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Use of Sunscreen, Sunburning Rates, and Tanning Bed Use Among More Than 10 000 US Children and Adolescents

Alan C. Geller, RN, MPH^*, Graham Colditz, MD, DrPH, Susan Oliveria, ScD, MPH^||, Karen Emmons, PhD^¶, Cynthia Jorgensen, DrPH^#, Gideon N. Aweh, MS and A. Lindsay Frazier, MD, MSc^,

^* Department of Dermatology, School of Medicine, and Department of Epidemiology and Biostatistics, School of Public Health, Cancer Prevention and Control Center, Boston University, Boston, Massachusetts
Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts
Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
^|| Dermatology Service, Department of Medicine, Memorial-Sloan Kettering Cancer Center, New York, New York
^¶ Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts
^# Centers for Disease Control and Prevention, Atlanta, Georgia

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	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objectives. To describe the association of sunscreen use, sunburning, and tanning bed use by age, sex, residence, and psychosocial variables associated with tan-seeking behaviors, and to compare these findings with sun protection recommendations from federal agencies and cancer organizations.

Methods. A cross-sectional study, from all 50 states, of 10 079 boys and girls 12 to 18 years of age in 1999. Data were collected from self-report questionnaires with the children of the participants from the Nurses Health Study (Growing Up Today Study).

Results. The prevalence of sunscreen use was 34.4% with girls more likely to use sunscreen than boys (40.0 vs 26.4, odds ratio: 1.86; 95% confidence interval: 1.70–2.03). Eighty-three percent of respondents had at least 1 sunburn during the previous summer, and 36% had 3 or more sunburns. Nearly 10% of respondents used a tanning bed during the previous year. Girls were far more likely than boys to report tanning bed use (14.4 vs 2.4), and older girls (ages 15–18) were far more likely than younger girls (ages 12–14) to report tanning bed use (24.6% vs 4.7). Tanning bed use increased from 7% among 14-year-old girls to 16% by age 15, and more than doubled again by age 17 (35%; N = 244). Multivariate analysis demonstrated that attitudes associated with tanning, such as the preference for tanned skin, having many friends who were tanned, and belief in the worth of burning to get a tan, were generally associated with sporadic sunscreen use, more frequent sunburns, and increased use of tanning beds.

Conclusions. Our findings suggest that many children are at subsequent risk of skin cancer because of suboptimal sunscreen use, high rates of sunburning, and tanning bed use. Recommendations in the United States for improved sun protection and avoidance of tanning beds and sunburning, which began in the early 1990s, have been primarily unheeded. Nationally coordinated campaigns with strong policy components must be developed and sustained to prevent skin cancer in a new generation of children and adolescents.

Key Words: melanoma • skin cancer prevention • children • epidemiology

Abbreviations: UV, ultraviolet • GUTS, Growing Up Today Study • NHS II, Nurses’ Health Study II • SPF, Sun Protection Factor; OR, odds ratio • CI, confidence interval

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Results from epidemiologic studies have shown that sun exposure is the major environmental risk factor for the development of both melanoma and nonmelanoma skin cancers.^1–3 It has been estimated that ultraviolet (UV) radiation from the sun is responsible for at least 65% of the melanoma cases worldwide.⁴ It has been suggested that limiting sun exposure during childhood and adolescence, through the use of sunscreen, could reduce the lifetime risk of developing nonmelanoma skin cancers by as much as 78%.⁵

Although skin cancers are rare in individuals under the age of 20, there is evidence to support a role of sun exposure during early life and subsequent risk of skin cancer during adulthood.^6–9 Furthermore, patterns of sun exposure seem to be important in the development of these cancers, specifically intermittent sun exposure received during the critical periods of childhood and adolescence.^9,10

The effects of sun exposure during early life are important because most of an individual’s exposure occurs during childhood and adolescence.^11,12 Children spend an estimated 2.5 to 3 hours outdoors each day^13,14 and may receive 3 times more annual UV-B rays than adults, because they have a greater opportunity for midday sun exposure during the summer months.^13,15 Health behaviors, including unprotected sun exposure, are established early in life and may "track" into adulthood.^16,17 Furthermore, there is some evidence to suggest that primary prevention programs to reduce sun exposure are beginning to have a beneficial effect on reducing skin cancer in younger age cohorts.¹⁸

Recent recommendations from the Centers for Disease Control and Prevention, the American Cancer Society, the American Academy of Dermatology, the Environmental Protection Agency, and the Skin Cancer Foundation, among others, have called for increased use of sun protection, minimizing sunburns, and avoiding tanning beds.^19–23

The purpose of the current study was to assess adherence to these new recommendations, and to examine the relationship between sunscreen use, sunburning, and tanning bed use by demographics and psychosocial correlates related to tan-seeking. We hypothesized that adolescents were not adopting these recommendations and that tan-seeking behaviors were related to noncompliance. In addition, we hypothesized that tan-seeking behaviors, including use of tanning beds, would be more prevalent among female adolescents. This is the first study to jointly examine sunscreen use, sunburning, and tanning bed use in US children.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Study Population and Survey Methods
In the current study, we analyzed the findings from white preadolescents and adolescents aged 12 to 18 years. Because children of nonwhite races have a far lower risk of skin cancer and sunburn, the focus of this study was on white children.

The Growing Up Today Study (GUTS) is a longitudinal study that was established in 1996 and originally involved the children and adolescent offspring of women participating in the Nurses’ Health Study II (NHS II). NHS II is a national longitudinal cohort study of 116 671 female nurses, established in 1989. Letters were first sent to the approximately 40 000 women who participated in NHS II and who had indicated that they had a child between 9 and 14 years of age. Mothers who gave permission for their child to participate provided each child’s name, age, gender, and address. These 25 000 children then were sent a packet including a letter inviting them to participate in a new study and a gender-specific questionnaire. Return of a completed questionnaire was considered consent to participate. This study was approved by the Human Subjects Committees at the Harvard School of Public Health and the Brigham and Women’s Hospital in Boston, Massachusetts. Mothers who gave permission to contact their children were slightly different from those who did not grant permission in terms of mother’s smoking status (8% vs 10%, respectively), age (37.7 vs 37.8 years), and body mass index (25.3 kg/m² vs 25.7 kg/m²).²⁴

In 1999, 16 625 adolescents of all races (ages 12–18) were eligible to complete the survey, and 94% of these were white (N = 15 627). Sunscreen questions were completed by 10 843 respondents, of whom 10 079 were white. The overall response rate for white adolescents was 65%.

Measures
We created a variable based on the child’s state of residence and then categorized these into warmer states (N = 13) and cooler states (N = 37; see methodology used elsewhere).²⁵ In general, warmer climates included Hawaii, Southern California, the Southeast, and the Southwest defined as having the highest mean UV Index at the time of survey completion.

In 1999, 7 questions on sun protection attitudes and practices were added to the GUTS questionnaire. The questions, divided into predictors and outcomes were:

Predictors

1. What is the color of your untanned skin?
   Color of untanned skin was categorized as very fair, fair, olive, and dark.
   
2. How many of your friends had a tan at the end of the summer (this past summer)?
   Responses were categorized on a 5-point scale, ranging from none to all.
   
3. How much do you agree with the following statement?
   It’s worth getting a little burned to get a good tan?
   Responses were categorized on a 5-point scale, from strongly agree to strongly disagree.
   
4. What kind of tan is most attractive to you?
   Responses included natural skin color, a little color from the sun, a light brown suntan, a moderate brown suntan, and a very dark brown suntan.
   For these 3 psychosocial questions, we then further categorized respondents into 2 groups: all, most, some friends tanned versus none and a few; worth getting a little burned to get a good tan into strongly agree and agree versus others; and attractiveness of tan into natural color and a little color from the sun compared with a light brown suntan, a moderate brown suntan, and very dark brown suntan.
   

Outcomes
The primary endpoints of interest included: 1) routine use of sunscreen, 2) the presence of at least 3 sunburns during the past summer, and 3) use of a tanning booth or salon during the past year. The outcomes are further described below:

1. When you were outside on a sunny day this past summer for >15 minutes, how often did you use sunscreen or sunblock with a Sun Protection Factor (SPF) of 15 or more?
   Sunscreen use was defined as "routine" if the child reported using sunscreen always or often.²⁶ Sporadic use of sunscreen was defined as sometimes, rarely, and never.
   
2. How many times did you get a sunburn this past summer (that is, how many times did exposed parts of your skin stay red for several hours after you had been out in the sun)?
   No sunburn, 1 to 2 times, 3 or more times.
   
3. During the past year, how many times did you use a tanning booth or tanning salon?
   Responses ranged from never to 10 or more times.
   

Data Analysis Plan
Statistical analyses were performed using SAS (SAS Insitute, Cary, NC). All analyses were stratified by gender. We calculated descriptive statistics to describe sun protection practices and attitudes of the study cohort. Univariate and multivariate analyses were performed to evaluate associations between the primary endpoints and demographic factors (age, gender, and residence), skin color (very fair, fair, olive, and dark), and psychosocial factors and attitudes related to beliefs about tanning. ² analysis tests for categorical data were performed and regression modeling was done to identify the sets of predictor variables for the three primary endpoints. In logistic regression analysis, we evaluated the association between the predictor variables and the trend toward the occurrence of multiple sunburns.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The mean age of the 10 079 respondents was 14 years of age, and girls represented 59% of the sample. Nearly one third of the cohort lived in warmer climates. Seventy-five percent of respondents had very fair or fair skin.

Summary of Practices and Psychosocial Variables
Girls used sunscreen more routinely than boys (40.0% vs 26.3%; odds ratio [OR]: 1.86; 95% confidence interval [CI]: 1.70–2.03), but were more likely to have received at least 3 sunburns the previous summer, (OR: 2.06; 95% CI: 1.83–2.32). Girls were far more likely than boys to have used a tanning booth during the past year (14.4% vs 2.4%; OR: 6.99; 95% CI: 5.65–8.65; Table 1).

Sunscreen Use
Only one third of the respondents reported routine use of sunscreen during the past summer. Use of sunscreen was inversely associated with age for both boys and girls. Overall, very fair children were more likely than olive-complected and dark-complected children to report routine use (49% vs 29% and 20%, respectively; P < .001). These relationships were consistent when stratified by gender. There were no differences between routine and sporadic users by residence. Children reporting that it was worth getting burned to get a good tan used sunscreen less frequently (21% vs 39%; OR 0.42; 95% CI: 0.37–0.46) as did those who preferred a tan versus natural or light color (31% vs 44%: OR: 0.57; 95% CI: 0.52–0.62). Univariate analyses showed strong differences between boys and girls for most variables. Multivariate analysis confirmed that girls, younger children, children with very fair skin and fair skin, children not believing that it was worth burning to get a tan, those preferring natural skin color or a little color, and having friends who were not tanned were more likely to report sunscreen use (Table 2).

Tanning Bed Use
Nearly 10% of respondents used a tanning bed during the previous year. Girls were far more likely to report tanning bed use and older girls (ages 15–18) were far more likely than younger girls to report tanning bed use (24.6% vs 4.7; P < .001). Tanning bed use increased from 7% among 14-year-old girls to 16% by age 15, and more than doubled again by age 17 (35%; P < .001).

A significant trend toward increased tanning bed use for olive- and dark-complected children was observed (OR: 1.90; 95% CI: 1.44–2.51). This may be partly explained by the fact that olive-skinned children were more likely than very fair children to prefer tanned skin (P < .001). Overall, having friends who tanned was strongly associated with tanning bed use (OR: 4.37; 95% CI: 3.18–6.00) as was stating that it was worth getting a little burned to get a tan (OR: 2.58; 95% CI: 2.26–2.96). Of those using tanning beds, 23% used sunscreen routinely compared with 35% among children who did not use tanning beds (P < .001).

Among girls, all 3 psychosocial variables were predictive of tanning bed use. In particular, tanning bed use among girls reporting that it was worth getting burned was nearly double than for those without this belief (22.3 vs 11.3; OR: 2.25; 95% CI: 1.94–2.60). Similarly, tanning bed use by girls was much higher when they believed that all, most, or some of their friends tanned, (OR: 3.57; 95% CI: 2.47–5.16) or if they preferred tanned skin, (OR: 4.45; 95% CI: 3.38–5.85). In the multivariate analysis, girls, older age, report of darkest untanned skin, stating that it was worth getting burnt to get a tan, having a preference for tanned skin, and having friends who were tanned remained significant (Table 2).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Current public health recommendations endorse "safe sun" behaviors, including use of sunscreens with SPF of 15 or higher, minimizing sunburns, and avoidance of tanning beds.^19–23 In this, the largest national survey on the sun protection attitudes and practices of US children and adolescents, we find that a majority of teens are not following these recommendations. Our findings suggest that many children are at subsequent risk of skin cancer because of suboptimal sunscreen use, high rates of sunburning, and tanning bed use. Specifically, we found that during the prior summer, only 34% of teenagers used sunscreen routinely and 83% sunburned at least one time. Moreover, among female adolescents, 14% used a tanning bed at least one time. Contrary to expectations, there were few differences in sunscreen use and sunburning rates in warmer versus cooler states.

Our study demonstrates that attitudes associated with tanning, such as the preference for tanned skin, having many friends who were tanned, and belief in the worth of burning to get a tan were generally associated with sporadic sunscreen use, more frequent sunburns, and increased use of tanning beds. There seems to be a gender difference as girls are more likely to be influenced by their peer network. In particular, the very high use of tanning beds among older teenage girls merits additional study.

Limitations
Although the results presented here are self-reported, we are less concerned about bias as the respondents report 2 findings of low social desirability-suboptimal use of sunscreen and high rates of sunburning. Furthermore, because these respondents are generally from middle-class families and the children of health professionals, the rates reported in this study may be different from those for other children. However, the lack of generalizability does not invalidate the data or preclude raising general hypotheses for other groups. Third, without data on cumulative exposure and intentional sunbathing, we cannot explain the contradictory finding of higher sunburning rates and more routine sunscreen use by girls. It is possible that facial or body creams, more frequently used by girls, lull girls into a false sense of protection thus enhancing their exposure to the sun. We were also surprised that tanning booth use was higher for olive- and dark-complected children compared with those of fairer skin, and we can only speculate that adolescents use tanning booths to maintain their tanned or darker appearance. Future studies will also need to determine whether children are applying enough sunscreen, using SPF of 15 or more, and seek to corroborate their report of sunscreen use. Finally, sunscreen use was the only type of sun protection examined, therefore overall rates of sun protection may be higher than reported.

Prevalence reported in this study is generally similar to that reported in other studies, although comparisons are limited because of variation in the wording and methodology of other surveys.^26–37 Coogan et al²⁷ asked a single question on the use of sun protection among 25 000 Connecticut children completing a Health Check survey and found that only 14% of boys and 20% of girls ages 13 to 18 routinely used sun protection. Tanning bed use in this current study is also similar to findings of a population-based survey in Quebec, where rates were highest among women and young people.²⁸ Geller and colleagues²⁹ surveyed lifeguards (median age 19) at poolsites in Massachusetts and Hawaii and found sunburning rates approaching 80%. However, sunburning rates of 83% in this study were markedly higher than parent reported rates of 53% for 10- to 11-year-olds in a Massachusetts coastal town.³⁰

In the United States, selected small-scale interventions for skin cancer prevention in community settings,^30,38 outdoor pools^29,39 and other recreation facilities^40,41 have shown the feasibility of implementing broader programs to change sun protection behaviors. But larger public educational campaigns and especially policy changes are also needed if we are to influence behavior and change social norms.⁴² After many years, such programs in the Australian State of Victoria have resulted in decreased value of a tan, although adolescents remain the most resistant to changing attitudes regarding the appeal of a tan.⁴³

In 1998, the Centers for Disease Control and Prevention launched the "Choose Your Cover" campaign,¹⁹ designed to influence social norms related to sun protection and tanned skin, and to increase awareness, knowledge and behaviors related to skin cancer prevention. Campaign planners conducted formative research with young people and found strongly held beliefs about the benefits of tanned skin, including how it can help one look younger, healthier, sexier, and thinner.¹⁹ The glamour and attractiveness of a tan seems to be widespread and seems to be a forerunner in the pathway toward inadequate sun protection and excessive burning. Changing these beliefs is crucial in increasing the acceptability and adoption of sun protection behaviors. In addition, focus group participants viewed sunburns as inconsequential, although few teens knew that sunburns increased one’s risk of skin cancer.¹⁹

Using multiple, mutually reinforcing strategies holds the most promise for successful sun protection educational programs. Long-term policy, for example, age restrictions on tanning bed use, and environmental changes can help encourage and support changes in attitudes and behaviors.⁴³ Finding few differences between the geographic regions supports a nationally based series of policies and recommendations. Such strategies may include improving sun protection education at US schools³⁷; building sun safe schools,³⁷ parks, and facilities; and incorporating sun safety awareness into everyday events, such as using the daily UV Index in weather, news, and other broadcasts.^42,44 Peer education programs in schools, commonly used in tobacco education but sparingly used for sun protection, holds promise for future interventions.

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Recent recommendations in the United States for improved sun protection and avoidance of tanning beds and sunburning have apparently yielded few positive results. As we look to the lessons learned from Australia, preventing skin cancer will require a long-term, sustained effort. Nationally coordinated campaigns must be developed and sustained to prevent skin cancer in a new generation of children and adolescents.

	ACKNOWLEDGMENTS

 
This work was supported by grants DK46834 and HL03533 from the National Institutes of Health and a cooperative grant from the Centers for Disease Control and Prevention and the Association of Teachers of Preventive Medicine.

	FOOTNOTES

 
Received for publication Sep 21, 2001; Accepted Jan 4, 2002.

Reprint requests to (A.C.G.) Boston University School of Medicine and School of Public Health, 720 Harrison Ave, DOB 801A, Boston, MA 02118. E-mail: ageller{at}bu.edu

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 

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