Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Sunless and Indoor Tanning Among U.S. Non-Hispanic White Women Ages 18-49 Years

The use of indoor UV tanning devices (also known as "indoor tanning") has declined in recent years. Less is known about use of dihydroxyacetone-containing products used for tanning (also known as "sunless tanning"). We analyzed data from the 2015 National Health Interview Survey. Analysis was limited to non-Hispanic White women ages 18-49 years. We estimated the proportion of women reporting spray tanning, self-applied lotion tanning, and indoor tanning and used weighted multivariable logistic regression models to examine the relationships between socio-demographic characteristics, skin cancer risk factors, and other cancer risk factors with sunless and indoor tanning. Overall, 17.7% of women reported sunless tanning. Lotion tanning was more common (15.3%) than spray tanning (6.8%), while 12.0% of women engaged in indoor tanning. Among sunless tanners, 23.7% also engaged in indoor tanning. Younger age, ever having a skin exam, skin reactions to the sun, binge drinking, and being at a healthy weight were associated with sunless tanning. While sunless tanning may be less harmful for skin cancer risk than indoor tanning, the frequency with which the two behaviors co-occur suggests that efforts to address societal pressures for women to alter their skin color may have important public health benefits.

Skin Cancer-Related Health Behavior Interventions in the Context of the Health Belief Model

The incidence of skin cancer is increasing around the world every year. Although there are many reasons for the occurrence of skin cancer, UV radiation caused by sunlight is seen as the most important factor. Therefore, reducing exposure to UV radiation should be a top priority for skin cancer prevention. In addition, different demographic features also affect the amount of UV exposure. These include age, gender and professional groups. On the other hand, people can be exposed to UV radiation voluntarily. Sunbathing or using tanning devices can be shown as examples for this. For these reasons, interventions to reduce exposure to UV radiation should focus on demographic features and the desire to tan. At the same time, it is emphasized in the literature that theory-based and systematic interventions are more effective than others. In this context, we think that the Health Belief Model, which is an effective psychosocial model for health behaviors, will be useful in developing sun protection behaviors. In this review, interventions based on the Health Belief Model in the context of tanning behavior, age, gender, and outdoor activities for the prevention of skin cancer and the improvement of sun protection behaviors have been discussed.

Bad lighting: Effects of youth indoor tanning prohibitions

Indoor tanning beds (ITBs) emit UV light at high intensity and have been classified as carcinogenic to humans by the World Health Organization since 2009. We are the first to study the role of state laws prohibiting youths from indoor tanning using a difference-in-differences research design. We find that youth ITB prohibitions reduced population search intensity for tanning-related information. Among white teen girls, ITB prohibitions reduced self-reported indoor tanning and increased sun protective behaviors. We also find that youth ITB prohibitions significantly reduced the size of the indoor tanning market by increasing tanning salon closures and reducing tanning salon sales.

An Epidemiological Update on Indoor Tanning and the Risk of Skin Cancers

Indoor tanning (sunbeds, solarium) uses artificial ultraviolet radiation (UVR) to stimulate cosmetic tanning of the skin. Indoor tanning has been officially classified as a human carcinogen in 2009 by the International Agency for Research on Cancer of the World Health Organization (WHO). The differences in the prevalence of sunbed use across countries and over the years highlight underlying legislative, climatic, and cultural differences. Indoor tanning-seeking behaviors may be driven by motivations for an appealing appearance, largely influenced by gender and age, and several misconceptions that a prevacation tan safeguards the skin, that sunbeds can be used to treat acne or to increase vitamin D, or that tanning is a healthy habit. This review provides an epidemiological update on the prevalence of sunbed use, who tends to use sunbeds and why, and details the current evidence on the association of sunbeds with skin cancers, including cutaneous melanoma, basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (cSCC). A statistically significant higher risk of cutaneous melanoma, BCC and cSCC with the use of sunbeds has been consistently demonstrated. This risk of skin cancer is even higher with the more frequent use of sunbeds, underscoring a dose-response relationship, and in those first exposed to sunbeds at a younger age. Preventive measures against sunbed use include legislation restricting sunbed use, educational campaigns to inform and discourage from indoor tanning, as well as using the internet, online advertising messages and the social media to reach larger audiences and to promote an untanned appearance.

"I Think There Should Be Photos": Female Indoor Tanners' Perceptions of Health Warning Labels for Tanning Beds

This study explores female indoor tanners' perceptions of the current, text-only Canadian health warning label (HWL) for tanning equipment, as well as pictorial, evidence-based alternative HWLs. We created 10 test HWLs that depicted skin health effects, eye damage, premature aging, and death. Young women who had tanned indoors in the past year discussed these and the current federal HWL in focus groups. Although the current Canadian HWL was seen as informative, several participants did not recognize it, and many said that they would not read it due to the small text, wordiness, and lack of an image. Graphic images, particularly those depicting permanent conditions affecting the face, eyes, or appearance, were seen as effective. Common criticisms of the images were lack of believability, relatability, and comprehensibility. Although concise text was important for encouraging reading, many participants expressed a desire for more information in the test HWLs. Premature aging was of great concern to many participants, but the images selected for these HWLs were not perceived as effective. Although the text was seen as effective in the death HWLs, most participants dismissed the images. This research has implications for IT HWLs in Canada and globally. These results suggest that graphic images may be impactful in IT HWLs. Images must be supplemented with informative text that increases believability, relatability, and comprehensibility. These modifications would create HWLs that are engaging, informative, and that form part of a wider effort to spread awareness about the harmful effects of IT.

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.

Cutaneous Photoprotection: A Review of the Current Status and Evolving Strategies

Ultraviolet radiation (UVR) exposure is well established as the major environmental risk factor for the development of melanoma, cutaneous squamous cell carcinoma (cSCC), and basal cell carcinoma (BCC). Additional risk factors including genetic mutations, other environmental agents, and immune status are important in modulating the effects of UVR. Dermatologists advocate a multi-pronged approach to minimizing UVR exposure including lifestyle modifications, UVR protective clothing, and topically applied sun-protective products, i.e. sunscreen. New Federal Drug Administration (FDA) regulations on sunscreen have brought certain long-standing ingredients in sunscreen products under scrutiny. The FDA's proposed rule for over the counter (OTC) monograph states that the inorganic sunscreens, zinc oxide and titanium dioxide, were found to be "generally recognized as safe and effective," but cite insufficient evidence to grant organic sunscreens the same designation. This proposed rule by the FDA and our increasing understanding of multifactorial mechanisms of UVR damage are an impetus for innovation and advances in sun protective technology. A complete set of strategies designed to limit the risk of UV-induced skin cell malignant transformation and tumor development must address the fuller consideration of genetic, environmental, and immune factors that cooperatively drive cutaneous carcinogenesis. Recent advances in our understanding of the biochemical processes underpinning UVR associated cutaneous cellular damage, genotoxicity, and clonal expansion provide investigators with a spectrum of opportunities for technologic innovation in the prevention of skin cancer. Strategies to improve upon current topical sunscreen formulations have strived for broader UVR spectral coverage, more favorable aesthetics, increased adherence, and minimal penetration into the living epidermis. In addition to improved sunscreens, future topical therapies may target processes within the epidermis that contribute to carcinogenesis. These include reactive species quenching, delivery of DNA repair enzymes, and targeting of cytokines essential to the proliferation of mutant keratinocytes.

Genetic Associations with Indoor Tanning Addiction among non-Hispanic White Young Adult Women

BACKGROUND

Some young people may become addicted to indoor tanning in a manner similar to other forms of addiction, but research on genetic associations with indoor tanning addiction remains limited.

PURPOSE

To examine if liabilities in genetic addiction reward pathways and psychiatric comorbidity influence the risk of indoor tanning addiction.

METHODS

This was a cross-sectional study with a community sample of 292 non-Hispanic white young adult women aged 18-30 years who reported indoor tanning in the past year. Self-report measures included indoor tanning frequency, appearance orientation, depressive symptoms, and two screeners of tanning addiction. DNA samples were analyzed for 34 single nucleotide polymorphisms (SNPs) in candidate genes in addiction reward pathways.

RESULTS

No SNPs were significantly associated with tanning addiction in univariate analyses after multiplicity adjustment. In multivariable analyses adjusting for indoor tanning frequency, appearance orientation, and depressive symptoms, variant genotypes (CC or CT) in two DRD2 dopamine receptor gene SNPs were associated with increased odds of indoor tanning addiction (rs4436578, odds ratio [OR]: 2.30, 95% confidence interval [CI]: 1.11-4.77; rs4648318, OR: 1.95, 95% CI: 1.02-3.72). Variant SNP genotypes interacted with depressive symptoms to increase the risk of indoor tanning addiction: OR: 10.79, 95% CI: 3.25, 35.80, OR: 13.60, 95% CI: 4.13, 44.78, respectively.

CONCLUSIONS

This study provides preliminary evidence that DRD2 dopamine receptor gene SNPs are associated with indoor tanning addiction and young women with variant genotypes and elevated depressive symptoms may be at higher risk. These preliminary results support a reward-based model for indoor tanning addiction and warrant further investigation.

Content analysis of Twitter chatter about indoor tanning

Twitter may be useful for learning about indoor tanning behavior and attitudes. The objective of this study was to analyze the content of tweets about indoor tanning to determine the extent to which tweets are posted by people who tan, and to characterize the topics of tweets. We extracted 4,691 unique tweets from Twitter using the terms "tanning bed" or "tanning salon" over 7 days in March 2016. We content analyzed a random selection of 1,000 tweets, double-coding 20% of tweets (κ = 0.74, 81% agreement). Most tweets (71%) were by tanners (n = 699 individuals) and included tweets expressing positive sentiment about tanning (57%), and reports of a negative tanning experience (17%), burning (15%), or sleeping in a tanning bed (9%). Four percent of tweets were by tanning salon employees. Tweets posted by people unlikely to be tanners (15%) included tweets mocking tanners (71%) and health warnings (29%). The term "tanning bed" had higher precision for identifying individuals who engage in indoor tanning than "tanning salon"; 77% versus 45% of tweets captured by these search terms were by individuals who engaged in indoor tanning, respectively. Extrapolating to the full data set of 4,691 tweets, findings suggest that an average of 468 individuals who engage in indoor tanning can be identified by their tweets per day. The majority of tweets were from tanners and included reports of especially risky habits (e.g., burning, falling asleep). Twitter provides opportunity to identify indoor tanners and examine conversations about indoor tanning.

A Qualitative Analysis of Canadian Indoor Tanning Policies

BACKGROUND

The International Agency for Research on Cancer classifies artificial tanning devices as Group 1 human carcinogens. Studies have shown that use of indoor tanning before age 35 can increase the risk of melanoma development by 75%. It has therefore been recommended that indoor tanning use be restricted in individuals younger than age 18.

OBJECTIVES

This study aims to review the state of provincial indoor tanning policies, especially in regards to use by youth across Canada, and what strategies are being implemented to enforce them.

METHODS

Focused interviews were conducted with representatives from the provincial Ministries of Health across Canada in May and June 2014. Follow-up interviews were performed between February and May 2017.

RESULTS

As of January 2018, regulations are in effect in all Canadian provinces restricting indoor tanning by minors and requiring display of signage warning of the risks of indoor tanning by salons. However, there are discrepancies among the provinces on how and if tanning salons are monitored and how and if these regulations are enforced.

CONCLUSIONS

While implementing youth bans on indoor tanning is a promising start, all Canadian provinces need to ensure that efforts are being undertaken to ensure compliance with these policies to effectively combat the rising incidence of skin cancer among the Canadian population.

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.

Assessing a ban on the use of UV tanning devices among adolescents in Ontario, Canada: first-year results

OBJECTIVES

To describe the effect of the first year of a ban on UV tanning device (beds, lamps) use among those under 18 years of age in Ontario, Canada.

METHODS

Online questionnaires were completed by adolescents in grades 7 to 12, aged less than 18 years: one when the ban was enacted (May 2014) and a second a year later (May 2015). Questionnaires asked grade, age, sex, and about use of UV tanning devices in the previous year. Recent users were asked about length, frequency, and location of use; service refusals and reasons; awareness of signs/warning labels; and use of eye protection. Weighted estimates and confidence intervals were generated.

RESULTS

There were 1561 participants in 2014 and 2305 in 2015. No reduction was observed in UV tanning device use (6.9% vs. 7.9%) in the 12 months preceding the survey. In 2015, most respondents used UV tanning devices in beauty establishments, which was a shift away from gyms and fitness centres as seen in 2014. Non-significant increases occurred in the proportions noticing warning signs/labels (57% vs. 71%), required to wear eye protection (92% vs. 99%), and refused service (17% vs. 21%). Most adolescents who were refused service did not use tanning devices that year (72%).

CONCLUSION

Use did not change in the year following enactment of a ban on UV tanning devices among youth in Ontario. The ban did lead to improvements in service refusal, awareness of warning signage, and use of eye protection. As service refusal deterred future use, enhanced enforcement is important.

Frequent Indoor Tanners' Beliefs About Indoor Tanning and Cessation

PURPOSE

Indoor tanning is associated with an increased risk of developing skin cancer. In the United States, nearly 1 in 5 white women aged 18 to 25 are indoor tanners. This study elicited beliefs about tanning indoors and quitting/cutting back on indoor tanning.

DESIGN

Semi-structured interviews.

PARTICIPANTS AND SETTING

Forty 18- to 25-year-old white females who engaged in frequent indoor tanning participated in either in-person or telephone interviews. Most were college students from southeastern Pennsylvania and Delaware.

METHOD

A semi-structured interview was used to elicit beliefs about indoor tanning and quitting or cutting back. Data analyses using NVivo and multiple coders identified key themes about going and quitting/cutting back on indoor tanning.

RESULTS

Key themes stated as reasons for indoor tanning included improving physical appearance, social acceptance, increased confidence, and happiness. The main themes identified as advantages of quitting/cutting back on indoor tanning were to decrease skin cancer risk and save money. Perceived disadvantages of quitting/cutting back included themes of concerns about being pale and a decline in self-confidence. The prospect of saving money and warm weather were seen as facilitating quitting/cutting back.

CONCLUSION

Findings suggest the necessity of addressing appearance concerns, psychological benefits associated with feeling more attractive, and short-term gains such as saving money. These findings provide a foundation for developing effective anti-indoor tanning communication.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

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.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT03178240; Pre-results.

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.

Youth access to indoor tanning salons in urban versus rural/suburban communities

BACKGROUND/PURPOSE

Research suggests that youth proximity to tanning salons may promote use; however, little is known about tanning salon proximity to schools. We assessed the proximity of tanning salons to schools in urban versus rural/suburban communities across Worcester County, Massachusetts (population > 800K). To put findings in context, we compared school proximity to tanning salons to school proximity to McDonald's restaurants, a large franchise that also caters to young people.

MATERIALS & METHODS

Accessibility was measured by ArcGIS 10.2 Network Analyzer (ESRI, Redlands, CA, USA) and the most current road network data layer from Massachusetts Department of Transportation (MassDOT).

RESULTS

A total of 145 schools were observed in the study area, of which about 39% of schools were within 1 mile from a tanning salon. Urban schools (53.41%) had a higher proportion within 1 mile of a tanning salon than rural/suburban schools (17.54%; P < .001). More schools (39.31%) were within 1 mile of a tanning salon than schools within 1 mile of a McDonald's (22.70%; P < .001).

CONCLUSIONS

Schools may be particularly impactful for implementing skin cancer prevention programing.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cancer Risk-Promoting Information: The Communication Environment of Young Adults

Young adulthood represents a time of myriad transitions, which leave young adults (YAs) more susceptible to the influences of cancer risk-promoting information. The tobacco, alcohol, indoor tanning, and food and beverage industries engage in aggressive marketing strategies through both traditional and social media to target this age group to consume their products, which have known links to cancer. Despite this barrage of messaging, detailed data are lacking on the communication behaviors of subgroups of this diverse age group, particularly those from low SES. This paper explores the available data on media usage among YAs and describes the cancer risk-promoting information environment, with a focus on communication inequalities and their implications for cancer research and control. Nationally representative data on media consumption patterns indicate that the majority of YAs access a diverse range of traditional and social media platforms, but these data do not fully describe differences at the intersection of age and important factors such as SES, gender, race/ethnicity, or urban/rural residence. Meanwhile, risk-promoting information is heavily marketed to YAs across media, with an increasing focus on using social media sites to normalize products and evade marketing restrictions. Gaps in the available data on YAs' media consumption behaviors, coupled with aggressive risk-promoting marketing strategies toward YAs, may impede cancer control efforts. Relationships between exposure to various cancer risk-promoting information, concurrent risk behaviors, SES disparities, and communication inequalities should be investigated to develop innovative and effective control programs and policies to promote cancer control in this important group.

Choctaw Nation Youth Sun Exposure Survey

The incidence of skin cancer is rising among American Indians (AI) but the prevalence of harmful ultraviolet light (UVL) exposures among AI youth is unknown. In 2013, UVL exposures, protective behaviors, and attitudes toward tanning were assessed among 129 AI and Non-Hispanic (NHW) students in grades 8–12 in Southeastern Oklahoma. Sunburn was reported by more than half the AI students and most of the NHW students. One-third of AI students reported never using sunscreen, compared to less than one-fifth of NHW students, but racial differences were mitigated by propensity to burn. Less than 10% of students never covered their shoulders when outside. Girls, regardless of race, wore hats much less often than boys. Regardless of race or sex, more than one-fourth of students never stayed in the shade, and more than one-tenth never wore sunglasses. The prevalence of outdoor tanning did not differ by race, but more than three-fourths of girls engaged in this activity compared to less than half the boys. Indoor tanning was reported by 45% of the girls, compared to 20% of girls nationwide, with no difference by race. Nearly 10% of boys tanned indoors. Among girls, 18% reported more than ten indoor tanning sessions. Over one-quarter of participants agreed that tanning makes people look more attractive, with no significant difference by race or sex. Investigations of UVL exposures should include AI youth, who have not been represented in previous studies but whose harmful UVL exposures, including indoor tanning, may place them at risk of skin cancer.

Research on Skin Cancer-Related Behaviors and Outcomes in the NIH Grant Portfolio, 2000-2014: Skin Cancer Intervention Across the Cancer Control Continuum (SCI-3C)

Importance

The Surgeon General's Call to Action to Prevent Skin Cancer broadly identified research gaps, but specific objectives are needed to further behavioral intervention research.

Objective

To review National Institute of Health (NIH) grants targeting skin cancer-related behaviors and relevant outcomes.

Design, Setting, and Participants

A portfolio analysis of the title, abstract, specific aims, and research plans of identified grant applications from 2000 to 2014 targeting skin cancer-related behaviors or testing behavioral intervention effects on cancer-relevant outcomes along the cancer continuum.

Main Outcomes and Measures

Funding trends were compared along the cancer control continuum, with respect to investigator demographics and use of theory, technology, policy, and changes to environmental surroundings (built environment).

Results

A total of 112 submitted applications met inclusion criteria; of these, 40 (35.7%) were funded, and 31 of the 40 were interventions. Comparing the 40 funded grants with the 72 unfunded grants, the overall success rates did not differ significantly between male (33.3%) and female (37.3%) investigators, nor did the frequency of R01 awards (36.7% and 28.1%, respectively). Among intervention awards, most (24 of 31) addressed prevention. Fewer awards targeted detection alone or in conjunction with prevention (3) or cancer survivorship (4), and no grant addressed emotional sequelae or adherence behavior related to diagnosis or treatment. Fewer than half of funded grants aimed for clinically related targets (eg, sunburn reduction). Use of theory and technology occurred in more than 75% of grants. However, the full capability of proposed technology was infrequently used, and rarely did constructs of the proposed behavior change theory clearly and comprehensively drive the intervention approach. Policy or environmental manipulation was present in all dissemination grants but was rarely used elsewhere, and 19.4% included policy implementation and 25.8% proposed changes in built environment.

Conclusions and Relevance

Grant success rate in skin cancer-related behavioral science compares favorably to the overall NIH grant success rate (approximately 18%), and the success rate of male and female investigators was not statistically different. However, gaps exist in behavioral research addressing all points of the skin cancer control continuum, measuring interventions that hit clinically related targets, and leveraging technology, theory, and environmental manipulation to optimize intervention approach.

Assessing the Potential Effectiveness of Pictorial Messages to Deter Young Women from Indoor Tanning: An Experimental Study

The recent Surgeon General's call-to-action to prevent skin cancer indicates an urgent need for research on messages to deter young women from tanning indoors. Answering this call, the current study assessed differences in the potential effectiveness of pictorial indoor tanning messages. We randomly assigned undergraduate female participants (N = 568) to one of three message conditions visually depicting health effects, appearance damage, or immediate risks, or to a text-only control. All participants viewed three messages within their condition and answered questions after message exposure. Factorial ANOVAs indicated that compared to the text-only condition, pictorial messages produced greater negative emotional reactions and were perceived as more effective than text-only messages. Text-only messages, however, were significantly more believable than pictorial messages. We observed several differences among the pictorial conditions and among the messages within the pictorial conditions. We conclude that messages discouraging indoor tanning should use pictorial messages illustrating the negative health and appearance damaging effects of indoor tanning, focusing on particular health and appearance consequences. Additional research is needed to guide the selection of images that are believable and will most discourage indoor tanning behavior.

State of the science on prevention and screening to reduce melanoma incidence and mortality: The time is now

Answer questions and earn CME/CNE Although overall cancer incidence rates are decreasing, melanoma incidence rates continue to increase about 3% annually. Melanoma is a significant public health problem that exacts a substantial financial burden. Years of potential life lost from melanoma deaths contribute to the social, economic, and human toll of this disease. However, most cases are potentially preventable. Research has clearly established that exposure to ultraviolet radiation increases melanoma risk. Unprecedented antitumor activity and evolving survival benefit from novel targeted therapies and immunotherapies are now available for patients with unresectable and/or metastatic melanoma. Still, prevention (minimizing sun exposure that may result in tanned or sunburned skin and avoiding indoor tanning) and early detection (identifying lesions before they become invasive or at an earlier stage) have significant potential to reduce melanoma incidence and melanoma-associated deaths. This article reviews the state of the science on prevention and early detection of melanoma and current areas of scientific uncertainty and ongoing debate. The US Surgeon General's Call to Action to Prevent Skin Cancer and US Preventive Services Task Force reviews on skin cancer have propelled a national discussion on melanoma prevention and screening that makes this an extraordinary and exciting time for diverse disciplines in multiple sectors-health care, government, education, business, advocacy, and community-to coordinate efforts and leverage existing knowledge to make major strides in reducing the public health burden of melanoma in the United States. CA Cancer J Clin 2016;66:460-480. © 2016 American Cancer Society.

Tanning among Ontario adolescents pre-legislation: Prevalence and beliefs

To establish adolescent tanning beliefs and behaviors, prevalence and location of UV tanning device (beds/lamps) use, awareness of risk and restriction signage, and frequency of tanning service refusal, noting differences by grade and sex, prior to a ban on UV tanning device use among those under 18 in Ontario, Canada. Data were collected May 5 to 20 of 2014. Children in grades 7 to 12, and under age 18 completed an on-line questionnaire that asked their age, sex, grade, methods used to tan, frequency, length and location of UV tanning device use, if services were refused and why, awareness and content of signs/warning labels, tanning beliefs and knowledge, and use of eye protection. Of 1561 participants (10% response rate), 49% were male, 51% female. There were significant differences between the sexes regarding tanning behaviors (e.g. not tanning, tanning outside). Seven percent (108) had 'ever' used UV tanning devices, females more than males (p=0.0026). Over half (57%) of the 104 using UV tanning devices in the past 12months noticed warning signs/labels, of which most noticed that UV tanning devices can cause cancer (65%), and that UV exposure can contribute to premature aging (67%). While most (66%) tanned at tanning salons/studios and beauty salons/studios, gyms/fitness clubs (35%) and home use were common (25%). A relatively low proportion of adolescents used UV tanning devices prior to the ban, with use more common among females and those in higher grades.

Toward quantifying the abuse liability of ultraviolet tanning: A behavioral economic approach to tanning addiction

Many adults engage in ultraviolet indoor tanning despite evidence of its association with skin cancer. The constellation of behaviors associated with ultraviolet indoor tanning is analogous to that in other behavioral addictions. Despite a growing literature on ultraviolet indoor tanning as an addiction, there remains no consensus on how to identify ultraviolet indoor tanning addictive tendencies. The purpose of the present study was to translate a behavioral economic task more commonly used in substance abuse to quantify the "abuse liability" of ultraviolet indoor tanning, establish construct validity, and determine convergent validity with the most commonly used diagnostic tools for ultraviolet indoor tanning addiction (i.e., mCAGE and mDSM-IV-TR). We conducted a between-groups study using a novel hypothetical Tanning Purchase Task to quantify intensity and elasticity of ultraviolet indoor tanning demand and permit statistical comparisons with the mCAGE and mDSM-IV-TR. Results suggest that behavioral economic demand is related to ultraviolet indoor tanning addiction status and adequately discriminates between potential addicted individuals from nonaddicted individuals. Moreover, we provide evidence that the Tanning Purchase Task renders behavioral economic indicators that are relevant to public health research. The present findings are limited to two ultraviolet indoor tanning addiction tools and a relatively small sample of high-risk ultraviolet indoor tanning users; however, these pilot data demonstrate the potential for behavioral economic assessment tools as diagnostic and research aids in ultraviolet indoor tanning addiction studies.

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.

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We analyzed data on indoor tanners from a national survey.

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A significant percentage of female tanners uses sunscreen regularly.

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

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Indoor tanners of both sexes engage in frequent risky behaviors.

Parental Use and Educational Campaigns on Sunbed Use Among Teenagers and Adolescents

This study aimed to evaluate the prevalence of sunbed use among teenagers and the association between familial behavior and the adoption of UV-protective practices in this age group. We also assessed the impact of an educational program on students' knowledge about the potential risks of sunbed use. The educational intervention focused on: (i) skin effects of UV radiation, (ii) photoaging and photocarcinogenesis, (iii) risk factors for skin cancer, (iv) indoor sun tanning and misleading concepts such as possible protective effect of sunbed use on skin cancer risk, (v) sun protection and relation with skin phototype, and (vi) early diagnosis of melanoma using the ABCDE check list and the ugly duckling sign. We carried out a survey of 3098 students and found a strong association between parental sunbed use and students' use of the same (P < 0.0001). Students who attended the educational intervention were more aware that sunbed use cannot prevent sunburns (P = 0.03) than those who did not attend, making adjustments for confounding variables. However, sunbed use by parents influenced the desire to use a sunbed more than participation in the educational intervention (P < 0.0001). In conclusion, although our results indicate that educational interventions can improve knowledge of the risk of sunbed use. They also reveal a strong correlation between sunbed use by teenagers and parental behavior that highlights the importance of educational interventions involving families.

Perceptions of the solarium ban in Australia: 'Fake it, don't bake it'

ISSUE ADDRESSED

The causal link between ultraviolet radiation from solarium use and skin cancer is well established. In 2012 and 2013, state governments across Australia announced plans to ban commercial solarium use from 31 December 2014. The present study examined the responses of solarium and non-solarium users to the ban on commercial solariums in Australia.

METHODS

Participants (n = 488; 388 females, 100 males; mean age = 26.02, s.d. = 9.95) completed an online questionnaire during the summer prior to the ban relating to solarium usage and their opinions about the ban.

RESULTS

Overall, 49% (n = 237) of participants were aware of the impending ban; 17% (n = 83) had used a solarium at some point in their life. The response to the solarium ban was positive; however, some current solarium users intended post-ban to use privately owned sunbeds and or spend a greater amount of time sun-tanning.

CONCLUSIONS

These findings indicate a high level of public support for the solarium ban, which has removed a risky source of ultraviolet radiation in Australia. SO WHAT? Further steps are now needed to monitor the tanning behaviours of previous solarium users post-ban and their access to private sunbed use and other potentially dangerous methods of tanning (e.g. tanning injections).

Improving outcomes in patients with melanoma: strategies to ensure an early diagnosis

Patients with thin, low-risk melanomas have an excellent long-term prognosis and higher quality of life than those who are diagnosed at later stages. From an economic standpoint, treatment of early stage melanoma consumes a fraction of the health care resources needed to treat advanced disease. Consequently, early diagnosis of melanoma is in the best interest of patients, payers, and health care systems. This review describes strategies to ensure that patients receive an early diagnosis through interventions ranging from better utilization of primary care clinics, to in vivo diagnostic technologies, to new "apps" available in the market. Strategies for screening those at high risk due to age, male sex, skin type, nevi, genetic mutations, or family history are discussed. Despite progress in identifying those at high risk for melanoma, there remains a lack of general consensus worldwide for best screening practices. Strategies to ensure early diagnosis of recurrent disease in those with a prior melanoma diagnosis are also reviewed. Variations in recurrence surveillance practices by type of provider and country are featured, with evidence demonstrating that various imaging studies, including ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging, provide only minimal gains in life expectancy, even for those with more advanced (stage III) disease. Because the majority of melanomas are attributable to ultraviolet radiation in the form of sunlight, primary prevention strategies, including sunscreen use and behavioral interventions, are reviewed. Recent international government regulation of tanning beds is described, as well as issues surrounding the continued use artificial ultraviolet sources among youth. Health care stakeholder strategies to minimize UV exposure are summarized. The recommendations encompass both specific behaviors and broad intervention targets (eg, individuals, social spheres, organizations, celebrities, governments).

Youth indoor tanning and skin cancer prevention: lessons from tobacco control

Youth use of ultraviolet-emitting indoor tanning beds represents a present and emerging public health crisis. Nearly 30% of white female high school students report tanning indoors, and a quarter of high school tanners have used a tanning bed more than 20 times in the past year. Despite the significant health risks of tanning beds, including potentially deadly melanoma and eye problems, limited actions have been taken in the U.S. to protect youth. Tobacco control policies and campaigns, which have sharply reduced youth smoking, may provide a useful framework to control indoor tanning among young people. This article describes several evidence-based tobacco control strategies with potential applicability to indoor tanning within the context of the U.S. Further, current tobacco control policies and current indoor tanning policies in the U.S. are compared, and recommendations on how to curtail youth indoor tanning are discussed.

Ultra-violet indoor tanning addiction: a reinforcer pathology interpretation

Ultra-violet indoor tanning (UVIT) is a pervasive issue that is increasing at record rates, despite obvious and well-publicized links to skin cancer. Recent studies on UVIT have found that frequent users face difficulty quitting and report symptomatology similar to substance-related disorders, causing the medical field to begin classifying excessive UVIT use as an addicting behavior. Despite calls for research, relatively little behavioral research has been aimed at determining the psychology of UVIT. This mini-review reinterprets the existing dermatology literature in light of the reinforcer pathology model of addiction. The relevancy of this model, in conjunction with the similarities between UVIT addiction and other substance-related addiction, suggests that behavioral economic research on UVIT is overdue. This mini-review concludes with directions for future research in this area.

Testing a social cognitive theory-based model of indoor tanning: implications for skin cancer prevention messages

The lack of a theory-based understanding of indoor tanning is a major impediment to the development of effective messages to prevent or reduce this behavior. This study applied the Comprehensive Indoor Tanning Expectations (CITE) scale in an analysis of indoor tanning behavior among sorority women (total N = 775). Confirmatory factor analyses indicated that CITE positive and negative expectations were robust, multidimensional factors and that a hierarchical structure fit the data well. Social cognitive theory-based structural equation models demonstrated that appearance-oriented variables were significantly associated with outcome expectations. Outcome expectations were, in turn, significantly associated with temptations to tan, intention to tan indoors, and indoor tanning behavior. The implications of these findings for the development of messages to prevent and reduce indoor tanning behavior are discussed in two domains: (a) messages that attempt to change broader societal perceptions about tan skin, and (b) messages that focus more narrowly on indoor tanning-challenging positive expectations, enhancing negative expectations, and encouraging substitution of sunless tanning products.

Preventing skin cancer through reduction of indoor tanning: current evidence

Exposure to ultraviolet radiation from indoor tanning devices (tanning beds, booths, and sun lamps) or from the sun contributes to the risk of skin cancer, including melanoma, which is the type of skin cancer responsible for most deaths. Indoor tanning is common among certain groups, especially among older adolescents and young adults, adolescent girls and young women, and non-Hispanic whites. Increased understanding of the health risks associated with indoor tanning has led to many efforts to reduce use. Most environmental and systems efforts in the U.S. (e.g., age limits or requiring parental consent/accompaniment) have occurred at the state level. At the national level, the U.S. Food and Drug Administration and the Federal Trade Commission regulate indoor tanning devices and advertising, respectively. The current paper provides a brief review of (1) the evidence on indoor tanning as a risk factor for skin cancer; (2) factors that may influence use of indoor tanning devices at the population level; and (3) various environmental and systems options available for consideration when developing strategies to reduce indoor tanning. This information provides the context and background for the companion paper in this issue of the American Journal of Preventive Medicine, which summarizes highlights from an informal expert meeting convened by the CDC in August 2012 to identify opportunities to prevent skin cancer by reducing use of indoor tanning devices.