Rates of melanoma, the deadliest form of skin cancer, have increased over the past few decades.1,2 Children and young adults have not been excepted, with melanoma rates among the pediatric population also increasing rapidly.3,4 Indoor tanning once in one's youth nearly doubles melanoma risk5–7 and a dose-response relationship between indoor tanning and melanoma has been confirmed by meta-analysis.7 Assessing populations that may indoor tan at higher rates remains critical; reducing adolescent indoor tanning exposure has become a national priority with Healthy People 2020.8 Despite legislative efforts to curb this behavior,9 tanning booths remain ubiquitous10 and youth indoor tanning rates remain high.11,12 Moreover, adolescents seem less likely to appreciate melanoma risk than in the past, evidenced by declining sunscreen use rates.13
The cause of why individuals indoor tan may be multifaceted. Prior research has linked indoor tanning use with other risky behaviors, including substance abuse and anxiety.14–16 Individuals' body image concerns, though, may prove as or more important for many individuals as a reason underlying their decision to indoor tan. Research characterizing individuals' indoor tanning use has often focused on concerns over skin attractiveness (e.g., acne, skin aging17) and, to a lesser extent, on concerns regarding perceived weight and body shame.15,16,18–21 Individuals who indoor tan may be at an increased risk for disordered or unhealthy weight control behaviors (e.g., fasting, vomiting, taking laxatives), even after considering individuals' other risky behaviors.16,19–21 Such unhealthy weight control behaviors have been linked to subsequent diagnosis of eating disorders22 and increased rates of suicidal behavior.23
Prior research on this topic has not been without limitations. The association between unhealthy weight control behaviors and indoor tanning has not been previously described in a nationally representative sample of female adolescents, nor has prior research compared male and female adolescents from the same sample. Importantly, some prior literature has not considered other, potentially confounding, sun-related behavior or individuals' overall psychological well-being.19,20 In this study, we attempt to address these limitations using newly released federal data. In a series of analyses, we examine if adolescent indoor tanning users display unhealthy weight control behaviors at higher rates than those who do not indoor tan. For comparison with prior research, we present results stratified by sex and additionally assess whether these associations differ between males and females.
The National Youth Risk Behavior Survey (YRBS) is a biennial, nationally representative, high school–based cross-sectional study conducted by the Centers for Disease Control and Prevention (CDC). The survey monitors priority health risks and, in 2009 and 2011, included questions regarding adolescents' use of indoor tanning and other risky health behaviors. The survey's methodology has been previously described,24 as has the rationale for study question inclusion.25 In brief, the YRBS used a stratified, multistage sample design and oversampled high schools with large minority populations to generate nationally representative estimates.
Participation was voluntary and local parental permission procedures were used. For 2009 and 2011, student response rates were 88% and 87%, respectively; the school response rates were 81% for both the years. Students completed anonymous, self-administered pencil-and-paper questionnaires. Data are publicly available, and the study design was approved by the institutional review board at the CDC.
Three dichotomous variables served as outcome measures. They assessed a recent history of unhealthy weight control behaviors. Respondents were asked, in the past 30 days: (1) “did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?”; (2) “did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight?”; and (3) “did you vomit or take laxatives to lose weight or keep from gaining weight?”
Respondents were asked, “During the past 12 months, how many times did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth? (Do not include getting a spray-on tan).” Results were dichotomized, and a variable indicating whether or not an individual indoor tanned within the past year was used.
Additional variables were used in the multivariate logistic regressions. These included individuals' self-perception of their weight. Individuals were asked to assess their weight status on a 5-point Likert scale as “very overweight,” “slightly overweight,” “about the right weight,” “slightly underweight,” and “very underweight”; responses were grouped as overweight, normal, or underweight. BMI percentile for child age and gender was calculated from self-reported height and weight. It was included as a categorical variable to reflect normal weight, overweight, and obese status (<85th, 85th–95th, ≥95th age and gender-specific percentiles, respectively). A variable indicating whether an individual was currently attempting to lose weight was also included, derived from a question asking, “Which of the following are you trying to do about your weight?” to which respondents could answer that they were attempting to, “lose weight,” “gain weight,” “stay the same weight,” or “not trying to do anything about my weight.” Because previous research has suggested that individuals' actual body weight, perceived body weight, and current attempts to change their weight may be associated with indoor tanning use,15,16,18–21 these measures were included as potential confounding factors. Because prior studies have also suggested that demographics may influence dieting and tanning behaviors,26 variables for academic grade, age, and ethnicity (non-Hispanic white, non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic, other/multiple) were included. Included as well were variables indicating whether or not an adolescent had, within the past 12 months, felt sad or hopeless, or reported having been bullied at school because, as discussed above, mental health has been previously linked with unhealthy eating behaviors.23 Variables indicating whether or not a respondent reported having ever had sex or having smoked, drunk alcohol, or drunk more than 5 alcoholic drinks in a row within the past 30 days were also included as potential confounders following prior research's suggestion that indoor tanning users may be risk taking.14–16,18–21 Additionally, a variable indicating an individual's routine use of sunscreen was included. Respondents were asked whether, when in the sun for over an hour, they wore sunscreen (SPF ≥15); following prior research,27 responses were grouped to indicate those individuals who used sunscreen always or most of the time.
Analyses were weighted and account for clustering of responses; standard errors were calculated by Taylor series linearization. Cross tabulations were assessed by χ2 tests that adjust for the complex survey design.28 Multivariate logistic analysis of pooled data was conducted. Analyses were stratified by respondent gender. All analyses were conducted using Stata 11.2 (StataCorp LP, College Station, Texas).
In 2009 and 2011, 31,835 high school students were surveyed by the Youth Risk Behavior Survey (YRBS). Of these, 85% (n = 26,951) responded to questions regarding indoor tanning use and were included in the analysis. Those who did not were less likely to be non-Hispanic white and more likely to be non-Hispanic Asian or Hispanic. Only 4% of non-Hispanic whites had missing data for indoor tanning use, whereas 16%, 26%, and 32% of non-Hispanic blacks, Hispanics, and non-Hispanic Asians did. Of females who indoor tanned, 87% were non-Hispanic whites; 67% of male tanners were non-Hispanic whites. The sample's demographic characteristics are described in Table 1.
Rates of indoor tanning use by adolescent characteristics are shown in Table 2. Data reveal 23.3% of females used indoor tanning within the past year; 6.5% of males did so as well. Rates increased by age and grade. Only 13.2% of girls aged ≤14 years reported indoor tanning within the past year, whereas 33.0% of women aged ≥18 years reported that they had done so. A similar increase was observed in males; 4.9% of those aged ≤14 years had used indoor tanning within the past year, whereas 10.7% of those aged ≥18 years reported that they had.
Differences existed between racial groups, though differences were larger in females than in males. Non-Hispanic white (33.7%) and Hispanic (10.3%) females were most likely to have indoor tanned within the past year. Non-Hispanic black females were least likely (3.0%). For males, those of multiple or other races (7.0%) and non-Hispanic whites (6.7%) were most likely to report indoor tanning within the past year, whereas non-Hispanic blacks were least likely (5.1%). Only among non-Hispanic blacks did males report indoor tanning use in higher numbers than females, though this difference was not statistically significant.
Table 3 displays that among both males and females, those who indoor tanned had higher rates of unhealthy weight control behaviors. They were more likely to report, within the past 30 days: having fasted for more than 24 hours; having taken a pill, powder, or liquid; and having vomited or taken a laxative to lose weight. Females who indoor tanned were more likely than those females who did not to perceive themselves as normal weight (60.2 vs 55.1%). Self-perception of one's weight did not differ between males who indoor tanned and those who did not. Females who indoor tanned were more likely than females who did not to report attempting to lose weight (67.7 vs 58.7%); male indoor tan users were, by contrast, less likely to do so (25.5 vs 31.1%).
Results from the gender-stratified multivariate logistic regression models assessing the association between indoor tanning and unhealthy weight control behaviors are displayed in Table 4. In all cases, adjusted results show statistically significant associations for both males and females, and results from sex-aggregated models confirm a statistically significant difference in these relationships by sex. All else equal, it was more likely that a female had fasted (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0–1.5), taken a pill, powder, or liquid (OR, 2.4; 95% CI, 1.9–3.0), or vomited or taken a laxative to lose weight (OR, 1.4; 95% CI, 1.1–1.7) within the past 30 days if she had indoor tanned within the past year. The estimated magnitudes of these associations were even greater for males. Males who indoor tanned within the past year were, on average, more likely to have fasted (OR, 2.3; 95% CI, 1.7–3.1), taken a pill, powder, or liquid (OR, 4.4; 95% CI, 3.3–6.0), or vomited or taken a laxative to lose weight (OR, 7.1; 95% CI, 4.4–11.4) within the past 30 days.
Indoor tanning is a preventable cause of melanoma, the incidence of which is increasing in epidemic proportions.1,29 Prior studies on the motivations of those who indoor tan suggest that users perceive tanned skin as healthy,30 have skin or body image concerns,15,16,18 and may be risk taking, frequently engaging in other risky behaviors.14–16,18–21 Yet, a comparison of whether male and female patrons of indoor tanning salons engage in unhealthy weight control behaviors at similar rates has not been previously assessed using a nationally representative sample. The results of this study confirm that indoor tanning use is associated with increased rates of unhealthy weight control behaviors and suggest that the association between unhealthy weight control behaviors and indoor tanning is even stronger among males.
These results indicate the need to reassess why adolescents indoor tan. Indoor tanning is common, with roughly one-third of high school senior females and nearly 10% of high school senior males reporting tanning within the past year. Of those who indoor tanned, over 1 in 5 had also fasted for more than 24 hours within the past month to lose weight. Indoor tanning users were also much more likely to have, in the past 30 days, taken a pill, powder, or liquid to lose weight, and to have vomited or taken a laxative to lose weight. In stratified adjusted analyses, the odds that a female who indoor tanned also reported recently engaging in an unhealthy weight control behavior were 1.3 to 2.4 times greater, depending on the behavior assessed, than those who did not indoor tan. The association was even stronger for males, with the odds that a male who indoor tanned also reported an unhealthy weight control behavior were, by comparison, 2.3 to 7.1 times greater than those who did not indoor tan. In assessing each unhealthy weight control behavior, the difference between the sexes was statistically significant and greater for men who indoor tanned than women who did so.
That the association between unhealthy weight control behaviors and indoor tanning was even stronger among males merits comment. The population of males who indoor tans may, when compared to those females that do so, constitute a self-selected group of their same-sex peers at higher risk for victimization, may be less risk averse, or may be less familiar with the potential risks of indoor tanning. Prior research, for example, has reported that, compared to their male peers, males who indoor tan engage in risky steroid use at higher rates and also report being targets of victimization at higher rates.19 Perhaps sex differences in the associations between indoor tanning use and unhealthy weight control behaviors belie different underlying processes motivating these behaviors. Alternatively, such differences might represent different temporal points along a spectrum of disease motivating indoor tanning use. One may note that in this study, females who indoor tanned were more likely than females who did not indoor tan to indicate both that they considered themselves currently of normal weight and that they were attempting to lose weight. Males who indoor tanned, by contrast, were not more likely than other males to indicate they were currently attempting to lose weight and did not describe their weight any differently from their peers who did not indoor tan. Moreover, the number of males who perceived themselves as underweight was increased among indoor tanners, albeit nonsignificantly. This may suggest that, for males, it could be desirable among those of low weight who already engage in unhealthy weight control behaviors to begin to tan. For females, by contrast, indoor tanning may be early evidence of increased risk to develop more frank disease. Although no firm conclusions can be reached from these cross-sectional data alone, they suggest a need to assess the interplay between body weight, self-perception of body weight, and the onset of indoor tanning in a longitudinal cohort.
The implications of these findings for child health and pediatric care are manifold. These results lend credence to prior hypotheses that concerns about a negative body image are a more likely cause for indoor tanning use25,28 than are positive ideals about body image (e.g., that tan skin appears healthy).30 Understanding and addressing why these behaviors move in tandem are essential to improved policies and patient counseling strategies to help curb the rising melanoma epidemic. Screening adolescents for indoor tanning use may serve a double purpose. Because melanoma is among the most common cancers in young adulthood,31 screening adolescents serves as an important vehicle for patient education and primary prevention.
Yet results of this study suggest that screening for indoor tanning may help identify patients at risk for unhealthy weight control behaviors as well. Health care providers may be able to capitalize on counseling techniques developed to target other problems, like smoking, with negative effects perceived by youth to be far-off consequences.32,33 Adolescents may respond to interventions highlighting shorter term problems like indoor tanning's negative effects on skin texture, wrinkles, and eye damage5,6; facial aging software may also hold promise as a technique by which to promote skin-healthy behaviors.34 A recent trial on physician counseling highlighting damaged skin increased subsequent sun-protective behaviors,35 providing proof of concept that, when framed appropriately, behavioral change regarding tanning is possible. In the best of circumstances, adolescent screening might identify, or perhaps in light of concerns over tanning's addictive nature,36,37 prevent adolescents from concomitant unhealthy weight control behaviors.
Although these results provide cause for already growing concern over indoor tanning, some caution in interpreting these results is needed. No study is without limitations, and data presented here are cross-sectional and cannot be used to infer causality. Data, including respondents' heights and weights, are self-reported and may be subject to recall or other biases. Unmeasured confounding may remain. Because the sample is nationally representative of high-school students, and not all adolescents, results may not be generalizable to other groups. Of potential theoretical importance and as mentioned above, we cannot assess the temporality between unhealthy weight control behaviors and indoor tanning use. One may precede the other or they may evolve contemporaneously. The corresponding associations of these with self-esteem and body image remain unknown.
Nonetheless, we believe this study has important strengths. The link between unhealthy weight control behaviors and indoor tanning has not been previously described in a nationally representative sample of female adolescents, nor has prior research compared male and female adolescents from the same sample. This study uses nationally representative data to do so. Though data are cross-sectional, adjustments have been made for skin and non-skin behavioral characteristics to assess more clearly the independent association of indoor tanning with unhealthy weight control behaviors. Results of this study expand the potential clinical usefulness of screening or counseling adolescents for indoor tanning use. The findings lend credence to prior research assessing potential effects of body image and suggest a need to redouble efforts to understand and target high-risk adolescent groups. An improved understanding of how media, peer networks, and other social influences affect adolescent decisions to indoor tan is much needed.
In summary, this study suggests an association exists between indoor tanning use and unhealthy weight control behaviors among both male and female adolescents. An even stronger relationship was observed in males. The number of adolescents at risk for harmful unhealthy weight control behaviors that indoor tan is sizable, and greater attention to these issues by pediatricians may help reduce the number of adolescents risking potentially deadly consequences.
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