Determinants of sunbed use in a population of Danish adolescents

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.

Systematic Review of Interventions to Increase Awareness of Ultraviolet Radiation-Induced Harm and Protective Behaviors in Post-Secondary School Adults

College and university students are a group known for excessive sun exposure and indoor tanning. Health education campaigns for avoidance of ultraviolet (UV) radiation have been relatively unsuccessful in this population. This systematic review examines interventions aimed at post-secondary school young adults on college and university campuses for skin cancer awareness, photoprotection, and change in UV-exposure-related behavior. Fifty-nine studies were identified for inclusion according to predetermined criteria. Study heterogeneity was high; methods of intervention were individual or group-based, and were mostly visually delivered and/or passive learning. Most interventions occurred at a single time point. Intervention success was assessed by evaluating subject behavior, intention, attitudes, knowledge, and emotion. Multicomponent interventions, generally consisting of UV photography and a passively delivered educational component, may be more effective than a single component alone. Overall, study quality was poor. Sample size of the majority of studies was <150 subjects. Most studies used self-report of behavior and had a short follow-up time. Generalizability of findings may be impacted as women, particularly white/Caucasian women, were overrepresented in the studies identified by this systematic review. For this specific target population, themes arising from the review include the importance of self-relevance and message framing. Self-affirmation was identified as a potential challenge in designing interventions for this target group, which can lead to defensiveness and a negative reaction to the health message. The findings of this systematic review may inform future research in this field, as well as guide planning of effective interventions in this target population.

Ultraviolet radiation exposure among Belgrade high school students: analysis of knowledge, attitudes and behaviour

BACKGROUND

The incidence of melanoma has been increasing worldwide. Extended UV exposure during childhood or adolescence significantly increases the probability of skin cancer in adulthood.

OBJECTIVE

The objective of this study was to analyse knowledge, attitudes and behaviour regarding exposure to natural and artificial UV radiation among Belgrade high school students.

METHODS

The study was conducted using a questionnaire among 549 students of 3rd and 4th grade (17 and 18 years of age) in four Belgrade high schools. The questionnaire had 32 questions: questions about gender, date and month of birth and parents' education, nine questions regarding sunbed use, nine questions regarding behaviour in the sun during summer months, four questions regarding personal and family history and skin phototype and seven questions regarding attitude and general knowledge about effects of UV radiation. Assessment of frequency rate and relative numbers was used as methods of descriptive statistics.

RESULTS

As many as 39% of participants had used a sunbed at least once, 38% plan on using it in the future. One quarter spends more than 3 hours in the sun on the beach during summer without any protection, and only one-third of participants had not experienced sunburn during last summer. Only one-half of students know what melanoma is, while 37% stated that they do not know.

CONCLUSION

General awareness of risk factors regarding sun exposure as well as general knowledge about melanoma is not on a high level among Belgrade high school students. Therefore, besides legislative measures, it is extremely important to conduct adequate education programmes in high schools.

Prevalence and determinants of sunbed use in thirty European countries: data from the Euromelanoma skin cancer prevention campaign

BACKGROUND

Although considered as a first-group carcinogen, indoor tanning is a common practice in Europe. Euromelanoma is a pan-European skin cancer prevention campaign.

OBJECTIVES

To compare several European countries in terms of the prevalence and determinants of sunbed use.

METHODS

Participants in the Euromelanoma campaigns filled in questionnaires containing demographics and risk factors, including type/duration of sunbed use. Multivariate analyses adjusted for age, gender, education, skin type and year of survey were employed to assess factors independently associated with sunbed use in each country.

RESULTS

In total, 227 888 individuals (67.4% females, median age 44, 63.4% highly educated, 71.9% skin types III-VI) from 30 countries participated. Overall, the prevalence of sunbed ever use was 10.6% (≤19-year-olds: 5.9%; 20 to 35-year-olds: 17.0%; >35-year-olds: 8.3%). Females displayed a higher prevalence than males in all countries. Balkan countries displayed the highest female/male ratios (≥4). Sunbed use was significantly more prevalent among skin type III-VI (14/30 countries) and highly educated participants (11/30 countries). Significant correlations were found between sunbed use prevalence and countries' latitude (P < 0.001) and sunshine (P = 0.002); Italy and Spain represented exceptions towards excessive exposure. Very different prevalence rates were found for Spain (19.3%) and Portugal (2.0%). Scandinavian countries ranked highest in sunbed use among ≤19-year-olds, Baltic countries among 20 to 35-year-olds.

CONCLUSIONS

Sunbed use prevalence was higher in northern, sun-deprived countries, with the exception of Italy and Spain. The main determinants of sunbed use were age (young adults) and gender (females), whereas education and skin type had a less relevant effect. Geographic particularities were found in four regions: Iberian (prevalence ten times higher in Spain than Portugal), Balkan (prevalence disproportionately higher among women), Baltic (highest prevalence among young adults) and Scandinavian (highest prevalence among adolescents). These data have public health relevance for future interventions aimed at reducing sunbed use in Europe.

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.

Decreasing sunbed use in the German population between 2001 and 2015: survey in 155 679 working persons

BACKGROUND

UV radiation is a proven cause of skin cancer. Use of sunbeds has been shown to provide an attributable risk.

OBJECTIVE

To evaluate the proportion of regular sunbed use in Germany based on large-scale population-based surveys over 15 years.

METHODS

Skin cancer screenings by dermatologists were conducted between 2001 and 2015 in more than 500 German companies, including a clinical examination and interviews on the risk behaviour related to sunburns and sunbeds.

RESULTS

Among 155 679 persons included regular sunbed use significantly declined from 11.0% in 2001 to 1.6% in 2015 (P < 0.001). There were significantly higher rates of sunbed use in women (12.5%/2.0%) vs. men (7.3%/1.3%; P < 0.001), in younger persons and in participants with darker skin (type II and III) vs. fair skin (type I). Individuals with sunburns in childhood were significantly more often sunbed users (5.1% vs. 4.6%; P = 0.002). A remarkable decline of sunbed use was observed after 2009 (7.0% in 2001-2008 and 2.2% in 2009-2015). This reduction occurred in the time of a legal ban of sunbed use for minors but also with the start of the national skin cancer screening programme.

CONCLUSION

Use of sunbeds in the German adult population has dropped by more than 85% in the past decade. Primary prevention, including the large public awareness following the legal ban of sunbed use for young people and the effects of the statutory skin cancer screening programme may have contributed to this.

Retrospective study of patients with cutaneous melanoma treated at the Federal University of São Paulo

OBJECTIVE

to evaluate the characteristics of the patients with cutaneous melanoma treated at the São Paulo Hospital - UNIFESP.

METHODS

we conducted a retrospective study of 184 cases of cutaneous melanoma. We analyzed information on gender, age, tumor characteristics, histological characteristics and staging.

RESULTS

mean age at diagnosis was 58.7 years, with homogeneous age distribution between genders and predominance in white individuals (70.6%). There was a predominance of trunk involvement in men (36.7%) and lower limbs in women (42%). Sun exposure, with sunburns, was more common among males (31.2%) than among females (23.5%). There was an approximately three-fold increase in lymph node involvement when the mitotic index rose from zero (11.9%) to one or more mitosis per field (36.2%). In addition, the greater the Breslow thickness, the greater the lymph node involvement and poor the outcomes: 10.2% when less than 1mm and 59.2% when greater than 4mm.

CONCLUSION

the characteristics of patients with cutaneous melanoma treated at Hospital São Paulo are similar to those found in the literature.

Sunbed Use Among Belgrade High School Students

Introduction: The incidence of melanoma has been increasing worldwide. Ultraviolet (UV) radiation from the sun and sunbeds are the major risk factors for the development of melanoma and non-melanoma skin cancers. Excessive UV exposure during childhood and adolescence increases the probablity of skin cancer in adulthood. The objective of this study was to analyze the exposure to artificial UV radiation using sunbeds among Belgrade high school students.

Material and Methods: The study was conducted using a questionnaire among 549 3rd and 4th grade students in 4 Belgrade high schools. The questionnaire included 10 questions on the sunbed use, attitudes, and general knowledge about effects of UV radiation from sunbeds. Statistical analysis assessed the frequency rate and relative frequency as methods of descriptive statistics.

Results: A total of 39% of participants had used a sunbed at least once, and 38% plan on using it in the future. When asked at what age they first used a sunbed, 45.66% of high school students stated that it was at the age of 13 or 14. Most adolescents have used a sunbed less than 5 times (38%), whereas 8% of them used it over 30 times.

Conclusion: The awareness of the risks associated with UV exposure in sunbeds is not at a satisfying level among Belgrade high school students. Educational and legislative measures are necessary to protect this highly sensitive population and prevent malignant consequences.

Sunbed use among 64,000 Danish students and the associations with demographic factors, health-related behaviours, and appearance-related factors

Sunbed use is associated with an increased risk for skin cancer and is particularly dangerous for younger persons. The objective of this study was to assess how demographic factors, health-related behaviours and appearance-related factors are associated with sunbed use. Cross-sectional data from the Danish National Youth Study collected by the National Institute of Public Health during 2014 was used. A total of 64,382 students aged 15-25years were included in the present study. Multilevel logistic regression analyses were used to determine associations. Sunbed use during the past 12months was reported by 22% of students, with a higher proportion among females (29%) than males (12%). Factors associated with sunbed use were older age, studying at a vocational college or a higher preparatory examination school compared to upper secondary school, and lower parental education. Furthermore, being a smoker, been binge-drinking, longer duration of exercise and been dieting were also associated with sunbed use. For females, poor dietary habits were also associated with sunbed use. Feeling overweight was associated with lower odds for sunbed use for males, but with higher odds for females. Lower body satisfaction was associated with higher odds of sunbed use, except for overweight males. Students who were underweight had lower odds for sunbed use, than normal weight students. Conclusively, we found evidence of associations between demographic factors, health-related behaviours and appearance-related factors and sunbed use. Understanding these relations could help to identify high-risk groups and guide preventive strategies for sunbed use and skin cancer prevention.

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.

Socioeconomic status and cutaneous malignant melanoma in Northern Europe

Socioeconomic status (SES) is associated with cutaneous malignant melanoma (CMM) in Northern Europe, despite equal access to health care. SES per se is not responsible for this association, which must be ascribed to important risk factors for CMM such as intermittent ultraviolet radiation (UVR) exposure, and screening for CMM possibly owing to a greater knowledge and understanding of CMM. Our review of the literature showed that high SES is associated with increased risk of CMM, thinner tumours, increased survival and decreased mortality from CMM - the latter shown among women, and in recent studies also among men. There is evidence that high SES is associated with sun holidays, whereas low SES is associated with the use of sunbeds. Findings suggest that high SES is associated with the use of physicians and dermatologists for marks and moles, possibly owing to more knowledge and better understanding of CMM. We conclude that there has been a true increase in CMM incidence among high SES individuals in Northern Europe probably due to past intense intermittent UVR exposure, especially in connection with sun holidays. However, the increased risk of CMM and a better outcome of CMM in high SES individuals may also be conditioned by frequent recourse to physicians, which may be ascribed to more knowledge and better understanding of CMM, although more studies on this subject are warranted. Thicker CMM tumours and increased CMM mortality among low SES individuals in recent decades may reflect exposure to intermittent UVR, such as the use of sunbeds, as well as delayed diagnosis.

The association of indoor tanning and melanoma in adults: systematic review and meta-analysis

BACKGROUND

Tanning beds are associated with increased risk of melanoma.

OBJECTIVE

We sought to update the evidence of the association of melanoma and indoor tanning focusing on frequency of use and exposure to newer tanning beds.

METHODS

We searched Scopus, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature on August 14, 2013. We included all observational studies that included patients with melanoma who had indoor tanned. Odds ratios (OR) with 95% confidence intervals (CI) were extracted and combined using generic inverse variance methods assuming a random effects model.

RESULTS

In all, 31 studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared with never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 (95% CI 1.05-1.28). Similar findings were identified in recent studies with enrollment occurring in the year 2000 onward (OR 1.22, 95% CI 1.03-1.45) and in subjects attending more than 10 tanning sessions (OR 1.34, 95% CI 1.05-1.71).

LIMITATIONS

The quality of evidence contributing to review results ranges from poor to mediocre.

CONCLUSION

Using tanning beds is associated with a subsequent melanoma diagnosis. Exposure from more than 10 tanning sessions is most strongly associated and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models.

The effect of a school-based intervention on sunbed use in Danish pupils at continuation schools: a cluster-randomized controlled trial

PURPOSE

To examine the effect of an educational intervention on sunbed use and intentions and attitudes toward sunbed use in 14- to 18-year-olds at continuation schools.

METHODS

We randomized 33 continuation schools either to receive the educational intervention (n = 16) or to be controls (n = 17). Intervention schools received an e-magazine addressing the health risks of sunbed use. Information on behavior and intentions and attitudes toward sunbed use was gathered through self-administrated questionnaires before the intervention and at 6 months as a follow-up. The effect of the intervention was examined by multilevel linear regression and logistic regression.

RESULTS

Sunbed use was significantly lower at follow-up among pupils at intervention schools versus pupils at control schools (girls: odds ratio .60, 95% confidence interval .42-.86; Boys: odds ratio .58, 95% confidence interval .35-.96). The intervention had no effect on intention to use sunbeds or attitudes toward sunbed use. The analyses revealed a significant impact of school on attitudes toward sunbed; the intraclass correlation coefficient was estimated to be 6.0% and 7.8% for girls and boys, respectively.

CONCLUSIONS

The findings from the present study provide new evidence of a positive effect of an educational intervention on sunbed use among pupils aged 14-18 years at continuation schools.

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.