Background. Tanning parlors have become common in the United States. Artificial ultraviolet radiation exposure from this source may be harmful and may increase the risk of melanoma, particularly when done for recreational purposes during childhood and early adult years. Population-based data on the prevalence and correlates of this activity is important in the evaluation of potential public health interventions for skin cancer prevention.
Study Design. In 1998, we conducted a population-based telephone survey of youth and their primary caregiver. The sample (N = 1192) was weighted to represent the population of US youth living in households with a primary caregiver. Interviewers used a standardized questionnaire to document the characteristics of the participant and their practices, attitudes, and experiences regarding ultraviolet exposures.
Method of Analysis. Weighted prevalence and adjusted prevalence odds ratios (aPOR) and 95% confidence interval (95% CI) were estimated. Independent factors were evaluated with multivariate logistic regression.
Results. Ten percent of youth and 8% of their primary caregivers used indoor tanning sunlamps in the previous year. Thirty percent of the youth whose caregivers used indoor tanning sunlamps did so themselves as well. Independent predictors associated with indoor tanning sunlamp use were as follows: age 17 to 18 years (aPOR = 11.1; 95% CI: 5.0, 25.0); female (aPOR = 8.3; 95% CI: 3.6, 19.2); having a parent who used indoor tanning sunlamps in the previous year (aPOR = 8.7; 95% CI: 4.0, 18.9); nonuser of Sun Protection Factor 15 sunscreen at the beach or pool (aPOR = 1.9; 95% CI: 1.0, 3.4); and low sun sensitivity (aPOR = 2.3; 95% CI: 1.0, 5.3).
Conclusion. A substantial minority of American youth engages in indoor tanning. However, it is particularly prevalent among older youth, girls, and youth whose parents themselves use indoor tanning sunlamps. The knowledge of these trends may help focus public health initiatives.
- skin cancer prevention
- artificial ultraviolet radiation
- surveillance epidemiology
- health promotion/prevention
Incidence rates in the United States of the 3 most prevalent forms of skin cancer associated with ultraviolet (UV) radiation exposure (ie, basal cell, squamous cell, and melanoma) have risen in recent years.1,2 Much of the increase in incidence in skin cancer can be attributed to increased exposure to UV radiation resulting from changes in high-risk behaviors, such as intentional or recreational sunbathing and inadequate sun protection.1,3
There are a variety of emission spectra in indoor sunlamps and sunbeds for use in commercial tanning parlors, although many, if not most, currently emit a spectrum similar to sunlight, and most patrons of these facilities are generally unaware of the emission spectra. The popularity of indoor tanning booths and sunlamps among the young should be of concern for various health-related reasons. Experimental animal studies have shown the direct effects of tanning salon-type radiation on the cutaneous carcinogenesis process,4,5 and another experimental study demonstrated the direct effects of the carcinogenic potential of sunbeds in humans (ie, DNA alterations and p53 expression in the skin).6 Second, some epidemiologic studies have reported an association between artificial tanning devices and melanoma risk7–11 and with nonmelanoma skin cancers12; for instance, a recent study in particular showed that for individuals younger than 36 years old who regularly use an indoor tanning lamp, the risk of melanoma was 8.1 times greater (95% confidence interval [CI]: 1.3–49.5) as compared with never users.11 However, at present because of the quality of the evidence from the epidemiologic literature, this relationship cannot be firmly established.13 Third, indoor tanning lamp and sunbed use also poses other health risks, such as skin or eye burns, alterations of the immune systems function, photoaging, and photo-drug reactions, and youth maybe less likely to be aware of such risk as adults.14–16 And fourth, children and adolescents are at particularly high risk for sun damage, in part because they spend substantially more time outdoors than adults and because sun exposure at young age as well as intermittent exposure have been associated with melanoma incidence.17,18 Thus, by additionally seeking indoor tanning lamp exposure some youngsters are significantly increasing their lifetime exposure to ultraviolet radiation and accruing significant harmful health effects to their skin.15,16,19
There is no national data available on the prevalence of indoor tanning sunlamp use in youth. Based on community or state-based cross-sectional studies conducted in adolescents,20,21 the estimated prevalence of youth indoor tanning use ranges between 13% to 34%. In other countries, particularly Nordic European countries, estimates as high as 75% in girls and 35% in boys have been reported for indoor tanning booth or sunlamps in the last year.22 The objective of this study was to estimate the prevalence in youth of indoor tanning sunlamp use and in their caregivers (parent or guardian) and to assess associated factors by using data from a national population-based survey of youth aged 11 to 18 and their primary caregivers.
The Sun Survey was sponsored by the American Cancer Society to provide nationally representative baseline estimates of sun exposure and sun protection practices and related factors among youth aged 11 to 18 and their primary caregivers. Data were collected from July through October of 1998 using a telephone-based survey and random-digit dialing methodologies. The complete participant sample consisted of 1192 youth and primary caregiver paired interviews using nearly identical questionnaires. The overall response rate was 58%, but the region specific response rates were above 65% in 4 geographic strata out of 7. Because of the complex sampling scheme, sampling weights for the youth and the caregiver data were applied for potential imbalance attributable to differential response rates and incomplete frame coverage. A detailed description of the American Cancer Society Sun Survey methods have been published previously, including a detailed description on the computation of sample weights.23
Use of Indoor Tanning Sunlamp
Participant youth and caregivers were asked whether in the past year they had used an indoor tanning booth or sunlamp. If they responded yes, then they were asked how often and why they sought to get a tan using indoor tanning booths or sunlamps in the past year. Hereafter, we refer to this exposure as “indoor tanning sunlamp use.”
Demographics and Skin Type
We determined participants’ age, sex, race, and sun sensitivity index. The latter index is a composite measure of 4 questions that asked about the participant’s skin ability to burn, ability to tan, skin color, and hair color; it is a validated measure and its derivation for use in this study has been reported elsewhere.23
We categorized parental education (≤high school degree, some college, and college graduate or higher), household income (under $30 000, between $30 000 and $50 000, and >$50 000), parental marital status (married or not), and place of residence (city or suburb, small town or rural town).
Sun Exposure and Sunscreen Use
Participant youth and caregivers were asked about the total number of days spent outdoors at the beach and an outdoor pool between 10 am and 4 pm. Using a 5-point Likert scale response format ranging from “never” to “always, ” participants were asked about outdoor use of sunscreen during the summer time and about specific use of sunscreen with a Sun Protection Factor (SPF) 15 or greater while at the beach or at the pool.
Participant youth and caregiver attitudes toward tanning were assessed by asking in a 5-point Likert scale format whether they agree/disagree with the following statements: “I feel healthy when I have a nice tan, ” “ I look better when I have a tan, ” “the sun feels good on my skin.” Using factor analysis, we derived separate indices of tanning desirability; in the parent data the tanning desirability index had a Cronbach α of 0.78, and in the youth data the tanning desirability index had a Cronbach α of 0.69.
Analytic Study Sample
The population-based participant samples consisted of 1192 youth aged 11 to 18 and 1187 youth’s caregivers aged 27 and older (5 parents had unknown age). Weighted statistics were used to describe the prevalence estimates of indoor tanning sunlamp in both youth and their caregivers and across factors. All statistical analyses, including logistic regression, were conducted using SUDAAN24 to appropriately compute the standard errors of the prevalence estimates and 95% CI of the prevalence odds ratios.
We first conducted categorical analysis to examine and compare the pattern of indoor tanning sunlamp use in the previous year by selected factors (sociodemographics, sun sensitivity, attitudes toward tanning, sun exposure and sunscreen use) in youth and parent/guardian, respectively. We performed χ2 tests with α = 0.05 to assess for statistical significance.
Univariate logistic regression analyses were used to examine the crude association between youth indoor tanning sunlamp use and factors of interest including caregiver characteristics. Factors to be modeled in the multivariate analysis were based on results of categorical analysis and assessment of the literature25–27; youth’s caregiver sociodemographics were assessed as potential confounders to be controlled for in the multivariate models.13,21 Multivariate logistic regression analyses were conducted to assess independent predictors of indoor tanning sunlamp use in youth and derive the adjusted prevalence odds ratios (POR) and 95% CI for the covariates. Final models were determined through a stepwise backward elimination process and statistical significance was assessed by the Wald statistic. A potential confounder remained in the final model if its removal was associated with a greater than 10% change in the β coefficient or if it was consistently reported in the literature.
The overall prevalence of indoor tanning sunlamp use in the last year was 10% and 8% in youth and their parent/guardian, respectively. However, the prevalence of youth indoor tanning sunlamp use in the previous year was 30% in those youth whose parent/guardian used indoor tanning sunlamps during the previous year, and 40% among girls ages 17 to 18. Also, the following subgroups showed a higher prevalence: those with darker skin complexion (or olive complexion; 25.2%), those with skin type that turns darker without sunburn (16.6%), those with skin that easily develops a tan (15.2%), nonregular use of SPF 15 sunscreen while at the beach or at the pool (15.6%), and having a high attitudinal appeal for a tanned look (14.6%). In general, there were comparable patterns of indoor tanning sunlamp use between youth and their caregivers. Among youth’s caregivers, the prevalence of indoor tanning sunlamp use in the previous year was more prevalent among: those aged 27 to 40 (13.7%), females (10.0%), those with olive skin (12.9%), those who spent 7 or more days at the beach in the previous year (16.6%), nonregular users of SPF 15 sunscreen while at the beach or at the pool (13.5%), and having a high attitudinal appeal for a tanned look (15.9%; Table 1). High frequency use of indoor tanning sunlamps (9 or more times in the past year) were 43% for youth and 66% for parent/guardians (data not shown).
The results of the multivariate analysis showed the following independent predictors after controlling for race and sun sensitivity index: ages 17 to 18 years old (adjusted POR [aPOR] = 11.1; 95% CI: 5.0, 25.0), female (aPOR = 8.3; 95% CI: 3.6, 19.2), low sun sensitivity index (aPOR = 2.3; 95% CI: 2.3, 95% CI: 1.0, 5.3), having a parent/guardian who used sunlamps in the previous year (aPOR = 8.7; 95% CI: 4.0, 18.9), having a high attitudinal appeal toward a tanned look (aPOR = 2.1; 95% CI: 0.8, 5.3), and nonuser of sunscreen with SPF 15 or greater while at the beach or pool (aPOR = 1.9; 95% CI: 1.0, 3.4; Table 2. Sample size limitation constrained our ability to adequately test for important interaction terms in multivariate analysis.
Our data shows that a substantial minority (10%) of youth has used indoor tanning sunlamps in the previous year. In addition, we observed substantially higher prevalence in these subgroups: 30% in youth who had a primary caregiver using indoor tanning sunlamps; 40% in girls aged 17 to 18, 26% in youth aged 15 to 18 years old; 16% in females; 16% in youth who never or rarely used sunscreen while outdoors in the sun; and 15% in youth having high attitudinal appeal for tanned look. Our estimates provide the first baseline national samples of youth indoor tanning sunlamp use in the previous year. Previous available estimates, ranging from 13% to 34%, had been based from other regional samples and school based studies.20,21 Variability in these estimates is likely attributable to sample differences and survey methodologies.
More importantly, our results are consistent with previous reports showing a higher prevalence of tanning sunbed use among older youth and girls.20,21,28,29 It has been suggested that women’s greater prevalence of indoor tanning salons and sunbed use is related to a strong desire to get a skin tan despite being aware of health hazards and other psychological effects associated with a tanned look.26,29–31 In our study, we explored the self-reported reasons youth gave for why they used indoor tanning sunlamps in the previous year. We found that over 60% of the reasons related to a tendency to seek and achieve a tanned look for contextual circumstances. In particular, 2 prominently stated common reasons were that “I wanted a tan for the prom” and “wanting to get a tan before going on vacation.” The least common reason was because of medical treatment (2% in youth and 4% in parents). Although the first reason is consistent with positive attitudes toward a tanned look as desirable ideal for beauty and self-esteem,26,29,31 the second reason raises concerns because it suggest that these youngster are compounding UV radiation exposure first from artificial sources and then from solar radiation. This compounding pattern of indoor tanning sunlamp use as a “radiation multiplier” has been suggested as potentially affecting the risk of melanoma.13 A second important concern of indoor tanning sunlamp use among youth is the lack of regulation in some states where underage minors are not prevented from using these establishments or even required to have obtained parental consent before use. Previous investigations have shown that some establishments do not follow such safety and health regulations or adequately inform their customers of the risk involved with using these devices.32–34
A recent analysis of our data shows that youth are spending a significant amount of time outdoors in the sun without adequate protection. Our results also indicate that youth who use indoor tanning sunlamps are less likely to use SPF 15 sunscreen while at the beach or at the pool, and it corresponds to findings from another Swedish study.35 A single 15- to 30-minute salon session exposes the body to the same amount of harmful UV sunlight as a day at the beach. Thus, these observations raise serious concerns because youth who use indoor tanning sunlamps are the least likely to practice any amount of photoprotection and therefore are putting themselves at greater (and unnecessary) risk of experiencing the short and long-term health impact of UV exposure.
Another interesting result of this study was that we found a strong association between parental indoor tanning sunlamp use and that of their youth. We are not aware of any reports documenting such a relationship, in part because previous investigations have not surveyed independently and simultaneously related family members. This observed association seems plausible in that parent’s behavior serve as social role models to some adolescents. Similar associations have been reported with other youth high-risk behaviors (ie, substance abuse and smoking behaviors).36,37 The exact nature of the role parents play on youth indoor tanning sunlamp use is unknown but it may be thought as inducing their youth to increase their intent to seek a tan, perceiving easier access to these devices and feeling less ambivalent about using indoor tanning sunlamp. Thus, the potential association between parents/caregivers use of indoor tanning sunlamp and youth indoor tanning sunlamp use warrants additional investigation. Besides modifying attitudes toward the desirability of a tanned skin, the possibility that parents also may exert an influence on their youth indoor tanning sunlamp use may be of importance to skin cancer prevention programs. Parents are able to directly advocate prevention and incorporate preventive behaviors into their family routines.28,38
At present, inadequate indoor tanning salon operations and regulatory compliance have been noted,32,39 which may lead to increasing the unnecessary and avoidable risk associated with indoor tanning booths and sunlamp use. In particular, teenagers may be the most vulnerable because of their lack of full awareness of the health risks involved and their proclivity to intentionally tan.31,40
The limitations of this study were that our methods relied on self-reports of both youth and primary care givers. As compared with other surveys on more sensitive matters (such as sexual behaviors), this survey was less invasive and parental presence may not have adversely influenced truthful reporting of youth. Also, our study lacked power to adequately test for important interactions terms, such as youth age and gender in multivariate analysis, as well as to examine independent correlates of high frequency use of indoor tanning sunlamps. The important strengths of our study were that it provides population-based estimates from a randomly selected sample of youth living in households with parents or guardians. In addition, this study examined the influence of important attitudinal and parental roles on youth use of indoor tanning sunlamp while controlling for potential confounders.
A larger proportion of certain demographics subgroups of US youth expose themselves to artificial UV. This practice may give rise to skin cancer problems later in life, and should be addressed from the public health point of view. Because our survey provides a population-based estimate of the prevalence of this practice in the United States, it can serve as a baseline for evaluation of future trends, including public health efforts directed at skin cancer prevention.
- ↵Howe HL, Wingo PA, Thun MJ, et al. Annual report to the nation on the status of cancer, 1973–1998. Featuring cancers with recent increasing trends. J Natl Cancer Inst.2001;93 :824– 842
- ↵Randle HW. Suntanning: differences in perceptions throughout history. Mayo Clinic Proc Symp.1997;72 :461– 466
- ↵Husain Z, Pathak M, Flotte T, Wick M. Role of ultraviolet radiation in the induction of melanocytic tumors in hairless mice following 7, 12-dimethylbenz (a)anthracene application and ultraviolet irradiation. Cancer Res.1991;51 :4964– 4970
- ↵Pathak M. Ultraviolet radiation and the development of non-melanoma and melanoma skin cancer: clinical and experimental evidence. Skin Pharmacol.1991;4(suppl 1) :85– 94
- Walter S, Marrett L, From L, Hertzman C, Shannin H, Roy P. The association of cutaneous malignant melanoma with the use of sunbeds and sunlamps. Am J Epidemiol.1990;131 :232– 243
- Chen YT, Dubrow R, Zheng RL, Barnhill RL, Fine J, Berwick M. Sunlamp use and the risk of cutaneous malignant melanoma: a population-based case-control study in Connecticut, USA. Int J Epidemiol.1998;27 :758– 765
- Westerdahl J, Olsson H, Masback A, Jonsson N, Olsson H. Use of sunbeds or sunlamps and malignant melanoma in southern Sweden. Am J Epidemiol.1994;140 :691– 699
- ↵Karagas M, Stannard V, Mott L, Slattery M, Spencer S, Weinstock M. Use of tanning devices and risk of basal cell and squamous cell skin cancer. J Natl Cancer Inst.2002;93 :224– 226
- ↵Kondo S. The roles of keratinocyte-derived cytokines in the epidermis and their possible responses to UVA-irradiation. J Inv Dermatol Symp Proc.1999;4 :177– 183
- ↵Weinstock MA, Colditz GA, Willett WC, Stampfer MJ, Bronstein BR, Mihm MC. Nonfamiliar cutaneous melanoma incidence in women associated with sun exposure before 20 years of age. Pediatrics.1989;84 :199– 204
- ↵SUDAAN. Professional Software for Survey Data Analysis. Version 8.0. Raleigh, NC: Research Triangle Institute; 1999
- ↵Banks B, Silverman R, Schwartz R, Tunnessen W. Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics.1992;89 :40– 42
- ↵Hillhouse J, Turrisi R, Holwiski F, McVeigh S. An examination of psychological variables relevant to artificial tanning tendencies. J Health Psychol.1999;4 :507– 516
- ↵Cohen D, Richardson J, LaBree L. Parenting behaviors and the onset of smoking and alcohol use: a longitudinal study. Pediatrics.1994;94 :368– 375
- ↵Buller D, Borland R. Skin cancer prevention for children: a critical review. Health Educ Behav.1999;26 :317– 343
- ↵Beasley TM, Kittel BS. Factors that influence health risk behaviors among tanning salon patrons. Eval Health Prof.1997;20 :371– 388
- Copyright © 2002 by the American Academy of Pediatrics