Use of Indoor Tanning Devices by Adults — United States, 2010

Indoor tanning is associated with an increased risk for skin cancer, the most common form of cancer in the United States (1,2). The World Health Organization considers ultraviolet (UV) tanning devices to be a cause of cancer in humans (3). Exposure to UV radiation, either from sunlight or indoor tanning devices, is the most important, avoidable known risk factor for skin cancer (4,5). Annually, skin cancer costs an estimated $1.7 billion to treat and results in $3.8 billion in lost productivity (6). Reducing the proportions of adolescents and adults who report using artificial sources of UV light for tanning are Healthy People 2020 objectives (7). Current state-level policies to restrict indoor tanning are directed at youths aged <18 years. To examine the proportion of the adult U.S. population reporting indoor tanning in the past 12 months, CDC and the National Cancer Institute analyzed data from the 2010 National Health Interview Survey (NHIS). Overall, the age-adjusted proportion of adults reporting indoor tanning in the past 12 months was 5.6%, with higher rates among whites, women, and adults aged 18–25 years. Nationwide, the highest rates of indoor tanning were among white women aged 18–21 years (31.8%) and 22–25 years (29.6%). Among white adults who reported indoor tanning, 57.7% of women and 40.0% of men reported indoor tanning ≥10 times in the past 12 months. Continued public health efforts are needed to identify and implement effective strategies for reducing indoor tanning among adults in the United States, particularly among whites, women, and adults aged 18–25 years.

NHIS data are collected annually from a continually conducted, nationally representative sample of the U.S. civilian, noninstitutionalized population, primarily through in-person household interviews. This report uses data from the NHIS cancer control supplement, which includes questions regarding indoor tanning.* Specifically, respondents were asked, "During the past 12 months, have you used an indoor tanning device such as a sunlamp, sunbed, or tanning booth even one time? Do not include times you have gotten a spray-on tan." Respondents replying "yes" to that question were then asked, "During the past 12 months, how many times have you used an indoor tanning device such as a sunlamp, sunbed, or tanning booth? Do not include times you have gotten a spray-on tan." Data from 25,233 adults aged ≥18 years were available for analysis. The response rate for the sample adult data used in this study was 60.8%. Indoor tanning prevalence was examined by age, sex, race/ethnicity, marital status, education level, poverty status, U.S. Census region (Northeast, Midwest, South, and West),† health status, family history of skin cancer, and having a sunburn in the past year. Analyses were performed using statistical software to account for the complex sampling design. Sample weights were applied to reflect probability of selection, adjustments for nonresponse, and poststratification to provide nationally representative estimates. Estimates were age-adjusted to the 2000 U.S. standard population for more direct comparison between groups. For racial/ethnic groups, persons identified as Hispanic might be of any race; persons in all other racial/ethnic categories are non-Hispanic.

Nationwide, 5.6% of adults reported indoor tanning in the past 12 months (Table 1). Compared with the overall adult population, a higher prevalence of indoor tanning was found among persons aged 18–21 years (12.3%), 22–25 years (12.3%), and 26–29 years (9.3%); those with a family history of skin cancer (9.0%); those in the Midwest (8.8%); white adults (8.1%); those who had a sunburn in the past 12 months (7.9%); those whose level of education was some college or technical school (7.5%); and those whose annual income exceeded 200% of the federal poverty level (6.5%).§ By sex, age-adjusted indoor tanning prevalence was higher among women (8.9%), particularly among white women (12.9%), women with a family history of skin cancer (13.1%), and women aged 18–21 years (21.2%) and 22–25 years (20.4%). The highest prevalence of indoor tanning was found among white women aged 18–21 years (31.8%) and aged 22–25 years (29.6%), particularly among those aged 18–21 years in the Midwest (44.0%), and those aged 22–25 years in the South (36.4%) (Figure). Among white adults who reported indoor tanning, the frequency of use was higher among women, with an average of 20.3 sessions per year, and 57.7% reported tanning ≥10 times in the past 12 months. Increased use was found among white women aged 18–21 years, with an average of 27.6 sessions per year, and 67.6% reported tanning ≥10 times in the past 12 months (Table 2).

Reported by

Anne M. Hartman, MA, MS, Div of Cancer Control and Population Sciences, National Cancer Institute. Gery P. Guy Jr, PhD, Dawn M. Holman, MPH, Mona Saraiya, MD, Marcus Plescia, MD, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC. Corresponding contributor: Gery P. Guy Jr, [email protected], 770-488-3279.

Editorial Note

The findings in this report indicate that recent indoor tanning is not uncommon among adults in the United States and is more common among certain subgroups. Similar to previous findings, indoor tanning was most common among women, whites, and young adults (8). The highest rates of indoor tanning were found among young women; particularly white women aged 18–25 years. Among white women who reported indoor tanning, more than half (57.7%) reported indoor tanning ≥10 times in the past 12 months. Melanoma incidence rates are increasing and are higher among young white women than among young white men, which might be attributable, in part, to their increased rates of indoor tanning (9,10). Indoor tanning is particularly dangerous for younger users because indoor tanning before age 35 years increases the risk for melanoma by 75% (1).

UV radiation levels from indoor tanning devices far exceed those from sunlight. The UVA (long wavelengths, 320–400 nm) output of tanning devices has been shown to be four times higher than the noon sunlight in Washington, DC, during the summer, and the UVB (midrange wavelengths, 290–320 nm) output was twice as high (5). The high frequency of use among indoor tanners is of great concern given these high levels of UV radiation and the elevated risk for skin cancer with increasing numbers of sessions (2).

The findings in this report are subject to at least four limitations. First, the results from this study are generalizable only to the noninstitutionalized civilian adult population; military personnel and persons in nursing homes and other institutions were excluded. Second, the response rate for the NHIS sample adult data was only 60.8%. Third, use of an indoor tanning device was self-reported, and the degree of misreporting cannot be determined. Finally, the length of exposure for each indoor tanning session, and cumulative exposure, could not be assessed.

A higher rate of indoor tanning among adults with a family history of skin cancer suggests that the dangers of indoor tanning might not be understood fully, the known risks might not discourage the behavior, or both. Increased use of indoor tanning also might be attributable to the association of tanning behaviors among children and their parents or caretakers. Continued public health efforts are needed to increase awareness of the risk for skin cancer and how it can be prevented. Given the regional differences in the prevalence of indoor tanning, improved surveillance at the state level can aid future efforts in monitoring indoor tanning trends. Reducing exposure to UV radiation from indoor tanning is an important strategy for reducing the occurrence of skin cancer. Evidence from a recent review by the U.S. Preventive Services Task Force suggests that behavioral counseling in a primary-care setting can reduce UV exposure, including indoor tanning, among persons aged 10–24 years. In young women, the most likely group to indoor tan, appearance-focused behavioral interventions reduced indoor tanning behavior by up to 35%.¶ Approaches to reduce indoor tanning also include consideration of limits on indoor tanning by minors. Currently, 33 states have laws restricting minors' access to indoor tanning under a certain age (typically under age 14, 16, or 18 years), including bans on access or requiring parental accompaniment or consent. Evaluations of these relatively new policies typically have focused on compliance and the importance of high compliance levels in reducing use among the target population. Additional approaches include increased regulation of indoor tanning devices through reclassification of indoor tanning devices to a category requiring stricter regulations and mandatory disclosure of risk information to purchasers of tanning devices and customers of tanning salons. Given the high prevalence of indoor tanning among young adult women, an increased focus should be placed on this population to prevent melanoma from increasing significantly as this generation ages. Continued surveillance of indoor tanning use will aid program planning and evaluation by measuring the effect of skin cancer prevention policies and monitoring progress toward achieving Healthy People 2020 national objectives.

Acknowledgment

Richard Lee, Information Management Svcs, Inc., Silver Spring, Maryland.

References

1. World Health Organization International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer 2007;120:1116–22.
2. Zhang M, Qureshi AA, Gellar AC, Frazier L, Hunter DJ, Han J. Use of tanning beds and incidence of skin cancer. J Clin Oncol 2012; 30:1588–93.
3. World Health Organization International Agency for Research on Cancer. A review of human carcinogens–part D: radiation. Lancet Oncol 2009;10:751–2.
4. Gilchrest B, Eller MA, Geller AC, Yaar M. The pathogenesis of melanoma induced by ultraviolet radiation. N Engl J Med 1999;340:1341–8.
5. Lim HW, James WD, Rigel DS, Maloney ME, Spencer JM, Bhushan R. Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan. J Am Acad Dermatol 2011;64:893–902.
6. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004: a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol 2006;55:490–500.
7. US Department of Health and Human Services. Cancer. Healthy people 2020. Washington, DC: US Department of Health and Human Services; 2011. Available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=5. Accessed May 1, 2012.
8. Choi K, Lazovich, D, Southwell B, Forster J, Rolnick SJ, Jackson J. Prevalence and characteristics of indoor tanning use among men and women in the United States. Arch Dermatol 2010;146:1356–61.
9. Jemal A, Saraiya M, Patel P, et al. Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992–2006. J Am Acad Dermatol 2011;65(5 Suppl 1):S17–25.
10. Wu X, Eide MJ, King J, et al. Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999–2006. J Am Acad Dermatol 2011;65(5 Suppl 1):S26–37.