Indoor tanning use among adolescents in the US, 1998 to 2004

Authors

  • Vilma Cokkinides PhD,

    Corresponding author
    1. Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia
    • Department of Epidemiology and Surveillance Research, American Cancer Society, 250 Williams Street, NW, Atlanta, GA, 30303-1002===

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    • Fax: (404) 327-6450;

  • Martin Weinstock MD, PhD,

    1. DermatoEpidemiology Unit, Veterans Affairs Medical Center Providence, Providence, Rhode Island
    2. Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island
    3. Department of Dermatology, Brown University, Providence, Rhode Island
    4. Department of Community Health, Brown University, Providence, Rhode Island
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  • DeAnn Lazovich PhD,

    1. Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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  • Elizabeth Ward PhD,

    1. Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia
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  • Michael Thun MD, MS

    1. Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia
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  • This article is a U.S. Government work and, as such, is in the public domain in the United States of America.

Abstract

BACKGROUND:

A recent meta-analysis found that indoor tanning use before the age of 35 years increases the risk of melanoma, supporting policies to restrict indoor tanning use among adolescents. The objectives of the current study were to provide a national assessment of prevalence and trends of indoor tanning use among US adolescents, to examine changes in the prevalence of indoor tanning use from 1998 to 2004 in relation to state policies on minors' access, and to assess the prevalence of burns, rashes, and infections among users.

METHODS:

Two cross-sectional population-based surveys of US youths ages 11 to 18 years and their parents/guardians conducted in 1998 (N = 1196) and 2004 (N = 1613) used identical questions to assess use of indoor tanning and correlates of this behavior.

RESULTS:

The prevalence of indoor tanning use by adolescents within the past year changed little from 1998 to 2004 (10% to 11%). In states with policies regarding minors' access to indoor tanning, the prevalence stayed the same or decreased from 1998 to 2004, whereas it increased in states without such policies. Neither trend was found to be statistically significant. Youth tanning attitudes, parental indoor tanning use, and parents' permission were strongly associated with youth use of indoor tanning. Fifty-eight percent of users reported burns from indoor tanning.

CONCLUSIONS:

The presence of state legislation restricting minors' access to indoor tanning appears to have limited effectiveness, perhaps because most states' policies permit use with parental consent. Multipronged approaches are needed to reduce indoor tanning use in youths. Cancer 2009. Published 2008 by the American Cancer Society.

Artificial (indoor) tanning can be a common source of ultraviolet radiation (UVR). Exposure of the skin to UVR in tanning booths has several adverse health consequences, including skin and eye burns, alterations of immune system function, photo-aging, photo-induced medication reactions, and increased risk of skin cancers.1 Recently, a large meta-analysis concluded that first exposure to sunbeds before 35 years of age was significantly associated with an increased risk of melanoma, based on 7 informative studies (summary relative risk, 1.75; 95% confidence interval [95% CI], 1.35-2.26).2

Previous studies conducted in adolescents have shown that the prevalence of indoor tanning use varies by sex (ranging from 2% to 11% in boys and from 12% to 37% in girls); this behavior is more prevalent in older adolescent girls, in those who intentionally tan outdoors or have positive attitudes toward a tan, and in those less likely to use sunscreens.3-6 Some studies have found that social influences, such as having friends or parents who use indoor tanning or having parental permission to use indoor tanning, are correlated with indoor tanning use by adolescents.3, 7 Because of the known health risks associated with indoor tanning, many health-related organizations recommend limiting minors' access to indoor tanning facilities through regulation.1, 2, 8

In the US, some states have passed legislation to limit minors' access to indoor tanning. Statutory requirements vary by state. Nearly all states permit minors' access with parental consent and/or accompaniment, and only a few prohibit access based on minors' age.9-11 Studies suggest that compliance with minors' access restrictions varies by state.9, 12-14 In 1 study in which compliance with laws regarding access to customers aged <15 years was assessed by telephone, the percentage of establishments adhering to the state's requirement was 11% in Texas, 77% in Wisconsin, and 80% in Illinois.9 No prior study has assessed whether indoor tanning use among adolescents differs in states with youth access legislation versus states with no such state laws.

Our objective was to analyze data from 2 national population-based surveys (1998 and 2004, respectively) that collected information regarding the recent use of indoor tanning in adolescents aged 11 to 18 years. In the current study, we assessed the change in past-year use of indoor tanning among adolescents between 1998 and 2004; in addition, we examined whether state legislation restricting minors' access to indoor tanning is associated with youths' use of indoor tanning after controlling for significant correlates and assessed short-term adverse effects from recent use of indoor tanning (eg, burns).

MATERIALS AND METHODS

In 1998, and again in 2004, the American Cancer Society conducted 2 national, population-based, cross-sectional telephone surveys of behaviors related to skin cancer risk among youths ages 11 to 18 years and their primary caregivers in the continental US. The surveys were conducted from August to November of the respective years. The surveys consisted of a youth interview (requiring permission and consent from a parent or caregiver) and a nearly identical parent module that asked questions regarding solar and nonsolar exposure and sun protection behaviors. The 1998 survey had a sample of 1196 youth-caregiver pairs; the 2004 subsequent survey had a sample of 1613 such pairs. Both surveys used a similar telephone-based sampling methodology (dual list-assisted random digit dialing methodology), field operations (training and monitoring of interviewers), and data collection surveys. According to standard formulas to estimate responses of telephone-based surveys, the overall response rate was 58% in 1998 and 44% in 2004. Despite lower response rates, there were no significant demographic differences noted among sampled adolescents by time periods. In a prior published study of trends in sun exposure and sun protection behaviors,15 we tested for any significant differences in the demographic profile of youths between the 2 surveys and determined that the samples were comparable. The adolescents surveyed were mostly white (77%), with a mean age of 14 years and a sex ratio of nearly 1:1.15 Additional information regarding survey methodology and statistical comparability of the 2 samples can be found elsewhere.15 Both surveys asked identical questions regarding the use of indoor tanning booths or sunlamps, frequency within the past year, demographics, individual susceptibility to UV exposure, and attitudes toward tanning. The 2004 survey also asked about burns or skin rashes incurred from indoor tanning use.

Measures

Use of Indoor Tanning and Adverse Reactions From Indoor Tanning

Participants were asked whether in the past year they had used an indoor tanning booth or sunlamp and the number of times (frequency of use) during the past year. The 2004 survey asked users a question regarding burns from indoor tanning (“got red or burned at any time in the past when you used tanning booth or a sunlamp”) and another question concerning skin infection or rash (“ever got an infection or skin rash from a tanning booth”).

Demographics and Skin Type

Each survey asked participants' age, sex, and race, and 4 questions relating to phenotypic skin characteristics (ie, tendency of the skin to burn, ability to tan, natural skin color, and hair color). From these, we derived a composite measure of sun sensitivity based on a validated measure.16

Attitudinal Correlates and Social Factors

Tanning attitudes were assessed using 2 items (“I feel healthy when I have a nice tan” and “I look better when I have a tan”) anchored on a 5-point Likert format from strongly agree to strongly disagree (Cronbach α of .69). In the 2004 survey, a new attitudinal item was added (“even though it may not be good for me, I still like to get a tan”), with a similar Likert format. This was combined with the other 2 attitudinal items to derive a composite tanning attitudinal factor (Cronbach α of .77) and used in the multivariate logistic analysis to assess correlates of indoor tanning use. In addition, in the 2004 survey, we assessed parental permission by asking youths about their level of agreement with the following statement: “My parents/guardian would allow me to use indoor sunlamps or booths.” Recent evidence suggests that this particular factor is a strong determinant of youth indoor tanning use.7, 17

Sunscreen Use

The frequency of using sunscreen in the most recent summer was assessed by asking “how often was sunscreen applied when going outside during the summer?” and “how often was sunscreen with SPF (skin protection factor) 15+ used when at the beach or at the pool?” Responses to these questions were provided on a 5-point scale ranging from always to never.

Parental Factors

Similar questions from the parent/caregiver survey were used to collect information regarding their use of indoor tanning booths or sunlamps in the past year as well as their demographic and educational status.

Legislation Restricting Minors' Access to Indoor Tanning

We reviewed policy-based reports regarding if and when states had passed regulations restricting minors' access to indoor tanning.10, 18 This information was linked to the state of residence of respondents and used to derive a state-policy indicator to be used for analysis. The categories of this state-policy indicator variable were developed using a coding of state level policies that took into account when legislation was implemented and the possibility of repeal by 2004.10, 18 Hence, state policies were categorized into 3 levels: 1) states that passed legislation before 1998 and retained the policy through 2004 (8 states); 2) states that passed legislation between 1998 and 2004 (11 states); and 3) states that had no legislation on this issue during the 1998 to 2004 period of interest. (See Table 1 for additional information regarding listing of states that had laws passed during the study period.)

Table 1. Listing of States With Legislation on Minors' Access Restrictions to Indoor Tanning
Policy DatesState, Date of Statute
  1. Policy reports used in reference to state legislation: McLaughlin et al10 and Francis et al.18

Prior to 1998 and up to 2004, n=8California, 1997
 Georgia, 1996
 Louisiana, 1992
 Maine, 1996
 Massachusetts, 1996
 Minnesota, 1995
 Mississippi, 1989
 Tennessee, 1996
From 1998 and up to 2004, n=11Florida, 1998
 Illinois, 2001
 Indiana, 1999
 Michigan, 2001
 North Carolina, 2001
 Ohio, 2001
 Oregon, 2000
 Rhode Island, 1998
 South Carolina, 2001
 Texas, 2001
 Wisconsin, 1999

Statistical Analysis

For both surveys, sampling weights took into account unequal probabilities of selection because of sampling design, nonresponse, and poststratification. Data management was conducted using SAS statistical software (version 9.1; SAS Institute Inc, Cary, NC).19 All descriptive and multivariate analysis were conducted using SUDAAN statistical software (version 9.0; Research Triangle Institute, Research Triangle Park, NC).20 This software takes into account the complex survey sampling design and sampling weights to derive appropriate standard errors used for statistical testing and derivation of 95% CIs for the weighted analysis.

Assessment of Change in Indoor Tanning Use

Weighted statistics were used to describe the prevalence estimates of indoor tanning and number of times of indoor tanning use within the past year (because of the skewed distribution of the latter variable, the median rather than the mean was used). To examine differences between 1998 and 2004, we subtracted the corresponding weighted percentages (of past-year use of indoor tanning and median number of times indoor tanning was used within the past year) and calculated 95% CIs around these differences. By using general linear contrasts, we tested the statistical significance of trends.

Predictors of Indoor Tanning Use Among Adolescents

A set of predictor variables, which included age, sex, skin sun sensitivity, attitudes toward having a tan, and parental factors, was selected based on previous research3, 4; the key predictor of interest was state policy on minor's access to indoor tanning. By performing (unadjusted) univariate analysis, we examined the unadjusted correlation between these predictors and indoor tanning use within the past year. From these analyses, all factors significant at P = .05 were considered for the weighted multivariate logistic regression that examined the independent association between state minors' access restrictions and youth indoor tanning use. Multivariate logistic regression modeling was used to test for differences in the likelihood of adolescents' indoor tanning use in states with policies relative to states without such policies after controlling for important covariates (see previously described measures).

Predictors of Burns From Indoor Tanning

Using data from the 2004 survey, we estimated the prevalence of burns and skin rash from indoor tanning in adolescent users of sunlamps or tanning booths within the past year. Weighted bivariate analysis were conducted to assess individual characteristics (age, sex, skin sun sensitivity) associated with self-reported adverse effects from indoor tanning. These individual factors were used as control factors in the assessment of the independent relation between experience of burns from indoor tanning and frequency of use among youths reporting use of indoor tanning within the past year. Because a small number of skin rashes were reported, we were unable to conduct multivariate analysis of this characteristic.

RESULTS

Trends in Indoor Tanning

Nationally, the prevalence of indoor tanning use among adolescents changed little from 1998 to 2004 (a 1% increase; 95% CI, −1.5%-3.5%) (Table 2). Although not statistically significant, increases in the prevalence of past-year use of indoor tanning were observed among: girls (from 15.6% to 17.7%), youths ages 14 to 15 years (from 7.1% to 10.5%), those with medium sun sensitivity (from 10% to 13.5%), and those with positive attitudinal preferences for a tan (from 18.8% to 25%). A significant increase was noted in those who reported applying sunscreen often or always while outdoors on sunny days (3.7% increase; P = .02 ), although this group had a lower prevalence of indoor tanning use. In contrast, among youths whose parents used indoor tanning, there was a slight decrease in use of indoor tanning between 1998 and 2004 (from 29.5% to 27.2%). We found a nonsignificant declining trend in the prevalence of indoor tanning use over the time period (1998-2004) in states with legislation that restricted access to indoor tanning by minors compared with those without such legislation.

Table 2. Prevalence and Change in Past Year Use of Indoor Tanning in Youths Between 1998 and 2004 and Among Past Year Users: Median Change in the Frequency of Use of Indoor Tanning Between 1998 and 2004
 Indoor Tanning Use Within the Past Year, PrevalenceFrequency of Use Among Users
19982004Change, % (95% CI)1998 (n= 123), median2004 (n = 204), medianChange, % (95% CI)
No.%No.%
  • 95% CI indicates 95% confidence interval; SPF, sun protection factor.

  • *

    Skin sun sensitivity index based on ability to tan, ability to burn, and natural hair and color of the skin.

  • P<.05.

  • Eight states had legislation restricting minors' access to indoor tanning before 1997 and through 2004.

  • §

    Eleven states had not passed legislation after 1997 and through 2004.

  • Remaining states with no such legislation passed in both 1998 and 2004.

Overall119610.1158911.11.0 (−1.5–3.5)6.46.0−0.4 (−4.0– 3.3)
Sex        
 Male6024.88084.80.0 (−2.6–2.6)3.74.10.4 (−3.2–4.1)
 Female59415.678117.72.1 (−2.1–6.3)6.98.51.6 (−1.9–5.1)
Age, y        
 11–135063.85332.7−1.1 (–3.9–1.7)2.64.11.5 (−1.8–4.8)
 14–152897.143710.53.4 (−0.7–7.6)7.14.0−3.1 (−10.0–3.7)
 16–1840019.560919.70.3 (−5.1–5.6)7.88.91.1 (−3.3–5.5)
Race        
 White101911.0137212.81.8 (−1.1–4.6)7.96.1−1.8 (−5.3–1.7)
 Nonwhite1667.02075.1−1.9 (−7.3–3.5)2.15.33.2 (−6.4–12.7)
Skin sun sensitivity index*        
 Low31811.841711.0−0.8 (−5.5–4.0)6.111.35.2 (−3.0–13.4)
 Medium59110.076813.53.5 (−0.3–7.3)9.05.1−3.9 (−8.7–1.0)
 High2878.34006.6−1.7 (−6.3–2.9)3.34.00.7 (−3.1–4.4)
Attitudes toward a tan        
 High19618.821325.06.2 (−2.4–14.6)8.59.71.2 (−5.5–7.9)
 Medium42510.763014.33.6 (−1.0–8.1)6.55.6−0.9 (−6.5–4.7)
 Low4446.87295.4−1.4 (−4.5–1.7)5.34.3−1.0 (−4.2–2.2)
Used sunscreen on sunny days        
 Always or often3916.06689.73.7 (0.2–7.1)7.04.9−2.1 (−5.7–1.6)
 Sometimes35412.651611.2−1.4 (−6.1–3.2)5.08.73.7 (−2.4–9.8)
 Rarely or never45011.640412.61.0 (−3.8–5.7)6.36.40.1 (−7.4–7.6)
Used sunscreen with SPF 15+ at beach/pool        
 Always or often5837.09518.41.4 (−1.5–4.2)5.65.70.1 (−3.6–3.9)
 Sometimes22411.933615.23.3 (−3.0–9.6)5.25.0−0.2 (−6.6–6.3)
 Rarely or never17815.528814.2−1.3 (−10.3–3.8)11.08.4−2.6 (−11.8–6.6)
Parent/guardian used indoor tanning in the past year        
 Yes10329.518827.2−2.3 (−13.8–9.3)6.69.02.4 (−6.6–11.4)
 No10938.514019.00.5 (−2.0–3.0)6.45.4−1.0 (−4.6–2.2)
State has legislation restricting youth indoor tanning        
 Policies present before 19972478.43118.0−0.4 (−5.1–4.3)6.83.0−3.8 (−8.9–1.4)
 Policies§ present after 1997 (up to 2004)41112.557010.0−2.5 (−6.8–2.0)5.48.73.3 (−0.7–7.3)
 No policies throughout 1998–20045389.470812.93.5 (−0.3–7.3)7.85.0−2.8 (−7.5–1.8)

Between 1998 and 2004, the median number of times indoor tanning was used during the past year was stable (Table 2). Characteristics predictive of indoor tanning use ≥6 times within the past year included older adolescence, female sex, medium sun sensitivity, and positive attitudes toward tanning.

Predictors of Indoor Tanning

Multivariate analysis identified 5 factors significantly associated with indoor tanning use (Table 3): older age (in those ages 16-18 years; adjusted prevalence odds ratio [aPOR] of 4.26 [95% CI, 1.91-9.47]), female sex (aPOR of 10.60; 95% CI, 5.74-19.59), positive attitudes toward a tan (aPOR of 8.65; 95% CI, 3.49-21.40), having a parent/guardian who used indoor tanning within the previous year (aPOR of 4.18; 95% CI, 2.20-7.90), and parental permission to use indoor tanning as reported by the adolescent (aPOR of 15.42; 95% CI, 8.94-26.60). State legislation restricting access to indoor tanning was not found to be significantly associated with indoor tanning use in either unadjusted or adjusted analyses (aPOR of 0.77; 95% CI, 0.49-1.21).

Table 3. Predictors of Youth Indoor Tanning (Booths/Sunlamps) Use in the Past Year
 Unadjusted POR* (95% CI)Adjusted POR (95% CI)
  • POR indicates prevalence odds ratio; 95% CI, 95% confidence interval.

  • *

    Unadjusted POR and corresponding 95% CIs enclosed in parenthesis; values shown in bold text indicate that the Wald test P value for the predictor is <.01.

  • Adjusted POR and corresponding 95% CIs enclosed in parenthesis; values shown in bold text indicate that the Wald test P value for the predictor is <.01.

  • Skin sun sensitivity index based on ability to tan, ability to burn, and natural hair and natural color of the skin.

  • §

    Attitudes toward tanning preferences (based on 3 attitudinal items; refer to measure specification in text).

  • Eight states had legislation restricting minors' access to indoor tanning before 1997 and through 2004.

  • Eleven states had not passed legislation after 1997 and through 2004.

  • #

    Remaining states with no such legislation passed in both 1998 and 2004.

Age, y  
 11–131.001.00
 14–153.89 (1.87–8.12)2.00 (0.85–4.60)
 16–188.04 (4.02–16.08)4.26 (1.91–9.50)
Sex  
 Female4.74 (3.18–7.07)10.60 (5.73–19.60)
 Male1.001.00
Skin sun sensitivity index  
 Low (bottom tertile score)1.001.00
 Medium1.23 (0.84–1.82)1.55 (0.88–2.71)
 High (top tertile score)0.55 (0.34–0.90)0.71 (0.35–1.43)
Attitudes toward tanning preferences§  
 High (top tertile score)10.72 (5.34–21.53)8.84 (3.57–21.86)
 Medium (medium tertile score)3.57 (1.65–7.75)3.36 (1.24–9.10)
 Low (bottom tertile score)1.001.00
State has legislation restricting minors' access to indoor tanning:  
 Policies present before 19970.64 (0.40–1.00)0.77 (0.43–1.39)
 Policies passed after 1997 (up to 2004)0.75 (0.52–1.09)0.76 (0.45–1.29)
 No policies# during 1998 and 20041.001.00
Parental factors: parent/guardian used indoor tanning booth in the past year  
 Yes4.61 (3.04–6.97)4.21 (2.23–7.98)
 No1.001.00
My parents/guardian would allow me to tan indoors using a sunlamp or a tanning booth  
 Agree20.3 (13.2–31.40)15.55 (9.02–26.80)
 Disagree1.001.00
Parent education  
 ≤high school1.53 (0.99–2.36)1.01 (0.55–1.85)
 Some college1.39 (0.99–2.05)1.20 (0.72–2.00)
 College graduate1.001.00

Adverse Effects From Indoor Tanning Use

Among 204 adolescents who used indoor tanning booths/sunlamps within the past year, the self-reported occurrence of burns from indoor tanning was 57.5% (Table 4). The occurrence of burns from indoor tanning was found to be significantly associated with the frequent use of indoor tanning (≥6 sessions within the past year; odds ratio [OR] of 3.23 [95% CI, 1.63-6.39]), but was not found to be related to sex, age, or sun sensitivity.

Table 4. Prevalence and Correlates of Erythema From Indoor Tanning Use Among Adolescents Who Used Indoor Tanning Booths/Sunlamps
 Erythema or Burns,* %Univariate OR (95% CI)Multivariate Logistic Model for Erythema/Burns, AOR (95% CI)
  • OR indicates odds ratio; 95% CI, 95% confidence interval; AOR, adjusted odds ratio.

  • *

    Adverse event assessed as “Have you gotten red or burned at any time in the past when you used a tanning booth or a sunlamp?”

  • AOR adjusted for sex.

  • AOR adjusted for age.

  • §

    AOR adjusted for sex and age.

  • P<.0001.

  • AOR adjusted for age, sex, and skin sun sensitivity.

Total20457.5  
Sex    
 Female16161.11.96 (0.91–4.20)1.96 (0.89–4.33)
 Male4344.61.01.0
Age, y    
 11–151450.81.01.0
 16–1813761.01.50 (0.76–2.95)1.46 (0.73–2.92)
Skin sun sensitivity index    
 Low5855.11.01.0
 Medium11257.21.10 (0.53–2.23)1.17 (0.56–2.44)§
 High3464.01.45 (0.57–3.69)1.46 (0.56–3.93)
No. of times used indoor tanning within the past year    
 ≥610772.13.41 (1.78–6.54) 3.23 (1.63–6.39),
 1–59742.51.01.0

Among 204 adolescents who used indoor tanning booths/sunlamps, 7 reported ever getting an infection or a skin rash (estimated prevalence of 3%) from indoor tanning. These 7 were all aged ≥15 years, were mostly girls (n = 6), and had high levels of skin sun sensitivity (n = 5) (data not shown).

DISCUSSION

The principal findings from these 2 population-based surveys of adolescents was that nationally the prevalence of past-year use of indoor tanning did not change from 1998 to 2004 (10% to 11%), despite an increasing number of states restricting such use by minors. The prevalence of indoor tanning use increased nonsignificantly among youths who resided in states that lacked policies to control minors' access to indoor tanning and decreased nonsignificantly in states that enacted policies. States that had minors' access restriction policies had lower odds of indoor tanning use among adolescents (unadjusted OR of 0.64; 95% CI, 0.40-1.00) compared with states that lacked such policies. However, after controlling for strongly associated (more proximate) determinants of indoor tanning use in youths, state policies were not significantly associated with indoor tanning (adjusted OR of 0.77; 95% CI, 0.43-1.39).

Strengths of the current study include the use of standardized methods and questions to assess trends in indoor tanning use over time, the inclusion of nationally representative samples of adolescents, and the ability to examine and control for multiple factors associated with indoor tanning use. Limitations of the study include reliance on self-reports of both youths and primary care givers and a sample size that was limited for certain analyses. Our study's sample was limited to reliably estimate prevalence of less common events from indoor tanning use (ie, rash or skin infections) and to assess state-to-state variations in minors' indoor access restrictions and indoor tanning use.

Power limitations may have contributed to the lack of a significant association between state minors' access laws and prevalence of indoor tanning use. It is also likely that inadequate compliance and poor enforcement mechanisms reduce the effectiveness of such legislation.1, 9, 12-14 For example, Forster et al14 studied 2 states (Minnesota and Massachusetts) with established policies requiring parental written permission before the usage of indoor tanning devices by an underage minor (aged <16 years) and found that 81% of indoor tanning businesses sold a session to an underaged minor on at least 1 of 2 attempts, and that the adolescents' age was not assessed in 40% of attempts.

In keeping with other reports,7, 21 we noted that youths' report of parental permission to use indoor tanning was strongly correlated with higher indoor tanning used among adolescents. Thus, in states that allow indoor tanning use with parental consent or accompaniment, greater efforts to inform parents about the hazards of indoor tanning and/or more restrictive legislation may be required to reduce adolescents' exposure to indoor tanning.22 Health professionals and the medical community could play a greater role in educating parents about the short-term and long-term skin cancer risks associated with the use of indoor tanning and the role they can play in assuring that their children do not use indoor tanning establishments.23, 24 The approach of adopting more restrictive legislation (based on minors' age) is supported by the World Health Organization and the International Commission on Non-Ionizing Radiation Protection. Both organizations recommend that use of these devices not be allowed by those aged <18 years.2, 8

Of particular concern with respect to the prevention of health effects related to indoor tanning exposure, no measurable decreases in indoor tanning were observed among the subgroups of adolescents who typically exhibit a higher prevalence of indoor tanning use, such as older youths, girls, those with medium skin sun sensitivity, those with high levels of positive tanning attitudes, those who are less consistent users of sunscreen, and those whose parent also used indoor tanning. As expected, many of these previously associated factors were confirmed as strong independent predictors of indoor tanning use in youths, and these findings are consistent with previous findings.4-7, 25 It is concerning that older adolescent girls continue to demonstrate higher use of indoor tanning. In the US, most adolescents are aware of the deleterious effects of UVR,15 yet many continue this unsafe practice. One principal factor driving tanning behavior is the sociocultural belief that equates tanned skin with healthiness and attractiveness.1, 3, 4 In addition, the lack of improvements in indoor tanning among teenage girls may be related to environmental factors; there is evidence to suggest that tanning facilities are more concentrated in geographic areas with higher proportions of teenagers and females ages 15 to 24 years26 Because of the ongoing growth and popularity of the indoor tanning industry,1 these findings underscore the need for significant education at both the individual and community level to change social norms pertaining to having a tan and to educate community members regarding the serious risks of indoor tanning.1, 2

Previous studies have also reported that indoor tanning causes burns (erythema) in 18% to 55% of users.27-29 Consistent with these findings, we found that 57.5% of adolescent users of indoor tanning reported getting red or burned from using these devices. The strongest factor associated with erythema from indoor tanning after controlling for possible confounders (sex, age, and skin sun sensitivity) was higher frequency of use (≥6 times). This apparent relation between burns from these devices and higher-frequency use may be the result of inconsistent usage of appropriate safety measures (ie, time-limited sessions) to reduce risks.30 Half of adolescent indoor tanners in the US used indoor tanning ≥6 times during the past year. It is important to bear in mind that a burn from UV equipment likely increases the risk for skin cancers as is the case for sunburns from excessive sunlight exposure, especially at younger ages.31 Such high levels of erythema associated with indoor tanning may ultimately result in an increasing burden of melanoma2 and keratinocyte carcinoma in middle age.32

Conclusions

In conclusion, the prevalence of indoor tanning use in youths did not markedly change between 1998 and 2004, despite increasing numbers of states with legislation restricting youth access to indoor tanning. This suggests the need to develop multipronged approaches that could enhance changes in this behavior among underage minors. Given the known health risks associated with this practice,1, 2, 8 strategies for reducing adolescent exposure to indoor tanning include more stringent legislative measures, such as prohibiting the use of indoor tanning facilities by those aged <18 years, along with appropriate enforcement mechanisms, as well as efforts to educate adolescents and their parents regarding the hazards of indoor tanning. It is important to continue to monitor the prevalence of indoor tanning use among adolescents and to evaluate strategies for reducing such exposure.

Conflict of Interest Disclosures

The American Cancer Society sponsored data collection for both surveys. Funding support for data collection of the second survey was provided by the American Cancer Society and Neutrogena, Inc. Other than financial support, the latter organization had no involvement in the analysis and interpretation of the data, or in the preparation, review, or approval of the article.

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