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Table 1.  
Univariate Analysis: Weighted Percentage of Tanning and Nontanning Students Reporting Substance Usea,b
Univariate Analysis: Weighted Percentage of Tanning and Nontanning Students Reporting Substance Usea,b
Table 2.  
Multivariate Analysis: Adjusted Logistic Regression Analysis Stratified by Sexa
Multivariate Analysis: Adjusted Logistic Regression Analysis Stratified by Sexa
1.
Mogensen  M, Jemec  GB.  The potential carcinogenic risk of tanning beds: clinical guidelines and patient safety advice.  Cancer Manag Res. 2010;2:277-282.PubMedGoogle ScholarCrossref
2.
Wehner  MR, Chren  MM, Nameth  D,  et al.  International prevalence of indoor tanning: a systematic review and meta-analysis.  JAMA Dermatol. 2014;150(4):390-400.PubMedGoogle ScholarCrossref
3.
Miyamoto  J, Berkowitz  Z, Jones  SE, Saraiya  M.  Indoor tanning device use among male high school students in the United States.  J Adolesc Health. 2012;50(3):308-310.PubMedGoogle ScholarCrossref
4.
Guy  GP  Jr, Berkowitz  Z, Tai  E, Holman  DM, Everett Jones  S, Richardson  LC.  Indoor tanning among high school students in the United States, 2009 and 2011.  JAMA Dermatol. 2014;150(5):501-511.PubMedGoogle ScholarCrossref
5.
Blashill  AJ.  Psychosocial correlates of frequent indoor tanning among adolescent boys.  Body Image. 2013;10(2):259-262.PubMedGoogle ScholarCrossref
6.
Petit  A, Karila  L, Chalmin  F, Lejoyeux  M.  Phenomenology and psychopathology of excessive indoor tanning.  Int J Dermatol. 2014;53(6):664-672.PubMedGoogle ScholarCrossref
Research Letter
May 2016

Associations Between Indoor Tanning and Substance Use Among Colorado High School Students

Author Affiliations
  • 1University of Colorado School of Medicine, Aurora
  • 2Colorado Department of Public Health and Environment, Denver
  • 3Michigan State University College of Human Medicine, Grand Rapids
  • 4Colorado School of Public Health, University of Colorado, Aurora
  • 5Department of Dermatology, University of Colorado School of Medicine, Aurora
  • 6Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora
  • 7Dermatology Service, Denver Veterans Affairs Medical Center, Denver, Colorado
JAMA Dermatol. 2016;152(5):575-577. doi:10.1001/jamadermatol.2015.5663

The World Health Organization classifies UV radiation as a group 1 carcinogen and deems the use of tanning devices that emit UV radiation a risk factor for melanoma, basal cell carcinoma, and squamous cell carcinoma.1 Nonetheless, about 1 in 5 adolescents have used a UV tanning bed in their lifetime.2

A growing national body of evidence links indoor tanning with other risky health-related behavior among adolescents.3,4 Motivation for indoor tanning is multifactorial, including physiological and psychological factors. For example, indoor tanning and use of steroids may both stem from the motivation to enhance one’s appearance.5 Data also implicate addictive physiological pathways in indoor tanning that may be similar to those of substance use.6 Knowledge of these similarities can help guide the physician. Studies examining these associations within states, such as Colorado, that lack age restrictions for indoor tanning may foster regulation of this carcinogenic activity. This study analyzes results from a survey of Colorado high school students to examine state-level associations between substance use and indoor tanning.

Methods

The Healthy Kids Colorado Survey collected self-reported health data from Colorado public schools. The University of Colorado Denver Institutional Review Board approved this study. More than 220 schools and 40 000 students in 21 regions participated in the 2013 Healthy Kids Colorado Survey that was administered from August through December 2013. Questionnaires including an item on the frequency of indoor tanning reached 12 671 high school students. Items regarding substance use examined the type and frequency of use. Active or passive parental consent was obtained via letters sent home several days before survey administration. Students were informed before survey administration that their participation was voluntary and anonymous.

Data analysis was conducted from July 28 to October 25, 2015. Sample-based survey weighting was used to support inferences about Colorado public high schools not surveyed. The weighted percentage of students reporting substance use from each population (tanners and nontanners) was calculated along with 95% CIs. Univariate analysis used weighted frequencies and percentages for each variable and outcome of interest. Measures of effect were calculated with odds ratios as determined through unadjusted and adjusted logistic regression modeling. Unadjusted logistic regression was performed to evaluate the potential association between the use of individual substances and indoor tanning practices (Table 1). Adjusted logistic regression models were then fit using a stepwise process of forward selection. This analysis was stratified by sex because univariate results showed that females were more likely than males to engage in indoor tanning practices (Table 2).

Results

A total of 12 144 students answered the question, “During the past 12 months, how many times did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth?” Univariate analysis showed that females were approximately twice as likely to engage in indoor tanning as males (unadjusted odds ratio, 2.0; 95% CI, 1.6-2.5; P < .001. Multivariate analysis identified any lifetime use of steroids as the variable most strongly associated with indoor tanning (adjusted odds ratio, 5.5; 95% CI, 3.4-9.1; P < .001). In males, this potential association was even stronger (adjusted odds ratio, 7.1; 95% CI, 3.6-14.0; P < .001). Any alcohol consumption within the prior 30 days and marijuana use were also associated with indoor tanning, as was lifetime use of select illicit drugs.

Discussion

In addition to the inherent adverse health effects of indoor tanning, this study provides evidence for a potential association between substance use and indoor tanning practices in Colorado high school students. Identifying risky health behavior patterns may facilitate preventive health efforts to reduce indoor tanning among adolescents. For example, a physician treating a patient who uses indoor tanning may also choose to assess that patient for use of steroids, particularly in male adolescents. Studying these ramifications is an important public health discussion that can aid in promoting wellness. These findings may be used in clinical settings to broaden patient risk assessments and tailor counseling.

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Article Information

Accepted for Publication: November 14, 2015.

Corresponding Author: Robert P. Dellavalle, MD, PhD, MSPH, Dermatology Service, Denver Veterans Affairs Medical Center, 1055 Clermont St, Mail Stop #165, Denver, CO 80220 (robert.dellavalle@ucdenver.edu).

Published Online: January 20, 2016. doi:10.1001/jamadermatol.2015.5663.

Author Contributions: Mr Bell and Ms Sendelweck had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sendelweck, Bell, Ashack, Dellavalle.

Acquisition, analysis, or interpretation of data: Sendelweck, Bell, Anderson, Pindyck, Townley.

Drafting of the manuscript: Sendelweck, Ashack, Townley.

Critical revision of the manuscript for important intellectual content: Sendelweck, Bell, Anderson, Ashack, Pindyck, Dellavalle.

Statistical analysis: Sendelweck, Bell, Anderson, Pindyck.

Administrative, technical, or material support: Sendelweck, Bell, Ashack, Townley.

Study supervision: Dellavalle.

Conflict of Interest Disclosures: Dr Dellavalle serves as chair of the Colorado Skin Cancer Task Force. Dr Dellavalle is supported by grants from the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH). No other conflicts were reported.

Funding/Support: The Healthy Kids Colorado Survey is sponsored by the Colorado Department of Education, Colorado Department of Public Health and Environment, and Colorado Department of Human Services Office of Behavioral Health. These 3 state agencies sponsored data collection and the Colorado Department of Public Health and Environment sponsored the data analysis. This study received no direct funding.

Role of the Funder/Sponsor: Mr Bell, Ms Anderson, and Ms Townley are employed by the Colorado Department of Public Health and Environment, who sponsored the data collection. These authors were involved in manuscript preparation. The funding sources had no other role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; review or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs, CDC, and NIH.

Additional Contributions: Lori Crane, PhD, MPH, Colorado School of Public Health, University of Colorado, provided manuscript review. She was not compensated for her contribution.

References
1.
Mogensen  M, Jemec  GB.  The potential carcinogenic risk of tanning beds: clinical guidelines and patient safety advice.  Cancer Manag Res. 2010;2:277-282.PubMedGoogle ScholarCrossref
2.
Wehner  MR, Chren  MM, Nameth  D,  et al.  International prevalence of indoor tanning: a systematic review and meta-analysis.  JAMA Dermatol. 2014;150(4):390-400.PubMedGoogle ScholarCrossref
3.
Miyamoto  J, Berkowitz  Z, Jones  SE, Saraiya  M.  Indoor tanning device use among male high school students in the United States.  J Adolesc Health. 2012;50(3):308-310.PubMedGoogle ScholarCrossref
4.
Guy  GP  Jr, Berkowitz  Z, Tai  E, Holman  DM, Everett Jones  S, Richardson  LC.  Indoor tanning among high school students in the United States, 2009 and 2011.  JAMA Dermatol. 2014;150(5):501-511.PubMedGoogle ScholarCrossref
5.
Blashill  AJ.  Psychosocial correlates of frequent indoor tanning among adolescent boys.  Body Image. 2013;10(2):259-262.PubMedGoogle ScholarCrossref
6.
Petit  A, Karila  L, Chalmin  F, Lejoyeux  M.  Phenomenology and psychopathology of excessive indoor tanning.  Int J Dermatol. 2014;53(6):664-672.PubMedGoogle ScholarCrossref
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