma, basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (cSCC). A statistically significant higher risk of cutaneous melanoma, BCC and cSCC with the use of sunbeds has been consistently demonstrated. This risk of skin cancer is even higher with the more frequent use of sunbeds, underscoring a dose-response relationship, and in those first exposed to sunbeds at a younger age. Preventive measures against sunbed use include legislation restricting sunbed use, educational campaigns to inform and discourage from indoor tanning, as well as using the internet, online advertising messages and the social media to reach larger audiences and to promote an untanned appearance.

Sun Exposure and Protection Index (SEPI) and Self-Estimated Sun Sensitivity

The incidence of skin cancer is increasing worldwide, mostly because of increasing exposure to ultraviolet (UV) radiation from the sun. The Sun Exposure and Protection Index (SEPI) questionnaire, developed in Linköping and validated in Sweden and Australia, is used to map sun habits, sun protection behaviour, and readiness to increase sun protection. We sought to examine differences in sun habits or sun protection behaviour and propensity to increase sun protection, based on SEPI as related to self-estimated skin UV sensitivity according to the Fitzpatrick classification. The study population comprised students at Linköping University, who were asked to complete the SEPI questionnaire. We examined differences in sun habits and sun protection behaviour according to skin type and gender. Individuals with lower UV sensitivity had significantly riskier sun habits and sun protection behaviour and were significantly less likely to increase sun protection. Women spent significantly more time tanning than men, more time in the midday sun, used sunscreen more frequently, and were more likely to seek the shade for sun protection. Individuals with higher UV sensitivity were significantly more likely to increase sun protection; individuals with low UV sensitivity tended to have a riskier attitude to sunbathing. In conclusion, self-estimated skin type and gender are important factors influencing sun exposure habits and sun protection behaviour.

Study of Sunbathing in Children: The Preliminary Evaluation of a Prevention Program

Aims and background

Sunburn during childhood is associated with an increased risk for developing melanoma in an adult age. The aim of the present study was to define the validity of our educational program in order to teach the positive effects and risks of sun exposure during childhood.

Patients and methods

We conducted a population-based, case-control study in primary schools of three towns in Northern Italy (Brescia, Bergamo and Trento) between 2001 and 2002. The study was carried out on 1945 pupils (aged 8-9 years) and included 1309 case children who received an educational program before the summer to increase awareness towards sun exposure and 636 control children who did not. Parents of case and control children were interviewed using a questionnaire about their children's skin characteristics, sun protective behavior and sunburns. The questionnaire was completed twice, before and after the summer, to verify the changes of sun exposure habits.

Results

A significant decrease in sunburns was demonstrated in the group of subjects who received the educational program, indicating the validity of our operative procedure (from 14.6% to 10%, P = 4 × 10−4).

Conclusions

Our educational melanoma program may be important to disseminate in a wider range of children a correct education on sun exposure during childhood.

Prevalence and determinants of sunbed use in thirty European countries: data from the Euromelanoma skin cancer prevention campaign

BACKGROUND

Although considered as a first-group carcinogen, indoor tanning is a common practice in Europe. Euromelanoma is a pan-European skin cancer prevention campaign.

OBJECTIVES

To compare several European countries in terms of the prevalence and determinants of sunbed use.

METHODS

Participants in the Euromelanoma campaigns filled in questionnaires containing demographics and risk factors, including type/duration of sunbed use. Multivariate analyses adjusted for age, gender, education, skin type and year of survey were employed to assess factors independently associated with sunbed use in each country.

RESULTS

In total, 227 888 individuals (67.4% females, median age 44, 63.4% highly educated, 71.9% skin types III-VI) from 30 countries participated. Overall, the prevalence of sunbed ever use was 10.6% (≤19-year-olds: 5.9%; 20 to 35-year-olds: 17.0%; >35-year-olds: 8.3%). Females displayed a higher prevalence than males in all countries. Balkan countries displayed the highest female/male ratios (≥4). Sunbed use was significantly more prevalent among skin type III-VI (14/30 countries) and highly educated participants (11/30 countries). Significant correlations were found between sunbed use prevalence and countries' latitude (P < 0.001) and sunshine (P = 0.002); Italy and Spain represented exceptions towards excessive exposure. Very different prevalence rates were found for Spain (19.3%) and Portugal (2.0%). Scandinavian countries ranked highest in sunbed use among ≤19-year-olds, Baltic countries among 20 to 35-year-olds.

CONCLUSIONS

Sunbed use prevalence was higher in northern, sun-deprived countries, with the exception of Italy and Spain. The main determinants of sunbed use were age (young adults) and gender (females), whereas education and skin type had a less relevant effect. Geographic particularities were found in four regions: Iberian (prevalence ten times higher in Spain than Portugal), Balkan (prevalence disproportionately higher among women), Baltic (highest prevalence among young adults) and Scandinavian (highest prevalence among adolescents). These data have public health relevance for future interventions aimed at reducing sunbed use in Europe.

Who, why, where: an overview of determinants of sunbed use in Europe

Although exposure to indoor tanning has been established as a clear risk factor for skin cancer, sunbeds are still commonly used in Europe. Understanding the determinants of sunbed use in Europe is key to plan educational interventions, behavioural strategies and legislative measures, which should be tailored to subgroups with different risk profiles. Evidences show that the typical sunbed users in Europe are young-adult women, with intermediate skin type, a current employment and a medium/high socio-economic status. Typical users display sun-seeking behaviours and other risky behaviours such as smoking. Indoor tanning seems more common in northern than southern Europe. However, sunbed use remains common in fair-skinned individuals and among adolescents/pre-adolescents. Commonly reported reasons for sunbed use in Europe include aesthetic motives (i.e. looking attractive), the pursue of a prevacation tan, the influence of peers/parents engaging in the same habit, and the treatment of health conditions. The most commonly reported places to get an artificial tan in Europe are tanning studios and beauty salons. However, sunbeds are also available in sport venues, such as swimming pools and gyms, hotels and private houses. All these factors should be taken into account when planning educational, behavioural and legislative interventions to reduce the popularity of artificial tanning in Europe.

A Randomized Trial of an Advanced Sun Safety Intervention for Vacationers at 41 North American Resorts

Taking vacations in sunny locations is associated with the development of skin cancer. This study tested a multi-component sun protection intervention based on diffusion of innovations theory and transportation theory designed to increase vacationers' comprehensive sun protection, i.e., use of clothing, hats, and shade, and use, pre-application, and reapplication of sunscreen. The trial enrolled 41 warm weather resorts in North America in a pair-matched group randomized pretest-posttest design and assessed samples of adult vacationers at resort outdoor recreation venues regarding sun protection at pretest (n = 3,531) and posttest (n = 3,226). While results showed no overall effect of the intervention on comprehensive sun protection across venues, the intervention produced statistically significant improvements in sun protection at waterside venues (pools and beaches). The intervention's overall effects may have been impeded by a lack of uniformly robust implementation, low interest in skin cancer prevention by guests, or shortcomings of the theories used to create prevention messages. The intervention may have worked best with guests in the highest-risk recreation venue, i.e., waterside recreation where they exposed the most skin. Alternative approaches that alter resort organizations, such as through changes in policy, environmental features, or occupational efforts might be more effective than targeting vacationers with behavior-change messages.

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.

The Growing Burden of Invasive Melanoma: Projections of Incidence Rates and Numbers of New Cases in Six Susceptible Populations through 2031

New melanoma therapies are being developed rapidly, complementing prevention and detection strategies for disease control. Estimating the future burden of melanoma is necessary for deciding how best to deploy limited resources to achieve effective melanoma control. Using three decades of cancer registry data (1982-2011) from six populations with moderate to high melanoma incidence (US whites and the populations of the United Kingdom, Sweden, Norway, Australia, New Zealand), we applied age-period-cohort models to describe current trends and project future incidence rates and numbers of melanomas out to 2031. Between 1982 and 2011, melanoma rates in US whites, and the populations of the United Kingdom, Sweden, and Norway increased at more than 3% annually and are projected to continue rising until at least 2022. Melanoma incidence in Australia has been declining since 2005 (-0.7% per year), and melanoma incidence in New Zealand is increasing but is projected to decline soon. The numbers of new melanoma cases will rise in all six populations because of aging populations and high age-specific rates in the elderly. In US whites, annual new cases will rise from around 70,000 in 2007-2011 to 116,000 in 2026-2031, with 79% of the increase attributable to rising age-specific rates and 21% to population growth and aging. The continued increases in case numbers in all six populations through 2031 will increase the challenges of melanoma control.

Environmental variables associated with vacationers' sun protection at warm weather resorts in North America

BACKGROUND

Vacationing at sunny, warm weather locations is a risk factor for excessive solar ultraviolet (UV) radiation exposure and skin cancer.

OBJECTIVES

This study examined the association of environmental variables related to UV levels with vacationers' sun protection.

METHODS

Vacationers at 41 summer resorts in 17 states and 1 Canadian Province were interviewed (n=3531) and observed (N=4347) during 2012 and 2013. Clothing coverage, sunglasses, and shade use were observed. Use of sunscreen and sunburns were self-reported. Environmental information was recorded by research staff or acquired from ground stations and the weather service.

RESULTS

Temperature was positively associated with sun protection behaviors; however clothing coverage was negatively associated with temperature. Cloud cover was negatively associated with sun protection, with the exception of clothing coverage which was positively associated with it. Elevation showed a mixed pattern of associations with vacationer's sun protection. Latitude of a resort was negatively associated with most sun protection behaviors, such that sun protection increased at more southerly resorts. Similarly, the farther south a vacationer traveled to the resort, the less sun protection they employed. The UV index showed a weak, positive relationship with some sun protection behaviors even when controlling for temperature.

CONCLUSIONS

Vacationers appeared aware that UV is higher at southern latitudes and may learn UV is intense when living in southern regions. However, many used temperature, an unreliable cue, to judge UV intensity and seemed to adjust clothing for warmth not UV protection. Efforts are needed to help individuals make more accurate sun safety decisions.

Rationale, design, samples, and baseline sun protection in a randomized trial on a skin cancer prevention intervention in resort environments

INTRODUCTION

Exposure to solar ultraviolet radiation during recreation is a risk factor for skin cancer. A trial evaluated an intervention to promote advanced sun protection (sunscreen pre-application/reapplication; protective hats and clothing; use of shade) during vacations.

MATERIALS AND METHODS

Adult visitors to hotels/resorts with outdoor recreation (i.e., vacationers) participated in a group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Hotels/resorts were pair-matched and randomly assigned to the intervention or untreated control group. Sun. protection (e.g., clothing, hats, shade and sunscreen) was measured in cross-sectional samples by observation and a face-to-face intercept survey during two-day visits.

RESULTS

Initially, 41 hotel/resorts (11%) participated but 4 dropped out before posttest. Hotel/resorts were diverse (employees=30 to 900; latitude=24° 78' N to 50° 52' N; elevation=2ft. to 9726ft. above sea level), and had a variety of outdoor venues (beaches/pools, court/lawn games, golf courses, common areas, and chairlifts). At pretest, 4347 vacationers were observed and 3531 surveyed. More females were surveyed (61%) than observed (50%). Vacationers were mostly 35-60years old, highly educated (college education=68%) and non-Hispanic white (93%), with high-risk skin types (22%). Vacationers reported covering 60% of their skin with clothing. Also, 40% of vacationers used shade; 60% applied sunscreen; and 42% had been sunburned.

CONCLUSIONS

The trial faced challenges recruiting resorts but result showed that the large, multi-state sample of vacationers were at high risk for solar UV exposure.

Ultraviolet Radiation on the Skin: A Painful Experience?

Excessive exposure of skin to ultraviolet radiation (UVR) has dramatic clinical effects in humans, and it is a significant public health concern. Discomfort and sensory changes caused by skin sunburn are the main common features experienced by many of us, a phenomena triggered by the combination of long and short wavelengths radiation (UVA and UVB, respectively). Although the biological processes underlying UVR exposure are not fully understood, in the last few years many studies have made significant progress in characterizing sunburn at the cellular and molecular levels, making use of both humans and laboratory animal models. Here we review and reason that UVR can be used as an excellent model of sensitization and inflammation for pain research. UVR, particularly UVB, produces a controllable and sterile inflammation that causes a robust dose‐dependent hypersensitivity with minimal confounding effects. Importantly, we show that UVR animal models precisely recapitulate the sensory, cellular, and molecular changes observed in human skin, giving it great confidence as a translational model. Furthermore, in this article, we give an overview of the pharmacology underlying UVB inflammation, the latest advances in the field, and potential new targets for inflammatory pain.

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.

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.

Erythema and ultraviolet indoor tanning: findings from a diary study

The use of artificial ultraviolet (UV) indoor tanning (IT) beds increases the risk of skin cancer. The IT industry claims IT devices provide users with control over the amount of UV radiation exposure and thus reduces risks of sunburn (i.e., skin erythema) when tanning. This study aims to establish the prevalence and predictors of IT-related erythema using diary data. Six bimonthly diary surveys were administered to 198 female college IT users. Diaries assessed IT use and IT-related erythema. Among participants who used IT, 66 % experienced at least one episode of erythema and nearly one in five IT sessions resulted in skin erythema. Those who reported the most frequent IT use prior to the study were less likely to experience an IT-related erythema on a given IT session compared to the least experienced IT users. Perceived susceptibility to burns from IT use was positively associated with risk of erythema. Erythema was a frequently reported experience among IT users. Implications for policy makers and behavioral medicine practitioners are discussed.

The role of skin cancer knowledge in sun-related behaviours: A systematic review

Skin cancer is the most commonly diagnosed cancer in many Western countries. This systematic review provides a comprehensive overview of the relationship between skin cancer knowledge and sun-protective, exposure and tanning behaviours in the general population. A total of 34 studies, published in peer-reviewed journals over three decades, were reviewed and synthesised. Sun-protective behaviour was positively associated with skin cancer knowledge in most cases. Findings were inconsistent regarding other sun-related behaviours. Heterogeneity in measurement compromised the capacity to definitively link knowledge and sun-related behaviours. There is a need for development and utilisation of a standardised skin cancer knowledge scale, and guidelines are suggested.

Predictors of sun-related behaviors among young women: comparisons between outdoor tanners, fake tanners, and tan avoiders

OBJECTIVE

Skin cancer incidence continues to rise as a tanned appearance remains desirable, particularly among young women. Fake tanning provides a tanned appearance without exposure to ultraviolet radiation. In order to advance our understanding of the factors that contribute to long-term behavior change, this study explores determinants associated with different types of tanning.

PARTICIPANTS

The sample included 162 female students from the University of Adelaide, Australia, aged 18-26 years. Data were collected in July 2010.

METHODS

The current study measured differences in skin type, skin cancer knowledge, unrealistic optimism, appearance motivation, and sun-protective and sun exposure behaviors amongst outdoor tanners, fake tanners, and tan avoiders through an online survey.

RESULTS

Differences were observed for skin type, skin cancer knowledge, unrealistic optimism, sun protection, and sun exposure.

CONCLUSIONS

A "one-size-fits-all" approach to skin cancer prevention may not be appropriate; type of tanning behavior may need to be considered in health promotion work.

French teenagers and artificial tanning

BACKGROUND

Exposure to solar and artificial ultraviolet (UV) radiations is a major risk factor for skin cancers. France has enacted one of the strictest laws that, notably, restrict tanning-bed access to adults ≥18 years old.

OBJECTIVE

We evaluated artificial tanning behaviours of French teenagers (11-17 years old): sunless-tanning products, sunlamps and artificial tanning beds.

METHODS

An anonymous questionnaire evaluating sunburn history, skin phototype, behaviours with sunless-tanning products and indoor tanning, and parents' behaviours was distributed to students enrolled in two middle and high schools in Antony, a typical city of the middle class French population, located in the Paris suburbs. RESULTS Among 713 teenagers (mean age: 13.5 years: male/female: 1.1) responding, more than half declared that it was important to be tanned during the summer, 1% reported having already used tanning pills, 9.9% tanning creams and 1.4% indoor tanning. Female teenagers significantly more frequently resorted to indoor tanning (P = 0.02), cited the importance of being tanned all year long (P < 0.0001), used tanning pills (P < 0.0001) or tanning creams (P < 0.006), and their parents relied on indoor tanning (P < 0.0001). Profiles of tanning-pill and -cream users were similar. Mean ages for the two groups were comparable.

CONCLUSION

French regulations for indoor tanning seem quite effective. Our analyses revealed a typical teenager profile with sun-exposure risk behaviours, for example, indoor tanning, and use of tanning pills or creams. They could be a selective target for sun-protection information campaigns.

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis

OBJECTIVE

To synthesise the literature on indoor tanning and non-melanoma skin cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present).

STUDY SELECTION

All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English.

DATA EXTRACTION

Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated.

RESULTS

12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52).

CONCLUSIONS

Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

Evaluating a measure of tanning abuse and dependence

OBJECTIVE

To evaluate the Structured Interview for Tanning Abuse and Dependence (SITAD).

DESIGN

Longitudinal survey.

SETTING

College campus.

PARTICIPANTS

A total of 296 adults.

MAIN OUTCOME MEASURES

The SITAD modified items from the Structured Clinical Interview for DSM-IV Axis I Disorders that focus on opiate abuse and dependence. Indoor tanning (IT) behavioral patterns and opiate-like reactions to tanning were measured, and IT behavior was measured 6 months later.

RESULTS

Of 296 participants, 32 (10.8%) met the SITAD criteria for tanning abuse (maladaptive pattern of tanning as manifested by failure to fulfill role obligations, physically hazardous tanning, legal problems, or persistent social or interpersonal problems) and 16 (5.4%) for tanning dependence as defined by 3 or more of the following: loss of control, cut down, time, social problems, physical or psychological problems, tolerance, and withdrawal. The IT frequency in dependent tanners was more than 10 times the rate in participants who do not meet the SITAD criteria for tanning abuse or dependence. Tanning-dependent participants were more likely to report being regular tanners (75%; odds ratio, 7.0). Dependent tanners scored higher on the opiate-like reactions to tanning scale than did abuse tanners, who scored higher than those with no diagnosis.

CONCLUSIONS

The SITAD demonstrated some evidence of validity, with tanning-dependent participants reporting regular IT, higher IT frequency, and higher scores on an opiate-like reactions to tanning scale. A valid tanning dependence screening tool is essential for researchers and physicians as a tanning-dependent diagnosis may facilitate a better understanding of tanning motivations and aid in the development of efficacious intervention programs.

Banning children and youth younger than 18 years of age from commercial tanning facilities

Cutaneous malignant melanoma has increased more than three-fold in the past 35 years. Because damage is cumulative, exposure to ultraviolet radiation early in life elevates a risk that is increased further as individuals use artificial sources of ultraviolet radiation. The full impact and scope of damage caused by year-round indoor tanning may take years to appreciate given the long latency period for most skin cancers. Teenagers are frequent visitors to tanning parlours, with girls being more frequent and sustained users. The tanning industry disputes the World Health Organization's and the International Agency for Research on Cancer's classification of their product as a Class 1 physical carcinogen. Tanning parlours have sought to establish and maintain a client-base among teenagers. Consequently, the Canadian Paediatric Society is joining other prominent health organizations in support of a ban on the use of commercial tanning facilities by Canadian children and youth younger than 18 years of age.

Indoor tanning and risk of early-onset basal cell carcinoma

BACKGROUND

Despite an increase in incidence of basal cell carcinoma (BCC) among young people and the ubiquity of indoor tanning in this population, few epidemiologic studies have investigated this exposure-disease relationship.

OBJECTIVE

We sought to evaluate the association between indoor tanning and early-onset BCC.

METHODS

Patients with BCC (n = 376) and control subjects with minor benign skin conditions (n = 390) who were younger than 40 years of age were identified through Yale Dermatopathology. Participants provided information on ever indoor tanning, age of initiation, frequency, duration, burns while tanning, and type of tanning device during an in-person interview. We calculated odds ratios (OR) and 95% confidence intervals (CI) using multivariate logistic regression with never indoor tanners as the referent group.

RESULTS

Ever indoor tanning was associated with a 69% increased risk of early-onset BCC (95% CI 1.15-2.48). This association was stronger among females (OR 2.14, 95% CI 1.31-3.47), for multiple BCCs (OR 2.16, 95% CI 1.26-3.70), and for BCCs on the trunk and extremities (OR 2.81, 95% CI 1.57-5.02). Risk increased dose dependently with years using regular indoor tanning devices (P trend = .003), number of overall burns (P trend < .001), and burns to biopsy site (P trend < .001) from indoor tanning. Approximately one quarter (27%) of early-onset BCCs (or 43% among women) could be prevented if individuals never tanned indoors.

LIMITATIONS

Potential recall bias of indoor tanning by patients and generalizability of the control population suggest replication in other studies is warranted.

CONCLUSIONS

Indoor tanning was a strong risk factor for early-onset BCC, particularly among females. Indoor tanning should continue to be targeted by both policy-based and behavioral interventions, as the impact on BCC-associated morbidity may be substantial.

Differences in sun exposure habits between self-reported skin type and ultraviolet sensitivity measured by phototest

BACKGROUND

Traditionally, classification of skin reactivity to ultraviolet (UV) light is based on self-estimation of tendency to burn and tan (Fitzpatrick's classification). Although widely accepted, the model has shown to correlate poorly with actual UV sensitivity, measured by phototest. The aim of the present study was to investigate how self-estimated skin type, according to Fitzpatrick, and actual UV sensitivity measured by phototest correlate with sun exposure and protection.

METHODS

One hundred and sixty-six voluntary patients visiting their general practitioner for investigation of suspicious skin tumours were recruited for the study, and filled out a questionnaire, mapping sun habits and sun protection behaviour, based on five-point Likert responses. The patients reported their skin type (I-VI) according to Fitzpatrick, and a phototest was performed to determine the minimal erythema dose.

RESULTS

For most of the questions, high self-estimated UV sensitivity, according to Fitzpatrick, appeared to be associated with a higher level of sun avoidance/protection (P<0.05). For actual UV sensitivity, however, the difference in response distribution was only significant for sunscreen use, and did not show a similar apparent association related to the degree of UV sensitivity.

CONCLUSION

Self-estimated skin UV sensitivity, according to Fitzpatrick's classification, appears to be a stronger predictor of sun exposure and protection than actual UV sensitivity measured by phototest.

How to guarantee adequate sun protection for a young sportsperson

BACKGROUND

Young male athletes involved in sports like soccer are subject to sun exposure which can often be intense because of the timing and duration of their practice time.

PATIENTS AND METHODS

The goal of this work was to study using a spectrophoto-metric method what level of sun protection was provided by the various articles of clothing which make up a standard soccer uniform, as well as by the cosmetics used by fan clubs.

RESULTS

We were able to demonstrate that the sports clothing does guarantee a good level of protection for the skin areas covered.

CONCLUSIONS

Depending on the type of clothing, the level of sun protection will vary greatly, with UPF values ranging from 30 for a T-shirt to 300 for a club shirt. This type of protection is higher than that obtained by sun creams and does not change over time.

Harm minimization in tan seekers: an exploration of tanning behaviour and the potential for substitutional use of sunless tanning products

Exposure to ultraviolet (UV) light from the sun or solaria is a major contributor to high rates of skin cancer. The study aimed to explore the intentions of active tan seekers in relation to the substitutional use of sunless tanning products. Participants were reluctant to reduce UV exposure in favour of using sunless tanning products, which were considered to be another tanning method rather than an avenue for reducing skin cancer risk. The 'sunless tan' approach is unlikely to reduce UV exposure in the majority of tan seekers, but may be valuable in targeting women with fairer skin.

The potential carcinogenic risk of tanning beds: clinical guidelines and patient safety advice

INTRODUCTION

In 2009, the WHO listed ultraviolet (UV) radiation as a group 1 carcinogen. In spite of this, each year, millions of people tan indoor in Western countries. The aim of this review is to summarize evidence of tanning bed carcinogenesis and to present guidelines for use of tanning beds and patient safety advice.

METHODS

A narrative review of the literature was conducted based on both PubMed and Medline searches and on literature review of the retrieved papers.

RESULTS

Use of indoor tanning beds represents a significant and avoidable risk factor for the development of both melanoma and nonmelanoma skin cancers. Frequent tanners are more often adolescent females. Tanning beds have additional potential adverse effects such as burns, solar skin damage, infection, and possibly also addictive behavior.

DISCUSSION

The effort in preventing UV light-induced carcinogenesis should currently be aimed at developing new strategies for public health information. Tanning beds are one preventable source of UV radiation. In the majority of people solar UV radiation continues to be the major factor and therefore anti-tanning campaigns must always include sunbathers.

Melanoma risk factors, perceived threat and intentional tanning: an international online survey

Cutaneous melanoma continues to increase in incidence in many countries, and intentional tanning is a risk factor for melanoma. The aim of this study was to understand how melanoma risk factors, perceived threat and preferences for a suntan relate to intentional tanning. Self-report data were collected on behalf of GenoMEL (www.genomel.org) from the general population using an online survey. A total of 8178 individuals completed the survey, with 72.8% of respondents being from Europe, 12.1% from Australia, 7.1% from the US, 2.5% from Israel and 5.5% from other countries. Seven percent of respondents had previously been diagnosed with melanoma and 8% had at least one first-degree relative with a previous melanoma. Overall, 70% reported some degree of intentional tanning during the past year, and 38% of respondents previously diagnosed with melanoma had intentionally tanned. The total number of risk factors was positively correlated with perceived risk of melanoma [correlation coefficient (rho) = 0.27], and negatively correlated with intentional tanning (rho = -0.16). Preference for a dark suntan was the strongest predictor of intentional tanning [regression coefficient (beta) = 0.35, P<0.001], even in those with a previous melanoma (beta = 0.33, P<0.01). A substantial proportion of participants reported having phenotypic and behavioural risk factors for melanoma. The preference regarding suntans seemed more important in the participants' decision to intentionally tan than their perceived risk of developing melanoma, and this finding was consistent among respondents from different countries. The drive to sunbathe to tan is a key factor to be moderated if melanoma incidence is to be reduced.

Sunbed use in children aged 11-17 in England: face to face quota sampling surveys in the National Prevalence Study and Six Cities Study

OBJECTIVES

To quantify the use of sunbeds in young people across England, identify geographical variation, and explore patterns of use, including supervision.

DESIGN

Two random location sampling surveys.

SETTING

National Prevalence Study in England; Six Cities Study in Liverpool, Stoke/Stafford, Sunderland, Bath/Gloucester, Oxford/Cambridge, and Southampton.

PARTICIPANTS

3101 children aged 11-17 in the National Prevalence study and 6209 in the Six Cities study.

RESULTS

In the National Prevalence Study 6.0% (95% confidence interval 5.1% to 6.8%) of those aged 11-17 had used a sunbed. Use was higher in girls than in boys (8.6% (7.2% to 10.0%) v 3.5% (2.6% to 4.4%), respectively), in those aged 15-17 compared with those aged 11-14 (11.2% (9.5% to 12.9%) v 1.8% (1.2% to 2.4%), respectively), and in those from lower rather than higher social grades (7.6% (5.7% to 9.5%) v 5.4% (4.5% to 6.3%), respectively). Sunbed use was higher in the "north" (11.0%, 8.9% to 13.0%) than in the "midlands" (4.2%, 2.5% to 5.8%) and the "south" (4.2%, 3.3% to 5.2%). In the Six Cities Study, sunbed use was highest in Liverpool and Sunderland (20.0% (17.5% to 22.4%) and 18.0% (15.6% to 20.3%), respectively), with rates especially high in girls, those aged 15-17, or from lower social grades. Mean age of first use was 14, and 38.4% (34.7% to 42.1%) of children used a sunbed at least once a week. Nearly a quarter (23.0%, 19.8% to 26.1%) of children had used a sunbed at home (including home of friends/relatives), and 24.7% (21.0% to 28.4%) said they had used sunbeds unsupervised in a tanning/beauty salon or gym/leisure centre.

CONCLUSIONS

Sunbed use by children is widespread in England, is often inadequately supervised, and is a health risk. National legislation is needed to control sunbed outlets.

UVA tanning is involved in the increased incidence of skin cancers in fair-skinned young women

Melanomas are the most prevalent cancers in 25-29 yr old females and compose roughly 12% of cancers in 20-40 yr old women; under the age of 40, women have a higher incidence of melanomas than do men. Within the past few decades, the alarming trend to use commercial sunlamps for cosmetic pigmentation is of particular concern, especially since 71% of those patrons are women with 50% of patrons under the age of 29. A major problem may be the use of UVA-rich sunlamps which produce a visible tan but afford little to no protection from subsequent UV exposure. We hypothesize that the additional exposure of adolescents to unnaturally large amounts of UVA from artificial UV sources is implicated in the increasing incidence of malignant melanomas disproportionately in young women.

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.

Skin cancer-related prevention and screening behaviors: a review of the literature

Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to self-report, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer.

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.

A preliminary investigation of the predictors of tanning dependence

OBJECTIVES

To investigate possible predictors of tanning dependence including demographic variables, exposure and protective behaviors, and other health-related behaviors.

METHODS

This study consisted of an online survey of 400 students and other volunteers from a university community.

RESULTS

Twenty-seven percent of the sample was classified as tanning dependent. Tanning dependence was predicted by ethnicity and skin type, indoor and outdoor tanning and burning, and lower skin protective behaviors, as well as smoking and body mass index.

CONCLUSIONS

Young adults are at risk for tanning dependence, which can be predicted by specific demographic and behavioral variables.

Estimation of avoidable skin cancers and cost-savings to government associated with regulation of the solarium industry in Australia

OBJECTIVE

In Australia there is growing concern about the expanding solarium industry, and the additive effect of persons seeking exposure to artificial ultraviolet radiation (UVR) against already intense background levels of solar UVR. We estimated the numbers of potential skin cancers prevented through regulation of solaria and the associated cost-savings to the Federal Government.

METHODS

A lifetime decision-analytic model was created using relative risk estimates based on a meta-analysis of the literature assessing the link between skin cancer risk and solarium use. The costs were limited to those incurred by Medicare Australia, for the medical care of individuals treated for skin cancer.

RESULTS

With stricter regulations, we estimated between 18 and 31 melanomas, 200-251 squamous cell carcinomas and associated costs of $AU 256,054 would be avoided per 100,000 persons. Our base findings were sensitive to estimates for prevalence of use, skin cancer risk and discounting rates.

CONCLUSIONS

Continued growth in the Australian solarium industry is likely to inflate the already substantial skin cancer burden. Subject to some limitations, our study indicates that by successfully enforcing solarium regulations to prohibit use by minors and by those with fair skin colour, the Federal Government could expect favourable cost and health benefits.