Review of interventions to reduce ultraviolet tanning: Need for treatments targeting excessive tanning, an emerging addictive behavior

Men's experiences of a personalised, appearance-based, facial-morphing, safer drinking intervention

Risky alcohol consumption behaviours remain commonplace, representing a major threat to health and safety, and are especially evidenced by young university students. Consequently, new interventions targeting this high-risk group are required. The current study investigated young male university students' experiences of a personalised, appearance-based, facial morphing, safer drinking intervention. Twenty-five male student participants were recruited, aged 18-34 years. Inductive thematic analysis of data gathered whilst participants were immersed in the intervention, and thereby exposed to alcohol-aged images of their own faces, produced four primary themes: alcohol as a threat to appearance and health, motivations to protect appearance, motivational aspects of the intervention, and proposed improvements and applications. The results of the current study suggested that participants expressed intentions towards healthier consumption/maintenance of already non-risky intake, supporting the potential of the facial-morphing appearance-based approach to address risky alcohol consumption, even in high-risk groups.

A Social Media-Delivered Melanoma Prevention Program for Young Women Engaged in Frequent UV Tanning: Protocol for a Randomized Controlled Trial

BACKGROUND

Rates of melanoma have increased dramatically in the United States over the past 25 years, and it has become among the most prevalent cancers for young adult women. Intentional skin tanning leads to a pattern of intense and intermittent UV radiation exposure that is associated with increased risk of melanoma. Frequent tanning is most common among young women and is linked to a variety of sociocultural pressures that negatively impact body image and drive appearance control behaviors. Unfortunately, there are no established interventions designed for frequent tanners. This intervention addresses this gap with unique content informed by body image and acceptance-based interventions. The intervention is delivered using Facebook secret groups, an approach designed to support behavior change and ensure scalability.

OBJECTIVE

This study aims to describe the rationale and methodology of a randomized controlled trial of a melanoma prevention program targeting young women engaged in frequent indoor or outdoor UV tanning.

METHODS

Participants are women aged 18-25 years who report high-risk tanning (ie, at least 10 indoor tanning sessions in the past 12 months or 10 outdoor sessions in the previous summer). After recruitment and screening, participants completed a baseline survey and were randomly assigned to receive the intervention or an attention-matched control condition. Both conditions were 8-week-long Facebook groups (approximately 25 members each) with daily posting of content. Follow-up surveys are administered at 3, 8, and 18 months after baseline. The primary trial outcome is the combined number of indoor and outdoor tanning sessions reported at the 8-month follow-up. Hypothesized intervention mediators are assessed at the 3-month follow-up.

RESULTS

This project was funded by a National Cancer Institute award (R01 CA218068), and the trial procedures were approved by the University of Kentucky Institutional Review Board in February 2020. Trial recruitment and enrollment occurred in 6 waves of data collection, which started in February 2022 and closed in May 2023. The study is closed to enrollment but remains open for follow-ups, and this protocol report was prepared before data analyses. As of February 2024, all participants have completed the 8-month follow-up assessment, and data collection is scheduled to close by the end of 2024 after the collection of the 18-month follow-up.

CONCLUSIONS

This trial will contribute unique knowledge to the field of skin cancer prevention, as no fully powered trials have examined the efficacy of an intervention designed for frequent indoor or outdoor tanning. The trial may also contribute evidence of the value in translating principles of body image and acceptance-based interventions into the field of skin cancer prevention and beyond. If successful, the use of the Facebook platform is intended to aid in dissemination as it provides a way to embed the intervention into individuals' everyday routines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03441321; https://clinicaltrials.gov/study/NCT03441321.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56562.

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.

Encouraging sun protection early in life: from a successful prevention programme in children to the identification of psychological barriers in adolescents

Children and adolescents have high rates of sunburn and high levels of ultraviolet radiation (UVR) exposure and are therefore at risk of developing skin cancer in later life. Minimizing UVR exposure in childhood and adolescence may be the most important component of skin cancer prevention efforts. Thus, age-adapted prevention campaigns, targeting children, adolescents and caregivers, are needed to change sun protection behaviour among individuals in these age groups. In the first part of this review, we describe the 'SunPass' programme, which was initiated in Germany in 2010 as the first nationwide educational intervention for sun safety designed to teach kindergarten children and their caregivers how to protect themselves from overexposure to the sun. Implemented in 55 kindergartens, this programme has been shown to be effective at improving sun protection behaviour (P < 0.001) and hat use (P = 0.029) among kindergarten children, as well as at improving shade practices and increasing demand for protective clothing (P < 0.001). Up to 40 000 children, 50 000 parents/grandparents and 2500 kindergarten caregivers took part in the SunPass programme in Germany from 2019 to June 2021. The programme has also been adapted and implemented in several other European countries and could be readily adapted for use elsewhere. In the second part of this review, we discuss the specific challenges faced by adolescents and consider how these issues may impact their sun protection behaviour. Adolescents have difficulties suppressing responses to reward-related cues and projecting themselves into the future. They also place a lot of importance on social acceptance and cosmetic appearance, and their higher risk of depression, addiction and impulsivity make them vulnerable to tanning addiction. These specificities need to be acknowledged by dermatologists, so they can adapt their therapeutic relationship and develop effective sun protection interventions for this generation.

Effect of a Face-Aging Mobile App-Based Intervention on Skin Cancer Protection Behavior in Secondary Schools in Brazil: A Cluster-Randomized Clinical Trial

Question

Can a face-aging mobile app improve the skin cancer protection behavior of secondary school students?

Findings

In this cluster-randomized clinical trial of 52 school classes with 1573 Brazilian pupils, meaningful improvements were observed in sunscreen use, tanning behavior, and skin self-examinations 3 to 6 months after an intervention using a face-aging app compared with the nonintervention group.

Meaning

Face-aging apps may be useful tools to increase skin cancer protection in adolescents and thereby decrease skin cancer risk.

Importance

Because exposure to UV radiation early in life is an important risk factor for melanoma development, reducing UV exposure in children and adolescents is of paramount importance. New interventions are urgently required.

Objective

To determine the effect of the free face-aging mobile app Sunface on the skin cancer protection behavior of adolescents.

Design, Setting, and Participants

This cluster-randomized clinical trial included a single intervention and a 6-month follow-up from February 1 to November 30, 2018. Randomization was performed on the class level in 52 school classes within 8 public secondary schools (grades 9-12) in Itauna, Southeast Brazil. Data were analyzed from May 1 to October 10, 2019.

Interventions

In a classroom seminar delivered by medical students, adolescents’ selfies were altered by the app to show UV effects on their future faces and were shown in front of their class, accompanied by information about UV protection. Information about relevant parameters was collected via anonymous questionnaires before and 3 and 6 months after the intervention.

Main Outcomes and Measures

The primary end point of the study was the difference in daily sunscreen use at 6 months of follow-up. Secondary end points included the difference in daily sunscreen use at 3 months of follow-up, at least 1 skin self-examination within 6 months, and at least 1 tanning session in the preceding 30 days. All analyses were predefined and based on intention to treat. Cluster effects were taken into account.

Results

Participants included 1573 pupils (812 girls [51.6%] and 761 boys [48.4%]; mean [SD] age, 15.9 [1.3] years) from 52 school classes. Daily sunscreen use increased from 110 of 734 pupils (15.0%) to 139 of 607 (22.9%; P < .001) at the 6-month follow-up in the intervention group. The proportion of pupils performing at least 1 skin self-examination in the intervention group rose from 184 of 734 (25.1%) to 300 of 607 (49.4%; P < .001). Use of tanning decreased from 138 of 734 pupils (18.8%) to 92 of 607 (15.2%; P = .04). No significant changes were observed in the control group. The intervention was more effective for female students (number needed to treat for the primary end point: 8 for girls and 31 for boys).

Conclusions and Relevance

These findings suggest that interventions based on face-aging apps may increase skin cancer protection behavior in Brazilian adolescents. Further studies are required to maximize the effect and to investigate the generalizability of the effects.

Trial Registration

ClinicalTrials.gov Identifier: NCT03178240

A randomized controlled trial of a web-based personalized feedback intervention targeting frequent indoor tanning bed users: Engagement, acceptability, and preliminary behavioral outcomes

Frequent indoor tanning bed use is an established public health concern, yet research on tanning cessation interventions for frequent tanners is lacking. We describe the protocol for a brief, web-based tanning behavior change intervention and present evidence that it is acceptable and engaging to frequent indoor tanners. Lower tanning rates were not observed among participants receiving the intervention in a randomized controlled trial but participants' interest in changing tanning increased. This intervention could be a useful approach to increasing frequent tanners' interest in behavior change and openness to engaging within a more intensive, multi-component tanning cessation program.Trial Registration: NCT03448224 Clinical Trials.gov (https://clinicaltrials.gov/ct2/show/NCT03448224?cond=NCT03448224&draw=2&rank=1).

Testing Wearable UV Sensors to Improve Sun Protection in Young Adults at an Outdoor Festival: Field Study

Background

Australia and New Zealand have the highest skin cancer incidence rates worldwide, and sun exposure is the main risk factor for developing skin cancer. Sun exposure during childhood and adolescence is a critical factor in developing skin cancer later in life.

Objective

This study aims to test the effectiveness of wearable UV sensors to increase sun protection habits (SPH) and prevent sunburn in adolescents.

Methods

During the weeklong school leavers outdoor festival (November 2019) at the Gold Coast, Australia, registered attendees aged 15-19 years were recruited into the field study. Participants were provided with a wearable UV sensor and free sunscreen. The primary outcome was sun exposure practices using the SPH index. Secondary outcomes were self-reported sunburns, sunscreen use, and satisfaction with the wearable UV sensor.

Results

A total of 663 participants were enrolled in the study, and complete data were available for 188 participants (188/663, 28.4% response rate). Participants provided with a wearable UV sensor significantly improved their use of sunglasses (P=.004) and sunscreen use both on the face (P<.001) and on other parts of the body (P=.005). However, the use of long-sleeve shirts (P<.001) and the use of a hat (P<.001) decreased. During the study period, 31.4% (59/188) of the participants reported receiving one or more sunburns. Satisfaction with the wearable UV sensor was high, with 73.4% (138/188) of participants reporting the UV sensor was helpful to remind them to use sun protection.

Conclusions

Devices that target health behaviors when outdoors, such as wearable UV sensors, may improve use of sunscreen and sunglasses in adolescents.

Indoor Tanning Trends Among US Adults, 2007-2018

Objectives. To examine indoor tanning trends among US adults, and the relation to indoor tanning youth access legislation.Methods. This study analyzed the Health Information National Trends Survey (HINTS), a mailed survey, from the years 2007, 2011, 2013, 2014, 2017, and 2018 (combined n = 20 2019).Results. Indoor tanning prevalence decreased significantly over time among all US adults from 2007 (10%) to 2018 (4%; P < .001), among young adults aged 18 to 34 years (14% to 4%; P < .001), and among both women (14% to 4%; P < .001) and men (5% to 4%; P < .05). Indoor tanning significantly decreased in states that enacted youth access legislation by 2018, but did not significantly decrease for other states. Frequent indoor tanning was common in 2018; about one quarter of respondents who reported any indoor tanning did so 25 times or more in the past year.Conclusions. This study identifies several challenges in continuing to reduce indoor tanning in the United States. Youth access legislation may be effective for reducing tanning among the broader population of tanners; however, there remains a need for focus on highly frequent tanners, as well as men.

Can neuroimmune mechanisms explain the link between ultraviolet light (UV) exposure and addictive behavior?

High ultraviolet (UV) light exposure on the skin acts as a reinforcing stimulus, increasing sun-seeking behavior and even addiction-like sun seeking behavior. However, the physiological mechanisms that underlie this process remain to be defined. Here, we propose a novel hypothesis that neuroimmune signaling, arising from inflammatory responses in UV-damaged skin cells, causes potentiated signaling within the cortico-mesolimbic pathway, leading to increased sun-seeking behaviors. This hypothesized UV-induced, skin-to-brain signaling depends upon cell stress signals, termed alarmins, reaching the circulation, thereby triggering the activation of innate immune receptors, such as toll-like receptors (TLRs). This innate immune response is hypothesized to occur both peripherally and centrally, with the downstream signaling from TLR activation affecting both the endogenous opioid system and the mesolimbic dopamine pathway. As both neurotransmitter systems play a key role in the development of addiction behaviors through their actions at key brain regions, such as the nucleus accumbens (NAc), we hypothesize a novel connection between UV-induced inflammation and the activation of pathways that contribute to the development of addiction. This paper is a review of the existing literature to examine the evidence which suggests that chronic sun tanning resembles a behavioral addiction and proposes a novel pathway by which persistent sun-seeking behavior could affect brain neurochemistry in a manner similar to that of repeated drug use.

A Skin Cancer Prevention Facial-Aging Mobile App for Secondary Schools in Brazil: Appearance-Focused Interventional Study

Background

The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. Southeast Brazil has especially high incidences of melanoma, and early detection is low. Exposure to ultraviolet (UV) radiation is a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation among adolescents for tanning. A medical student-delivered intervention that takes advantage of the broad availability of mobile phones and adolescents’ interest in their appearance indicated effectiveness in a recent study from Germany. However, the effect in a high-UV index country with a high melanoma prevalence and the capability of medical students to implement such an intervention remain unknown.

Objective

In this pilot study, our objective was to investigate the preliminary success and implementability of a photoaging intervention to prevent skin cancer in Brazilian adolescents.

Methods

We implemented a free photoaging mobile phone app (Sunface) in 15 secondary school classes in southeast Brazil. Medical students “mirrored” the pupils’ altered 3-dimensional (3D) selfies reacting to touch on tablets via a projector in front of their whole grade accompanied by a brief discussion of means of UV protection. An anonymous questionnaire capturing sociodemographic data and risk factors for melanoma measured the perceptions of the intervention on 5-point Likert scales among 356 pupils of both sexes (13-19 years old; median age 16 years) in grades 8 to 12 of 2 secondary schools in Brazil.

Results

We measured more than 90% agreement in both items that measured motivation to reduce UV exposure and only 5.6% disagreement: 322 (90.5%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 321 (90.2%) that it motivated them to improve their sun protection; 20 pupils (5.6%) disagreed with both items. The perceived effect on motivation was higher in female pupils in both tanning bed avoidance (n=198, 92.6% agreement in females vs n=123, 87.2% agreement in males) and increased use of sun protection (n=197, 92.1% agreement in females vs n=123, 87.2% agreement in males) and independent of age or skin type. All medical students involved filled in a process evaluation revealing that they all perceived the intervention as effective and unproblematic, and that all pupils tried the app in their presence.

Conclusions

The photoaging intervention was effective in changing behavioral predictors for UV protection in Brazilian adolescents. The predictors measured indicated an even higher prospective effectiveness in southeast Brazil than in Germany (>90% agreement in Brazil vs >60% agreement in Germany to both items that measured motivation to reduce UV exposure) in accordance with the theory of planned behavior. Medical students are capable of complete implementation. A randomized controlled trial measuring prospective effects in Brazil is planned as a result of this study.

A skin cancer prevention photoageing intervention for secondary schools in Brazil delivered by medical students: protocol for a randomised controlled trial

INTRODUCTION

The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. The Southeast of Brazil has especially high incidences of melanoma, and early detection is low. Exposure to UV radiation represents a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation for adolescents for tanning. A medical student-delivered intervention that harnesses the broad availability of mobile phones as well as adolescents' interest in their appearance may represent a novel method to improve skin cancer prevention.

METHODS AND ANALYSIS

We developed a free mobile app (Sunface), which will be implemented in at least 30 secondary school classes, each with 21 students (at least 30 classes with 21 students for control) in February 2018 in Southeast Brazil via a novel method called mirroring. In a 45 min classroom seminar, the students' altered three-dimensional selfies on tablets are 'mirrored' via a projector in front of their entire class, showing the effects of unprotected UV exposure on their future faces. External block randomisation via computer is performed on the class level with a 1:1 allocation. Sociodemographic data, as well as skin type, ancestry, UV protection behaviour and its predictors are measured via a paper-pencil questionnaire before as well as at 3 and 6 months postintervention. The primary end point is the group difference in the 30-day prevalence of daily sunscreen use at a 6-month follow-up. Secondary end points include (1) the difference in daily sunscreen use at a 3-month follow-up, (2) if a self-skin examination in accordance with the ABCDE rule was performed within the 6-month follow-up and (3) the number of tanning sessions.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of the University of Itauna. Results will be disseminated at conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03178240; Pre-results.

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.

Interdisciplinary Perspectives on Sun Safety

Overexposure to the sun is associated with an increased risk of melanoma and nonmelanoma skin cancer, but indications of improvements in sun protection behavior are poor. Attempts to identify emerging themes in skin cancer control have largely been driven by groups of experts from a single field. In December 2016, 19 experts from various disciplines convened for Interdisciplinary Perspectives on Skin Cancer, a 2-day meeting hosted by the National Academy of Sciences. The group discussed knowledge gaps, perspectives on sun exposure, implications for skin cancer risk and other health outcomes, and new directions. Five themes emerged from the discussion: (1) The definition of risk must be expanded, and categories for skin physiology must be refined to incorporate population diversities. (2) Risky sun exposure often co-occurs with other health-related behaviors. (3) Messages must be nuanced to target at-risk populations. (4) Persons at risk for tanning disorder must be recognized and treated. (5) Sun safety interventions must be scalable. Efficient use of technologies will be required to sharpen messages to specific populations and to integrate them within multilevel interventions. Further interdisciplinary research should address these emerging themes to build effective and sustainable approaches to large-scale behavior change.

A smoking prevention photoageing intervention for secondary schools in Brazil delivered by medical students: protocol for a randomised trial

INTRODUCTION

Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous; the dramatic health consequences are too far in the future to fathom. We recently designed and tested an intervention that takes advantage of the broad availability of mobile phones as well as adolescents' interest in their appearance. A free photoageing mobile app (Smokerface) was implemented by medical students in secondary schools via a novel method called mirroring. The pupils' altered three-dimensional selfies on tablets were 'mirrored' via a projector in front of their whole grade. This is the first randomised trial to measure the effectiveness of the mirroring approach on smoking behaviour in secondary schools.

METHODS AND ANALYSIS

The mirroring intervention, which lasts 45 min, is implemented by Brazilian medical students in at least 35 secondary school classes with 21 participants each (at least 35 classes with 21 participants for control) in February 2018 in the city of Itauna, Brazil. External block randomisation via computer is performed on the class level with a 1:1 allocation. In addition to sociodemographic data, smoking behaviour is measured via a paper-pencil questionnaire before, 3 and 6 months postintervention plus a random carbon monoxide breathing test at baseline and end line. The primary outcome is cigarette smoking in the past week at 6 months follow-up. Smoking behaviour (smoking onset, quitting) and effects on the different genders are studied as secondary outcomes. Analysis is by intention to treat.

ETHICS AND DISSEMINATION

Ethical approval is obtained from the ethics committee of the University of Itauna in Brazil. Results will be disseminated at conferences, in peer-reviewed journals, throughout the Education Against Tobacco network social media channels and on our websites.

TRIAL REGISTRATION NUMBER

NCT03178227.

Indoor Tanning Dependence in Young Adult Women

Background: There is mounting evidence that young people can develop a dependence on indoor tanning, but research on factors associated with indoor tanning dependence remains limited.Methods: This cross-sectional study investigated factors associated with indoor tanning dependence in a community sample of 389 non-Hispanic white young adult women ages 18 to 30 who had indoor tanned ≥1 time in the past year. Participants completed measures of indoor tanning dependence, including the modified CAGE and modified Diagnostic and Statistical Manual for Mental Disorders-IV psychiatric screening assessments, indoor tanning behavior and beliefs, and behavioral and psychiatric comorbidity.Results: Overall, 22.6% of the sample screened positive for indoor tanning dependence. In multivariable analyses, indoor tanning dependence was associated with younger age of indoor tanning initiation [adjusted odds ratio (aOR) = 0.79; P = 0.017], indoor tanning ≥20 times in the past year (aOR = 3.03; P = 0.015), stronger beliefs about the benefits of tanning (aOR = 2.15; P = 0.004), greater perceived susceptibility to indoor tanning risks (aOR = 2.72; P < 0.001), stronger beliefs about physical appearance (aOR = 1.73; P = 0.037), and depressive symptoms (aOR = 3.79; P < 0.001).Conclusions: Indoor tanning dependence among young, non-Hispanic white women is associated with behaviors that increase the risk of skin cancer, beliefs favoring the perceived benefits of tanning, and comorbid risks such as stronger beliefs about physical appearance and depressed mood.Impact: Comprehensive skin cancer prevention efforts should address indoor tanning dependence among young women and its leading risk factors. Cancer Epidemiol Biomarkers Prev; 26(11); 1636-43. ©2017 AACR.

Photoaging Mobile Apps in School-Based Melanoma Prevention: Pilot Study

BACKGROUND

Around 90% of melanomas are caused by exposure to ultraviolet (UV) radiation and are therefore eminently preventable. Tanning behavior is mostly initiated in early adolescence, often with the belief that it increases attractiveness; the problems related to malignant melanoma and other skin cancers are too far in the future to fathom. Given the substantial amount of time children and adolescents spend in schools, as well as with their mobile phones, addressing melanoma prevention via both of these ways is crucial. However, no school-based intervention using mobile apps has been evaluated to date. We recently released a photoaging mobile app, in which a selfie is altered to predict future appearance dependent on UV protection behavior and skin type.

OBJECTIVE

In this pilot study, we aimed to use mobile phone technology to improve school-based melanoma prevention and measure its preliminary success in different subgroups of students with regard to their UV protection behavior, Fitzpatrick skin type and age.

METHODS

We implemented a free photoaging mobile phone app (Sunface) in 2 German secondary schools via a method called mirroring. We "mirrored" the students' altered 3-dimensional (3D) selfies reacting to touch on mobile phones or tablets via a projector in front of their whole grade. Using an anonymous questionnaire capturing sociodemographic data as well as risk factors for melanoma we then measured their perceptions of the intervention on a 5-point Likert scale among 205 students of both sexes aged 13-19 years (median 15 years).

RESULTS

We measured more than 60% agreement in both items that measured motivation to reduce UV exposure and only 12.5% disagreement: 126 (63.0%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 124 (61.7%) to increase use of sun protection. However, only 25 (12.5%) disagreed with both items. The perceived effect on motivation was increased in participants with Fitzpatrick skin types 1-2 in both tanning bed avoidance (n=74, 71.8% agreement in skin types 1-2 vs n=50, 53.8% agreement in skin types 3-6) and increased use of sun protection (n=70, 68.0% agreement in skin types 1-2 vs n=52, 55.3% agreement in skin types 3-6), and also positively correlated with higher age.

CONCLUSIONS

We present a novel way of integrating photoaging in school-based melanoma prevention that affects the students' peer group, considers the predictors of UV exposure in accordance with the theory of planned behavior, and is particularly effective in changing behavioral predictors in fair-skinned adolescents (Fitzpatrick skin types 1-2). Further research is required to evaluate the intervention's prospective effects on adolescents of various cultural backgrounds.