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Table.  
Selected Characteristics by Indoor Tanning After Diagnosis
Selected Characteristics by Indoor Tanning After Diagnosis
1.
Chen  J, Ruczinski  I, Jorgensen  TJ,  et al.  Nonmelanoma skin cancer and risk for subsequent malignancy. J Natl Cancer Inst. 2008;100(17):1215-1222.
PubMedArticle
2.
Boniol  M, Autier  P, Boyle  P, Gandini  S.  Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757.
PubMedArticle
3.
Mujumdar  UJ, Hay  JL, Monroe-Hinds  YC,  et al.  Sun protection and skin self-examination in melanoma survivors. Psychooncology. 2009;18(10):1106-1115.
PubMedArticle
4.
Nolan  BV, Taylor  SL, Liguori  A, Feldman  SR.  Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed. 2009;25(1):12-19.
PubMedArticle
5.
Ferrucci  LM, Cartmel  B, Molinaro  AM,  et al.  Host phenotype characteristics and MC1R in relation to early-onset basal cell carcinoma. J Invest Dermatol. 2012;132(4):1272-1279.
PubMedArticle
6.
Hillhouse  JJ, Baker  MK, Turrisi  R,  et al.  Evaluating a measure of tanning abuse and dependence. Arch Dermatol. 2012;148(7):815-819.
PubMedArticle
Research Letter
September 2013

Indoor Tanning and Tanning Dependence in Young People After a Diagnosis of Basal Cell Carcinoma

Author Affiliations
  • 1Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 2Yale Cancer Center, New Haven, Connecticut
  • 3Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
  • 6Department of Medicine, University of Massachusetts Medical School, Worcester
  • 4Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
  • 5Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
JAMA Dermatol. 2013;149(9):1110-1111. doi:10.1001/jamadermatol.2013.5104

Individuals who have had basal cell carcinoma (BCC) are at high risk of subsequent BCCs and melanoma.1 Indoor tanning is an established risk factor for BCC, squamous cell carcinoma, and melanoma.2 As such, continuing to tan indoors after a BCC diagnosis may elevate one’s risk for future skin cancers. Skin cancer survivors have sun protection behaviors that are similar to those of the general population,3 but little is known about their indoor tanning behavior. Notably, research suggests that some individuals develop tanning dependence, analogous to substance dependence,4 which could be related to continued indoor tanning. To understand better the patterns of and reasons for indoor tanning after BCC diagnosis, we assessed indoor tanning and symptoms of tanning dependence in people who had received at least 1 BCC diagnosis before age 40 years.

Methods

Non-Hispanic white patients in Connecticut diagnosed as having BCC before age 40 years who participated in a case-control study of BCC5 were recontacted 1 to 4 years after diagnosis to complete an online survey (response rate, 81%). The study was approved by the Yale School of Medicine Human Investigation Committee. We assessed indoor tanning in the past year and lifetime symptoms of tanning dependence using the modified 4-item “Cut down, Annoyed, Guilty, Eye-opener” (mCAGE) Questionnaire.4 Participants with 2 or more affirmative responses on the mCAGE were classified as having symptoms of tanning dependence. History of indoor tanning prior to BCC diagnosis (eg, age at initiation, number of indoor tanning sessions) had been collected during the case-control study.

This analysis is limited to those who reported indoor tanning prior to BCC diagnosis. We evaluated differences by indoor tanning after BCC diagnosis using the χ2 test, Fisher exact test, and Wilcoxon rank sum test.

Results

Among the 178 individuals who had tanned indoors prior to BCC diagnosis, 26 (15%) reported tanning indoors in the past year. The median (interquartile range) number of indoor tanning sessions in the past year was 10 (3-20) in those who tanned indoors. Those who reported tanning indoors after BCC diagnosis were similar to those who did not (Table), with the exception of the frequency of indoor tanning prior to BCC diagnosis being much higher in those who continued to tan indoors after diagnosis (P = .001). In addition, those who tanned indoors after BCC diagnosis were more likely to have symptoms of tanning dependence (58%) than those who had not tanned indoors since diagnosis (38%) (P = .06).

Discussion

Despite mounting evidence of the harmful effects of indoor tanning, in this group of young people who already had received at least 1 BCC diagnosis, nearly 15% tanned indoors after their skin cancer diagnosis and 8% would be defined as frequent indoor tanners (≥10 sessions per year). Notably, individuals with BCC who tanned indoors after receiving a BCC diagnosis were more likely to have symptoms of tanning dependence than those who did not tan indoors following BCC diagnosis, suggesting that tanning dependence may contribute to continued indoor tanning in spite of health consequences. A similar phenomenon is observed in nicotine-dependent individuals, who sometimes continue to smoke after a tobacco-related cancer diagnosis.

Our findings would benefit from replication but suggest that clinicians should discuss the risks of tanning indoors with BCC survivors who continue this behavior and be cognizant of tanning dependence, which can be assessed clinically with a recently validated measure.6

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Article Information

Corresponding Author: Brenda Cartmel, PhD, Department of Chronic Disease Epidemiology, Yale School of Public Health, 55 Church St, Ste 801, New Haven, CT 06510 (Brenda.cartmel@yale.edu).

Accepted for Publication: April 9, 2013.

Published Online: July 3, 2013. doi:10.1001/jamadermatol.2013.5104.

Author Contributions: Dr Cartmel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Cartmel, Ferrucci, Bale, Pagoto, Gelernter, Mayne.

Acquisition of data: Cartmel, Spain, Mayne.

Analysis and interpretation of data: Cartmel, Ferrucci, Bale, Pagoto, Leffell, Gelernter, Mayne.

Drafting of the manuscript: Cartmel, Ferrucci, Spain.

Critical revision of the manuscript for important intellectual content: Cartmel, Ferrucci, Bale, Pagoto, Leffell, Gelernter, Mayne.

Statistical analysis: Ferrucci.

Obtained funding: Cartmel, Bale, Pagoto, Mayne.

Administrative, technical, and material support: Spain, Bale, Mayne.

Study supervision: Cartmel, Bale, Pagoto, Leffell.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by grants R21 CA155952 and P50 CA121974 from the National Cancer Institute, National Institutes of Health.

References
1.
Chen  J, Ruczinski  I, Jorgensen  TJ,  et al.  Nonmelanoma skin cancer and risk for subsequent malignancy. J Natl Cancer Inst. 2008;100(17):1215-1222.
PubMedArticle
2.
Boniol  M, Autier  P, Boyle  P, Gandini  S.  Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757.
PubMedArticle
3.
Mujumdar  UJ, Hay  JL, Monroe-Hinds  YC,  et al.  Sun protection and skin self-examination in melanoma survivors. Psychooncology. 2009;18(10):1106-1115.
PubMedArticle
4.
Nolan  BV, Taylor  SL, Liguori  A, Feldman  SR.  Tanning as an addictive behavior: a literature review. Photodermatol Photoimmunol Photomed. 2009;25(1):12-19.
PubMedArticle
5.
Ferrucci  LM, Cartmel  B, Molinaro  AM,  et al.  Host phenotype characteristics and MC1R in relation to early-onset basal cell carcinoma. J Invest Dermatol. 2012;132(4):1272-1279.
PubMedArticle
6.
Hillhouse  JJ, Baker  MK, Turrisi  R,  et al.  Evaluating a measure of tanning abuse and dependence. Arch Dermatol. 2012;148(7):815-819.
PubMedArticle
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