Use of the multi-theory model (MTM) in explaining initiation and sustenance of indoor tanning cessation among college students

Skin cancer, including melanoma, is the most common cancer worldwide and a significant public health concern. A significant risk factor for melanoma is through increased exposure to ultraviolet (UV) radiation through the use of indoor tanning beds. Although rates of indoor tanning bed use have decreased in recent years, young adults, particularly White, college-age women, comprise the majority of indoor tanning bed users in the United States. The purpose of this cross-sectional study was to explore and explain the initiation and sustenance of indoor tanning cessation among college students using the multi-theory model (MTM) of health behavior change. Data were collected from 254 college students who reported current indoor tanning use using a validated 46-item survey to assess demographics and the MTM constructs. Data were analyzed using multiple linear regression to determine the ability of the MTM constructs to predict the initiation and sustenance of indoor tanning cessation. For initiation of indoor tanning cessation, participatory dialogue: advantages (B = 0.038, p = 0.001), behavioral confidence (B = 0.129, p < 0.001) and changes in the physical environment (B = 0.088, p < 0.001) were significantly associated with indoor tanning cessation following covariate adjustment. For sustenance, only emotional transformation (B = 0.140, p < 0.001) demonstrated a significant relationship with indoor tanning cessation, following adjustment. Findings from this study demonstrate the utility of the MTM in explaining indoor tanning cessation and designing intervention strategies and clinical recommendations to encourage indoor tanning cessation among college students.

Artificial tanning devices (Sunbeds): where do we stand?

Exposure to ultraviolet radiation emitted by indoor tanning devices (sunbeds) has well-documented negative effects on human health, but no clear benefit beyond cosmetic outcomes. Sunbed use is responsible for a significant proportion of both melanoma and non-melanoma skin cancers, especially in patients exposed to this practice in early life, premature skin ageing, immunosuppression, skin burns, and eye damage. Artificial tanning is now seen as a public health issue. In this review we discuss the potential additive effect of indoor tanning, misleading facts regarding sunbed benefit, safety concerns and negative effects on human health, indoor tanning legislation and current position of several international organisations, and the impact of some policies adopted in order to mitigate the effects of this dangerous practice.

Reasons for indoor tanning use and the acceptability of alternatives: A qualitative study

RATIONALE

Using indoor tanning devices is associated with substantial health consequences, such as an increased risk of melanoma and other skin cancers. Many people including minors and some at high risk of skin cancer continue to use these devices. In the absence of effective restrictions on use, it is important that behaviour change interventions are designed to reduce indoor tanning.

OBJECTIVE

To explore reasons for use of indoor tanning devices and the acceptability of alternatives in adult users residing in North-West England.

METHODS

Participants were required to be current indoor tanners aged 18 years and above and were recruited online. Twenty-one participants took part in either a focus group or semi-structured interview. An inductive thematic analysis was conducted.

RESULTS

Six themes were identified: psychological benefits; improving physical health; denial of health risks; alternatives do not meet psychological needs; alternatives do not meet physical needs; and perceived side-effects. Participants used indoor tanning devices to improve their self-esteem and to prevent sun damage to their skin (by gaining a 'base tan'). Participants appeared to justify their usage by responding defensively to avoid accepting they were at risk, exaggerating the benefits of indoor tanning, and discounting alternatives to indoor tanning. Alternatives to indoor tanning were perceived as risky for health, inadequate to provide the desired aesthetic, and incapable of meeting their self-esteem needs.

CONCLUSIONS

Interventions to reduce indoor tanning behaviour should increase sources of self-esteem other than appearance, increase media literacy and address defensive responses to information around indoor tanning and alternatives. Further research is needed to develop these interventions and assess their feasibility.

Results of a social media campaign to prevent indoor tanning by teens: A randomized controlled trial

Indoor tanning (IT) increases risk of developing skin cancer. A social media campaign to reduce mother’s permissiveness toward their teenage daughters IT was evaluated. Mothers (N = 869) of daughters aged 14–17 in 34 states without bans on IT by minors were enrolled in a randomized trial with assessments at baseline and 12-months follow-up in 2017–19. A year-long adolescent health campaign was delivered to all mothers. The intervention group received posts on preventing IT and the control group, posts about preventing prescription drug misuse. Daughters (n = 469; 54.0%) completed the assessments at baseline and 12 months. At 12-month follow-up, intervention-group mothers were less permissive of IT by daughters (unadjusted means = 1.70 [95% CI: 1.59, 1.80] v. 1.85 [1.73, 1.97] [5-point Likert scale], b = -0.152), reported more communication about avoiding IT with daughters (4.09 [3.84, 4.35] v. 3.42 [3.16, 3.68] [sum of 7 yes/no items], b = 0.213), and had lower intentions to indoor tan (1.41 [1.28, 1.55] v. 1.60 [1.43, 1.76] [7-point likelihood scale], b = -0.221) than control-group mothers. Daughters confirmed intervention-group mothers communicated about IT (3.81 [3.49, 4.14] v. 3.20 [2.87, 3.53] [sum of 7 yes/no items], b = 0.237) and shared IT posts (unadjusted percentages = 52.4% v. 36.4%, b = 0.438) more than control-group mothers. No differences were found in IT behavior, self-efficacy to refuse permission, and negative attitudes toward IT. A social media campaign may be an effective strategy to convince mothers to withhold permission for IT, which may help increase the effectiveness of state laws designed to reduce IT by minors by requiring parental permission.

Epidemiology and Prevention of Cutaneous Cancer

Cutaneous malignancy is becoming an increasing public health burden in terms of morbidity and cost, associated with changing environmental exposures and increased longevity of the general and the immunosuppressed population. Yet the understanding of the scope of this problem is hindered by lack of robust registries for nonmelanoma skin cancer. The risk factor responsible for most of these cancers, exposure to ultraviolet radiation, can be mitigated. However, greater consensus is necessary to enact effective prevention and screening programs. New developments, including identification of biomarkers and use of artificial intelligence, show promise for targeting screening efforts.

Body image perception, smoking, alcohol use, indoor tanning, and disordered eating in young and middle-aged adults: findings from a large population-based Swedish study

BACKGROUND

Body image concerns may give rise to a multitude of risk behaviors, such as unhealthy weight control practices, disordered eating behaviors (e.g., compensatory purging or preoccupation with food), smoking, excessive alcohol intake, or sunbed use. However, the distribution of these risk behaviors across adulthood has rarely been studied.

METHODS

The aim of this study was to explore health risk behaviors as correlates of body image perception in a randomly selected study population of 30,245 individuals aged 30-66 in Stockholm, Sweden, utilizing data from the Stockholm Public Health Cohort. Bivariate correlations were explored and a hierarchic binary logistic regression analysis was performed.

RESULTS

The prevalence of body image discrepancy was higher among smokers and respondents displaying disordered eating behaviors. In contrast, alcohol and sunbed use were inversely correlated to body image discrepancy. Body mass index was the substantially strongest explanatory factor behind the observed variance in body image discrepancy, followed by loss-of-control eating. Notably, no major gender differences in body image perception were detected. Some unexpected patterns of association between variables other than body image perception, such as those between smoking, alcohol use, and sunbed use, were seen.

CONCLUSIONS

Overall, the patterns differ substantially from what has previously been found in adolescent and young adult samples, indicating that the synergy and aggregation of risk behaviors observed among younger individuals may not apply to adults aged 30-66.

A Process Evaluation of the Skin Cancer Prevention Act (Tanning Beds): A Survey of Ontario Public Health Units

Evidence of the dangers of indoor tanning and its popularity, including among youth, led the Government of Ontario to pass the Skin Cancer Prevention Act (Tanning Beds) (SCPA) in 2014. This legislation includes prohibiting the sale of indoor tanning services to individuals under 18, requiring warning signs be posted, and other safety regulations. We collected information from Ontario Public Health Units to conduct a process evaluation of the SCPA to: understand legislation implementation; assess available evidence about compliance, inspection, and enforcement; and, note barriers and facilitators related to inspection and enforcement. Data was collected March-April 2018. All 36 Ontario Public Health Units were invited to participate in an online questionnaire about the SCPA. Questions covered complaints, inspection, and enforcement, and used both close- and open-ended questions. Participants from 20 Public Health Units responded to the questionnaire; a response rate of 56%. These agencies reported 485 facilities offer indoor tanning. Since 2014, there have been 242 infractions by tanning facility owner/operators related to the SCPA, with most being uncovered during non-mandatory routine inspections (n = 234, 97%), rather than mandatory complaint-based inspections (n = 8, 3%). Most infractions were related to warning signs (n = 201, 83%). No charges were issued for any infractions. Instead, providing education (n = 90, 62%) and issuing warnings (n = 33, 23%) were the most common enforcement strategies. SCPA amendments are needed, including mandatory, routinely scheduled inspections. In addition to providing education, fines may improve compliance. More resources are required for inspection and enforcement of the SCPA.

Consequences of banning commercial solaria in 2016 in Australia

OBJECTIVE

To quantify the consequences of a total ban on indoor tanning for short-term regulatory enforcement, for consumers, and the longer-term health economic effects.

METHODS

Instances of illegal solarium prosecutions and tanning bed confiscations in the state of Victoria (population 7 million) were obtained from government surveillance records. Consumer interest for indoor tanning and spray/fake tanning were assessed using Google Trends' Search Volume Index (range 0 to maximum 100). Long-term health economic effects were estimated using a Markov cohort model.

RESULTS

The Victorian Government completed 13 prosecutions and confiscated 39 illegal tanning units. Consumer interest for indoor tanning reduced to less than one quarter of pre-regulation seasonal peaks (Search Volume Index 12/48) while spray tanning interest remained high (70-88). For young Australians over their remaining lives, banning commercial indoor tanning is expected to avert 31,009 melanomas (-3.7%), avert 468,249 keratinocyte cancers (-3.6%) and save over AU$64 (US$47) million in healthcare costs and produce over AU$516 (US$375) million in productivity gains.

CONCLUSIONS

Three years after the nationwide ban, regulation enforcement activities have decreased, and consumers have adopted substitute tanning methods.

Connections between sources of health and beauty information and indoor tanning behavior among college women

Objective: This study tested how media, family, and peer sources of health and beauty information predict indoor tanning (IT) beliefs and behavior. Participants: 210 undergraduate women at a state university in the southeastern United States. Methods: Respondents completed a survey about sources of health and beauty information, IT beliefs, and IT behavior. Correlations and a path model were used to test associations between variables. Results: Friends were positively and family were negatively associated with positive outcome expectations, with mood enhancement beliefs positively predicting behavior. Reliance on news positively predicted appearance damage and immediate risk, which both predicted behavior. Reliance on social media was negatively associated with beliefs about immediate risks. Conclusion: Health and beauty information from social media and from friends may promote beliefs about tanning, while information from news or one's family may reduce risky beliefs. Prevention efforts could leverage information sources to shift tanning beliefs and behavior.

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.

Skin Cancer and Skin Cancer Risk Factors in Sexual and Gender Minorities

Sexual and gender minorities have unique risk factors that may increase their risk of developing skin cancer. In particular, sexual minority men report a higher prevalence of skin cancer (including both keratinocytes carcinomas and melanoma), higher rates of indoor tanning, and overall poorer sun protection behaviors. Sexual and gender minorities also have high rates of alcohol and tobacco use, and infection with human immunodeficiency virus and human papillomavirus, which may increase overall risk of developing skin cancer in these populations. In this review, we discuss the evidence surrounding skin cancer and associated risk factors among sexual and gender minorities.

Epidemiology and Risk Factors of Melanoma

The incidence of melanoma continues to increase worldwide. In the United States, melanoma is the fifth most common cancer in men and the sixth most common cancer in women. The risk factors contributing to melanoma have largely remained unchanged, but there is a new focus on modifiable risk factors including sun exposure and ultraviolet light. A large public initiative supported by the Centers for Disease Control focuses on educating the public on the risks of sun exposure and indoor tanning. Early detection and resection of melanoma lesions is necessary to prevent metastasis and reduce medical costs.

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.

Impact of legislation on youth indoor tanning behaviour: A systematic review

Jurisdictions around the world have implemented indoor tanning legislations, which aim to protect all individuals, especially youth, from dangers of artificial ultraviolet radiation exposure. The objective of this study was to conduct a systematic review to synthesize the available peer-reviewed literature to determine whether indoor tanning legislation has impacted the prevalence of youth indoor tanning. Following PRISMA guidelines, six databases were searched in 2016. Reference lists from relevant articles were also searched. An updated literature search was conducted in 2018. Each article was critically appraised using a merged checklist created from two previously validated checklists. All articles meeting the inclusion criteria were retained after appraisal. Seven studies, all conducted in the U.S., met the inclusion criteria. All studies used an observational, cross-sectional design. There were small absolute decreases in youth indoor tanning prevalence after legislation vs before (n = 3, mean = 3% decrease, range = 1%-6% decrease). Prevalence of youth indoor tanning was significantly lower in states with indoor tanning legislation vs states without legislation (n = 4, mean = 5% lower, range = 1%-18% lower). Prevalence of youth indoor tanning was lower in states with longer standing indoor tanning legislation vs states with more recently implemented legislation (n = 2, mean = 9% lower, range = 2%-20% lower). Indoor tanning legislation is generally associated with lower indoor tanning prevalence among youth. The small percent differences equate to millions of youth at the population level. Longer time lapses from legislation implementation to evaluation, coupled with greater enforcement, compliance, legislative stringency, and public education may result in even more pronounced declines in youth indoor tanning prevalence.

Estimates of the current and future burden of melanoma attributable to ultraviolet radiation in Canada

Exposure to ultraviolet radiation (UVR) is an established cause of cutaneous melanoma. The purpose of this study was to estimate the current attributable and future avoidable burden of melanoma related to exposure to UVR and modifiable UVR risk behaviors (sunburn, sunbathing, and indoor tanning). The population attributable risk (PAR) associated with UVR in 2015 was estimated by comparing Canadian melanoma incidence rates in 2015 to estimated incidence rates of a 1920 birth cohort. Rates were adjusted for changes in reporting and ethnicity. We estimated PARs for modifiable UVR risk behaviors using Caucasian prevalence data from the Second National Sun Survey and relative risks that are generalizable to Canada from meta-analyses of relevant studies. Attributable cases apply to 98.9% of melanomas in Canada that occur in Caucasians. We also estimated the future burden of UVR risk behaviors using the potential impact fraction framework and potential reductions in prevalence of 10% to 50% from 2018 to 2042. Adult sunburn and sunbathing were associated with increased risks of melanoma of 1.28 (95% CI: 1.15, 1.43) and 1.44 (95% CI: 1.18, 1.76), respectively. In 2015, we estimate that 62.3% of melanomas in Canada were attributable to exposure to UVR and that 29.7% were attributable to the combination of sunburn (7.4%), sunbathing (17.8%), and indoor tanning (7.0%). A 50% reduction in modifiable UVR behaviors could avoid an estimated 11,980 melanoma cases by 2042. Prevention strategies aimed at modifiable UVR behaviors are crucial to reduce the growing burden of melanoma in Canada.

Indoor tanning and skin cancer in Canada: A meta-analysis and attributable burden estimation

BACKGROUND

Consistent epidemiologic and experimental studies have demonstrated that UV-emitting tanning devices cause melanoma and non-melanoma skin cancer. The purpose of this study was to estimate the relative risk of skin cancer associated with the use of indoor tanning devices relevant to Canada, to estimate the proportion and number of skin cancers in Canada in 2015 that were attributable to indoor tanning, and to explore differences by age and sex.

METHODS

Skin cancer cases attributable to the use of an indoor tanning devices were estimated using Levin's population attributable risk (PAR) formula. Relative risks for skin cancer subtypes that were relevant to Canada were estimated through meta-analyses and prevalence of indoor tanning was estimated from the 2006 National Sun Survey. Age- and sex-specific melanoma data for 2015 were obtained from the Canadian Cancer Registry, while estimated NMSC incidence data were obtained from the 2015 Canadian Cancer Statistics report.

RESULTS

Ever use of indoor tanning devices was associated with relative risks of 1.38 (95% CI 1.22-1.58) for melanoma, 1.39 (1.10-1.76) for basal cell carcinoma (BCC), and 1.49 (1.23-1.80) for squamous cell carcinoma (SCC). Overall, 7.0% of melanomas, 5.2% of BCCs, and 7.5% of SCCs in 2015 were attributable to ever of indoor tanning devices. PARs were higher for women and decreased with age.

CONCLUSION

Indoor tanning contributes to a considerable burden of skin cancer in Canada. Strategies aimed at reducing use should be increased and a total ban or restrictions on use and UV-intensity should be considered by health regulators.

'I am happier with my fairer complexion': factors associated with former indoor tanning and reasons for quitting in college women

This study of 312 female undergraduates investigated the association of recently, formerly, or never indoor tanning with self-perceptions and social influence, and examined reasons to tan and not to tan. Previous research on indoor tanning has focused on recent or current tanners, and few studies have examined former indoor tanners. By examining self-perceptions and social influence, this study aimed to understand how these common tanning correlates, measured in former indoor tanners, compared to those who have never tanned indoors (i.e., never tanners) and those who have recently tanned indoors. Appearance and global self-perceptions were more positive in former indoor tanners compared to never tanners and recent tanners. Recent indoor tanning was positively associated with both higher outdoor tanning frequency and having a higher number of friends performing skin cancer risk behaviors, and formerly indoor tanning was also associated with both, but to a lesser extent. Appearance and social influence were commonly described as reasons for indoor tanning, and perceived health risk, appearance, and social influence were described as prominent reasons for tanning cessation. This study improves what is known about former indoor tanners, which may be useful for behavior change maintenance efforts and developing approaches for skin cancer screening interventions.

A systematic review of compliance with indoor tanning legislation

BACKGROUND

Many jurisdictions have enacted indoor tanning legislation in response to the health risks of artificial ultraviolet (UV) radiation exposure. Key components of these legislations include banning minors' access, requiring parental consent or accompaniment, providing protective eyewear, posting health warning signs, and communicating important health risk information. However, legislation must be complied with to be impactful. Evidence around compliance with indoor tanning legislations has not been synthesized and is an important step toward determining changes in practice due to legislation.

METHODS

A systematic review was conducted to obtain peer-reviewed literature about compliance with indoor tanning legislation worldwide. Six databases were searched, resulting in 12,398 citations. Sixteen studies met the inclusion criteria (peer-reviewed scientific studies, published in English, focused primarily on compliance with indoor tanning legislations, and focused on commercial indoor tanning in indoor tanning facilities).

RESULTS

Compliance with most aspects of indoor tanning legislation varied widely. There was good compliance for provision of protective eyewear (84 to 100%; mean = 92%; SD = 8). Compliance with age restrictions ranged from 0 to 100% (mean = 65%; SD = 25), while compliance with posting warning labels in the required locations within a tanning facility ranged from 8 to 72% (mean = 44%; SD = 27). Variation in compliance may be due to true differences, study methodology, or temporal trends.

CONCLUSIONS

Variability in compliance with indoor tanning legislation, as found in this systematic review, indicates the legislations may not be having their intended protective effects on the public's health. The reasons for such low and varied compliance with certain aspects of legislation, and high compliance with other aspects of legislation, deserve further attention in future research to inform best practices around ensuring high and consistent compliance with indoor tanning legislations worldwide.

Availability of tanning salons in Ontario relative to indoor tanning policy (2001-2017)

Ultraviolet (UV) radiation from indoor tanning equipment is a known cause of skin cancer; however, little is known about how the availability of indoor tanning salons has been impacted by indoor tanning legislation, including Ontario's Skin Cancer Prevention Act: Tanning Beds (SCPA). Tanning salon listings were obtained from the 2001 to 2017 editions of InfoCanada's Ontario Business to Business Sales and Marketing directories. Using descriptive statistics and regression analysis, we assessed the number of tanning salons before and after: 1) the 2006 International Agency for Research on Cancer (IARC) report on indoor tanning and skin cancer; 2) the 2009 World Health Organization (WHO) reclassification of artificial UV radiation as carcinogenic; and 3) the passing and enactment of Ontario's SCPA in 2013 and 2014, respectively. There were fewer tanning salon listings in the years after vs. before the IARC report, the WHO reclassification, and the passing and enactment of the SCPA. The number of tanning salons in Ontario, Canada has been declining since 2006, which may reflect a decline in indoor tanning bed use. Key public health policy instruments, including legislation and public education, appear to be associated with this trend, suggesting they may contribute to deterring indoor tanning.

•

Number of tanning salons in Ontario, Canada decreased from 2006 to 2017.

•

Number of tanning salons declined after passing and enactment of indoor tanning legislation.

•

Number of tanning salons declined after international report and decision on carcinogenic nature of tanning devices.

•

Legislation, expert exhortation, and public education may contribute to declines in tanning salon availability.

A brief facial morphing intervention to reduce skin cancer risk behaviors: Results from a randomized controlled trial

The current study was designed to test the efficacy of an appearance-based facial morphing program to reduce intentional UV exposure among individuals at risk for skin cancer. A three-arm randomized controlled trial was employed (N = 219) comparing facial morphing + health information to: (1) mindfulness + health information; and (2) health information only. Participants were young adults with a history of recent intentional tanning and future intentions to tan. Primary outcomes were indoor and outdoor tanning frequency and tanning intentions, with secondary outcomes of tanning attitudes, body image, and affect. Facial morphing participants reported less frequent tanning, compared to mindfulness and control participants at 1-month follow-up. Facial morphing participants also generally reported lower intentions to tan at immediate follow-up, although the magnitude of these effects weakened at 1-month follow-up. Facial morphing programs may offer a brief, efficacious, and scalable augmentation to standard of care in reducing intentional UV exposure. This trial is registered with clinicaltrials.gov (NCT03237013).

Compliance with indoor tanning bans for minors among businesses in the USA

Indoor tanning is a known risk factor for skin cancer and is especially dangerous for adolescents. Some states have passed indoor tanning bans for minors, but business compliance with the bans is not well understood. Thus far, studies have assessed ban compliance in one or two states at a time. This study aimed to assess compliance with indoor tanning bans for minors and knowledge of dangers and benefits of tanning among indoor tanning businesses. Female research assistants posing as minors telephoned a convenience sample of 412 businesses in 14 states with tanning bans for minors under age 17 or 18. We evaluated differences in compliance by census region and years since ban was implemented and differences in reported dangers and benefits by compliance. Most (80.1%) businesses told the "minor" caller she could not use the tanning facilities. Businesses in the south and in states with more recent bans were less compliant. Among those (n = 368) that completed the full interview, 52.2% identified burning and 20.1% mentioned skin cancer as potential dangers. However, 21.7% said dangers were no worse than the sun and 10.3% denied any dangers. Stated benefits included vitamin D (27.7%), social/cosmetic (27.2%), and treats skin diseases (26.4%), with only 4.9% reporting no benefits. While most businesses followed the indoor tanning ban when a minor called, one-fifth did not. Many stated inaccurate health claims. Additional enforcement or education might increase compliance with indoor tanning bans and action is needed to prevent businesses from stating false health information.

Significant Engagement in Tanning Behaviors by Men at a U.S. University

Adolescent and young adult men are a potentially overlooked population with respect to risky tanning behaviors. This study sought to determine the prevalence of various modes of tanning and associated variables among young men in a university setting in the southeastern United States. Undergraduate students at a public institution in Mobile, Alabama were surveyed electronically in March 2016. Of the 818 undergraduate men surveyed, over 90% reported tanning behaviors, with 37% reporting engaging in indoor tanning. Additionally, over 25% reported engaging in two or more types of tanning concurrently. These findings indicate that early intervention efforts targeting young men are needed to reduce risky tanning behaviors and associated negative health outcomes.

A Web-Based Intervention to Reduce Indoor Tanning Motivations in Adolescents: a Randomized Controlled Trial

Youthful indoor tanning as few as ten sessions can increase the risk of melanoma by two to four times with each additional session adding another 2 % to the risk. Recent research estimates that indoor tanning can be linked to approximately 450,000 cases of skin cancer annually in the USA, Europe, and Australia. Despite these risks, indoor tanning remains popular with adolescents. This study tested the efficacy of a web-based skin cancer prevention intervention designed to reduce indoor tanning motivations in adolescent females. A nationally representative sample of 443 female teens was enrolled from an online panel into a two-arm, parallel group design, randomized controlled trial. Treatment participants received an appearance-focused intervention grounded in established health behavior change models. Controls viewed a teen alcohol prevention website. Outcome variables included willingness and intentions to indoor tan, willingness to sunless tan, and measures of indoor tanning attitudes and beliefs. The intervention decreased willingness and intentions to indoor tan and increased sunless tanning willingness relative to controls. We also examined indirect mechanisms of change through intervening variables (e.g., indoor tanning attitudes, norms, positive and negative expectancies) using the product of coefficient approach. The web-based intervention demonstrated efficacy in changing adolescent indoor tanning motivations and improving their orientation toward healthier alternatives. Results from the intervening variable analyses give guidance to future adolescent skin cancer prevention interventions.

Is initiating tanning bed use as a minor associated with increased risky tanning behaviors and burning? An exploratory study

Tanning bed use is most common among youth and young adults, and is associated with an increased risk of skin cancer. Recently, numerous states have adopted restrictions on minors' access to tanning beds; however, little has been reported on how such policies may impact tanning behaviors and burning. The purpose of this study was to examine the associations between age of indoor tanning initiation and risky tanning behaviors and burning. Female students (n=567) attending a large southeastern public university completed a questionnaire (spring of 2015) assessing tanning bed use history, including age of initiation. The analytic sample was limited to participants reporting past year indoor tanning (n=134). Multivariable logistic regression was used to compare the odds of risky tanning behaviors and burning among those initiating indoor tanning before and after their 18th birthday. Participants initiating indoor tanning as a minor had significantly (ps<0.05) greater odds of using a tanning bed 10 or more times in the previous year, typically indoor tanning for ≥10min, ever indoor tanning without wearing goggles, and ever fallen asleep inside a tanning bed. Further, those that initiated as a minor had significantly greater odds of ever burning from indoor tanning (p<0.05). Indoor tanning initiation as a minor was associated with several risky tanning behaviors and burning. Youth access restrictions may help reduce the harms caused by tanning beds.

Recall of indoor tanning salon warnings and safety guidelines among a national sample of tanners

Indoor tanning (IT) is a known carcinogen, and regulation has increased across the USA. However, there is minimal point-of-sale regulation for adult users. The purpose of the present study is to explore whether IT users recall being provided with warnings or safety guidelines at tanning salons. A national sample of 273 young adult, female IT users (mean age = 22.26, SD = 2.38) was surveyed regarding the frequency that they recalled being provided with six different warnings and safety guidelines when at tanning salons. Between 65 and 90.1 % of participants reported recalling the various warnings and guidelines. Having very fair skin was reported by 16.8 % of participants, and these high-risk individuals were less likely to recall having read and signed a consent form than other IT users (p = .002). The current level of regulation is insufficient to provide IT users with consistent warnings and safety guidelines at tanning salons.

Support for indoor tanning policies among young adult women who indoor tan

The purpose of this study to examine support for indoor tanning policies and correlates of policy support among young adult women who indoor tan. Non-Hispanic white women ages 18-30 who indoor tanned in the past year (n = 356, M 23.3 age, SD 3.1) recruited in the Washington, DC area from 2013 to 2016 completed measures of indoor tanning behaviors, attitudes, perceptions, beliefs, and policy support. Most women in the sample supported policies to prevent children under the age of 18 from indoor tanning (74.0 %) and stronger warnings about the risks of indoor tanning on tanning devices (77.6 %); only 10.1 % supported a total ban. In multivariable analyses, support for individual indoor tanning policies varied by demographics (e.g., age), frequent indoor tanning behavior, indoor tanning beliefs, and risk perceptions. Non-Hispanic white young adult women who indoor tan, the primary consumers of indoor tanning, and a high-risk population, largely support indoor tanning prevention policies implemented by many state governments and those currently under review for national enactment. Given low levels of support for a total indoor tanning ban, support for other potential policies (e.g., increasing the minimum age to 21) should be investigated to inform future steps to reduce indoor tanning and the associated health risks.

Indoor tanning promotions on social media in six US cities #UVTanning #tanning

There is no research investigating indoor tanning advertising on social media. We assessed the use of social media to promote indoor tanning. We subscribed to social media platforms in six US cities and content-analyzed promotional messages received. We captured 662 messages on Twitter and Facebook, through salon emails, and in daily deal coupons. Salon postings were most frequent on Twitter and Facebook, with an average of 2-3 postings per week. National chains posted more frequently than local businesses. Forty percent of messages were devoid of tanning content and included photos, jokes, or popular references. Thirty percent mentioned price reductions, and 28 % referenced an upcoming holiday. Sunless tanning (17 %) was promoted more often than ultraviolet tanning (9 %). Tanning salons actively use social media as a strategy for maintaining relationships with customers and offer pricing deals that promote loyalty and high-frequency tanning.

An integrated model of skin cancer risk in sexual minority males

Sexual minority males are an at-risk group for developing skin cancer. Elevated rates of skin cancer among this population are thought to be driven by excess indoor tanning; however, motivations to indoor tan among this population are unknown. Theoretically, appearance-based and affect regulation motives may be proximal predictors of increased indoor tanning in this population. The current study tests an integrated biopsychosocial model of indoor tanning behaviors and future intentions among a sample of sexual minority males. Participants were 231 sexual minority males, between the age of 14 and 35 years, residing in San Diego County, California, who completed a battery of self-report questionnaires online. Constructs assessed included skin tone, perceived susceptibility to skin cancer, sociocultural pressures to tan, appearance-based motives to tan, affect regulation in regard to indoor tanning, indoor tanning behaviors over the previous 3 months, and future intentions to indoor tan. The three proposed proximal predictors of indoor tanning all displayed significant pathways; however, results varied depending upon the specific outcome measure modeled. Affect regulation was significantly associated with increased odds of indoor tanning, and future intentions to indoor tan. Increased appearance reasons to tan were significantly associated with future intentions to indoor tan, while increased appearance reasons not to tan were significantly associated with fewer number of indoor tanning sessions. Results underscore the unique pathways of affect regulation and appearance-based motives in indoor tanning behaviors. Skin cancer prevention programs focusing on sexual minority males may wish to address affect and appearance concerns.

The association between beliefs about vitamin D and skin cancer risk-related behaviors

Major health organizations recommend obtaining most of one's vitamin D through dietary sources rather than from sun exposure, given the link between sun exposure and increased skin cancer risk. The purpose of this study is to examine the association between beliefs about vitamin D and skin cancer risk-related behaviors, a topic on which research is limited. We analyzed cross-sectional online survey data collected in the summer of 2015 from 4127U.S. adults aged 18years and older. Overall, 19.7% of adults believed that sun protection would put them at risk of not getting enough vitamin D. However, less than half (43.1%) thought they could get enough vitamin D from dietary sources. Individuals with this belief were more likely to protect their skin when spending time outdoors (71.3%) compared with those who were neutral or disagreed (56.5%; P<0.001). Only 5.1% of adults believed that indoor tanning is an effective way to get vitamin D. Compared to those who disagreed or were neutral, those who thought it was effective were more likely to be outdoor tanners (45.1% vs. 28.5%; P<0.001) and indoor tanners (13.8% vs 1.9%; P<0.001). Beliefs about vitamin D were associated with skin cancer risk-related behaviors. Including information about vitamin D in skin cancer prevention messages may be beneficial.

Creating the first indoor tan-free skin smart college campus

Given the prevalence and risk associated with indoor tanning among college students, university campuses constitute a prime target for skin cancer prevention. This report identifies the successes and challenges faced in promoting a campus-wide tan-free policy through the National Council on Skin Cancer Prevention (NCSCP) Indoor Tan-Free Skin Smart Campus Initiative. Beginning in February 2016, we communicated with university faculty or staff members who have participated in skin cancer prevention via education, clinical care, or research at 20 universities regarding the steps to adopt the tan-free policy. One campus, East Tennessee State University (ETSU), successfully fulfilled all criteria and implemented the policy change to become the first US Indoor Tan-Free Skin Smart Campus. The greatest challenge faced in recruiting campuses was gaining administrative support. Reported reasons for not adopting the policy change included wanting to wait for other schools to join first and not seeing it as a top priority. Despite the importance of improving skin cancer awareness and decreasing tanning among university students, we faced several challenges in promoting campus-wide policy change. We identify a need for research on effective ways to disseminate university health policies and increased involvement of healthcare providers in policy-related work.

"These people, you just guide them until they become these people": learning to become a frequent indoor tanner

Background

Many young women experiment with using indoor tanning beds with some becoming regular users. There is a dearth of research focused on factors related to the development of regular tanning. This study was designed to gain an in-depth understanding of the experiences of a regular indoor tanning bed user for the purpose of discovering working hypotheses related to the development of this behavior. The article thesis is that initial interactions with tanning salon employees transmit insider knowledge that serves to encourage the regular use of indoor tanning beyond experimentation.

Methods

We used Spradley’s ethnographic interviewing technique to conduct six iterative interviews with a key informant who was an active indoor tanning bed user and former salon employee. The research was completed in the United States in 2015.

Results

The informant described her experiences as a salon employee including her interactions with salon patrons. The informant was trained as a salon employee to talk about tanning as a complex process that requires multiple salon visits to achieve desired results and to develop rapport with salon patrons to be viewed as an important source of guidance and advice. In the informant’s experience, indoor tanning users who viewed tanning as a complex process and felt connected to salon employees were more receptive to purchasing larger amounts of bulk tanning sessions and committing to purchasing salon memberships.

Conclusions

Findings provide insights into our understanding of the development of regular tanning behavior and we propose working hypotheses about this behavior to be examined in future research. There are also implications for policy makers to reduce excessive tanning behaviors including considering point-of-sale regulations that limit sales techniques of salon employees and pricing restrictions.

Friendly tanning: young adults' engagement with friends around indoor tanning

Indoor tanning (IT), particularly during early adulthood, increases risk for melanoma and is exceedingly common among youth. Social influence, including social norms, promotes IT but little is known about young adults' engagement with friends around tanning. We examined IT behaviors and tanning-related communication with friends at three universities. Of 837 participants, 261 (31%) reported ever tanning (90% female, 85% White). Of those, 113 (43%) were former tanners and 148 (57%) current tanners. Current tanners reported more social tanning and discussions with friends about tanning, more frequent outdoor tanning, high propensity to tan, and greater lifetime IT exposure than former tanners. Risks-to-benefits discussion ratios were greater for former tanners. In adjusted analyses, current tanners were more likely to make plans to tan and to talk about tanning benefits with friends. Findings confirm IT is a social experience. Future work should examine social tanning's role in the promotion and reduction of IT among youth.

Theory-Driven Longitudinal Study Exploring Indoor Tanning Initiation in Teens Using a Person-Centered Approach

BACKGROUND

Younger indoor tanning initiation leads to greater melanoma risk due to more frequent and persistent behavior. Despite this, there are no published studies exploring the predictors of indoor tanning initiation in teen populations.

PURPOSE

This longitudinal study uses latent profile analysis to examine indoor tanning initiation in indoor tanning risk subgroups from a national sample of female adolescents.

METHODS

Latent profile analysis used indoor tanning beliefs and perceptions to identify indoor tanning initiation risk subgroups. The teens in each subgroup were reassessed on indoor tanning initiation after a year.

RESULTS

Three subgroups were identified: a low risk, anti-tanning subgroup (18.6 %) characterized by low scores on positive indoor tanning belief scales and high scores on beliefs about indoor tanning dangers; a moderate risk aware social tanner subgroup (47.2 %) characterized by high scores on positive indoor tanning belief scales but also high scores on beliefs about indoor tanning dangers; and a high risk risky relaxation tanner subgroup (34.2 %) characterized by high scores on positive indoor tanning belief scales and low scores on beliefs about indoor tanning dangers. Teens in the aware social tanner and risky relaxation tanner subgroups were significantly more likely to initiate indoor tanning in the following year.

CONCLUSIONS

These findings highlight the need to identify teens at risk for indoor tanning initiation and develop tailored interventions that will move them to the lowest risk subgroup. Subgroup correlates suggest parent and peer-based interventions may be successful.

Mood Changes After Indoor Tanning Among College Women: Associations with Psychiatric/Addictive Symptoms

Indoor tanning (IT) has been linked with psychiatric and addictive symptoms, and frequent tanning may indicate tanning dependence (addiction). The current study evaluated the effects of an IT episode on mood states and the association of these effects with psychiatric and addictive symptoms among young adult female indoor tanners. One-hundred thirty-nine female university students aged 18-25 years who had indoor tanned completed an online survey including the Positive and Negative Affects Scales and a standardized psychiatric interview (the MINI International Neuropsychiatric Interview) via telephone. Psychiatric and addictive symptoms were relatively common among these young adult female indoor tanners. Overall, participants reported significant decreases in both negative (upset, scared, irritable, nervous, jittery, afraid) and positive (feeling interested) mood states after their most recent tanning episode. Multivariable linear regression analyses showed that more frequent indoor tanning in the past month and symptoms of illicit drug use disorders were associated with decreases in negative mood, and symptoms of generalized anxiety disorder were associated with a decrease in feeling interested. In summary, indoor tanners report relatively high rates of psychiatric and substance use symptoms, including symptoms of tanning dependence, and indoor tanning appears to alter mood. Women with certain substance use and psychiatric characteristics may be more vulnerable to such mood changes after tanning indoors. Further research is needed to clarify the relationships among these variables.

Sex differences and risk behaviors among indoor tanners

Objective

The objectives were to examine (1) sex differences in factors associated with indoor tanning, and (2) the relationship between cancer risk perception and skin cancer screening among indoor tanners.

Methods

Data are from the 2010 National Health Interview Survey. The sample was limited to U.S. adults (≥ 18 years) using an indoor tanning device in the last year (N = 1177). We conducted bivariate and multivariate weighted analyses.

Results

Among indoor tanners, less than 30% of men and women reported having ever had a skin exam. Male sex was significantly associated with rarely/never using sunscreen (51.4% of men vs. 36.4% of women) and with binge drinking of alcohol (47.6% of men vs. 37.4% of women). No sex differences in smoking were present. Indoor tanners who perceived themselves “about equally likely” to develop cancer (any type) as similar others were less likely to have received a skin cancer examination than those with high perceived risk.

Conclusion

The relationship of cancer risk perception to skin cancer screening is complex. Rates of risk and protective behaviors observed among men and women who indoor tan suggest mixed-sex tanning prevention efforts should target multiple risk behaviors.

•

We analyzed data on indoor tanners from a national survey.

•

A significant percentage of female tanners uses sunscreen regularly.

•

Tanners who perceive moderate cancer risk reported lowest rates of cancer screening.

•

Indoor tanners of both sexes engage in frequent risky behaviors.

Indoor Tanning, Skin Cancer and the Young Female Patient: A Review of the Literature

Young, non-Hispanic white females represent the population most likely to use indoor tanning facilities. This population may be at increased risk of skin cancer as recent meta-analyses support a strong association between cutaneous malignancy and indoor tanning. Public perception of the purported health benefits of indoor tanning may be partially to blame for the popularity of tanning salons as a desire to prepare skin prior to sun exposure is among the most commonly cited motivations for indoor tanning. Improving education and counseling to address misconceptions regarding tanning safety will require the participation of healthcare providers for both physical and psychological screenings as well as for information dissemination. This review presents the association between tanning bed use and skin cancer, biological effects of UV radiation exposure, UV burden associated with tanning devices, public perception of tanning, demographic and psychological profile of indoor tanners, and current legislation regulating tanning bed use.

The window of opportunity for indoor tanning legislation

As of August 2014, 11 states in the USA have passed under-age-18 bans on indoor tanning. The Society of Behavioral Medicine, the American Academy of Dermatology, and the American Academy of Pediatrics have all issued statements in support of an under-age-18 ban. The World Health Organization and the Food and Drug Administration have both declared indoor tanning devices as carcinogenic, and this year, the Surgeon General for the first time issued a warning on the dangers of UV radiation and indoor tanning. This essay highlights how the awareness of the risks of indoor tanning, effective policies, and a conducive political atmosphere have aligned to create a window of opportunity for further under-age-18 indoor tanning legislation. The rising number of preventable skin cancers and mortalities is an issue that transcends political party lines, and now, there is a need for support from health professionals and advocates to motivate legislators to push new under-age-18 bills past their sticking points.

Quitting the "Cancer Tube": a qualitative examination of the process of indoor tanning cessation

This study examined health belief model (HBM) relevant constructs in the context of indoor tanning cessation. Telephone interviews were conducted between December 2011 and April 2012 with participants drawn from the Growing Up Today Study (GUTS) population, specifically, former tanning bed users (N = 14, all females; mean age, 25.65 years) who reported frequent use in 2007, but had quit by 2010. Participants identified important motivations for quitting including health and financial reasons and the central role of family and friends in providing encouragement for indoor tanning cessation. However, participants also noted substantial barriers to maintaining indoor tanning quitting (e.g., social pressures to look good, tanning salon incentives). Participants' experience of withdrawal highlighted psychological factors more often than physical factors; some were open to resuming use in the future. The findings will be useful in intervention development to encourage cessation, the strengthening of policies to regulate the indoor tanning industry, as well as public health messaging to raise awareness of this prevalent, easily accessible cancer risk behavior.

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

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

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.

Using research data to impact consumer protection legislation: lessons learned from CITY100 dissemination efforts

The Correlates of Indoor Tanning in Youth (CITY100) project evaluated individual, built-environmental, and policy correlates of indoor tanning by adolescents in the 100 most populous US cities. After CITY100's completion, the research team obtained supplemental dissemination funding to strategically share data with stakeholders. The primary CITY100 dissemination message was to encourage state-level banning of indoor tanning among youth. We created a user-friendly website to broadly share the most relevant CITY100 data. Journalists were a primary target audience, as were health organizations that would be well positioned to advocate for legislative change. CITY100 data were used to pass the first US state law to ban indoor tanning among those under 18 (CA, USA), as well as in other legislative advocacy activities. This paper concludes with lessons learned from CITY100 dissemination activities that we hope will encourage more health researchers to proactively address policy implications of their data and to design relevant, effective dissemination strategies.