Robin Ashinoff, MD, Director, Dermatologic, Mohs and Laser Surgery, Hackensack and University Medical Center, Hackensack, New Jersey; Vicki J. Levine, MD, Chief, Dermatologic and Mohs Surgery, New York University Medical Center, New York, New York; Alexa B. Steuer, Cresskill High School, Cresskill, New Jersey, Carly Sedwick, Quinnipiac College, Hamden, Connecticut
Abstract
Background: The incidence of skin cancer, including melanoma, continues to increase. Teenagers are especially vulnerable, as are young females. The incidence of melanoma among young women in their twenties and thirties has begun to increase again. These young people are also the population that frequent tanning salons. Objective: This voluntary, anonymous, New York University, Institutional Review Board-approved survey was given to students in grades 9 through 12 to ascertain their understanding of what causes skin cancers and the dangers of excessive sun exposure and tanning salons.Methods and materials: An Institutional Review Board-approved, 22-question survey was administered anonymously to more than 450 students with 368 returned responses. The survey was administered to students in grades 9 through 12 at two high schools in New York and New Jersey.Results: More than 80 percent of students view movie stars as tan and almost 60 percent see “tan” people as better looking. In addition, more than 90 percent believe that a tan does not prevent further damage to the skin (as opposed to the customary belief that a “base” tan can protect against extreme sun exposures, such as when on a tropical vacation). There appears to be a disconnect between knowledge and sun tanning behaviors. Most teenagers still believe that tans are attractive and teenage girls continue to use tanning salons and tan naturally. We need to address the connection between sun tanning in youth and skin cancers years later. Legislation to limit access of tanning salons to teenagers needs to be enacted.
(J Clin Aesthetic Dermatol. 2009;2(2):48–50)
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According to the Skin Cancer Foundation, every year nearly 2.3 million American teenagers visit tanning salons.[1,2] This habit may contribute to the increasing incidence of skin cancer among the under 40 years of age population.[3–5] Tanning is now thought to be truly “addictive” because endorphin release during sun exposure reinforces this unhealthy habit.[6,7]
Recent findings indicate that nonmelanoma skin cancer is increasing in young adults, especially in young women.[8] In a recent report by Purdue et al,[9] analyzing SEER (Surveillance, Epidemiology, and End Results Program) data suggested that melanoma incidence is increasing in young women as well, and this may be directly linked to increasing ultraviolet radiation exposure in this population.[9] It has been shown that ultraviolet light exposure early in life is linked to skin cancer later in life, since younger skin is particularly sensitive to the detrimental effects of ultraviolet light.[5,10–13]
We administered a survey of 26 questions to more than 450 high school students in grades 9 through 12 in two high schools in two northeastern states (New York and New Jersey) to ascertain their baseline knowledge and beliefs concerning ultraviolet light exposure and skin cancer and to then see where we can begin to target better education efforts.
Materials and Methods
A New York University Institutional Review Board (IRB)-approved, voluntary, anonymous survey was administered to more than 450 high school students in two schools. Two of the authors (Steuer and Sedwick) were high school student and were responsible for collecting the surveys. Steuer compiled the cumulative data for statistical analysis and helped write the report. Both school principals consented to the administration of the survey to the student bodies. The survey consisted of 26 questions including demographics, such as gender, eye color, and hair color. Most of the questions required “yes” or “no” answers to ensure ease of completion, but several questions required short answers. The high schools were both public schools located in Bergen County, New Jersey and Westchester County, New York. The socioeconomic level of the participants varied from lower middle class to upper class. The survey was administered to students in grades 9 through 12 (ages 14–18). Statistical analysis of the results was performed using the binomial test.
Results
Among the approximately 430 students who responded, there were 368 evaluable responses. The mean age was 16, and there were roughly equal numbers of males and females. There were 275 students with brown eyes, 66 with blue eyes, 40 with green eyes, and 49 with hazel eyes. In terms of hair color, there were 259 with brown hair, 117 with black hair, 41 with blond hair, and 10 with red hair. This information was included to illustrate that there was a range of eye and hair color and not a predominance of any one ethnic type. The data was evaluated, and no correlation could be found between hair/eye color and behavior or beliefs.
The overwhelming majority of teenagers did not use sunless tanners. More than 80 percent did not believe that tanning salons were safer than natural exposure to the sun, yet almost 65 percent of the students felt that they should be able to use a tanning salon without the consent of their parents. Sixty percent of teens thought that “tan” people were better looking (Figure 1). Fifty-four percent of the students said that tanning now would cause their skin to look ugly in the future; however, they stated that they would continue to tan as adults (Figure 2). These students were aware of the threat that skin cancer posed to their lives and believed that a tan did not prevent future damage to the skin. Only 50 percent of students knew what a melanoma was, and almost 85 percent were not familiar with a basal cell carcinoma.
Discussion
Skin cancer is the most frequently diagnosed cancer in the United States, with increased incidence annually.[14] In fact, the incidence of malignant melanoma is increasing faster than any other cancer.[15] Ultraviolet radiation (including radiation from indoor tanning sources) is a major cause of skin cancer.[16] In one study of 385 adolescents and young adults at the University of Washington, 26 percent of participants met the CAGE criteria (a psychological questionnaire used to screen for substance abuse) and 53 percent met the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV-TR) criteria for a substance-related disorder. Screening for a substance-related disorder was positive in 12 percent of the total sample, 18 percent of the self-reported sun tanners, and 28 percent of indoor tanners.[6] Frequent tanning has biologic reinforcing properties as shown in a study of eight frequent tanners and eight control, nontanner subjects.[7] Fifty percent of the frequent tanners showed withdrawal-type symptoms with naltrexone administration.[7]
Heckman et al[16] reported that overall, indoor tanning rates were higher among young, white females having a higher level of education. Females between the ages of 20 and 39 years have shown the greatest use of indoor tanning salons. This is problematic because indoor tanning and high rates of ultraviolet exposures have been linked to higher rates of melanoma and nonmelanoma skin cancers.[17,18]
Robinson et al[2] surveyed beachgoers between the ages of 18 and 30 in Chicago and compared their answers with responses to similar surveys performed in 1988 and 1994. In 1988, only 42 percent of the respondents were aware of the relationship between tanning and sun exposure compared to 87 percent in 2007. Sixty-four percent of the respondents in 1988 thought that tan people were “better looking,” compared to 81 percent in 2007.[2] Indoor tanning salon use went from one percent in 1988 to 27 percent in 2007.[2] These results are consistent with our own survey of high school students in New York and New Jersey. Most are aware of the relationship between sun tanning and skin cancer, but believe that they will continue to tan as adults. Two explanations for this may be that: 1) teenagers often feel invincible and 2) there is a long lag time between exposure to ultraviolet radiation and the development of skin cancers.
The association between skin cancer and tanning booth use has been vehemently denied by the indoor tanning industry, but there are now good studies showing the association.[19] In a prospective study by Veierod et al,[20] the authors studied more than 100,000 Scandinavian women for an average of eight years to try to correlate an increased risk of melanoma and its association with any factors.[20] After adjustments were made for measures of sun exposure and sensitivity, the study demonstrated that there was a 55-percent increase in risk for young women developing malignant melanoma associated with a history of 40 hours or more of tanning bed use. Exposure to indoor tanning before the age of 35 has shown positive associations with the development of malignant melanoma, according to The International Agency for Research on Cancer.[4] A study by Demko et al21 found that 36.8 percent of females versus 11.2 percent of males 13 to 19 years of age had used a tanning booth and that the number of young women who had used a tanning booth increased as they got older.[21] A retrospective study looking at the incidence of dysplastic nevi in males and females 14 to 30 years of age found that extensive outdoor activity, living in a sunny locale, and use of a tanning booth was associated with having more dysplastic nevi.[22]
Looking at the results of our study and prior studies, we can see that there is concordance in our results in that teenagers still do believe that “tanner people are better looking.” Although intellectually, young people (particularly females) realize that tanning may not be healthy for them, they continue to expose themselves to dangerous ultraviolet rays. The American Academy of Dermatology (AAD) is concerned with the growing incidence of skin cancer, especially in younger people. In 2006, the AAD launched a public education campaign aimed specifically at teens telling them that indoor tanning was not safe. Many states have begun to pass legislation limiting access to tanning salons to those over the age of 14 or 16 and many require parental consent.[23,24] Overall, however, it seems that we have still not communicated this information to teenagers effectively. Therefore, national legislation is needed to prevent teenagers from accessing tanning salons.
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