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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
Arch Dermatol. 2002;138:1311-1315.
ABSTRACT
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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, 1999.
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.
INTRODUCTION
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
Previously published studies6-8 have
examined 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 American Academy of Dermatology and others.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.
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 Fitzpatrick10 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, 1999. 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.
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Table 1. Population Frequency Distribution
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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, 3.25.
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).
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Table 2. Current vs Past Users
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Most past and current users reported that skin cancer was a possible
complication of tanning lamps. Similarly, 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
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% reported use 1 to 5 times per month, and 11%
reported use 1 to 5 times per week.
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Table 3. Behaviors of Current Users
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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 history of skin cancer was positively associated with
tanning bed use.
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Table 4. Characteristics of Current Users, Holding Skin Type Constant
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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 1.5.9 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 reports12-13 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 broad-based 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 reports4, 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
investigators7, 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 Amonette4 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 despite 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.
AUTHOR INFORMATION
Accepted for publication January 29, 2002.
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 23507 (e-mail: hoodaf{at}evms.edu).
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.
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