What are the trends in the prevalence of indoor tanning and the association between indoor tanning and sunburn among US high school students?
This analysis of cross-sectional, nationally representative data from US high school students found a substantial reduction in indoor tanning among US high school students from 2009 to 2015. Indoor tanning was associated with sunburn, with three-quarters of indoor tanners experiencing at least 1 sunburn.
Public health and medical community efforts are needed to further reduce the prevalence of indoor tanning and sunburn and thus prevent future cases of skin cancer.
Indoor tanning and sunburns, particularly during adolescence and young adulthood, increase the risk of developing skin cancer.
To examine the trends in the prevalence of indoor tanning and the association between indoor tanning and sunburn among US high school students.
Design, Setting, and Participants
This study pooled and examined cross-sectional data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Survey. During 2009, 2011, 2013, and 2015, the overall response rates were 71%, 71%, 68%, and 60%, respectively, and unweighted sample sizes were 16 410, 15 425, 13 538, and 15 624, respectively. It included nationally representative samples of US high school students. Data were collected during the spring semester (January to June) in each survey cycle beginning February 9, 2009, through June 18, 2015.
Main Outcomes and Measures
Prevalence of indoor tanning in the past year from 2009 to 2015 and its association with sunburn in 2015.
Among high school students in the United States, the prevalence of indoor tanning decreased from 15.6% (95% CI, 13.7%-17.6%) in 2009 to 7.3% (95% CI, 6.0%-8.9%) in 2015. Decreases in indoor tanning were found among male (from 6.7% in 2009 to 4.0% in 2015) and female (from 25.4 % in 2009 to 10.6 % in 2015) students overall, non-Hispanic white (from 21.1 % in 2009 to 9.4% in 2015) and Hispanic (from 8.2% in 2009 to 4.7% in 2015) students overall, and all age groups. Among non-Hispanic white female students, the prevalence decreased from 37.4% (95% CI, 33.6%-41.4%) in 2009 to 15.2% (95% CI, 11.7%-19.5%) in 2015. In 2015, indoor tanning was associated with sunburn in the adjusted model: 82.3% (95% CI, 77.9%-86.0%) of indoor tanners had at least 1 sunburn during the preceding year compared with 53.7% (95% CI, 48.9%-58.4%) of those who did not engage in indoor tanning (P < .001).
Conclusions and Relevance
Despite declines in the prevalence of indoor tanning from 2009 to 2015 among high school students nationwide, indoor tanning remains commonplace among certain subgroups, especially non-Hispanic white female students. Three-quarters of those who engaged in indoor tanning had experienced at least 1 sunburn. Efforts by the public health and medical communities are needed to further reduce the prevalence of indoor tanning and sunburn and thus prevent future cases of skin cancer.
Incidence of skin cancer is increasing in the United States. Each year, an estimated 4.9 million individuals are treated for skin cancer at a cost of $8.1 billion.1 Intentional exposure to UV radiation from both the sun and indoor tanning is the most preventable risk factor for skin cancer.2 A substantial portion of lifetime UV exposure occurs during childhood and adolescence.3 Indoor tanning is associated with an increased risk of skin cancer, particularly among younger users.4 Moreover, the risk of developing skin cancer is strongly associated with sunburns during youth.3 Although indoor tanning is prevalent, especially among young non-Hispanic white females, it seems to have peaked and has begun to decline.5 Little is known about the association between indoor tanning and sunburn. To address these questions, we used nationally representative samples of US high school students to examine trends in indoor tanning and its association with sunburn.
We pooled cross-sectional data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Survey (YRBS). The YRBS uses a 3-stage cluster sample design to produce nationally representative samples of public and private high school students in grades 9 to 12. Each year, YRBS respondents were asked, “During the past 12 months, how many times did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth? (Do not include getting a spray-on tan).” In 2015, respondents were asked, “During the past 12 months, how many times have you had a sunburn? (Count the number of times even a small part of your skin turned red or hurt for 12 hours or more after being outside in the sun or after using a sunlamp or other indoor tanning device).” Students completed the self-administered questionnaires and recorded their responses directly on a computer-scannable questionnaire booklet or answer sheet. During 2009, 2011, 2013, and 2015, the overall response rates were 71%, 71%, 68%, and 60%, respectively, and unweighted sample sizes were 16 410, 15 425, 13 538, and 15 624, respectively.
The YRBS protocol was approved by the Centers for Disease Control and Prevention institutional review board. Participation in the survey was anonymous and voluntary, and local parental permission procedures were used. Student consent was assumed with the completion of the questionnaire. Data were collected during the spring semester (January to June) in each survey cycle beginning on February 9, 2009, through June 18, 2015.
We calculated the prevalence of indoor tanning in the past year by sex, age, and race/ethnicity. Race/ethnicity was computed from 2 questions: (1) Are you Hispanic or Latino? (response options were “yes” or “no”), and (2) What is your race? (response options were American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, or white). Students could select more than 1 response option for the second question. For this study, students were classified as Hispanic/Latino and were referred to as “Hispanic” if they answered “yes” to the first question regardless of how they answered the second question.
Because non-Hispanic white female students have the highest rates of indoor tanning,5 we conducted additional analyses among this population. Logistic regression analyses examined linear trends in indoor tanning prevalence from 2009 to 2015, controlling for sex, age, and race/ethnicity in the overall model and for age in the non-Hispanic white female students model. To examine the association between indoor tanning and sunburn in 2015, we used multivariable logistic regression models controlling for age, sex, and race/ethnicity. We assessed the association between indoor tanning and sunburn in the past year with the adjusted Wald F statistic. Data were weighted to account for school and student nonresponse and oversampling of non-Hispanic black and Hispanic students. SUDAAN software, version 10.1 (RTI International), which accounts for weighted data and the complex sample design of the survey, was used for all data analysis. The level of statistical significance was set at P < .05. Logistic regression analyses were used to calculate 2-sided P values.
Indoor Tanning Prevalence, 2009-2015
In 2015, across the United States, 7.3% (95% CI, 6.0%-8.9%) of students engaged in indoor tanning, a substantial decline from 15.6% (95% CI, 13.7%-17.6%) in 2009 (P < .001) (Table 1). From 2009 to 2015, indoor tanning declined among female students from 25.4% to 10.6% (P < .001) and from 6.7% to 4.0% (P < .001) among male students. Indoor tanning also decreased among all age groups and among non-Hispanic white (from 21.1% [95% CI, 18.3%-24.2%] to 9.4% [95% CI, 7.5%-11.6%]) students, non-Hispanic other (from 7.9% [95% CI, 5.2-11.7] to 4.8% [95% CI, 3.%0-7.8%]) students, and Hispanic (from 8.2% [95% CI, 6.9%-9.7%] to 4.7% [95% CI, 3.5%-6.3%]) students. Indoor tanning among the group with the highest rates—non-Hispanic white female students—also decreased from 37.4% (95% CI, 33.6%-41.4%) in 2009 to 15.2% (95% CI, 11.7%-19.5%) in 2015 (P < .001) (Table 2).
Association Between Indoor Tanning and Sunburn
In 2015, across the United States, 55.8% of students (95% CI, 51.2%-60.3%) reported at least 1 sunburn during the year (12 months) preceding the survey. In the adjusted model, indoor tanning was positively associated with sunburn; 82.3% (95% CI, 77.9%-86.0%) of indoor tanners reported at least 1 sunburn during the preceding year compared with 53.7% (95% CI, 48.9%-58.4%) of those who did not engage in indoor tanning (P < .001) (Figure). Similarly, among non-Hispanic white female students who were indoor tanners, 88.2% (95% CI, 84.4%-91.2%) had a sunburn during the preceding year compared with 75.8% (95% CI, 69.4%-81.2%) of those who did not engage in indoor tanning (P < .001).
We observed a substantial reduction (53%) in indoor tanning among US high school students from 2009 to 2015. Approximately 1.2 million high school students engaged in indoor tanning in 2015, down from an estimated 2.5 million in 2009. These reductions are encouraging, but more than three-quarters of those who engaged in indoor tanning also experienced 1 or more sunburns during the same period.
Reductions in indoor tanning could be attributed to several factors. In 2009, following numerous scientific publications that consistently demonstrated an association between indoor tanning and skin cancer,4 the World Health Organization6 classified indoor tanning devices as carcinogenic to humans. In 2010, a 10% excise tax on indoor tanning was implemented. In 2014, the US Food and Drug Administration7 reclassified indoor tanning devices from low risk to moderate risk and recommended against their use by individuals younger than 18 years. Also in 2014, The Surgeon General’s Call to Action to Prevent Skin Cancer2 was released in which reducing the harms from indoor tanning was 1 of 5 strategic goals. Together, these actions could have raised awareness to the health risks of indoor tanning.
There was a substantial increase in state laws during our study period that restricted minors from accessing indoor tanning.8 In 2009, only 5 states had laws that addressed youth access to indoor tanning. By 2015, 42 states had passed such laws, including 13 states that prohibit indoor tanning for individuals younger than 18 years.8 Previous research has demonstrated that states with age restrictions had lower rates of indoor tanning among high school students.9 In 2015, the Food and Drug Administration proposed prohibiting minors (<18 years) from indoor tanning. If finalized, the restrictions may further reduce the prevalence of indoor tanning.10 Given the variation in current state laws and the proposal by the Food and Drug Administration, further research is needed to examine the effects of such policy changes.
Consistent with those of other studies,11 our findings show that indoor tanners were more likely to experience sunburn than those who did not engage in indoor tanning, although it was not possible for us to determine whether the sunburns occurred because of indoor tanning. This association may be related to the general behavior of indoor tanners. The misconception that tanned skin (or a “base tan”) provides UV protection and reduces the risk of a sunburn before a vacation or the summer season may encourage people to tan indoors.12 In fact, our study shows that indoor tanning is associated with an increased likelihood of sunburn.
This study is subject to certain limitations. First, the findings apply only to youth who attend high school and may not represent all persons in this age group. However, in 2012, only 3% of individuals aged 16 to 17 years were not enrolled in high school or had not completed high school.13 Second, indoor tanning was self-reported, and the degree of misreporting cannot be determined. Although reliability data are not available for the indoor tanning or sunburn questions, there is evidence of good test-retest reliability on many other YRBS questions.14 Third, we were unable to control for skin type, which may predict sunburns; however, we included race/ethnicity as a proxy. Last, because we used cross-sectional data, we were unable to examine causation between sunburn and indoor tanning.
Despite declines in indoor tanning, continued efforts are needed. Public health efforts could help address the misconception that indoor tanning protects against sunburn. The medical community also can play a key role in counseling adolescents and young adults in accordance with the US Preventive Services Task Force guidelines.15 Reducing the proportion of youth who engage in indoor tanning and experience sunburns presents an important cancer prevention opportunity.
Corresponding Author: Gery P. Guy, Jr, PhD, MPH, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mailstop F-76, Atlanta, GA 30341 (email@example.com).
Accepted for Publication: November 30, 2016.
Published Online: March 3, 2017. doi:10.1001/jamadermatol.2016.6273
Author Contributions: Dr Guy and Ms Berkowitz had full access to all of 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: All authors.
Acquisition, analysis, or interpretation of data: Guy, Berkowitz, Everett Jones, Watson.
Drafting of the manuscript: Guy, Berkowitz.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Guy, Berkowitz, Everett Jones.
Administrative, technical, or material support: Guy, Berkowitz, Watson.
Study supervision: Guy, Richardson.
Conflict of Interest Disclosures: None reported.
Meeting Presentation: This paper was presented at the annual meeting of the American Academy of Dermatology; March 3, 2017; Orlando, Florida.
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