BRIEF REPORT Pediatric Dermatology Vol. 32 No. 4 e169–e170, 2015
Indoor Tanning Practices of Colorado High School Students Abstract: For the first time, the 2013 Colorado Youth Risk Behavior Survey assessed indoor tanning practices of Colorado high school students. The survey revealed that girls are more likely to use indoor tanning devices than boys and that the majority of students who tan do so once or twice annually. Health care professionals and policymakers should focus on these groups in efforts to curtail indoor tanning and the associated risk of skin cancer in youth.
Ultraviolet (UV) radiation is the leading risk factor for skin cancer, the most common malignancy worldwide. Modern tanning beds emit primarily UVA rays and can deliver radiation exposure that is up to 12 times as great as that of the sun (1). The national Youth Risk Behavior Survey (YRBS) has included a tanning bed question for several years (2), yet although tanning beds are actively marketed to college students (3), patterns of tanning device use in the high school population have been poorly studied. In 2013, for the first time, the Colorado YRBS included a question regarding indoor tanning in high school students. Part of the Healthy Kids Colorado Survey (HKCS), YRBS is a comprehensive survey to assess health behaviors of more than 40,000 Colorado youth. The tanning bed question specifically assessed the frequency of “indoor tanning device use in the past 12 months.” The HKCS 2013 used a two-stage stratified clustered sampling design, with schools sampled in the first stage and classrooms sampled within selected schools in the second stage. The survey was then administered to all students within the selected classrooms during a normal classroom or homeroom period. Results were weighted to represent student enrollment in all Colorado public high schools to account for unequal chances of completing the survey. Publicly available survey data and demographic characteristics of survey responders were extracted for the indoor tanning question.
DOI: 10.1111/pde.12598
© 2015 Wiley Periodicals, Inc.
A total of 12,144 high school students representing 19 Colorado regions provided responses to the indoor tanning question. Tanning beds were used over the last 12 months by 4.1% of boys (95% confidence interval [CI] 3.4%, 4.8%) and 8% of girls (95% CI 7.3%, 8.7%). Groups at greater risk for tanning bed use were girls age 16 or 17 years (10.2% [95% CI 9%,11.3%]), 11th-grade girls (9.0% [95% CI 7.5%, 10.6%]), 12thgrade girls (13.8% [95% CI 11.3%, 16.2%]), and white girls overall (9.4% [95% CI 8.4%, 10.3%]). Male counterparts demonstrated much lower rates of usage (3.4% [95% CI 2.7%, 4.1%], 2.3% [95% CI 1.6%, 3.1%], 6.4% [95% CI 4.5%, 8.2%], and 3.5% [95% CI 2.7%, 4.3%], respectively). Black high school boys (7.6% [95% CI 4.3%, 10.8%]) and girls (6.7% [95% CI 2.9%, 10.6%]) used UV tanning devices at similar rates. Of high school students who used indoor tanning in the past 12 months, most tanned “1 or 2 times,” followed in decreasing order by “3 to 9 times,” “40 or more times,” and “10 to 19 times” (Table 1). This cross-sectional survey confirms that high school girls in Colorado are more likely to use indoor tanning devices than boys. The Colorado HKCS survey is administered every other year, with the next iteration in 2015. Centers for Disease Control and Prevention research using multiyear national YRBS data demonstrates that states with age-restricted indoor tanning laws have lower rates of indoor tanning in minors (4). The International Agency for Research on Cancer classifies indoor tanning devices as class I (carcinogenic to humans) (5). Despite this classification, only 11 states have successfully banned UV tanning for minors. State-level YRBS indoor tanning data may be important to inform evidence-based policy changes to restrict indoor tanning bed use by minors and ultimately reduce the incidence of skin cancer. FUNDING SOURCE This study received no direct funding. The Colorado YRBS is a jointly funded project by three state agencies: Colorado Department of Education, ColoTABLE 1. Frequency of Indoor Tanning Use in Past 12 Months by Colorado High School Students Number of uses of indoor tanning in the past 12 months
% (95% confidence interval)
0 1–2 3–9 10–19 20–39 ≥40
93.9 (93.3, 94.4) 1.8 (1.6, 2.1) 1.5 (1.2, 1.8) 1.0 (0.8, 1.2) 0.6 (0.4, 0.8) 1.2 (1.0, 1.3)
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rado Department of Public Health and Environment, and Health and Human Services Office of Behavioral Health. Dr. Dellavalle is supported by grants from the CDC and National Institutes of Health (NIH). CONFLICT OF INTEREST Robert Dellavalle is chair of the Colorado Skin Cancer Task Force. The Department of Veterans Affairs, CDC, and NIH had no role in the design and execution of the study, and any opinions expressed herein do not necessarily reflect the opinions of these organizations. REFERENCES 1. Hornung RL, Magee KH, Lee WJ et al. Tanning facility use: are we exceeding the Food and Drug Administration limits? J Am Acad Dermatol 2003;49:655–661. 2. Guy GP Jr, Berkowitz Z, Everett Jones S et al. Trends in indoor tanning among US high school students. JAMA Dermatol 2014 Dec 23. doi: 10.1001/jamadermatol. 2014.4677. [Epub ahead of print]. 3. Boyers L, Karimkhani C, Crane L et al. Buying indoor tanning with university debit cards. J Am Acad Dermatol 2014;71:199–201. 4. Guy GP Jr, Berkowit Z, Jones SE et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health 2014;10:e69–e74.
5. International Agency for Research on Cancer. Sunbeds and UV radiation [online]. http://www.iarc.fr/en/mediacentre/iarcnews/2009/sunbeds_uvradiation.php. Accessed on November 24, 2014. Chante Karimkhani, B.A.* Yuri T. Jadotte, M.D.†,‡,§ Cate Townley, MURP, M.U.D.¶ Nicole Collins, M.P.H.¶ Robert P. Dellavalle, M.D., Ph.D., MSPH**,††,‡‡ *College of Physicians and Surgeons, Columbia University, New York, New York, †Division of Science, School of Nursing, ‡Department of Quantitative Methods, Biostatistics and Epidemiology, School of Public Health, §Northeast Institute for Evidence Synthesis and Translation, A Collaborating Center of the Joanna Briggs Institute, Rutgers University, Newark, New Jersey, ¶Colorado Department of Public Health and Environment, Denver, Colorado, Departments of **Dermatology and ††Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, ‡‡Department of Dermatology, Denver Veterans Administration Hospital, Aurora, Colorado Address correspondence to Robert P. Dellavalle, M.D., Ph.D., MSPH, Chief of Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont Street, Box 165, Denver, CO 80220, or e-mail: [email protected].
Indoor Tanning Practices of Colorado High School Students Abstract: For the first time, the 2013 Colorado Youth Risk Behavior Survey assessed indoor tanning practices of Colorado high school students. The survey revealed that girls are more likely to use indoor tanning devices than boys and that the majority of students who tan do so once or twice annually. Health care professionals and policymakers should focus on these groups in efforts to curtail indoor tanning and the associated risk of skin cancer in youth.
Ultraviolet (UV) radiation is the leading risk factor for skin cancer, the most common malignancy worldwide. Modern tanning beds emit primarily UVA rays and can deliver radiation exposure that is up to 12 times as great as that of the sun (1). The national Youth Risk Behavior Survey (YRBS) has included a tanning bed question for several years (2), yet although tanning beds are actively marketed to college students (3), patterns of tanning device use in the high school population have been poorly studied. In 2013, for the first time, the Colorado YRBS included a question regarding indoor tanning in high school students. Part of the Healthy Kids Colorado Survey (HKCS), YRBS is a comprehensive survey to assess health behaviors of more than 40,000 Colorado youth. The tanning bed question specifically assessed the frequency of “indoor tanning device use in the past 12 months.” The HKCS 2013 used a two-stage stratified clustered sampling design, with schools sampled in the first stage and classrooms sampled within selected schools in the second stage. The survey was then administered to all students within the selected classrooms during a normal classroom or homeroom period. Results were weighted to represent student enrollment in all Colorado public high schools to account for unequal chances of completing the survey. Publicly available survey data and demographic characteristics of survey responders were extracted for the indoor tanning question.
DOI: 10.1111/pde.12598
© 2015 Wiley Periodicals, Inc.
A total of 12,144 high school students representing 19 Colorado regions provided responses to the indoor tanning question. Tanning beds were used over the last 12 months by 4.1% of boys (95% confidence interval [CI] 3.4%, 4.8%) and 8% of girls (95% CI 7.3%, 8.7%). Groups at greater risk for tanning bed use were girls age 16 or 17 years (10.2% [95% CI 9%,11.3%]), 11th-grade girls (9.0% [95% CI 7.5%, 10.6%]), 12thgrade girls (13.8% [95% CI 11.3%, 16.2%]), and white girls overall (9.4% [95% CI 8.4%, 10.3%]). Male counterparts demonstrated much lower rates of usage (3.4% [95% CI 2.7%, 4.1%], 2.3% [95% CI 1.6%, 3.1%], 6.4% [95% CI 4.5%, 8.2%], and 3.5% [95% CI 2.7%, 4.3%], respectively). Black high school boys (7.6% [95% CI 4.3%, 10.8%]) and girls (6.7% [95% CI 2.9%, 10.6%]) used UV tanning devices at similar rates. Of high school students who used indoor tanning in the past 12 months, most tanned “1 or 2 times,” followed in decreasing order by “3 to 9 times,” “40 or more times,” and “10 to 19 times” (Table 1). This cross-sectional survey confirms that high school girls in Colorado are more likely to use indoor tanning devices than boys. The Colorado HKCS survey is administered every other year, with the next iteration in 2015. Centers for Disease Control and Prevention research using multiyear national YRBS data demonstrates that states with age-restricted indoor tanning laws have lower rates of indoor tanning in minors (4). The International Agency for Research on Cancer classifies indoor tanning devices as class I (carcinogenic to humans) (5). Despite this classification, only 11 states have successfully banned UV tanning for minors. State-level YRBS indoor tanning data may be important to inform evidence-based policy changes to restrict indoor tanning bed use by minors and ultimately reduce the incidence of skin cancer. FUNDING SOURCE This study received no direct funding. The Colorado YRBS is a jointly funded project by three state agencies: Colorado Department of Education, ColoTABLE 1. Frequency of Indoor Tanning Use in Past 12 Months by Colorado High School Students Number of uses of indoor tanning in the past 12 months
% (95% confidence interval)
0 1–2 3–9 10–19 20–39 ≥40
93.9 (93.3, 94.4) 1.8 (1.6, 2.1) 1.5 (1.2, 1.8) 1.0 (0.8, 1.2) 0.6 (0.4, 0.8) 1.2 (1.0, 1.3)
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rado Department of Public Health and Environment, and Health and Human Services Office of Behavioral Health. Dr. Dellavalle is supported by grants from the CDC and National Institutes of Health (NIH). CONFLICT OF INTEREST Robert Dellavalle is chair of the Colorado Skin Cancer Task Force. The Department of Veterans Affairs, CDC, and NIH had no role in the design and execution of the study, and any opinions expressed herein do not necessarily reflect the opinions of these organizations. REFERENCES 1. Hornung RL, Magee KH, Lee WJ et al. Tanning facility use: are we exceeding the Food and Drug Administration limits? J Am Acad Dermatol 2003;49:655–661. 2. Guy GP Jr, Berkowitz Z, Everett Jones S et al. Trends in indoor tanning among US high school students. JAMA Dermatol 2014 Dec 23. doi: 10.1001/jamadermatol. 2014.4677. [Epub ahead of print]. 3. Boyers L, Karimkhani C, Crane L et al. Buying indoor tanning with university debit cards. J Am Acad Dermatol 2014;71:199–201. 4. Guy GP Jr, Berkowit Z, Jones SE et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health 2014;10:e69–e74.
5. International Agency for Research on Cancer. Sunbeds and UV radiation [online]. http://www.iarc.fr/en/mediacentre/iarcnews/2009/sunbeds_uvradiation.php. Accessed on November 24, 2014. Chante Karimkhani, B.A.* Yuri T. Jadotte, M.D.†,‡,§ Cate Townley, MURP, M.U.D.¶ Nicole Collins, M.P.H.¶ Robert P. Dellavalle, M.D., Ph.D., MSPH**,††,‡‡ *College of Physicians and Surgeons, Columbia University, New York, New York, †Division of Science, School of Nursing, ‡Department of Quantitative Methods, Biostatistics and Epidemiology, School of Public Health, §Northeast Institute for Evidence Synthesis and Translation, A Collaborating Center of the Joanna Briggs Institute, Rutgers University, Newark, New Jersey, ¶Colorado Department of Public Health and Environment, Denver, Colorado, Departments of **Dermatology and ††Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, ‡‡Department of Dermatology, Denver Veterans Administration Hospital, Aurora, Colorado Address correspondence to Robert P. Dellavalle, M.D., Ph.D., MSPH, Chief of Dermatology Service, Department of Veteran Affairs Medical Center, 1055 Clermont Street, Box 165, Denver, CO 80220, or e-mail: [email protected].
