STUDY. Awareness of the Risks of Tanning Lamps Does Not Influence Behavior Among College Students

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1 STUDY Awareness of the Risks of Tanning Lamps Does Not Influence Behavior Among College Students J. Matthew Knight, MD; Anna N. Kirincich, MD, MPH; Evan R. Farmer, MD; Antoinette F. Hood, MD Hypothesis: Awareness of the risks of artificial tanning influences tanning behavior among college students. Objective: To correlate the prevalence of tanning lamp use, the perceived benefits and risks associated with UV exposure, and knowledge about skin cancer among university students. Design: A survey was designed and administered to college students seeking walk-in care at a university student health center from September 7, 1999, through September 30, Setting: A large midwestern public university student health center. Participants: Undergraduate and graduate students attending the student health center for any medical condition. Intervention: None. Main Outcome Measure: Completion of the survey. Results: Of the surveyed students, 47% had used a tanning lamp during the preceding 12 months. Female students were more common users than male students. Of the students surveyed, 39% reported never having used tanning lamps. More than 90% of users of tanning lamps were aware that premature aging and skin cancer were possible complications of tanning lamp use. Conclusions: Despite adequate knowledge of the adverse effects of UV exposure, university students freely and frequently use tanning lamps, primarily for desired cosmetic appearance. To alter this risky behavior will require a fundamental change in the societal belief that tans are attractive and healthy. Arch Dermatol. 2002;138: From the Departments of Dermatology (Drs Knight, Farmer, and Hood) and Pathology and Laboratory Medicine (Drs Farmer and Hood) and the Bowen Research Center (Dr Kirincich), Indiana University School of Medicine, Indianapolis. Drs Farmer and Hood are now affiliated with the Division of Dermatology, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk. DESPITE THE fact that tanning lamp use has been associated with nonmelanoma skin cancer and cutaneous melanoma, 1,2 it is estimated that nearly 25 million Americans artificially tan each year. 3 Several organizations, including the American Academy of Dermatology and the British Photodermatology Group, have publicly discouraged the practice of artificial tanning, 4 and the American Medical Association has adopted a resolution requesting a ban on the sale and use of artificial tanning equipment for nonmedical purposes. 5 Previouslypublishedstudies 6-8 haveexamined the attitudes and characteristics of various populations of individuals who use UV light (UVL) beds, booths, and lamps (henceforth referred to as tanning lamp use). These studies deal with adults or adolescents in the United States or other countries. A 1997 American Academy of Dermatology telephone survey inquiring about skin cancer knowledge and sun-related behavior in a general population in the United States showed that the regular use of tanning lamps had increased during a 10-year period. This occurred despite educational efforts by the AmericanAcademyofDermatologyandothers. 9 The researchers also concluded that young adults, and especially young women, are particularly likely to engage in the high-risk behavior of artificial tanning. This study determines the prevalence of tanning lamp use, the perceived benefits and risks associated with UV exposure, and knowledge about skin cancer among students in a large midwestern public university. If, as dermatologists, we are to develop effective strategies to educate Americans about sun safety, we believe it is important to understand the beliefs and practices of young adults, particularly those who are in a learning climate and, therefore, potentially educable. 1311

2 Table 1. Population Frequency Distribution No. (%) of Participants Characteristic (N = 489)* Sex Male 147 (30) Female 342 (70) Age, y 17 2 ( 1) (82) (12) (5) Skin type I (always burn and never tan) 12 (2) II (usually burn and tan with difficulty) 139 (29) III (sometimes mildly burn and tan with ease) 295 (61) IV (never burn and always tan) 41 (8) Region Northeast 39 (8) North Central 363 (74) South 50 (10) West 17 (3) Outside the United States 20 (4) History of skin cancer Personal Yes 3 (1) No 484 (99) Family Yes 143 (29) No 268 (55) Unknown 77 (16) Belief that a tan represents a healthy appearance Yes 194 (40) No 184 (38) Undecided 110 (23) Belief that tanning beds/lamps are safe Yes 61 (12) No 346 (71) Undecided 81 (17) Tanning bed use Never 187 (39) Past 71 (15) Current (used in the past year) 226 (47) MATERIALS AND METHODS Members of the Department of Dermatology and the Bowen Research Center, Indiana University School of Medicine, developed a multiple-choice questionnaire. The survey was designed to assess student perceptions regarding tanning lamp use, the frequency of tanning lamp use among those surveyed, and the occurrence of adverse reactions to artificial UVL exposure. Inquiries were made regarding age, sex, and family history of cutaneous disease. Students were asked to classify their skin type using the Fitzpatrick 10 classification that was provided on the questionnaire. The students were asked a series of questions regarding the appearance of pigmented lesions to determine if they could identify certain characteristics that should warrant medical attention. The region of the country in which students were raised was also assessed; regions were divided according to the US Census Bureau classification scheme into Northeast, North Central, Southern, and Western. Permission to administer the questionnaire was obtained from the Indiana University School of Medicine Institutional Review Board, the Indiana University Bloomington Human Subjects Committee, and the Health Center Research Committee. With the assistance and full support of health center faculty and staff, questionnaires were administered to undergraduate and graduate students seeking walk-in care at the Indiana University Student Health Center, Bloomington, from September 7, 1999, through September 30, Questionnaires were distributed by nursing assistants and triage secretaries to each student entering the clinic waiting area. Surveys were self-administered; there was no time limitation on, and no incentive offered for, document completion. RESULTS STUDY POPULATION Table 1 shows a frequency distribution of our surveyed population. Self-reported skin types are also listed. The sample included 147 male students and 342 female students. Of the sample, 82% were between the ages of 17 and 22 years. About half of the students reported using a tanning lamp at least once during the past year; this population will be referred to as current users. Of the sample, 15% reported having used a tanning lamp before, but not during, the past year (referred to as past users). The duration of treatments, lamp type, and intensity data were not collected because this was a recall study, and the data would not be reliable. Fewer than half of the students reported never having used a tanning lamp (referred to as never users). Students were asked 4 questions regarding their knowledge of the criteria for concern for skin cancer and pigmented lesions that should warrant physician attention. These questions were based on the ABCDs of melanoma detection: To the best of your knowledge, is an asymmetrical mole something to bring to your doctor s attention? To the best of your knowledge, is a mole with an irregular border something to bring to your doctor s attention? To the best of your knowledge, is a mole that varies in color something to bring to your doctor s attention? To the best of your knowledge, is a mole that is greater than 6 mm in diameter (the size of a pencil eraser) something to bring to your doctor s attention? Correct identification of suspicious lesion characteristics earned 1 point, and all incorrect or undecided responses earned 0 points. A cumulative score was calculated for each respondent. The mean score for never users was 3.42; past users, 3.55; and current users, The average cumulative score of the 3 groups was not significantly different (analysis of variance, P=.11). COMPARISON OF CURRENT VS PAST USERS Table 2 shows a comparison between current and past tanning lamp users. Female students comprised 84% of current users and 70% of past users (P.001). Most current users (93%) were between the ages of 17 and 22 years, while 69% of past users were in the same age group (P.001). Significantly more current users believed that tanning lamps were safe than did past users (P.001). Most past and current users reported that skin cancer was a possible complication of tanning lamps. Simi- 1312

3 Table 2. Current vs Past Users No. (%) of Participants* Past Users Current Users Characteristic (n = 70) (n = 225) Sex Female 49 (70) 190 (84) Male 21 (30) 35 (16) Age, y (69) 210 (93) (21) 12 (5) 27 7 (10) 3 (1) Skin type I 1 (1) 1 ( 1) II 26 (37) 52 (23) III 39 (56) 161 (72) IV 4 (6) 11 (5) History of skin cancer Personal Yes 1 (1) 0 No 69 (99) 225 (100) Family Yes 24 (34) 73 (32) No 38 (54) 121 (54) Unknown 8 (11) 31 (14) Belief that a tan represents a healthy appearance Yes 26 (37) 101 (45) No 30 (43) 67 (30) Undecided 14 (20) 57 (25) Belief that tanning beds/lamps are safe Yes 2 (3) 54 (24) No 57 (81) 118 (52) Undecided 11 (16) 53 (24) Adverse effects from tanning beds/lamps Yes 23 (33) 50 (22) No 47 (67) 175 (78) Possible complication of tanning beds/lamps Skin cancer Yes 65 (93) 204 (91) No 0 4 (2) Unknown 5 (7) 15 (7) Premature aging Yes 65 (93) 207 (93) No 0 5 (2) Unknown 5 (7) 11 (5) larly, 93% of both groups believed that premature aging was a possible complication of tanning lamps. There was no significant difference between current and past users regarding family history of skin cancer (P=.87), belief that a tan represents a healthy appearance (P=.12), or the occurrence of adverse effects from tanning beds (P=.07). BEHAVIORS OF CURRENT USERS P Value Table 3 lists the frequency of reported current user behavior. When questioned about tanning bed use during the past year, more than half (57%) of the current users reported using tanning beds 1 to 5 times in total, 32% Skin types are described in Table Table 3. Behaviors of Current Users No. (%) of Current Users Behavior (n = 225)* Tanning bed use during the past year 1-5 times per year 127 (57) 1-5 times per month 71 (32) 1-5 times per week 25 (11) Daily 0 Wear protective goggles Always 147 (65) Sometimes 43 (19) Never 35 (16) Reasons for using a tanning bed Enjoy a tanned appearance Yes 207 (92) No 14 (6) Undecided 4 (2) Skin burns in natural sunlight Yes 33 (15) No 182 (81) Undecided 10 (4) Relaxation Yes 93 (42) No 128 (57) Undecided 3 (1) Friends use Yes 28 (12) No 195 (87) Undecided 2 (1) No time for natural sunlight Yes 159 (71) No 60 (27) Undecided 6 (3) Treatment for skin disease Yes 34 (15) No 189 (84) Undecided 2 (1) Vacation preparation Yes 136 (61) No 88 (39) reported use 1 to 5 times per month, and 11% reported use 1 to 5 times per week. When asked about their motivation for tanning lamp use, almost all (92%) of the current users reported using a tanning bed because they enjoyed a tanned appearance, 71% reported use because they could not find time to tan with natural sunlight, and 61% reported use for vacation preparation. Only 12% reported using tanning beds because their friends used them. Similarly, 15% of current users reported using tanning beds for the treatment of skin disease (defined in our study as psoriasis, acne, or dermatitis). LOGISTIC REGRESSION ANALYSIS Table 4 shows the odds ratios for all predictor variables in current users, holding skin type constant. Female sex was positively associated with tanning bed use, as were the beliefs that a tan represents a healthy appearance and that tanning beds are safe. Ironically, a family 1313

4 Table 4. Characteristics of Current Users, Holding Skin Type Constant Characteristic Wald 2 P Value Odds Ratio (95% Confidence Interval) Female sex ( ) Family history of skin ( ) cancer Adverse effects after ( ) tanning bed use Belief that a tan represents ( ) a healthy appearance Belief that tanning beds are safe ( ) history of skin cancer was positively associated with tanning bed use. LIMITATIONS Because we surveyed young adults at a large midwestern university, our population was mildly homogeneous; most of those sampled had either type II or III skin, which potentially reduced the generalizability of our data. Students also self-reported their skin type, which, although commonly used, 11 is a potential subjective limitation. Approximately 95% of the distributed questionnaires were completed by the students. No attempt was made to evaluate the population of nonresponders. COMMENT Almost half of our population used tanning lamps within the year previous to being surveyed. This value is higher than those reported in previous broad-based studies, 9,11 but was expected given our belief that young adults are more apt to engage in high-risk tanning behavior. In our student population, female students were much more likely than male students to be current users. This is higher than the odds ratio for women in the general population, which has been reported as Most current users were aged 17 to 22 years, while more past users were older. This older age group may benefit from a more extensive education and, therefore, may be more astute toward the risks of artificial UVL exposure. However, 2 previous reports 12,13 found no difference between undergraduate and health professional students in their frequency of tanning lamp use. Our classification scheme to assess frequency of tanning lamp use among current users was designed to correlate with those reported in the literature. Our values were quite consistent with those of a previous US broadbased study. 14 Thus, while more of our respondents used tanning beds when compared with the general population, they are not outpacing the general population for frequency of use. However, we believe that our values may have been conservative for 2 reasons. Because our study was conducted toward summer s end, we believe that student responses may have been affected by recall bias; we suspect that the frequency of tanning lamp use may escalate during the colder months. In addition, most of our population reported using tanning lamps for vacation preparation. If these respondents used tanning lamps exclusively for vacation preparation, tanning lamp use might have been reported as 1 to 5 times per year when factually these students used tanning lamps several times in the few weeks before travel. It was casually noted during our study that prevacation package deals are a mainstay of tanning facilities. High-risk tanning behavior, as seen in our population, probably includes those individuals who also engage in excessive outdoor UV exposure. We did not separately attempt to measure the outdoor exposure. Our young adult population, who were attending college, was exceptionally knowledgeable about the risks of artificial UVL exposure and skin cancer detection. A few current tanning lamp users surveyed believed that tanning beds were safe. This contrasts with a 1999 report, 6 which found that 60.4% of tanning lamp users in the 18- to 60-year-old age group believed that tanning salons were not dangerous. Our college student study group probably accounts for some of the differences, and for the entry point being the student health center. It can be surmised from our data then that educational efforts regarding the risks of artificial tanning are reaching young adults. Most current users recognized the development of skin cancers and premature aging as potential complications of tanning lamp use. Regardless of tanning habits, our group was similarly well versed on the characteristics of pigmented lesions that should be brought to a physician s attention. More than three fourths of the current users polled, however, either believed that tanning lamps are unsafe or are unsure of their safety. Despite Food and Drug Administration recommendations to the contrary, and consistent with reports 4,14 regarding the general population, 16% of our respondents reported never using protective goggles while tanning. And, strikingly, students in our study with a positive family history of skin cancer were 1.5 times more likely to use tanning lamps than those without a family history. The dangers of tanning lamp use seem to be widely known, yet have little bearing on behavior patterns. As other investigators 7,9,11,12,14,15 have suggested, education alone will probably not alter high-risk tanning habits. Our statistics solidify the notion that education on the dangers of artificial UVL exposure, through media, direct intervention, or personal experience, plays little role in young adults decisions regarding tanning. Cosmetic appeal seemed to be the principal motivating factor for tanning lamp use; most students reported that they seek artificial UVL because they enjoy a tanned appearance. In contrast, a few respondents used tanning lamps for the treatment of skin diseases such as acne. Particularly concerning is the assertion by many current users that they used tanning lamps for vacation preparation. As Spencer and Amonette 4 reported, this practice is not protective; a tan acquired via indoor tanning provides little defense against subsequent sun exposure, and may actually be cumulatively more damaging to the skin than sun exposure alone. Our study indicates that the young adult population freely engages in high-risk tanning behavior de- 1314

5 spite adequate, and even exemplary, knowledge of the risks involved. This demographic group seems much more driven by the perceived immediate cosmetic appearance gained through tanning lamp use than by the potential long-term deleterious complications of artificial UVL exposure. Prevalence rates for other high-risk activities in young adults mirror this concept. 16 On questioning in 1995 as part of the Centers for Disease Control and Prevention s National College Health Risk Behavior Survey, 17 29% of college students reported habitually smoking cigarettes, 35% reported episodic heavy drinking, 27% reported drinking alcohol and driving, and only 30% reported using condoms during sexual intercourse. These are all behaviors for which large-scale public education campaigns have long been established. To effectively decrease the rate of artificial tanning in this high-risk young adult population, it seems that public opinion will have to change regarding what is aesthetically admirable. Our study showed that those who believe that a tan represents a healthy appearance were 5 times more likely to use artificial tanning methods. Almost half of current users believed that a tan represents a healthy appearance, and 25% were undecided. We believe that education, as provided on the dangers of tanning lamp use in this population, is minimally effective, if at all. It will take a concentrated joint effort on behalf of health care organizations, industry, and physicians to bring about an eventual change in the belief that damaging tans are attractive and healthy. Accepted for publication January 29, We thank Jennifer L. Burba and Christopher P. Smith, MPA, for their assistance in statistical analysis; Hugh Jessop, MD, director of Indiana University Student Health Center, and his staff of nurses and physicians for their cooperation with the student survey; and Ginat Mirowski, DMD, MD, for reviewing and critiquing the manuscript. Corresponding author: Antoinette F. Hood, MD, Department of Pathology and Anatomy, Eastern Virginia Medical School, Lewis Hall, 700 Olney Rd, Room 2070a, Norfolk, VA ( hoodaf@evms.edu). REFERENCES 1. Council on Scientific Affairs. Harmful effects of ultraviolet radiation. JAMA. 1989; 262: Walter SD, Marrett LD, From L, Hertzman C, Shannon HS, Roy P. The association of cutaneous malignant melanoma with the use of sunbeds and sunlamps. Am J Epidemiol. 1990;131: Accomplishments of the American tanning industry. Tanning Trends. May 1995: Spencer JM, Amonette RA. Tanning beds and skin cancer: artificial sun+old sol=real risk. Clin Dermatol. 1998;16: AMA House of Delegates Interim Meeting, Resolution 217. Chicago, Ill: American Medical Association; Rhainds M, De Guire L, Claveau J. A population-based survey on the use of artificial tanning devices in the Province of Quebec, Canada. J Am Acad Dermatol. 1999;40: Brandberg Y, Ullen H, Sjoberg L, Holm LE. Sunbathing and sunbed use related to self-image in a randomized sample of Swedish adolescents. Eur J Cancer Prev. 1998;7: Robinson JK, Rademaker AW, Sylvester JA, Cook B. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med. 1997;26: Robinson JK, Rigel DS, Amonette RA. Trends in sun exposure knowledge, attitudes, and behaviors: 1986 to J Am Acad Dermatol. 1997;37: Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124: Hillhouse JJ, Stair AW, Adler CM. Predictors of sunbathing and sunscreen use in college undergraduates. J Behav Med. 1996;19: Jerkegren E, Sandrieser L, Brandberg Y, Rosdahl I. Sun-related behaviour and melanoma awareness among Swedish university students. Eur J Cancer Prev. 1999;8: Treharne-Davies J. Healthcare students attitudes to sunbathing. Nurs Stand. 1999; 13: Mawn VB, Fleischer AB. A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing, and sunscreen use. J Am Acad Dermatol. 1993; 29: Vail-Smith K, Felts WM. Sunbathing: college students knowledge, attitudes, and perceptions of risks. J Am Coll Health. 1993;42: Wechsler H, Rigotti NA, Gledhill-Hoyt J, Lee H. Increased levels of cigarette use among college students: a cause for national concern [published correction appears in JAMA. 1999;281:136]. JAMA. 1998;280: Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey United States, Mor Mortal Wkly Rep CDC Surveill Summ. 1997;46: