Attitudes Toward Indoor Tanning Among Users of Sunless Tanning Products

Despite primary prevention efforts aimed at reducing exposure to UV radiation (UVR), tanning bed use among women and girls remains high, ranging from 35% to 47% for young women aged 17 to 19 years.^1-3 Rising melanoma incidence rates among women and girls aged 15 to 39 years⁴ coupled with high rates of tanning bed use^1,2 call for innovative alternatives such as sunless tanning products (STPs).⁵ In the United States, few studies have examined the use of STPs. In a recent national survey of 1600 adolescents, nearly 20% of young women reported STP use in the previous year. Use was high among those with strong tan preferences and was also associated with higher rates of indoor tanning and recent sunburns.⁶ In a smaller sample, Sheehan et al⁷ found that 73% of STP users had or were planning to decrease their tanning bed use.

We report herein on young women's use of STPs, including lotions, creams, and salon-administered sprays, during the 12 months prior to a survey conducted in the summer of 2007. The purpose of this pilot study was to examine associations between use of STPs and use of tanning beds and to explore differences in tan-promoting attitudes among STP users.

We approached women who appeared to be between the ages of 18 and 40 years on Boston streets and at 2 local university campuses. From counts of respondents and nonrespondents, we estimated that more than 50% of passers-by completed the survey. Exempt approval to conduct this study was provided by the institutional review boards at Boston University Medical Center and the Harvard School of Public Health.

The survey instrument included questions from earlier surveys and new ones developed specifically for this survey.^7,8 The pilot survey included 6 women aged 23 to 31 years. The survey asked for respondent demographic information and how often they had used tanning beds and STPs within the past year. Participants responded to statements addressing tan-promoting attitudes, for example, “It is worth burning to get a tan. ” They also addressed sun protection practices, exposures, and reasons for sunless tanning (Table).

Among STP users, bivariate associations were assessed between measures of attitudes, practices, tanning bed use, and changes in tanning bed use. Proportions were calculated, and differences were assessed using the χ² test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs.

For this report, we restricted our analysis to the 181 women who had used STPs in the previous 12 months (ages ranged from 18 to 38 years, with a median age of 21 years). Among these, 131 used a sunless lotion only (72%); 8 used a spray tan only (4%); and 42 used both types of STPs (23%). Of the 181 respondents, 98 used a tanning bed at least once in the previous 12 months (54%). Of the 98 respondents who used a tanning bed and an STP at any time in the previous 12 months, 40 did not change their tanning bed use while using STPs; 9 increased their tanning bed use; 24 decreased tanning bed use; and 25 stopped using a tanning bed altogether while using STPs.

Among the 49 respondents who maintained or increased their tanning bed use, 43 agreed or strongly agreed with the statement that “people are more attractive if they have a tan ” (88%) compared with 28 of the 49 respondents who decreased or stopped tanning bed use (58%) (OR, 5.12; 95% CI, 1.83-14.32) (P   <  .001). Respondents who maintained or increased tanning bed use were more likely to report that they “found it hard not to tan ” (OR, 4.51; 95% CI, 1.81-11.28), to state that it was “worth burning to get a tan ” (OR, 3.11; 95% CI, 1.01-9.54), and to use sunscreen rarely or never (OR, 10.23; 95% CI, 2.19-47.81). Those respondents who reported that they had decreased or stopped tanning bed use were more likely to use STPs as a substitute for receiving a tan from tanning beds (OR for maintained or increased vs decreased or stopped, 0.34; 95% CI, 0.12-0.96), to use STPs for special occasions (OR, 0.36; 95% CI, 0.15-0.83), and to worry about wrinkles (OR, 0.33; 95% CI, 0.15-0.83) or skin cancer (OR, 0.40; 95% CI, 0.16-1.01) (Table).

Sales of STPs in the United States nearly quadrupled between 2003 and 2008,⁹ but, it is unclear whether these products are working to reduce tan-seeking practices. One trial found that STPs helped to decrease rates of sunbathing¹⁰; however, another study found conflicting results.¹¹ Neither of these studies reported on STPs' association with tanning bed use. We found that of the 50% of STP users who used a tanning bed at least once in the prior 12 months, and 50% stopped or decreased the use of tanning beds while using STPs. These results leave room for cautious optimism.

Our findings suggest that specific tan-promoting attitudes might predispose particular individuals to use sunless tanners. We found that women who maintained or increased their use of tanning beds were more likely to have stronger tan-promoting attitudes than their counterparts who decreased or stopped such use and were also far more likely to practice other risky sun behaviors such as not using sunscreen. Understanding the foundations of these attitudes may provide direction for ways to reduce adverse UVR exposures.

We cannot determine whether users of STPs might have used tanning beds more frequently had they not been using STPs. Participants were recruited in Boston using a nonrandomized sample. While a random sample from more localities would be preferable, similar methods have been used in surveys conducted at single beaches.^12-14

For half of the respondents, STPs appeared to work as a temporary harm reduction strategy; however, it remains to be seen whether reduction in tan-promoting behaviors can be sustained. In addition, this study revealed a significant majority of tan seekers who continue to incur skin damage through both natural and artificial UVR exposure, despite STP use.

Correspondence: Mr Geller, Department of Society, Human Development, and Health, Harvard School of Public Health, Kresge Bldg, 677 Huntington Ave, Room 701A, Boston MA, 02115 (ageller@hsph.harvard.edu).

Accepted for Publication: August 5, 2011.

Author Contributions: Dr Mahoney, Ms Biello, and Mr Geller had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: Mahoney, Resnick, and Geller. Acquisition of data: Mahoney. Analysis and interpretation of data: Mahoney, Swetter, Biello, Feuerstein, and Geller. Drafting of the manuscript: Mahoney, Swetter, and Geller. Critical revision of the manuscript for important intellectual content: Mahoney, Swetter, Biello, Resnick, Feuerstein, and Geller. Statistical analysis: Biello. Administrative, technical, and material support: Resnick and Geller. Study supervision: Mahoney and Geller.

Additional Contributions: Marie-France Demierre, MD, provided writing assistance and guidance throughout the project.