Association of Lifetime Indoor Tanning and Subsequent Risk of Cutaneous Squamous Cell Carcinoma | Cancer Screening, Prevention, Control | JAMA Dermatology | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Green  AC, Olsen  CM.  Cutaneous squamous cell carcinoma: an epidemiological review.  Br J Dermatol. 2017;177(2):373-381. doi:10.1111/bjd.15324PubMedGoogle ScholarCrossref
Robsahm  TE, Helsing  P, Veierød  MB.  Cutaneous squamous cell carcinoma in Norway 1963-2011: increasing incidence and stable mortality.  Cancer Med. 2015;4(3):472-480. doi:10.1002/cam4.404PubMedGoogle ScholarCrossref
Armstrong  BK, Kricker  A.  The epidemiology of UV induced skin cancer.  J Photochem Photobiol B. 2001;63(1-3):8-18. doi:10.1016/S1011-1344(01)00198-1PubMedGoogle ScholarCrossref
Nehal  KS, Bichakjian  CK.  Update on keratinocyte carcinomas.  N Engl J Med. 2018;379(4):363-374. doi:10.1056/NEJMra1708701PubMedGoogle ScholarCrossref
International Agency for Research on Cancer.  Exposure to Artificial UV Radiation and Skin Cancer. Geneva, Switzerland: World Health Organization; 2006.
Gordon  L, Hirst  N.  The Health Effects of Using Solaria and Potential Cost-Effectiveness of Enforcing Solaria Regulations in Australia. Queensland, Australia: Queensland Institute of Medical Research; 2007.
Boniol  M, Autier  P, Boyle  P, Gandini  S.  Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis.  BMJ. 2012;345:e4757. doi:10.1136/bmj.e4757PubMedGoogle Scholar
Wehner  MR, Shive  ML, Chren  MM, Han  J, Qureshi  AA, Linos  E.  Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis.  BMJ. 2012;345:e5909. doi:10.1136/bmj.e5909PubMedGoogle Scholar
Karagas  MR, Stannard  VA, Mott  LA, Slattery  MJ, Spencer  SK, Weinstock  MA.  Use of tanning devices and risk of basal cell and squamous cell skin cancers.  J Natl Cancer Inst. 2002;94(3):224-226. doi:10.1093/jnci/94.3.224PubMedGoogle ScholarCrossref
Zhang  M, Qureshi  AA, Geller  AC, Frazier  L, Hunter  DJ, Han  J.  Use of tanning beds and incidence of skin cancer.  J Clin Oncol. 2012;30(14):1588-1593. doi:10.1200/JCO.2011.39.3652PubMedGoogle ScholarCrossref
Wu  S, Han  J, Laden  F, Qureshi  AA.  Long-term ultraviolet flux, other potential risk factors, and skin cancer risk: a cohort study.  Cancer Epidemiol Biomarkers Prev. 2014;23(6):1080-1089. doi:10.1158/1055-9965.EPI-13-0821PubMedGoogle ScholarCrossref
Veierød  MB, Couto  E, Lund  E, Adami  HO, Weiderpass  E.  Host characteristics, sun exposure, indoor tanning and risk of squamous cell carcinoma of the skin.  Int J Cancer. 2014;135(2):413-422. doi:10.1002/ijc.28657PubMedGoogle ScholarCrossref
Ghiasvand  R, Rueegg  CS, Weiderpass  E, Green  AC, Lund  E, Veierød  MB.  Indoor tanning and melanoma risk: long-term evidence from a prospective population-based cohort study.  Am J Epidemiol. 2017;185(3):147-156. doi:10.1093/aje/kww148PubMedGoogle Scholar
Lund  E, Dumeaux  V, Braaten  T,  et al.  Cohort profile: the Norwegian Women and Cancer Study–NOWAC—Kvinner og kreft.  Int J Epidemiol. 2008;37(1):36-41. doi:10.1093/ije/dym137PubMedGoogle ScholarCrossref
Larsen  IK, Småstuen  M, Johannesen  TB,  et al.  Data quality at the Cancer Registry of Norway: an overview of comparability, completeness, validity and timeliness.  Eur J Cancer. 2009;45(7):1218-1231. doi:10.1016/j.ejca.2008.10.037PubMedGoogle ScholarCrossref
Cancer Registry of Norway.  Cancer in Norway 2017: Cancer Incidence, Mortality, Survival and Prevalence in Norway. Oslo, Norway: Institution of Population-Based Cancer Research; 2018.
Edvardsen  K, Veierød  MB, Brustad  M, Braaten  T, Engelsen  O, Lund  E.  Vitamin D-effective solar UV radiation, dietary vitamin D and breast cancer risk.  Int J Cancer. 2011;128(6):1425-1433. doi:10.1002/ijc.25463PubMedGoogle ScholarCrossref
Veierød  MB, Parr  CL, Lund  E, Hjartåker  A.  Reproducibility of self-reported melanoma risk factors in a large cohort study of Norwegian women.  Melanoma Res. 2008;18(1):1-9. doi:10.1097/CMR.0b013e3282f120d2PubMedGoogle ScholarCrossref
Lund  E, Kumle  M, Braaten  T,  et al.  External validity in a population-based national prospective study: the Norwegian Women and Cancer Study (NOWAC).  Cancer Causes Control. 2003;14(10):1001-1008. doi:10.1023/B:CACO.0000007982.18311.2ePubMedGoogle ScholarCrossref
Veierod  MB, Lydersen  S, Laake  P.  Causal inference.  Med Stat Clin Epidemiol Res. 2012;1:493-527.Google Scholar
Buuren  Sv, Groothuis-Oudshoorn  K.  mice: Multivariate imputation by chained equations in R.  J Stat Softw. 2010;45(3):1-68.Google Scholar
Concato  J, Shah  N, Horwitz  RI.  Randomized, controlled trials, observational studies, and the hierarchy of research designs.  N Engl J Med. 2000;342(25):1887-1892. doi:10.1056/NEJM200006223422507PubMedGoogle ScholarCrossref
Murad  MH, Asi  N, Alsawas  M, Alahdab  F.  New evidence pyramid.  Evid Based Med. 2016;21(4):125-127. doi:10.1136/ebmed-2016-110401PubMedGoogle ScholarCrossref
Iannacone  MR, Wang  W, Stockwell  HG,  et al.  Patterns and timing of sunlight exposure and risk of basal cell and squamous cell carcinomas of the skin: a case-control study.  BMC Cancer. 2012;12(1):417. doi:10.1186/1471-2407-12-417PubMedGoogle ScholarCrossref
Nilsen  LT, Hannevik  M, Aalerud  TN, Johnsen  B, Friberg  EG, Veierød  MB.  Trends in UV irradiance of tanning devices in Norway: 1983-2005.  Photochem Photobiol. 2008;84(5):1100-1108. doi:10.1111/j.1751-1097.2008.00330.xPubMedGoogle ScholarCrossref
Nilsen  LT, Aalerud  TN, Hannevik  M, Veierød  MB.  UVB and UVA irradiances from indoor tanning devices.  Photochem Photobiol Sci. 2011;10(7):1129-1136. doi:10.1039/c1pp05029jPubMedGoogle ScholarCrossref
Nilsen  LT, Hannevik  M, Veierød  MB.  Ultraviolet exposure from indoor tanning devices: a systematic review.  Br J Dermatol. 2016;174(4):730-740. doi:10.1111/bjd.14388PubMedGoogle ScholarCrossref
Grange  F, Mortier  L, Crine  A,  et al.  Prevalence of sunbed use, and characteristics and knowledge of sunbed users: results from the French population-based Edifice Melanoma survey.  J Eur Acad Dermatol Venereol. 2015;29(s2)(suppl 2):23-30. doi:10.1111/jdv.12899PubMedGoogle ScholarCrossref
Norwegian Cancer Society and Norwegian Radiation Protection Authority.  Survey of Sun Exposure Habits. [in Norwegian] Oslo, Norway: TNS Gallup; 2014.
de Vries  E, Boniol  M, Severi  G,  et al.  Public awareness about risk factors could pose problems for case-control studies: the example of sunbed use and cutaneous melanoma.  Eur J Cancer. 2005;41(14):2150-2154. doi:10.1016/j.ejca.2005.04.042PubMedGoogle ScholarCrossref
Rothman  KJ.  Epidemiology: An Introduction. 2nd ed. Oxford, UK: Oxford University Press; 2012.
Buonaccorsi  JP.  Measurement Error: Models, Methods, and Applications. Boca Raton, FL: Chapman and Hall/CRC; 2010. doi:10.1201/9781420066586
Perea-Milla López  E, Miñarro-Del Moral  RM, Martínez-García  C,  et al.  Lifestyles, environmental and phenotypic factors associated with lip cancer: a case-control study in southern Spain.  Br J Cancer. 2003;88(11):1702-1707. doi:10.1038/sj.bjc.6600975PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    October 2, 2019

    Association of Lifetime Indoor Tanning and Subsequent Risk of Cutaneous Squamous Cell Carcinoma

    Author Affiliations
    • 1Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
    • 2Department of Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
    • 3Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Australia
    • 4Cancer Research UK Manchester and Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
    • 5Department of Public Health, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
    • 6Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
    JAMA Dermatol. 2019;155(12):1350-1357. doi:10.1001/jamadermatol.2019.2681
    Key Points

    Question  Is there a dose-response association between lifetime indoor tanning and risk of cutaneous squamous cell carcinoma?

    Findings  In this prospective cohort study of 159 419 women in Norway, a significant dose-response association was found between indoor tanning and risk of squamous cell carcinoma. The association between cumulative exposure to indoor tanning and risk of squamous cell carcinoma was the same regardless of duration of use and age at initiation.

    Meaning  The findings provide supporting evidence that indoor tanning is associated with increased risk of squamous cell carcinoma, with a greater risk among women with higher cumulative number of indoor tanning sessions.


    Importance  No study, to our knowledge, has prospectively investigated a dose-response association between lifetime indoor tanning and risk of cutaneous squamous cell carcinoma (SCC).

    Objective  To investigate the dose-response association between lifetime indoor tanning and SCC risk, the association between duration of use and age at initiation with SCC risk, and the association between age at initiation and age at diagnosis.

    Design, Setting, and Participants  This cohort study included data from women born from 1927 to 1963 from the Norwegian Women and Cancer study, established in 1991 with follow-up through December 31, 2015. Baseline questionnaires were issued to participants from 1991 to 2007, with follow-up questionnaires given every 5 to 7 years. Data analysis was performed from January 2, 2018, to March 2, 2019.

    Exposures  Participants reported pigmentation factors. Sunburns, sunbathing vacations, and indoor tanning were reported for childhood, adolescence, and adulthood.

    Main Outcomes and Measures  Information on all cancer diagnoses and dates of emigration or death were obtained through linkage to the Cancer Registry of Norway, using the unique personal identification number of Norwegian citizens.

    Results  A total of 159 419 women (mean [SD] age at inclusion, 49.9 [8.3] years) were included in the study. During follow-up (mean [SD], 16.5 [6.4] years), 597 women were diagnosed with SCC. Risk of SCC increased with increasing cumulative number of indoor tanning sessions. The adjusted hazard ratio (HR) for highest use vs never use was 1.83 (95% CI, 1.38-2.42; P < .001 for trend). A significantly higher risk of SCC was found among women with 10 years or less of use (HR, 1.41; 95% CI, 1.08-1.85) and more than 10 years of use (HR, 1.43; 95% CI, 1.16-1.76) and among women with age at initiation of 30 years or older (HR, 1.36; 95% CI, 1.11-1.67) and younger than 30 years (HR, 1.51; 95% CI, 1.18-1.92) vs never users. No significant association was found between age at initiation and age at diagnosis (estimated regression coefficient, −0.09 [95% CI, −1.11 to 0.94] for age at initiation of ≥30 years and −0.02 [95% CI, −1.27 to 1.22] for <30 years vs never use).

    Conclusion and Relevance  The findings provide supporting evidence that there is a dose-response association between indoor tanning and SCC risk among women. The association between cumulative exposure to indoor tanning and SCC risk was the same regardless of duration of use and age at initiation. These results support development of policies that regulate indoor tanning.