Understanding students' indoor tanning practices and beliefs to reduce skin cancer risks

Abstract: The purpose of this study was to assess indoor tanning beliefs and practices of university students to identify future preventive efforts. A questionnaire was developed, field tested, and validated, surveying 317 students about artificial tanning device (ATD(use, injuries, protective measures, knowledge, and tanning beliefs. Sixty percent had previously used ATD's, with 71% before age 18. Over 66% received skin burns from ATD use, and 81% who used ATD's also sunbathed. Students' desire for year-round tan increases their future risk of skin cancer. Comprehensive consumer education and "skin health" programs are needed to counter students' current practices and beliefs. (Am J Health Studies 1998; 14(3): 120-127]

Many young Caucasian Americans believe that tanned skin is both healthy and desirable (Leary & Jones, 1993; Vail-Smith & Felts, 1993; Elesha-Adams & White, 1990; Karvonen, 1992; and Munnings, 1991). In the quest to maintain a year-round tan, individuals have turned to indoor methods.

Indoor tanning has come to almost every city and town in the United States. Facilities range from a tanning booth in the corner of a beauty shop to a complete tanning salon open 24 hours a day. However, most facilities that have tanning devices offer other services such as nail manicuring, hair dressing, and body toning or weight training facilities, thereby linking indoor tanning to other types of services that promote health, beauty, and fitness.

It is conservatively estimated that over a million Americans use tanning booths every day (Skolnick, 1991; and Anderson, 1989). During the winter months, in the United States, the number of indoor tanning customers increase (Skolnick, 1991; and Oliphant, Forster, & McBride, 1994). The people who use tanning devices are likely to be individuals wanting to maintain a year-round tan, fair-skinned people who believe they can tan indoors without burning, or those desiring a "base" tan before going on a winter vacation or spring break (Oliphant, Forster, & McBride, 1994; Kansas Department of Health, 1992; and Dougherty, McDermott, & Hawkins, 1988).

BACKGROUND
The Food and Drug Administration, the American Medical Association, the American Cancer Society, the Skin Cancer Foundation, the National Institutes of Health, and the American Academy of Dermatology recognize no health benefits from indoor tanning devices (Greeley, 1991; Food & Drug Administration [FDA], 1987; National Institutes of Health [NIH], 1989; and Greeley, 1993). Each group sees indoor tanning as a potentially dangerous activity with immediate and long-term photo-aging damage to the skin.

The use of artificial tanning devices (ATD's) increases the potential risks for a variety of health hazards which can include premature skin aging, skin and eye burns, photosensitive reactions, cataracts, skin cancer, reduced immunity, and blood vessel damage (FDA, 1987). It has been suggested that people who use ATD's have a greater likelihood of getting skin cancer due to the increased exposure to ultraviolet radiation (Skolnick, 1991). Combining the use of ATD's with sunbathing further increases the cumulative exposure to ultraviolet radiation (UVR) and the potential risk of skin cancer (Staberg, Wulf, Klemp, Poulsen, & Brodthagen, 1983; Willis, Menter, & Whyte, 1981).

The major risk factors for skin cancer should be well known by all Caucasians. individuals with the highest risk of skin cancer are those who have blonde or red hair, blue or green eyes, and fair skin which easily sunburns (Thompson, 1987; and Hopkins, 1982). People who sunburn easily have higher incidence rates of basal cell carcinomas (Karagas et al., 1992) and one severe sunburn early in life can double a person's chances of developing malignant melanoma (Crane, Marcus, & Pike, 1993).

Another potential risk is females who take birth-control hormones while they tan. The use of birth-control hormones increases photosensitivity and increases the risk of burns from any UVR source (FDA, 1987). Many female students are completely unaware of their skin's elevated sensitivity to natural or artificial light due to the use of birth-control hormones and of their increased risk of burning.

Tanning salons frequently market their advertising toward individuals who do not tan well in the sun (Greeley, 1991; The University Daily Kansan, 1994; and Kansas Department of Health, 1992) and these are the ones most vulnerable to UVR injury. The individuals who use ATD's should have a better understanding of their immediate and future health risks, beyond the lure tanning's cosmetic appeal.

Major indoor tanning advertisement campaigns occur before spring break, prom, and winter holidays when adolescents and young adults are especially motivated to start a tan. The tanning salons are almost booked solid before major holidays and spring break, offering extended hours, early-bird and late-night appointments to meet the demand at these times.

Most tanning salons use a variety of sales techniques including student discounts and packages promoting multiple tanning visits at decreasing cost per visit or minutes of tanning used. Another sales tactic is a bonus point system in which the client accumulates points for each tanning session, for new customer referrals, and for purchasing tanning products. With a specified number of bonus points, these tanning salons award free tanning sessions or products to their customers.

One marketing technique in the indoor tanning business is to capitalize on the hassles of sunbathing. Tanning indoors is often promoted for the comfort and ease of tanning in air-conditioned facilities, the convenience of not fighting the traffic to the beach, and the efficiency of being able to get a tan in less time than in sunlight.

Many print advertisements or newsletters produced by tanning salons promote the positive physiological and psychological effects of sunlight (The University Daily Kansan, 1994). Unfortunately, the ultraviolet radiation (UVR) produced by today's tanning devices is quite different than sunlight. Tanning devices can generate more than five times the solar ultraviolet A (UVA) radiation at the equator (NIH, 1989). Unlike sunlight, ultraviolet A can penetrate and damage the dermis which contains blood vessels, sweat glands, and nerve endings (Jaroff, 1990). Damage to the dermis also affects the collagen and elastic fibers of the skin resulting in premature wrinkling and aging of the skin (MacKie, 1992; and Greeley, 1991).

Indoor tans are being marketed with such claims as "safer than sunlight," "increases your sex drive," "lowers blood pressure," and "raises vitamin D levels" (The University Daily Kansan, 1994). Legally, the only claim that tanning salon operators may make is that the devices are to be used for cosmetic tanning purposes (US Code). Tanning devices are not safer than sunlight (Greeley, 1993). The long-term effects of ATD's are presently not known (National Cancer Institute, 1988) and tanning devices have no known benefits (FDA, 1987) despite the advertising claims made.

Skin burns still occur with the use of ATD's, including second degree burns and eye burns treated at emergency rooms (Leads from the MMWR, 1989). Indoor tans do not provide a safe "base" tan nor increased protection from sunlight during a winter or tropical vacation. An UVA tan penetrates both the epidermis and dermis and is distributed differently in the skin than a suntan (Greeley, 1991). An indoor tan offers a Sun Protection Factor (SPF) of 2 or 3 (Greeley, 1991; and FDA, 1987), yet most individuals do not realize these basic facts.

PURPOSE
Most of the research literature regarding indoor tanning has focused on the physical injuries artificial tanning devices (ATD's) can cause (Kansas Department of Health, 1992; Greeley, 1991; Thompson, 1987; Ellis, 1992; FDA, 1987; and NIH, 1989). Currently, there is little information available about indoor-tanning attitudes and practices of the general population (Dougherty, McDermott, & Hawkins, 1988) and even less of the high school and college age populations. Adolescents' use of tanning facilities in Minnesota (Oliphant, Forster, & McBride 1994) has been investigated, and a profile of tanning salon users was made in New York City (Fairchild & Gemson, 1992). The purpose of this study was to assess the indoor-tanning beliefs and practices of university students in order to identify future preventive health education efforts for the high school and college levels.

METHODS
A questionnaire was developed by the investigators. To assess content validity, a panel of five health education professors and a dermatologist reviewed the questionnaire. A pilot study was conducted to improve format and item clarity, as well as to establish test-retest reliability for the instrument. The students in the pilot study were similar to the participants in this investigation. The instrument was administered twice to the pilot group of 35 students with one week between administrations. The students' initial responses were correlated with their re-test responses in order to determine test-retest reliability. A Pearson Product Moment Correlation was utilized. The coefficient for the total inventory was .7403. Permission to conduct this study was granted from the University Advisory Committee on Human Experimentation.

Students enrolled in an introductory health course at a midwestern university were the subjects for the study during the spring of 1995. The students were briefed on the content of the study and were assured of confidentiality in completing the questionnaire.

RESULTS
A total of 317 students participated in this study, with 104 male and 213 female respondents. The majority (86%) of the students were 18-21 years of age, single (97%), and Caucasian (92%). These demographics were representative of the total university population.

Half of the respondents reported having blue or green eyes, 30% had blonde or red hair, and 14% identified their skin tone as Type I or II (light or fair skin). Forty-six percent of the females reported the use birth control hormones. One in four of the students reported having a family history of skin cancer. Only one percent of those aged 25 and older had never used artificial tanning devices (ATD's).

Sixty percent of the students surveyed had previously used an ATD, with 71% of these students using tanning beds or lamps before they were 18 years old. Of this group of indoor tanners, 81% used ATD's and also sunbathed.

Over one-third of all the students in the study responded that they would never use a tanning device (Table 1), but the majority (63%) stated that they would tan indoors before prom, a wedding, a vacation, spring break, to get a base tan, or to maintain a year-round tan. The students' reports of actual ATD use (Table 1) were very similar to their projected use. Of the 185 respondents who used tanning devices, 54% used ATD's one or more times per week.

Over two-thirds of the students who used ATD's had received a skin burn during an indoor tanning session (Table 1). Sixty-six percent had been burned once or twice, 28% of the respondents had burned 3-5 times, while 6% received skin burns more than five times. A small number reported eye irritations and skin rashes after indoor tanning sessions.

Of the sources which influenced the actual use of ATD's, 60% of students listed their close friends. Newspapers and magazines, a significant other, TV and radio advertisements, or family members were also cited as motivating factors for an indoor tan. Friends using the same tanning facility influenced 79% of the respondents to use ATD's. Multiple tanning packages and tanning coupons were strong motivators for these indoor tanners, while campus newspaper ads and a convenient location also influenced ATD use.

Time constraints and the opportunity to relax appeared to be other key reasons for these students to tan indoors. Seventy-three percent stated that they could tan in less time using an ATD than in sunlight. The ability to tan at almost any time of the day and being tan all year were also reasons given for ATD use. Students rationalized the use of ATD's by reporting that tanning time was relaxing or they simply enjoyed the use of tanning devices. Further rationales given for indoor tanning included: a significant other or close friends who liked the tan, and receiving compliments about the tan. The belief that ATD's cleared blemishes or skin problems was also cited by respondents as a reason for indoor tanning.

The majority of students in this study appeared to believe the popular American myth of a "healthy" tan, with 62% of all the respondents stating that "tans look healthy" and 86% believing that they "look better with a tan" (Table 2). The value of a tan was powerful enough for 65% of all the students to state that "tanned skin is more attractive than having no tan", with 64% believing that tans gave them "a positive social appearance." Fifty-six percent of the students reported that having a tan made them "feel sexy," and 35% believed that they "looked thinner with a tan" (Table 2).

DISCUSSION
Adolescents and college students are very concerned about their appearance and presently are quite likely to engage in behaviors that increase their risks for skin cancer (Leary & Jones, 1993; Banks, Silverman, Schwartz, & Tunnessen, 1992; Cockburn, Hennrikus, Scott, & Sanson-Fisher, 1989; and Johnson & Lookingbill, 1984). Caucasians have the highest risk for skin cancer and the risk increases as the socioeconomic status increases (Banks, Silverman, Schwartz, & Tunnessen, 1992). Therefore, Caucasian students need intervention efforts and education programs to help them reduce the risk of future skin cancer.

The results of this study provide support for educational interventions on several different levels. Primary prevention should begin with the parents. Skin cancer/skin health education should be presented at prenatal courses and well-baby clinics. Many young parents unwittingly over-expose their babies and toddlers to sunlight and ultraviolet radiation (UVR). The cycle of unnecessary UVR exposure which increases skin cancer risks needs to be broken for the sake of innocent children. Skin protection measures cannot be taught nor practiced too early in life.

In this study, 60% of the students had used ATD's with over 70% of them indoor tanning by age 17. Over 80% of these students were also sunbathers, greatly increasing their exposure to ultraviolet radiation and increasing their future skin-cancer risks. Students who use ATD's should have a better understanding of the risks involved than they currently possess.

In 1989, the American Medical Association Council on Scientific Affairs Report (1989) advised individuals with skin that will "tan moderately well" to limit their ATD exposure to 30 to 50 half-hour exposures per year. Despite this recommendation, over half of the indoor tanners in this study reported ATD use which exceeded this amount. Similar to successful drug education programs that target children before they are likely to use drugs, skin health/skin cancer programs should be implemented before Caucasian students learn to believe that tanned skin is attractive and desirable.

A comprehensive K-12 skin-health/skin-cancer education program would demonstrate sun/UVR protection practices to elementary students, address positive attitudes about untanned skin, include knowledge about proper skin care and skin cancer risks, and provide consumer skills to combat the advertising methods used by the tanning and fashion industries. Students also need to be provided with basic information about personal care of the skin as well as the properties, limitations, and uses of sunscreens and moisturizers.

The American Cancer Society, the Skin Cancer Foundation, the Food and Drug Administration, and the American Academy of Dermatology have a wide variety of pamphlets, booklets, videos, posters, and other educational items available. These materials can be incorporated into a comprehensive skin-cancer/skin-health program for grades K-12 and college level students. In addition, these materials can be distributed to the parents at low cost.

School administrators and parents could further support such a comprehensive program by equipping school playgrounds and athletic fields with more shaded areas. City planners and administrators should consider increasing the amount of available shaded areas in local parks and recreation areas. Skin cancer prevention efforts would receive an incredible boost if insurance companies were to include sunbathing and the use of ATD's as high risk activities which are injurious to future health.

In the middle schools and high schools, tanning prevention should be integrated into health education, physical education, science, psychology, and family living curriculums. Educational efforts should be concentrated in the spring semesters in order to impact students who plan to use ATD's before spring break, prom, a June wedding, or for a head start on a summer tan.

With over two-thirds of the indoor tanners in this study reporting ATD skin burns, students and parents should be made aware that skin burns pose a much greater risk than temporary soreness, itching, and peeling skin. In a comprehensive skin cancer/ skin health program, students would learn that the potential for skin cancer is related to lifetime exposure to ultraviolet radiation whether it is caused by natural or artificial sources. The damaging effects of UVR begin at an early age (NIH Consensus Panel, 1992) and nothing has been found to undo previous UV damage to the skin. Students need to know that a tan is an indicator of UV skin damage (Karvonen, 1992) and that UV damage is cumulative (Munnings, 1991; and FDA, 1987);

If students were equipped with the facts about skin health, had observed positive adult role models, and practiced sun protection methods since childhood, they would be less likely to voluntarily damage their skin. Young females who use birth control hormones and also actively sunbathe or use ATD's are a classic example. College females from the authors' health courses are frequently surprised to learn of their increased photosensitivity. They simply do not know the side effects. Family practitioners, gynecologists, university health care and wellness staff, health education teachers and professors, parents, and counselors should provide this information to sexually active students in order to prevent needless skin burns.

Tanning facilities frequently target their promotions and advertising to teenagers and students (Oliphant, Forster, & McBride, 1994). High school and college students are willing customers anti are bombarded by a wide variety of sales techniques, health jargon, and the misrepresentation of health information related to the use of tanning devices. Consumer health knowledge and skills would help students to make informed choices to counter the effects of radio, television, print media, and Internet advertising. Collectively, these efforts will help to dispel the myth of a "healthy tan."

CONCLUSIONS
The results of this study indicate that these university students' beliefs and practices regarding tanned skin increase the health risks to their skin and eyes. Elementary through university health educators, public health officials, physicians, and parents should demonstrate that indoor tanning is inconsistent with high-level wellness by recommending alternative practices which fulfill the personal and social needs for these age groups. Health education efforts should promote protective behaviors of one's skin and eyes to minimize premature aging and damage. Alternatives to indoor tanning include: promoting the natural color of one's skin as beautiful, sexy, attractive, and healthy; and improving students' self-esteem. There are many other healthy activities which can provide the "relaxation" students receive from a lying in a tanning bed.

If a tanned look is desired, using skin bronzers and self-tanning lotions instead of UVR should be promoted. These products do not protect the skin from UVR, so the use of sun protection methods is also necessary.

Not using artificial tanning devices will reduce the unnecessary immediate and longterm injuries that they can cause. It is theorized that the future rate of skin cancers will significantly increase due to the increased use of ATD's (Jaroff, 1990) within the last fifteen years.

Potential cases of skin cancer associated with tanning devices could be prevented and ultimately, eliminated in the future (Ellis, 1992). When students become educated consumers of health products and services, they may be less inclined to voluntarily spend money to potentially damage their eyes, prematurely wrinkle and age their skin, and increase their skin cancer risks.

Additional research on ATD use should be conducted among the high school and college populations in the New England and northern Midwest states. Due to the reduced sunlight during the winter months in these areas, the likelihood of ATD use increases. With the widespread use of ATD's in the U.S., future research should also be directed at the potential acceleration of skin cancer rates in susceptible young individuals who have frequently used ATD's (Jaroff, 1990).

Table 1 Artificial Tanning Device Use (N=317)

Legend for Chart:

A - Never
B - Before Spring Break
C - Before Vacation
D - Before Prom or Wedding
E - To Get a Base Tan
F - For Year Round Tan

A B C D E F

When Would
You Use ATD's? 37% 16% 6% 19% 14% 8%

When Do 40% 15% 4% 20% 13% 8%
You Use ATD's?

(n = 185)

<15 15-17 18-24 25-30 >30
yrs. yrs. ws. yrs. yrs.

Age when

First Used ATD 9% 62% 29% 0% 1%

1X/Mo 2X/Mo 1X/Wk 2X/Wk 3+X/Wk

Frequency
of ATD Use 29% 17% 24% 23% 7%

Never Once Twice 3 X 4-5 X >5 X

Frequency of
of Sunburn
From ATD 31% 32% 34% 13% 15% 6%

Use ATD Yes No
and Sunbathe 81% 19%
Table 2 Student Beliefs about Tans (N=317)

Agree Disagree Neither A/D

I look better with a tan. 86% 6% 8%

Tanned skin is more attractive
than untanned skin. 65% 13% 22%

Tans give me a positive
social appearance. 64% 12% 24%

Tans look healthy. 62% 8% 30%

Having a tan makes me
feel sexy. 56% 15% 29%

I look thinner with a tan. 35% 29% 37%
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By Janice Clark Young, EdD, CHES and Robert Walker, EdD, CHES

Adapted by EdD, CHES and EdD, CHES

Janice Clark Young, EdD, CHES, is an Assistant Professor in the Department of Health, Physical Education and Recreation at South west Missouri State University. Robert Walker, EdD, CHES is an Associate Professor Health Coordinator in the Department of Health, Physical Education, and Recreation at The University of Kansas. Address Correspondence to: Janice Clark Young, EdD, CHES, Department of HPER. Southwest Missouri State University, 901 South National Avenue, Springfield, MO 65804.

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