Naquin, Tori E.
Studies have shown that over million people use tanning salons each day in the United States (Whitmore, Morison, Potten, & Chadwick, 2001). Nearly 70% of these users are Caucasian women ages 16–29 years (Swerdlow & Weinstock, 1998). Individuals exposed to ultraviolet (UV) radiation from tanning beds have a 75% increased risk for developing melanoma (Lazovich et al., 2010). Skin cancer is the most common form of cancer in the United States, and according to Robinson (2005), approximately 20% of Americans will develop the cancer over their lifetime (as cited in The Skin Cancer Foundation, 2011). The annual incidence of melanoma among young women increased by 50% between 1980 and 2004 (The Skin Cancer Foundation, 2011). “Women under the age of 40 diagnosed with basal cell carcinoma in the last 30 years has more than doubled, and the incidence of squamous cell carcinoma among women under the age of 40 has increased by almost 700%” (The Skin Cancer Foundation, 2011, p. 2). Tanning beds offer convenient year-round access to UV rays that produce tan skin that women seek. Tanning beds pose an unnecessary risk of UV radiation; therefore, an understanding of young women’s knowledge and exposure to tanning beds is needed.
Approximately 47% of a person’s lifetime sun exposure happens between the ages 19 and 40 years (Godar, Urbach, Gasparro, & Ven der Leun, 2003). According to Lew, Sober, Cook, Marvell, & Fitzpatrick (1983), a person’s chance for developing melanoma later in life more than doubles with one or more blistering sunburns during childhood or adolescence years (as cited in The Skin Cancer Foundation, 2011). The period of greatest susceptibility for skin cancer occurs during adolescence, because the target cells for UV radiation are still immature (Edwards, 2007). Young women should be educated on the risk associated with tanning to reduce the incidence of skin cancer.
Society has contributed to this overwhelming increase in the prevalence of skin cancer, because it has failed to take this issue seriously and take preventative measures. A few barriers individuals face when realizing the importance of skin cancer prevention include media and peers promoting tan skin, the convenience of tanning beds, and the ineffectiveness of sunscreen education and promotion campaigns (White et al., 2008). The overall concern is the lack of education and easy access to tanning beds. People are made fully aware of the correlation between tobacco use and lung cancer, and as much effort should be put toward increasing the awareness of the correlation between tanning bed use and skin cancer.
PURPOSE AND SIGNIFICANCE TO NURSING
The purpose of this systematic review is to identify the knowledge and exposure that young women, aged 15–25 years, have toward tanning beds. According to Heckman and Coups (2011), “The prevalence of melanoma, the deadliest form of skin cancer, has been increasing over the past thirty years and is now the second most common cancer among women in their twenties”(p. 1). The Cancer Journal for Clinicians “estimates 34,350 new cases of skin cancer and 3,980 deaths for females this year” (Siegel, Naishadham, & Jemal, 2012, p. 1). This systematic review of literature will be to identify whether young women aged 15–25 years are aware of the consequences of the tanning salon and still see note from page one: decide not decided and “or” not “and” and unaware of the consequences, they tan and how often... The overall outcome of the systematic review will identify whether young women need more education relating to skin cancer prevention and exposure. According to the American Academy of Dermatology (2012), “Evidence from several studies has shown that exposure to UV radiation from indoor tanning devices is associated with an increased risk for melanoma and non melanoma skin cancer, such as squamous cell and basal cell carcinoma” (p. 1). Today’s society places a premium on the appearance of tan skin, and women have easy access to tanning beds, which increases their UV exposure and risk for skin cancer. Increased rates of skin cancer are associated with early intense UV exposure; therefore, evidence indicates that skin cancers can be prevented by limiting sun exposure with protective practices and avoiding UV radiation in tanning beds (Heckman & Coups, 2011).
Skin cancer is one of the most preventable forms of cancer; yet, the prevalence of skin cancer has risen substantially in the last few decades (Edwards, 2007). Cultural influences put pressure on young women to increase UV exposure. Previous research has shown that most individuals understand the risk associated with UV exposure; however, they still do not participate in sun-protecting behavior. Young women are increasing their chances of being diagnosed with skin cancer by exposing themselves to harmful UV rays in tanning beds.
The principles of Nola Pender’s Health Promotion Model will be applied to this systematic review by focusing on holistic and preventative patient care. The Health Promotion Model assists nurses in understanding the major factors of health behaviors as a basis for behavioral counseling to promote healthy lifestyles (Sakraida, 2010). According to Sakraida: “A health promoting behavior is an end point or action outcome that is directed toward attaining positive health outcomes, such as optimal well being, personal fulfillment, and productive living” (p. 439). Young women should be educated on the risk associated with tanning and advised not to tan, which would reduce their risk for skin cancer and increase their overall health and wellness.
FRAMEWORK FOR SYNTHESIS OF LITERATURE
The systematic procedure for this review was modeled after the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement consists of a 27-item checklist and four-phase flow diagram for improving the reporting of systematic reviews and meta-analyses (Moher, Liberati, Tetziaff, & Altman, 2009). The computer databases used were Cinahl, PubMed, and Cochrane. The databases were searched using the following keywords in various combinations: young adults, young women, behavior, knowledge, tanning beds, and indoor tanning. The search results were further filtered to include publication dates later then 2006. All searches were performed before September 29, 2012, and all articles were in the English language.
One hundred twenty-five articles were retrieved from the original search in conducting the systematic review on young women’s knowledge and exposure to tanning beds. A review of titles and abstracts reduced the number of relevant articles to 12. All 12 articles were analyzed. Five articles were chosen as significantly correlated with young women’s knowledge and exposure to tanning beds, whereas seven articles were excluded as not. The articles not significantly correlated were excluded, because they addressed other issues such as the effectiveness of certain interventions, qualitative reports predicting tanning bed use, and the effect of magazine/media exposure. Some articles did not include women in the age range of 15–25 years. Additional articles were chosen from the reference list of the articles read. The inclusion criteria were that the articles had to include at least one of the ages in the range of ages 15–25 years, had to solicit knowledge regarding the risk of tanning bed exposure, and had to measure exposure to tanning beds. Five articles met the inclusion criteria for purposes of this systematic review on whether young women ages 15–25 years are aware of the consequences of the tanning bed use and still decided to tan or unaware of the consequences of tanning bed use, they tan and how often they do tan. No blinded or independent reviewers were used in the selection of the articles.
A literature review was conducted to evaluate young women’s exposure to tanning beds and their perceived risk of using tanning beds. The literature identifies people’s knowledge of skin cancer risks and their prevalence of tanning bed use. The key attributes of each study are summarized in Table 1. The studies vary in sample size, sample source, and age range of participants. Two of the studies dealt with young adults aged 18–23 years, which is within the target population of this systematic review. Two studies included large sample sizes with individuals’ ages ranging from 18 to over 65 years, whereas the other two included ages of 14–17 and 12–40 years, respectively. For the purposes of the research question in this review, only results on women are desired. All the studies included male and female participants in the sample, but reported separate results for each gender. All of the studies are from the United States with three of them representing university students. The culture and beliefs of young adults can vary from decade to decade, so it is important to know the data generation periods. Data generation periods range from 2005 to 2010 in this review. All studies used cross-sectional surveys to gather data and used either bivariate or logistic regression analyses to synthesize the data. Most of the studies reported exposure to tanning beds as prevalence in the past year, whereas some also included lifetime prevalence. A limitation to all the studies is that behaviors were assessed by self-report.
Many of the studies identified lifestyle correlates with tanning bed use. Factors such as tobacco use, alcohol use, poor diets, and lack of physical activity were analyzed (Heckman et al., 2008). Most of the studies linked risky or addictive behavior with tanning bed use. Appearance-related motives were overwhelmingly reported as the cause of tanning bed use.
Tanning bed exposure is defined as using an artificial UV lamp for the purposes of tanning skin. The studies reported different levels of prevalence of exposure, but for purposes of this review, 1-year prevalence is measured. In the studies representative of the entire U.S. population, 1-year prevalence of women in the age range of 15–25 years was targeted in this study, ranging from 13.6% to 31.8% (Hartman et al., 2012; Heckman et al., 2008; Mayer et al., 2011)
According to Heckman et al. (2008), 27.3% of women ages 18–29 years engaged in indoor tanning at least once in the past year. The purpose of this study was to describe the prevalence of indoor tanning throughout adulthood, because many of the previous studies did not include the older population. The age bracket measured in the study includes older women and does not include the age range of 15–17 years, so the figure reported could be skewed in relevance to the range of 15–25 years. Although the sample size is large and appears to be representative of the U.S. demographic, only approximately 10% of the sample included women ages 18–29 years.
Mayer et al. (2011) studied a sample size of 6,125 men and women ranging from 14 to 17 years old and showed a 10% prevalence of indoor tanning use in the last year. Results of the study were broken by gender and age. Approximately 30% of women at the age of 17 years had used indoor tanning with the past year. The prevalence rose by age from 8.5% with 14-year-olds (Mayer et al., 2011). The purpose of this study was to evaluate environmental and policy-related correlates with adolescent indoor tanning use. Surveys of adolescents and their parents were conducted in 100 U.S. cities via telephone interviews. The parents were asked about their tanning beliefs and gave consent to interview their children. Although the exposure rate does appear to be consistent with other surveys, the adolescents’ answers could have been altered by parental knowledge of the survey.
Basch et al. (2012) set out to assess the behaviors, beliefs, and barriers related to sun exposure and sun protective behaviors among 15- to 29-year-olds. As part of the overall study, participants were asked whether they had used a tanning salon less than or more than five times in the past year. Fifty-two percent of the female participants reported using a tanning salon more than five times in the past year, and 77% reported using a tanning salon at least once in their life time (Basch et al., 2012). The sample for this study was selected from undergraduate students enrolled in the Health Promotion program of a university in western New York. The sample in this study targets college students, which does not reflect the U.S. population of young women; however, it is within the age range targeted in this study. Although the prevalence rate of this sample is obviously higher than studies with a more inclusive sample, college students are a vulnerable population for tanning bed exposure, and it is important to understand this group.
Tanning bed knowledge is defined as the awareness of the risks associated with engaging in tanning bed exposure (Dennis et al., 2009). Four of the studies identified in this review sought to determine whether the participants using tanning beds were aware of the possible negative health consequences associated with tanning. Each study had a unique way of identifying an individual’s knowledge of tanning beds.
Dennis et al. (2009) selected a sample of 162 men and women from sororities and fraternities at a Midwestern university. The purpose of the study was to understand the attitudes of frequent tanners and their knowledge regarding skin cancer prevention. The participants were given a self-administered questionnaire consisting of questions reflecting their knowledge of the risk associated with UV rays and tanning beds. The participants were asked true-or-false questions such as “Sunlamps are safer than the sun,” “Sunlamps can be dangerous,” and “Sun burning to get a tan is not harmful” (Dennis et al., 2009). The overwhelming majority of participants answered correctly to the true-or-false questions, displaying high levels of skin cancer prevention knowledge. Although 94% of the total population agreed that UV lamps can cause skin damage, 94% of the women admitted to using a tanning bed at least once in the past year (Dennis et al., 2009). The participants in this study were college students, making them more educated and more knowledgeable on tanning bed exposure. Also, the participants were not directly asked whether they felt that their specific tanning bed use could result in skin cancer. According to the study by Mayer et al. (2011) previously noted, 84% of the population agreed that indoor tanning can cause skin cancer. Approximately half of this sample included women, aged 14–17 years. Their parents were asked the same question, with roughly the same percentage agreeing to the same belief, demonstrating the possibility that the adolescents’ responses were influenced by the parents. Fifty-three percent of the population agreed with the statement that their chances of skin cancer were small (Mayer et al., 2011).
Heckman et al. (2008) attempted to understand the beliefs of individuals by asking questions soliciting the individuals’ beliefs of their skin cancer risk compared with others and their use of certain sun protective measures. The study reported results for different age groups. In the 18- to 29-year age group, 31% of the participants reported that they perceive themselves to have higher skin cancer risk compared with others (Heckman et al., 2008). This is not directly informative of the knowledge of skin cancer risk with tanning bed use, because the knowledge and prevalence questions did not coincide. This study is representative of the U.S. demographics; however, the results of this study cannot be relied upon when trying to assess whether individuals using a tanning bed are aware of the skin cancer risk associated with tanning. It is unknown what percentage of the 31% used tanning beds. It is possible that participants included in this percentage could be answering that they are more susceptible to skin cancer because they are fair-skinned rather than because they use a tanning bed.
SYNTHESIS OF LITERATURE
The quantitative data collected from the individual studies are not homogenous; therefore, narrative summaries will be used for this systematic review. Three of the studies did have fairly homogenous samples, and the studies produced similar results relating to the prevalence of exposure to tanning beds. The prevalence of tanning bed use within 1 year of the study for women within the age range of 18–29 years averaged between 27% and 32%. One of the studies reported that a combined percentage of women between 14 and 17 years old who used tanning beds in the past year was 17.1%, beginning with 14 years old at 8.5% and ending with 17 years old at 27% (Mayer et al., 2011). The percentage of use increased per year of age, so this does seem to be congruent with the prevalence cited for the age range of 18–29 years. The percentage of use is highest with 18- to 21-year-olds and slightly declines with 22- to 25-year-olds. One of the studies showed excessive bias in the sample and was determined to be unreliable in assessing exposure to tanning beds among young women (Lostritto et al., 2012). The sample was drawn from a previous study of early-onset benign skin conditions. The study did attempt to exclude participants from the sample who had a history of skin cancer or other potential benign skin conditions; however, the motive for the study was to determine behavioral correlates for people who engage in indoor tanning.
Tanning bed users’ knowledge of the risks involved in the activity was measured in four of the six studies identified, albeit to varying degrees. Two of the studies had homogenous samples representative of the U.S. population, but the survey questions were not similar enough to rely on the results as two independent comparable studies (Heckman et al., 2008; Mayer et al., 2011). The Mayer survey of 14- to 17-year-old women found that 84% agreed that indoor tanning could cause skin cancer, whereas the Heckman study reported 31% of persistent tanners perceived that they had a higher chance of developing skin cancer. Heckman’s 31% is a more reliable figure as it relates to women who do use the tanning booth, because it was measured from women who reportedly tanned at least once in the past year. However, the question posed to them was not direct enough to determine that they know the tanning bed increases their risk of skin cancer. The positive answers could have come from women who are fair-skinned and believe they are at a greater risk. The study by Dennis et al. (2009) directly sought to determine the beliefs and behaviors of frequent tanners. They found that almost 94% of the sample of individuals who tanned in the past year agreed that UV lamps can cause skin damage. The study did not measure whether the participants believed that their own use of the UV lamps caused skin damage that could lead to cancer. Overall, the level of consistency in the studies was too low when gathering data on the knowledge of tanning bed users to synthesize a result of how many women understand the effect of their actions.
Adolescent women between the ages of 15 and 25 years are using tanning beds. Approximately one out of every four women between the ages of 15 and 25 years uses a tanning bed at least once a year. Exposure to tanning beds increases with age and is associated with social influences. This age group of women does display knowledge that tanning beds can cause cancer; however, it is unclear whether they believe that their use of tanning beds increases their risk for skin cancer.
SUMMARY AND SIGNIFICANCE
The prevalence of tanning bed exposure for women ages 15–25 years is approximately what was expected before the study. The knowledge of the risk associated with tanning beds was not clearly showed by the studies. The studies do, however, show that almost all users understand that there are some risks involved. In summary, the 15- to 25-year age group of young women is at a high risk for developing skin cancer, and it is not apparent that they fully understand the risk they are subjecting themselves to. These are women at a reproductive age, and it would be detrimental to society if the risk they are subjecting themselves to became a reality.
The implications to this study are that women’s knowledge of tanning bed use is not enough to prevent use. Although it is not necessary to get a sunburn to have skin cancer, the risk significantly increases with a severe sunburn. A survey reported that greater than half of adolescent tanning bed users had burns because of frequent exposure (Cokkinides, Weinstock, Lazovich, Ward, & Thun, 2009). Women should be educated on how skin cancer evolves. Frequently going to a tanning bed for moderate tans can produce precancerous or cancerous cells. According to the Skin Cancer Foundation, “Studies have demonstrated that exposure to UV radiation during indoor tanning damages the DNA in the skin cells…[and] can lead to premature skin aging, immune suppression, and eye damage, including cataracts and ocular melanoma” (The Skin Cancer Foundation, 2011, p. 1). Because this age range generally produces the highest prevalence of UV exposure, it would be ideal to deepen their knowledge on the risk associated with tanning.
PLANS FOR DISSEMINATION
Skin cancer awareness programs should be implemented into middle schools. The programs could be incorporated into the physical education curriculum or have a program similar to the DARE programs. Dermatologists or dermatology nurses could occasionally travel to different schools educating students on skin cancer risks and prevention. Because early adulthood is the period of greatest sun exposure and vulnerability, it would be ideal to educate early, promoting sun protective behaviors and reducing tanning bed use. Educating the children at this age is important before they are subjected to increasing peer pressure with age.
Indoor tanning has drawn some attention in the legislature over the past few years. Some states have banned indoor tanning use for individuals 18 years old and younger (The Skin Cancer Foundation, 2011). Although this ban is encouraging, this will still not prevent 18- to 25-year-old women from using tanning beds, and an outdoor tan is a simple substitute for those who are banned from using tanning beds. Congress has enacted a healthcare bill, which includes a 10% tax on individuals using a tanning bed (U.S. Government, 2010). The tax may discourage some individuals from using tanning beds, which is a step in the right direction. However, it would be much more beneficial if the tax revenue were used to fund mass media campaigns and skin cancer prevention and awareness programs instead of being applied to other healthcare programs. After completing this systematic review, it can be concluded that women need to be further educated at an early age on the prevalence of skin cancer, risk of tanning bed exposure, and skin cancer prevention.
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