Not all tanners are created equal: implications of tanning subtypes for skin cancer prevention

Beliefs, attitudes and perceptions to sun-tanning behaviour in the Norwegian population: a cross-sectional study using the health belief model

BACKGROUND

Norway has one of the highest incidences of melanoma in the world. It has been suggested that the majority of all skin cancers could be prevented by changes related to sun-tanning behaviour. This study explores the sun-tanning behaviour of the Norwegian population using a modified Health Belief Model (HBM). Increased knowledge about beliefs, attitudes and sun-tanning behaviour can provide information which may be useful for future sun protection interventions.

METHODS

In 2017, 1004 members of the Norwegian population completed cross-sectional online surveys. People who seek the sun for tanning purposes was the eligibility criterion for this study, reducing the study population to 569. With the aid of the constructs from the HBM, predictive factors explaining sun-tanning behaviour were determined using multivariate linear regression adjusted for demographics (gender, age, education and income). Furthermore, the predictor variables, empowerment and benefits of tanning, were added to the model.

RESULTS

Five of the constructs in the modified HBM showed significant correlation with sun-tanning behaviour using bivariate analysis. The strongest correlation was perceived barriers of sun protection (0.42), with the next strongest being the benefits of tanning (0.30). The modified model explained 31% of the variation in sun-tanning behaviour using multivariate analysis. Significant predictors from the HBM to sun-tanning behaviour were perceived barriers to sun protection (Beta = 0.36, p < 0.001) and the severity of melanoma (Beta = - 0.20, p < 0.001). In addition, empowerment (Beta = 0.05, p = 0.05) and the benefits of tanning (Beta = 0.28, p < 0.001) proved to be variables with significant effect on sun-tanning behaviour. The demographic factors age, education and income were also associated with sun-tanning behaviour (p < 0.05).

CONCLUSION

Based on the results of this study, several factors in the modified HBM had a significant impact on Norwegians' sun-tanning behaviour. The results indicate that future sun protection interventions should focus on reducing barriers in relation to sun protection behaviour, as well as emphasizing the severity of adverse tanning behaviour and melanoma. Efforts to alter the perceptions of the beneficial factors of tanning behaviour can also be appropriate in health promotion campaigns and interventions. Finally, implementing empowerment strategies could have a positive effect on promoting healthy sun-tanning behaviour.

Correlates of intentional tanning among adolescents in the United States: a systematic review of the literature

PURPOSE

Exposure to ultraviolet radiation and a history of sunburn in childhood contribute to risk of skin cancer in adolescence and in adulthood, but many adolescents continue to seek a tan, either from the sun or from tanning beds (i.e., intentional tanning). To understand tanning behavior among adolescents, we conducted a systematic review of the literature to identify correlates of intentional tanning in the United States.

METHODS

We included articles on original research published in English between January 1, 2001, and October 31, 2011, that used self-reported data on intentional tanning by U.S. adolescents aged 8 to 18 years and examined potential correlates of tanning behaviors. Thirteen articles met our criteria; all used cross-sectional survey data and quantitative methods to assess correlates of intentional tanning.

RESULTS

Results indicate that multiple factors influence tanning among adolescents. Individual factors that correlated with intentional tanning include demographic factors (female sex, older age), attitudes (preferring tanned skin), and behaviors (participating in other risky or appearance-focused behaviors such as dieting). Social factors correlated with intentional tanning include parental influence (having a parent who tans or permits tanning) and peer influence (having friends who tan). Only four studies examined broad contextual factors such as indoor tanning laws and geographic characteristics; they found that proximity to tanning facilities and geographic characteristics (living in the Midwest or South, living in a low ultraviolet area, and attending a rural high school) are associated with intentional tanning.

CONCLUSIONS

These findings inform future public health research and intervention efforts to reduce intentional tanning.

New approaches to melanoma prevention

Skin cancer is a major public health concern, and tanning remains a modifiable risk factor. Multidimensional influences, including psychosocial, individual, environmental, and policy-related factors, create the milieu for individuals to engage in tanning. Parents and physicians can modify the behavior of teens and young adults using strategies based on harm reduction. Environmental and policy-related factors similar to those used to limit smoking by restricting access of minors to cigarettes in the United States in the 20th century need to be created. Federal regulations can restrict direct advertising and the excise tax can be increased to a prohibitive amount. Social networking may assist with affect regulation.

Addiction to indoor tanning: relation to anxiety, depression, and substance use

OBJECTIVE

To assess the prevalence of addiction to indoor tanning among college students and its association with substance use and symptoms of anxiety and depression.

DESIGN

Two written measures, the CAGE (Cut down, Annoyed, Guilty, Eye-opener) Questionnaire, used to screen for alcoholism, and the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV-TR) criteria for substance-related disorders, were modified to evaluate study participants for addiction to indoor tanning. Standardized self-report measures of anxiety, depression, and substance use also were administered.

SETTING

A large university (approximately 18 000 students) in the northeastern United States.

PARTICIPANTS

A total of 421 college students were recruited from September through December 2006.

MAIN OUTCOME MEASURES

Self-reported addiction to indoor tanning, substance use, and symptoms of anxiety and depression.

RESULTS

Among 229 study participants who had used indoor tanning facilities, 90 (39.3%) met DSM-IV-TR criteria and 70 (30.6%) met CAGE criteria for addiction to indoor tanning. Students who met DSM-IV-TR and CAGE criteria for addiction to indoor tanning reported greater symptoms of anxiety and greater use of alcohol, marijuana, and other substances than those who did not meet these criteria. Depressive symptoms did not significantly vary by indoor tanning addiction status.

CONCLUSION

Findings suggest that interventions to reduce skin cancer risk should address the addictive qualities of indoor tanning for a minority of individuals and the relationship of this behavior to other addictions and affective disturbance.

Addiction to indoor tanning: relation to anxiety, depression, and substance use

OBJECTIVE

To assess the prevalence of addiction to indoor tanning among college students and its association with substance use and symptoms of anxiety and depression.

DESIGN

Two written measures, the CAGE (Cut down, Annoyed, Guilty, Eye-opener) Questionnaire, used to screen for alcoholism, and the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) (DSM-IV-TR) criteria for substance-related disorders, were modified to evaluate study participants for addiction to indoor tanning. Standardized self-report measures of anxiety, depression, and substance use also were administered.

SETTING

A large university (approximately 18 000 students) in the northeastern United States.

PARTICIPANTS

A total of 421 college students were recruited from September through December 2006.

MAIN OUTCOME MEASURES

Self-reported addiction to indoor tanning, substance use, and symptoms of anxiety and depression.

RESULTS

Among 229 study participants who had used indoor tanning facilities, 90 (39.3%) met DSM-IV-TR criteria and 70 (30.6%) met CAGE criteria for addiction to indoor tanning. Students who met DSM-IV-TR and CAGE criteria for addiction to indoor tanning reported greater symptoms of anxiety and greater use of alcohol, marijuana, and other substances than those who did not meet these criteria. Depressive symptoms did not significantly vary by indoor tanning addiction status.

CONCLUSION

Findings suggest that interventions to reduce skin cancer risk should address the addictive qualities of indoor tanning for a minority of individuals and the relationship of this behavior to other addictions and affective disturbance.

A comparison of the efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups identified by latent profile analysis

The reduction of intentional exposure to ultraviolet (UV) radiation is an important area of skin cancer prevention. Hillhouse et al. (Cancer 113:3257-3266, 2008) have developed an appearance-focused intervention with evidence of efficacy in lowering indoor tanning UV exposure in young women. In the current study, a subgroup approach was used to determine moderators of intervention efficacy. Undergraduate females in two regions of the United States (n = 362) were randomized into an intervention or control condition. Latent profile analysis was used to identify subgroups of indoor tanners based on patterns of indoor tanning motives. Intervention efficacy was examined within each subgroup. We found evidence for 4 subgroups of tanners: knowledgeable-appearance tanners, low-knowledge tanners, low-knowledge, relaxation tanners, and knowledgeable, low-appearance and low-relaxation tanners. The intervention significantly reduced indoor tanning for the low-knowledge subgroup (34% of the sample). The utility of the subgroup approach in developing targeted behavioral skin cancer interventions is discussed.

Design and methods for a cluster randomized trial of the Sunless Study: a skin cancer prevention intervention promoting sunless tanning among beach visitors

Background

Skin cancer is the most prevalent yet most preventable cancer in the US. While protecting oneself from ultraviolet radiation (UVR) can largely reduce risk, rates of unprotected sun exposure remain high. Because the desire to be tan often outweighs health concerns among sunbathers, very few interventions have been successful at reducing sunbathing behavior. Sunless tanning (self-tanners and spray tans), a method of achieving the suntanned look without UVR exposure, might be an effective supplement to prevention interventions.

Methods and Design

This cluster randomized trial will examine whether a beach-based intervention that promotes sunless tanning as a substitute for sunbathing and includes sun damage imaging and sun safety recommendations is superior to a questionnaire only control group in reducing sunbathing frequency. Female beach visitors (N = 250) will be recruited from 2 public beaches in eastern Massachusetts. Beach site will be the unit of randomization. Follow-up assessment will occur at the end of the summer (1-month following intervention) and 1 year later. The primary outcome is average sunbathing time per week. The study was designed to provide 90% power for detecting a difference of .70 hours between conditions (standard deviation of 2.0) at 1-year with an intra-cluster correlation coefficient of 0.01 and assuming a 25% rate of loss to follow-up. Secondary outcomes include frequency of sunburns, use of sunless tanning products, and sun protection behavior.

Discussion

Interventions might be improved by promoting behavioral substitutes for sun exposure, such as sunless tanners, that create a tanned look without exposure to UVR.

Trial registration

NCT00403377