Reconnaissance study of sunbed use by primary school children in Lanarkshire

Sunbed Use among 11- to 17-Year-Olds and Estimated Number of Commercial Sunbeds in England with Implications for a 'Buy-Back' Scheme

Prior to 2011 legislation prohibiting children from using commercial sunbeds, the prevalence of sunbed use in 15- to 17-year-olds in some areas in England was as high as 50%. Despite significant decreases since 2011, children today still practice indoor tanning. We estimated current sunbed use in 11- to 17-year-olds in England, the number of available commercial sunbed units, and the associated cost of a ‘buy-back’ scheme to remove commercial sunbeds under a potential future policy to ban sunbeds. We undertook a calibration approach based on published prevalence rates in English adults and other sources. Internet searches were undertaken to estimate the number of sunbed providers in Greater Manchester, then we extrapolated this to England. Estimated mean prevalence of sunbed use was 0.6% for 11- to 14-year-olds and 2.5% for 15- to 17-year-olds, equating to 62,130 children using sunbeds in England. A predicted 2958 premises and 17,865 sunbeds exist nationally and a ‘buy-back’ scheme would cost approximately GBP 21.7 million. Public health concerns remain greatest for 11- to 17-year-olds who are particularly vulnerable to developing skin cancers after high ultraviolet exposure.

Who, why, where: an overview of determinants of sunbed use in Europe

Although exposure to indoor tanning has been established as a clear risk factor for skin cancer, sunbeds are still commonly used in Europe. Understanding the determinants of sunbed use in Europe is key to plan educational interventions, behavioural strategies and legislative measures, which should be tailored to subgroups with different risk profiles. Evidences show that the typical sunbed users in Europe are young-adult women, with intermediate skin type, a current employment and a medium/high socio-economic status. Typical users display sun-seeking behaviours and other risky behaviours such as smoking. Indoor tanning seems more common in northern than southern Europe. However, sunbed use remains common in fair-skinned individuals and among adolescents/pre-adolescents. Commonly reported reasons for sunbed use in Europe include aesthetic motives (i.e. looking attractive), the pursue of a prevacation tan, the influence of peers/parents engaging in the same habit, and the treatment of health conditions. The most commonly reported places to get an artificial tan in Europe are tanning studios and beauty salons. However, sunbeds are also available in sport venues, such as swimming pools and gyms, hotels and private houses. All these factors should be taken into account when planning educational, behavioural and legislative interventions to reduce the popularity of artificial tanning in Europe.

International prevalence of indoor tanning: a systematic review and meta-analysis

IMPORTANCE

Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

OBJECTIVE

To summarize the international prevalence of exposure to indoor tanning.

DATA SOURCES

Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

STUDY SELECTION

Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

MAIN OUTCOMES AND MEASURES

Ever and past-year exposure to indoor tanning.

RESULTS

The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

CONCLUSIONS AND RELEVANCE

Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

Self-reported sun-related knowledge, attitudes and behaviours among schoolchildren attending South African primary schools

BACKGROUND

Skin cancer and other adverse health effects result from excess solar ultraviolet radiation exposure. Sun protective practices are important interventions for skin cancer prevention, particularly when implemented early in life. Several international studies have assessed children's sun-related knowledge, attitudes and behaviours in school settings but never before in Southern Africa, where multiethnic populations exist.

PURPOSE

The purpose of this study is to describe the sun-related knowledge, attitudes and behaviours as self-reported by South African primary schoolchildren and consider the roles of sex and skin type.

METHODS

A randomly selected sample of 707 schoolchildren from 24 government, urban schools in all nine provinces of South Africa were surveyed regarding their sun-related knowledge, attitudes and behaviours.

RESULTS

Approximately 56% of students reported experience of sunburn last summer and 59% stated that they had got a suntan. Many students (64.5%) believed that one could protect oneself from getting skin cancer by avoiding getting sunburnt. Other means reported to do so by the students were to use sunscreen (65.4%), stay out of the summer sun (48.0%), cover up with clothing (45.5%) and eat the right foods (38.0%). Only about a quarter of the students (22.4%) wrongly agreed that it is safe to get sunburnt once or twice a year. Few students (8.7%) agreed that they like to have a suntan because they feel healthier and agreed that they think a suntan makes them feel more attractive to others (17.3%). Few also agreed that most of their friends (16.1%) and family (14.2%) think that a suntan is a good thing. Children reporting to have white/light brown skin (69.4%) were more likely to agree that they used sunscreen to protect themselves from getting sunburnt compared with children having brown/dark brown/black skin (54.8%) (P = 0.0005).

CONCLUSION

South African schoolchildren at urban government schools do have some knowledge about sun protection, and they do have some positive sun behaviours; however, the reported occurrence of sunburn, a risk factor for skin cancer, was relatively high. There were few differences in responses by sex and some differences by skin type. These findings are important for the development of appropriate sun protection programmes aimed at schoolchildren in South Africa and other countries with similar multi-ethnic populations.

International prevalence of indoor tanning: a systematic review and meta-analysis

IMPORTANCE

Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

OBJECTIVE

To summarize the international prevalence of exposure to indoor tanning.

DATA SOURCES

Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

STUDY SELECTION

Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

MAIN OUTCOMES AND MEASURES

Ever and past-year exposure to indoor tanning.

RESULTS

The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

CONCLUSIONS AND RELEVANCE

Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

Sunbed use, attitudes, and knowledge after the under-18s ban: a school-based survey of adolescents aged 15 to 17 years in Sandwell, United Kingdom

BACKGROUND

Sunbed use in childhood increases risk of melanoma. The under-18s sunbed ban was introduced in England, April 2011. Impact on use has not been investigated since. This cross-sectional study estimates the prevalence of under-18s' use in Sandwell after the commercial ban and identifies factors associated with use/intention.

METHODS

Adolescents aged 15 to 17 years in schools were surveyed using self-completed anonymous questionnaires. Data collected include demographics, sunbed use, tanning attitudes, knowledge of risks and ban awareness. All Sandwell schools were approached; adolescents available on the survey days were included.

RESULTS

Five out of 22 schools participated, 407 adolescents responded (95.1%). Twenty participants (5.3%; 95% confidence interval [CI] = 3.4-8.0) had used sunbeds, of who 16 reported use in commercial settings. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational course and European migrants), the prevalence of use was 1.7% (95% CI = 0.7-3.9, n = 5). Less than half of all were aware of the ban (48.2%; 95% CI = 43.2-53.3). Users/potential users were less aware of associated risks. Being female, having family/friends who use sunbeds increased use/intention 2- to 4-fold.

CONCLUSION

Strategies targeting parents, stricter enforcement, and greater publicity of the ban are needed. Further research exploring the possible association between certain vocational courses, migrants, and sunbed use is required.

Sunbed use in children aged 11-17 in England: face to face quota sampling surveys in the National Prevalence Study and Six Cities Study

OBJECTIVES

To quantify the use of sunbeds in young people across England, identify geographical variation, and explore patterns of use, including supervision.

DESIGN

Two random location sampling surveys.

SETTING

National Prevalence Study in England; Six Cities Study in Liverpool, Stoke/Stafford, Sunderland, Bath/Gloucester, Oxford/Cambridge, and Southampton.

PARTICIPANTS

3101 children aged 11-17 in the National Prevalence study and 6209 in the Six Cities study.

RESULTS

In the National Prevalence Study 6.0% (95% confidence interval 5.1% to 6.8%) of those aged 11-17 had used a sunbed. Use was higher in girls than in boys (8.6% (7.2% to 10.0%) v 3.5% (2.6% to 4.4%), respectively), in those aged 15-17 compared with those aged 11-14 (11.2% (9.5% to 12.9%) v 1.8% (1.2% to 2.4%), respectively), and in those from lower rather than higher social grades (7.6% (5.7% to 9.5%) v 5.4% (4.5% to 6.3%), respectively). Sunbed use was higher in the "north" (11.0%, 8.9% to 13.0%) than in the "midlands" (4.2%, 2.5% to 5.8%) and the "south" (4.2%, 3.3% to 5.2%). In the Six Cities Study, sunbed use was highest in Liverpool and Sunderland (20.0% (17.5% to 22.4%) and 18.0% (15.6% to 20.3%), respectively), with rates especially high in girls, those aged 15-17, or from lower social grades. Mean age of first use was 14, and 38.4% (34.7% to 42.1%) of children used a sunbed at least once a week. Nearly a quarter (23.0%, 19.8% to 26.1%) of children had used a sunbed at home (including home of friends/relatives), and 24.7% (21.0% to 28.4%) said they had used sunbeds unsupervised in a tanning/beauty salon or gym/leisure centre.

CONCLUSIONS

Sunbed use by children is widespread in England, is often inadequately supervised, and is a health risk. National legislation is needed to control sunbed outlets.

Who uses sunbeds? A systematic literature review of risk groups in developed countries

Skin cancer is caused by ultraviolet radiation (UVR). Indoor tanning is a totally avoidable risk behaviour. This review addresses the specific characteristics of sunbed users and the differences in motivation and risk perception compared with non-users. This review is based solely on empirical original articles. Based on literature searches with widely used reference databases ('PubMed', 'OVID', 'Social Citation Index', 'ERIC--Educational Resources Information Center', 'Web of Science' and the 'International Bibliography of the Social Sciences'), we included studies from developed nations with a publication date between 1 January 2000 and 12 August 2008. All studies were selected, classified and coded simultaneously by both authors on a blinded basis. All searches were performed on 13 and 14 August 2008. In accordance with the QUOROM and the MOOSE Statements, we identified 16 original studies. The typical sunbed user is female, between 17 and 30 years old, and tends to live a comparatively unhealthy lifestyle: Users smoke cigarettes and drink alcohol more frequently and eat less healthy food than non-users. Users are characterized by a lack of knowledge about health risks of UVR, and prompted by the frequent use of sunbeds by friends or family members and the experience of positive emotions and relaxation by indoor tanning. This review is the first systematic review on risk groups among sunbed users that has been published in a scientific journal. There is still a lack of information among users, particularly among young people regarding the safety of solariums.

Issues in medical exposures

Medical exposures account, on average, for some 14% of the background ionising radiation exposure in the UK and form the great majority of the non-natural component. In the United States of America, medical exposures comprised over 50% of the total in 2006. This is due primarily to an increase in x-ray computed tomography (CT) and positron emission tomography (PET) procedures. This paper highlights the potential problems in the use of CT scanning to investigate the asymptomatic individual, where the traditional risk/benefit considerations are less clear-cut than in conventional clinical situations. It draws on a recent COMARE report which examined the use of CT for whole body, heart, lung and colon studies. The number of PET facilities is increasing rapidly in the UK and, in addition to considerations of radiation dose to subjects, careful planning is necessary to limit doses to staff. In non-ionising radiation, a topic of keen interest at present is the use of increasingly powerful sunbeds, particularly by those aged under 18. Legislation and regulation vary widely across Europe and the Scottish Parliament has recently introduced the first UK regulation. It is suggested that further research is required into the effects of current UV systems and the reasons why tanning is thought so desirable by Caucasians. Lastly, a number of issues requiring radiobiological and epidemiological input are considered and actions to satisfy these identified.

The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review

Exposure to solar ultraviolet (UV) radiation is a known cause of skin cancer. Sunbed use represents an increasingly frequent source of artificial UV exposure in light-skinned populations. To assess the available evidence of the association between sunbed use and cutaneous malignant melanoma (melanoma) and other skin cancers, a systematic review of the literature till March 2006 on epidemiological and biological studies on sunbed use was performed in Pubmed, ISI Web of Science, Embase, Pascal, Cochrane library, Lilacs and Medcarib. Search for keywords in the title and in the abstract was done systematically and supplemented by manual searches. Only case-control, cohort or cross-sectional studies were selected. Data were abstracted by means of a standardized data-collection protocol. Based on 19 informative studies, ever-use of sunbeds was positively associated with melanoma (summary relative risk, 1.15; 95% CI, 1.00-1.31), although there was no consistent evidence of a dose-response relationship. First exposure to sunbeds before 35 years of age significantly increased the risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% CI, 1.35-2.26). The summary relative risk of 3 studies of squamous cell carcinoma showed an increased risk. For basal cell carcinoma, the studies did not support an association. The evidence does not support a protective effect of the use of sunbeds against damage to the skin from subsequent sun exposure. Young adults should be discouraged from using indoor tanning equipment and restricted access to sunbeds by minors should be strongly considered.

Access to commercial indoor tanning facilities by adults with highly sensitive skin and by under-age youth: compliance tests at solarium centres in Melbourne, Australia

The study aimed to establish solarium operators' compliance with a newly revised voluntary code for the industry in 2002. The revisions incorporate guidelines to ensure customers are adequately informed of the risks associated with solarium use and that access by high-risk groups, such as customers with fair skin that does not tan (skin type 1) or those less than 18 years of age, is limited or barred. Compliance tests with the industry standard were conducted at 30 solarium centres in Melbourne, Australia. Compliance was tested by surveys and in-person visits from three research assistants, each presenting as potential customers but with different eligibility to attend a sunbed session: young adults eligible to attend a solarium, young adults with skin type 1 and under-age (16 year old) customers. This is the first study to assess solarium compliance using confederates with customer profiles that correspond to the required restrictions on sunbed access. Results showed poor compliance with specific aspects of the voluntary code. Fifty-two per cent of centres gave the underage teenagers access to sunbeds without written parental consent. Ninety per cent of centres provided sunbed access to clients with poor tanning ability and 75% of centres tried to reassure them about using the sunbeds. Seven per cent of centres did not provide any form of eye protection for customers and 7% provided sub-standard stickers for eye protection. The study suggests that there is much room for improvement in solarium centres' current practices and further regulation may well be warranted.

Cutaneous malignant melanoma: facts about sunbeds and sunscreen

The incidence of cutaneous malignant melanoma is still increasing in most light-skinned populations. Sunscreen use has been proposed for the primary prevention of melanoma. However, sunscreen use may increase time spent in the sun when users are willing to acquire a tan or to stay in the sun for a long time, which may increase melanoma risk. When sun exposure is not associated with the desire to acquire a tan or stay in the sun for a long time, sunscreen use may prevent squamous cell skin carcinoma. Sun protection should give priority to clothing and sun exposure reduction. Over the last 20 years, tan acquisition through exposure to artificial sources of ultraviolet radiation has become frequent among fair-skinned adolescents and young adults. There is accumulating evidence that sunbed use is associated with melanoma when started before approximately 30 years of age.

Perspectives in melanoma prevention: the case of sunbeds

The incidence of cutaneous malignant melanoma (melanoma) and of basal cell carcinoma is still increasing in most fair-skinned populations. The fashion of intermittent exposure to solar ultraviolet (UV) radiations is considered the main cause of this increase. In 20 years time, tan acquisition through exposure to artificial sources of UV radiations has become frequent among fair-skinned adolescents and young adults. Modern sunbeds are powerful sources of UV radiations that do not exist in the nature, and repeated exposures to high doses of UVA constitute a new phenomenon in humans. A large prospective cohort study on 106,379 Norwegian and Swedish women conducted between 1991 and 1999 has provided evidence for a significant, moderate increase in melanoma risk among regular sunbed users. Failure of past case-control studies to document with consistency the sunbed-melanoma association was probably due to a too short latency period between sunbed use and melanoma diagnosis, and to too few subjects with high total durations of sunbed use. Regulations of sunbed installation, operation and use should become standardised across the 25 European Union countries. Enforcement of regulations in tanning parlours remains inadequate. In contrast, the existence of regulations is presented by many tanning salon operators as a guarantee that sunbed use is safe. We stress the need for the control of information disseminated by the "tanning industry" on suppositions that sunbed use is safer than sun exposure, and on the hypothetical health benefits of tanning. New fluorescent UV lamps are proposed that have a spectrum similar to the midday sun. Given the known association between intermittent sun exposure and melanoma, public-health authorities should reconsider the soundness of the commercialisation of these lamps.