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An Epidemiological Update on Indoor Tanning and the Risk of Skin Cancers
Indoor tanning (sunbeds, solarium) uses artificial ultraviolet radiation (UVR) to stimulate cosmetic tanning of the skin. Indoor tanning has been officially classified as a human carcinogen in 2009 by the International Agency for Research on Cancer of the World Health Organization (WHO). The differences in the prevalence of sunbed use across countries and over the years highlight underlying legislative, climatic, and cultural differences. Indoor tanning-seeking behaviors may be driven by motivations for an appealing appearance, largely influenced by gender and age, and several misconceptions that a prevacation tan safeguards the skin, that sunbeds can be used to treat acne or to increase vitamin D, or that tanning is a healthy habit. This review provides an epidemiological update on the prevalence of sunbed use, who tends to use sunbeds and why, and details the current evidence on the association of sunbeds with skin cancers, including cutaneous melanoma, basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (cSCC). A statistically significant higher risk of cutaneous melanoma, BCC and cSCC with the use of sunbeds has been consistently demonstrated. This risk of skin cancer is even higher with the more frequent use of sunbeds, underscoring a dose–response relationship, and in those first exposed to sunbeds at a younger age. Preventive measures against sunbed use include legislation restricting sunbed use, educational campaigns to inform and discourage from indoor tanning, as well as using the internet, online advertising messages and the social media to reach larger audiences and to promote an untanned appearance.
1. Introduction
Ultraviolet radiation (UVR), consisting predominantly of UVA (320–400 nm) and a small fraction of UVB (280–320 nm) wavelengths, is emitted by the sunlight and sunbed indoor tanning devices, and is responsible for tanning (natural or artificial tanning, respectively) [ 1 ]. In modern times, tanning (from the sun or sunbeds) presents as a wolf in sheep’s clothing. On the one hand, part of the public embraces tanning and perceives it as fashionable due to advertised and long-standing social constructs of beauty. On the other hand, tanning is a priori a marker that the skin has been under sun (UVR) “attack”.
Tanning represents acquired skin pigmentation that is induced after exposure to UVR, in contrast to the constitutional pigmentation that characterizes baseline skin color. While constitutional skin pigmentation is influenced by a variety of factors, including melanin, capillary blood flow, cutaneous chromophores (lycopene, carotene), and dermal collagen, it is the production of melanin by the melanocytes that primarily determines skin color [ 2 ]. Melanin is produced in cutaneous melanocytes, via the biochemical pathway of tyrosine, either as the brown-black eumelanin or as the yellow-red pheomelanin which differ in color and in the size, shape and packaging of their granules [ 2 , 3 ]. Pheomelanin is more photolabile and can produce hydrogen peroxide, superoxide and hydroxyl radicals, that result in oxidative stress and further DNA damage [ 3 ]. The pigmentation signaling pathway is under a complex genetic control and the ratio of eumelanin to pheomelanin determines skin color [ 2 , 4 , 5 ]. Tanning occurs after the UVR-induced production of melanin is packaged and delivered to keratinocytes by melanosomes. The melanosomes resemble umbrellas and protect the sun-exposed side of nuclei of the keratinocytes, after exposure to UVR [ 3 ].
However, tanning itself may be triggered following DNA damage from UVR exposure [ 3 ]. UVA-induced DNA damage occurs mostly indirectly, through the production of melanin, that in turn stimulates the production of reactive oxygen species (ROS) which induce single-stranded breaks in DNA, in key genes implicated in skin carcinogenesis. UVB induces direct DNA damage through the creation of photoproducts, such as cyclobutane pyrimidine dimers (CPDs), that are mutagenic if left unrepaired. However, CPDs seem to also play a central role in UVA-induced mutagenesis, as UVA may induce CPDs as a major pro-mutagenic DNA photoproduct [ 6 ]. In addition, UVA and UVB, even at suberythematogenic doses, may mediate skin carcinogenesis through immunosuppressive pathways, after cell membrane damage, DNA damage, and trans-urocanic isomerization [ 1 , 7 , 8 , 9 ].
Indoor ultraviolet radiation tanning (referred as indoor tanning from hereon) uses artificial UVR to stimulate cosmetic tanning of the skin [ 10 ]. The International Agency for Research on Cancer (IARC) regards the whole spectrum of UVR as well as UV-emitting tanning devices as first-group carcinogens alongside tobacco smoking and asbestos [ 11 ]. Regardless of the well documented harmful effects of indoor tanning, there is still a considerable frequency of sunbed use which poses questions on the motivations for tanning-seeking behaviors and whether the public is aware of the health harms and carcinogenicity induced by sunbeds, including the significant risk of skin cancers.
This is a scholarly review, and not a systematic review, aiming to present a comprehensive synthesis of the prevalence of sunbed use across various countries, which groups tend to use sunbed use and why, and summarize the up-to-date evidence on the association of sunbeds with skin cancers, including cutaneous melanoma, basal cell carcinoma (BCC), and cutaneous squamous cell carcinoma (cSCC). With this aim, we performed searches in PubMed using the terms related to each topic addressed, e.g., “indoor tanning”, “sunbed” and “melanoma”, “skin cancer”, “nonmelanoma skin cancer”, “basal cell carcinoma”, and “cutaneous squamous cell carcinoma”. Moreover, we carried out secondary referencing by manually reviewing reference lists of assessed articles.
2. Epidemiology of Sunbed Use: Variation across Countries and among Individuals
Despite the documented harmful effects of indoor tanning and restrictive legislation, a considerable prevalence of indoor tanning use has been reported across countries worldwide. The prevalence of indoor tanning use varies according to individual characteristics such as the age and gender, and according to the countries studied, (summarized in Table 1 , Figure 1 and Figure 2 ). Australia shows the lowest prevalence of indoor tanning use. The meta-analysis of Wehner et al. (1986–2012) reported a prevalence of ever-use of indoor tanning in adults ranging from 11% in Australia to 35% in the US and 42% in Europe ( Figure 1 ). The past-year prevalence of indoor tanning use was 18.3% in adolescents and 14% in adults, overall, varying across regions. Past-year use of indoor tanning in adults ranged from 2% in Australia, to 13% in the US, and to 21% in Europe ( Figure 2 ) [ 12 ]. Rodriguez-Acevedo et al. performed a meta-analysis on the prevalence of indoor tanning, from data collected after the 2009 WHO classification of indoor tanning as a carcinogen (2009–2018) [ 13 ]. Since 2009, the worldwide prevalence of ever exposure to indoor tanning was 9.7% for adolescents and 33.4% for adults. The past-year prevalence was 6.7% in adolescents and 12.5% among adults. Past-year use of indoor tanning in adults ranged from 2.5% in Australia, to 11.1% in Europe, and to 14.4% in the US ( Figure 2 ) [ 13 ]. Including the gender, the worldwide prevalence of past-year indoor tanning was higher in women compared to men (16.8% vs. 8.5%, respectively) and in adolescent girls compared to adolescent boys (8.9% vs. 3.9%, respectively), in the meta-analysis of Rotriguez-Acevedo et al. [ 13 ] ( Table 1 ).
Summary prevalence estimates (%) reported in published meta-analyses on the ever-use of indoor UVR tanning. (The prevalence for the years 1986–2012 is reported in Wehner et al. [ 12 ], and for the years 2009–2018 in Rodriguez-Acevedo et al. [ 13 ]).
Summary prevalence estimates (%) reported in published meta-analyses on the past-year use of indoor UVR tanning. (The prevalence for the years 1986–2012 is reported in Wehner et al. [ 12 ], and for the years 2009–2018 in Rodriguez-Acevedo et al. [ 13 ]).
A summary of recent publications with international results on the prevalence of indoor UVR tanning across countries.
n : number of overall participants, UVR: ultraviolet radiation, 95% CI: 95% confidence interval, (-): not reported data.
In the Euromelanoma survey study in 227,888 individuals from 30 European countries (2009–2014), the overall prevalence of ever-use of sunbed was 10.6%, with very large variations across countries. Belgium, Denmark, Estonia, Hungary, Italy, Latvia, and Spain had the higher prevalence of sunbed use of 18–27% ( Table 1 ). The majority of sunbed users were light users (<20 sessions/year, <10 years). The highest proportion of heavy users (>20 sessions/year) was found for Turkey (60%), Malta (40%), Hungary (19.1%), Russia (19%), and Spain (17.1%). Indoor tanning was reported by 5.9% of adolescents (<20 years old), 17% of young adults (20–35 years old) and 8.3% of adults/elderly (>35 years old). Overall, sunbed use was more prevalent for females compared to males, independently from age, education, skin type and year of survey. Moreover, sunbed use was significantly more frequent by those with darker skin types in 14 countries, and by fairer skin types in Switzerland [ 14 ]. In another Euromelanoma report, regarding the prevalence of sunbed use according to age, young adults were found to be the most frequent sunbed users in European studies, and variable rates of sunbed use were reported in adolescents in Sweden, the UK, Italy, Germany, France, Denmark, and the Netherlands [ 15 ]. A recent study by the Italian Cancer League in 3692 participants in the skin cancer prevention campaign across 18 Italian centers reported a prevalence of sunbed use of 2.2% before the age of 15 years and 22.2% after the age of 15 [ 16 ].
The differences in the prevalence of sunbed use across countries highlight underlying climatic and cultural differences. Sunbed use has been associated with latitude [ 14 , 17 ]. A European case-control study (1999–2001) reported higher prevalence of indoor tanning in Northern Europe and lower prevalence in the South [ 17 ]. More recently, in the Italian Cancer League study (2018–2019), the prevalence of sunbed use was significantly higher among residents in Northern Italian regions (22%) compared to the Center (17%) and South of Italy (6%) [ 16 ]. On the other hand, the risk of melanoma with sunbed use did not differ with variations in latitude in the meta-analysis of Boniol et al. [ 18 ]. The Euromelanoma study (2009–2014) used the term ‘Baltic particularity’ to describe the high prevalence of sunbed use among young adults (<35 years old) that was reported in Estonia, Lithuania and Latvia. The authors suggested that this could be attributed to the consumerism and beautification methods incurred by the rapid globalization that occurred in these countries in recent years [ 14 ]. In addition, this study used the term ‘Scandinavian particularity’ to describe the high prevalence of sunbed use among adolescents in Norway, Belgium, Denmark, and Sweden [ 14 ], as previously described [ 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. These findings underscore the importance of raising awareness on the sunbed-related risks and changing intentions and attitudes towards artificial tanning among adolescents in Scandinavian countries [ 14 ].
Over the years, the prevalence of past-year indoor tanning has decreased. Rodriguez-Acevedo et al., performed a systematic review and meta-analysis on the prevalence of indoor tanning, from data collected after the 2009 WHO classification of indoor tanning as a carcinogen (2009–2018) [ 13 ]. The change of the prevalence of indoor tanning over time was assessed by comparing with the results of a previous meta-analysis of Wehner et al. The prevalence of past-year indoor tanning among adolescents was 6.5% (95% CI: 3.3–10.6) for the period 2013–2018 [ 13 ], compared with 22% (95% CI: 17.2–26.8) reported for the 2007–2012 period by Wehner et al. [ 12 ]. This was reported as a statistically significant reduction of 70%. The indoor tanning prevalence among adults was 10.4% for 2013–2018 [ 13 ] compared with 18.2% for 2007–2012 [ 12 ], which was not a statistically significant change.
3. Motivations and Influences for Sunbed Use
A variety of motivations and influences are determinants of indoor tanning-seeking behaviors, including motivations for an appealing appearance, largely driven by gender and age, and several misconceptions that a prevacation tan safeguards the skin, that sunbeds can be used to treat acne or to increase vitamin D, or that tanning is a healthy habit.
Beautification motives of looking attractive were among the primary reasons for sunbed use in Europe, as was the influence of peers/parents using sunbeds [ 15 ]. The typical indoor tanner is female and late adolescent or young adult [ 16 , 26 , 27 ]. A review of determinants of sunbed use in Europe reported that the typical sunbed users in Europe are young-adult women, with a medium/high socio-economic status. In this study, women were 2–3 times more likely to use indoor tanning than males across all age groups [ 15 ]. A higher prevalence of sunbed use has been reported in sexual-minority men (including men who identify as homosexual, gay, bisexual, or other) compared to heterosexual men [ 28 , 29 ]. Motivations for indoor tanning among sexual-minority men include perceived appealing appearance, mood elevation, and perceived ‘healthy’ appearance of tanned skin [ 29 , 30 ].
Several misconceptions may motivate towards sunbed use. A common reason for sunbed use reported in European studies, was the wish for a ‘prevacation tan’. Most users believed that artificial tanning before the sun exposure during holidays would be beneficial for them, based on the false idea that it prepares the skin for further sun exposure [ 15 ]. However, inside the sunbeds, almost 100% of the body surface is exposed to UVA with higher amounts of irradiation compared to the partial body surface exposure to lower amounts of UVA during natural sunshine [ 31 ]. UVA irradiance emitted from indoor tanning devices has been measured to be much higher than from nature sun [ 10 ]. Moreover, as described above, tanning itself is a marker of UVR-induced DNA damage and there is no safe limit for exposure to UV radiation from sunbeds for cosmetic purposes.
Further misconceptions may promote the use of sunbeds for acne or vitamin D deficiency [ 15 , 32 ]. Patients with acne may expose themselves to indoor tanning due to the false perception that UVR is used to improve their acne. However, the use of UVR is contra-indicated for acne in the current European guidelines [ 33 ]. Devices emitting blue light may be used for the treatment of acne. However, blue light is part of the visible light spectrum, with a wavelength of 420 nm, and it has no carcinogenic effects. This is in sharp contrast with indoor tanning devices that emit the carcinogenic UVR spectrum. In these lines, sunbeds should not be used to increase vitamin D due their carcinogenic effects [ 15 ]. The false perception that tanning is healthy may arise from the presence of tanning beds in gyms and fitness facilities that are linked to exercise-associated health benefits and well-being [ 34 , 35 ]. In Canada, nearly half of the gyms offer indoor tanning, as do some of the largest American gym chains [ 34 , 36 ]. A survey in 636 indoor tanners reported that 24.2% had tanned at least once in a gym. Compared to other indoor tanners, individuals who had tanned in a gym were younger, more physically active, and more likely to be at risk for tanning dependence [ 34 ].
4. Sunbed Use and Risk of Cutaneous Melanoma
Several systematic reviews and meta-analyses have consistently established a statistically significant higher risk of cutaneous melanoma with the use of sunbeds (summarized in Table 2 ) [ 18 , 37 , 38 , 39 , 40 , 41 , 42 ]. Nevertheless, the quantification of the measure of the association of sunbed use with melanoma risk is hindered by limitations inherent to the design of individual studies. The most recent meta-analysis of An et al. (2021), included 36 studies in 14,583 melanoma cases and reported that the risk of cutaneous melanoma increased by 27% for those ever exposed to indoor tanning (RR: 1.27, 95% CI: 1.16–1.39) [ 37 ]. Similar risk estimates have been reported in previous meta-analyses (RR ranging from 1.15 to 1.27) ( Table 2 ).
Meta-analyses reporting indoor UVR tanning and risk of cutaneous melanoma. Available results by age group and dose/frequency of sunbed use are shown.
UVR: ultraviolet radiation, n : number, CM: cutaneous melanoma, y: years old, RR: relative risk, 95% CI: 95% confidence interval. (-): not reported data. Statistically significant results are shown in bold. a Different studies were included in different meta-analyses, accounting for the differences in the number of overall included cases. Apart from adding new studies, the most recent meta-analysis of An et al., 2021, did not include 8 studies that were included in the previous meta-analysis by Colantonio et al., 2014 (Beitner 1990, Gallagher 1986, Dubin 1989, Holly 1987, Kaskel 2001, Klepp and Magnus 1979, Rodenas 1996, Schmitt 2011). The meta-analysis of Boniol et al., updated the meta-analysis by IARC. b correction by Boniol et al. [ 43 ]. c Included longest duration or highest frequency of use. d Included studies with different age cut-offs ranging from 10–19 years to <30.
A dose-response relationship has been consistently shown between the amount of sunbed use and the risk of melanoma ( Table 2 ). A significantly higher risk of melanoma was associated with 10 or more annual times of sunbed use [ 37 , 38 , 39 ] and with high [ 18 ] or longest exposure [ 42 ]. The meta-analysis of Boniol et al. (2012) reported a 1.8% increase in risk of melanoma for each additional session of indoor tanning per year [ 18 ].
The younger age at first exposure to sunbeds has been associated with significantly higher risk of melanoma in individual studies [ 44 , 45 , 46 , 47 , 48 ], systematic reviews and meta-analyses [ 18 , 37 , 41 , 49 ] ( Table 2 ). The study of Lazovich et al., was the first to investigate age-specific and sex-specific associations between indoor tanning and melanoma and suggested that sunbed use may be contributing to the steeper increase in melanoma rates in younger women [ 44 ]. Age before 35 years old and ever sunbed use, as well as repeated/prolonged use between 10 and 39 years of age have been associated with significant increase in melanoma risk (75% and 237%, respectively) [ 18 , 41 , 50 ]. The meta-analysis by the IARC in 2007, showed a 1.75-fold higher risk of melanoma with the first use of tanning beds before the age of 35 [ 41 ]. In the meta-analysis of Boniol et al. (2012), there was a 1.59-fold higher risk of cutaneous melanoma for those that first used sunbeds at an age younger than 35 [ 18 ]. In the meta-analysis of An et al. (2021), exposure to indoor tanning before the age of 20 was associated with 1.47-fold higher risk for cutaneous melanoma (95% CI: 1.16–1.85) [ 37 ]. On the other hand, the meta-analysis of Colantonio et al. reported a higher, but not statistically significant, risk for those younger than 25. The authors mentioned that they included studies using a different cut-off of 20 years as well, to increase the sample size [ 39 ].
The development of multiple primary melanomas compared to a single melanoma, was 2.75 times more likely for those with indoor tanning exposure in a case-control melanoma study, even after adjusting for age, a family history of melanoma, the presence of atypical and dysplastic nevi and recreational sun exposure [ 51 ].
The melanoma burden attributable to the use of sunbeds is substantial. In the meta-analysis of Wehner et al. (2014), the population proportional attributable risk was 2.6%–9.4% for melanoma, translating to 11,374 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia [ 12 ]. Based on prevalence data from GLOBOCAN 2008, in Western Europe, an estimated 3438 cases of melanoma could be attributable to sunbed use, most developing among women [ 18 ]. The melanoma burden attributable to the use of sunbeds in the French population over 30 years old, was reported to be 4.6% of melanoma cases in women and 1.5% in men in 2015 [ 52 ]. In these studies, the melanomas attributed to sunbed use were associated with high intensity of sunbed use (>10 sessions/year) and were more frequently observed in younger individuals [ 52 , 53 ].
A causal relationship between sunbed use and melanoma was proposed in the review of Suppa et al., based on the discussion that the epidemiological criteria of causality [ 54 ] are met, including the strength of association, dose response, temporality of the association, consistency, specificity, and plausibility of mechanism and analogy (the effect of the similar factor of sun exposure on melanoma risk is well established) [ 55 ].
5. Sunbed Use and Risk of Keratinocyte Carcinoma (cSCC and BCC)
There are fewer studies on indoor tanning and risk of keratinocyte carcinoma. Published evidence supports that indoor tanning is an independent risk factor for the development of cSCC [ 56 , 57 , 58 , 59 , 60 ]. Furthermore, a dose-dependent association of sunbed use and cSCC development in women has been reported in the prospective large questionnaire studies in the Melanoma in Southern Sweden (MISS) cohort [ 56 ] and in the Norwegian Women and Cancer study cohort [ 57 ]. The meta-analyses reporting indoor tanning and risk of cSCC are presented in Table 3 . The meta-analysis of Wehner et al. (2012), included six studies with patients with cSCC and reported a 67% higher risk for those that had ever exposure to indoor tanning compared to never exposure (RR: 1.67, 95% CI: 1.29–2.17) [ 40 ]. Similarly, in the most recent meta-analysis of An et al. (2021), there was a significant risk for cSCC with indoor tanning (RR: 1.58, 95% CI: 1.38–1.81) [ 37 ]. This meta-analysis also reported dose–response effects of sunbed use on the risk of cSCC development, while younger age (<20) at first exposure to indoor tanning was not associated with significantly higher risk of cSCC [ 37 ] ( Table 3 ).
Meta-analyses reporting indoor UVR tanning and risk of keratinocyte carcinoma. Available results by age group and dose/frequency of sunbed use are shown.
UVR: ultraviolet radiation, n : number, KC: keratinocyte carcinoma consisting of cSCC and BCC, also termed as nonmelanoma skin cancer), cSCC: cutaneous squamous cell carcinoma, BCC: basal cell carcinoma, y: years old. RR: relative risk, 95% CI: 95% confidence interval. (-): not reported data. Statistically significant results are shown in bold.
Regarding BCC, sunbed use was a risk factor for sporadic basal cell carcinoma in Germany [ 61 ]. A study from the Icelandic Cancer Registry reported a higher annual percentage change and multiplicity of BCC in women than in men in all age groups [ 62 ]. Although sunbed use was not assessed, it was suggested that the parallel widespread use of tanning beds in Iceland, especially among younger women, may have contributed to this sex-specific trend [ 63 ]. A US study in the Nurses’ Health Study II (73,494 female nurses with 20-year follow-up) reported a statistically significant higher risk of BCC (HR: 1.15, 95% CI: 1.11–1.19) with the use of tanning beds of four times per year [ 64 ]. The meta-analyses reporting indoor tanning and risk of BCC are presented in Table 3 . The ever exposure to indoor tanning was associated with a higher risk for BCC in the meta-analysis of Wehner et al. (2012) [ 40 ]. However, this was not confirmed as statistically significant in the meta-analysis of An et al. (2021) [ 37 ]. The younger age at first exposure to sunbeds has been associated with significantly higher risk of BCC [ 37 , 40 , 64 ]. Younger age (use during high school/college versus at ages 25–35 years) and more frequent use of tanning beds (more than six times per year compared with no use) were significantly associated with BCC [ 64 ]. The meta-analysis of Wehner et al. (2012), showed that exposure to indoor tanning at a younger age was associated with a significantly higher risk for BCC (RR: 1.40, 1.29–1.52) [ 40 ], and this was confirmed in the meta-analysis of An et al. (2021) (RR: 1.86, 1.44–2.41) [ 37 ].
The KC cases attributable to the use of sunbeds is comparable to the cases of lung cancer attributable to smoking [ 12 ]. In the meta-analysis of Wehner et al. (2014), the population proportional attributable risk was 3.0%–10.8% for BCC and 6.7%–21.8% for cSCC, corresponding to 452,796 cases of BCC and SCC each year attributable to indoor tanning in the United States, Europe, and Australia [ 12 ].
6. Preventive Measures against Sunbed Use
Preventive measures against sunbed use include legislation restricting sunbed use, educational campaigns to inform and discourage from indoor tanning, focusing on high-risk groups, and using the internet, online advertising messages, and social media to reach larger audiences and to promote an untanned appearance.
6.1. Restrictive Legislation
In 2009, the World Health Organization classified all forms of sunlamps, tanning beds, and UV light as class 1 carcinogens, which are known to cause cancer in humans [ 65 ]. The European Commission, by its Scientific Committee on Health, Environmental and Emerging Risks (SCHEER), stated that ‘based on available evidence, exposure to UVR, including that emitted by sunbeds, causes cutaneous melanoma and SCC at all ages and that the risk for cancer is higher when the first exposure takes place in younger ages’ [ 66 ]. In addition, the Association of European cancer Leagues (ECL) has included a message against sunbed use in their European Code Against Cancer ( www.cancercode.eu , accessed on 4 November 2022). In particular, within a set of 12 messages to prevent cancer, the UV-related message states: ‘Avoid too much sun, especially for children. Use sun protection. Do not use sunbeds’ [ 67 ].
Legislation of indoor tanning restrictions varies across countries. Pawlak et al. provided a comprehensive list of 2011 legislation of indoor tanning restrictions across countries. Indoor tanning laws for youth were implemented, nationwide for eleven countries (France, Spain, Portugal, Germany, Austria, Belgium, England, Wales, Northern Ireland, Scotland, Brazil), as well as in the province of Nova Scotia and the Capital Regional District of British Columbia in Canada, and in 11 states in the United States. In addition, 21 US states require parental consent or accompaniment for tanning bed use [ 65 ]. Interestingly, by 2019, three countries had an outright ban (Australia, Brazil, Iran) and 24 countries and 38 states/provinces (in the USA and Canada) had age limits and 15 US states had prohibited unsupervised access for minors. This reflected an increase of 16 countries and 29 states/provinces with age limits since 2011 [ 13 ]. The European situation was described more recently in a questionnaire study by Longo et al. in 2019. Within 23 responding countries of the Euromelanoma network, 27% did not report any specific legislation on sunbed use and one-third of the countries did not have a restriction for minors [ 68 ]. The inspections related to the use of sunbeds in Denmark, France, Germany, Hungary, Latvia, Norway, Portugal, and United Kingdom reported considerable failure to meet the recommended standards, including enforcement of the age limit and information on potential hazards. Ultraviolet irradiance above the threshold limit (0.3 W/m 2 ) was observed in more than 55% of inspected centers, and in more than 90% of centers in some countries. Lack of warning displays and insufficient eye protection was reported in up to 45% centers, and a lack of a mandatory technical inspection in 42% of countries [ 68 ]. Furthermore, the European SCHEER recently stated that there is no safe limit for exposure to UV radiation from sunbeds for cosmetic purposes [ 66 ].
International regulations on access of minors to sunbeds vary considerably across Australia, Europe and North America (reviewed by Diehl et al., in 2022) [ 69 ]. In Australia, there is a total ban on commercial tanning beds, including for minors. In New Zealand, there is a strict ban for minors under the age of 18. In Europe, only 25 out of 47 countries have strict access restrictions for minors. In the UK, a strict ban for minors was reported in England, Northern Ireland, Scotland, and Wales. In the US, there is varied legislation, with a strict ban for minors under the age of 18 in 23 states, and for minors of different age limit in nine states. Twenty-five states have a ‘soft ban’ including access restrictions to minors and the requirements of parental/guardian consent or presence at the tanning salon. In Canada, out of the 12 provinces and territories, 10 have introduced a strict ban for minors under the age of 18 or 19 [ 69 ]. A web registry of indoor tanning legislation is provided by the National Conference of State Legislatures in the US. It has been proposed to have a web registry for the continuously evolving indoor tanning legislation around the world, to inform on the current policies across countries and assist towards common advocacy efforts [ 65 ].
The implementation of legislation has been reported as an effective strategy to reduce harmful indoor tanning behavior. It was reported that 85% fewer adolescents and 50% fewer adults tanned indoors in the last 12 months in countries that banned indoor tanning for minors (based on studies after 2012) [ 13 ] compared with the 2007–2012 period [ 12 ]. A systematic review on the impact of US legislation on youth indoor tanning found that indoor tanning prevalence among youth decreased after indoor tanning legislation (3% mean decrease, range:1–6%), especially in states with longer standing indoor tanning legislation (9% mean decrease, range: 2–20%). The small percent differences equate to millions of youths at the population level, suggesting some positive impacts and encouraging results [ 70 ]. Additional studies showed that sunbed use in minors has decreased over time since the implementation of a legal ban [ 71 , 72 , 73 ]. Experience from Australia, where an outright ban of commercial sunbeds has been in place since 2016, showed that this policy intervention was highly effective and had strong public support [ 74 ].
In order to inform policy-maker decisions, the health costs and consequences of introducing a ban on commercial indoor tanning have been estimated in England, USA and Europe. In their modeling study, Eden et al. estimated that a nationwide ban on commercial indoor tanning supported by a public health campaign would reduce melanoma and keratinocyte cancers and skin cancer treatment costs in England [ 75 ]. Similarly, restricting indoor tanning among minors (<18 years old) in the US would have the potential to reduce melanoma incidence, mortality and save $342.9 million in treatment costs over the lifetime of the 61.2 million youth aged 14 years or younger [ 76 ]. Another modeling study by Gordon et al. in 2020 reported that regulatory actions to ban indoor tanning devices could be expected to avert 8.2% (240,000) of melanomas and 7.8% of keratinocyte carcinomas in North America, and to avert 4.9% melanomas and 4.4% keratinocyte carcinomas in Europe [ 77 ].
6.2. Educational Campaigns
Educational campaigns to inform and discourage from indoor tanning may act in concert with restrictive legislation and reach high-risk groups [ 13 ]. The 2019 Euromelanoma study reported the ‘Iberian particularity’ to describe the large difference in the prevalence of sunbed use in Spain (19.3%) and in neighboring Portugal (2%). Interestingly, the authors commented that this difference could be, at least in part, due to the fact that Portugal was part of the Joint Market Surveillance Action on sunbeds and solarium services coordinated by PROSAFE (Product Safety Forum of Europe), that could have raised awareness to avoid the hazards of sunbed use in Portugal [ 14 ]. A behavioral strategy to discourage the use of sunbeds could be the display of strong images of skin cancers in indoor tanning facilities [ 78 ]. This tactic would follow the use of relevant images put on cigarette packages to discourage smoking, which are more effective in communicating health messages and stimulate cognitive processes than text-only messages [ 79 ].
Given the higher risk of skin cancer with an earlier age at first sunbed exposure and the potential to more easily modify behaviors in younger individuals, adolescents are a key target group for educational interventions to inform and shape the choice for untanned skin [ 80 , 81 , 82 ]. A survey in 31 public high schools from 22 states in the US showed that only 10 high schools (32%) provided curricula regarding sun safety, mainly on the importance of sunscreen, while only one curriculum discussed skin cancer risk. These findings suggest a potential role of school education on sun safety messages, including information on skin cancer risk caused by indoor tanning [ 83 ].
Parental influence may also drive the adolescents’ attitude towards indoor tanning, not only by example, but also given the fact that parental consent is necessary for the use of sunbeds by minors in certain states. A US national online survey identified characteristics of parents who were more likely to have positive attitudes towards adolescent indoor tanning: male parents, parent indoor tanning and no reported skin cancer prevention counselling from pediatric healthcare provides. These findings underscore the importance of a family-center approach to disapprove indoor tanning and the role of primary care providers to offer skin cancer prevention counselling [ 84 ]. The effects of a social media campaign for mothers (intervention) over 12 months with posts on social media on preventing indoor tanning by adolescent daughters versus control, was assessed in a randomized trial. At six months after the campaign, the intervention-group mothers were less permissive of indoor tanning by daughters, had greater self-efficacy to refuse daughter’s indoor tanning requests, and were more supportive of bans on indoor tanning by minors [ 85 ].
Using the internet, online advertising messages, and social media with the aim to reach large, targeted audiences appears a promising and relatively inexpensive tool for public health. Google’s online advertising was used in a pilot study, to deliver targeted prevention messages related to indoor tanning and skin cancer to users entering searches related to tanning beds [ 86 ]. Advertisements using wording of educational messages (the truth of tanning beds/the truth beyond UV light/know what tanning beds do) were more popular and had higher click-through rates, compared to messages on health (protect your skin/tanning causes cancer/prevent skin cancer) or appearance (tanning causes winkles/prevent skin aging/tanning makes you ugly) [ 86 ]. Google searches for tanning bed key words peak in April and May of each year (before summertime), highlighting the season during which to focus educational and preventive messages [ 86 ]. Facebook and Instagram may reach out to the young female audiences that are primary users of indoor tanning [ 87 ]. Facebook advertising using three short (<1 min) videos on skin cancer prevention were directed to young women. The videos received 1288 comments and 11,415 reactions. However, there was no significant difference for knowledge between those that were shown the videos compared to those that received their regular newsfeed. There was a short average view duration of the videos (3–9 s) [ 87 ].
On the other hand, the marketing and online advertising of sunbed use by the indoor tanning industry is reminiscent of the advertisements of cigarette smoking of the past [ 88 , 89 ]. Social media platforms (e.g., Facebook, Twitter) are used to advertise directly to internet users, promote harmful habits of tanning, and project concerning influences on the beauty and body ideals of children, teenagers, and young adults [ 90 ]. The influences of the indoor tanning industry are complex and there is a need to account for industry funding and financial conflict of interests in publications related to indoor tanning. In their systematic review, Adekunle et al., in 2020, reported that 7.2% of articles on indoor tanning had financial links to the indoor tanning industry, and among these, the majority (78%) favored indoor tanning [ 91 ].
Clear messages are necessary for raising the public’s awareness on the risks of tanning beds. Educating that tanning is the skin’s defense mechanism trying to compensate for further damage after already being attacked and damaged with UVR exposure may dispel the misinformation that a pre-vacation tan is beneficial. Emphasis on the strict contraindication of indoor tanning with the purpose to increase vitamin D may separate the perceptions of the benefits of vitamin D in normal health that may be acquired by oral vitamin D supplementation from the use of sunbeds that causes skin cancer [ 92 ]. The implementation of successful strategies to educate on the risks of indoor tanning and promote an untanned appearance is one part of the equation. The evaluation of the short- and long-term effects of such interventions may select and determine those that are most effective, feasible, and sustainable [ 89 ].
7. Conclusions
The use of indoor tanning seems to have decreased quite substantially over the years. However, despite the documented harmful effects of tanning and the increasing number of countries adopting restrictive legislation worldwide, there is still a considerable prevalence of sunbed use among adolescents and adults.
Attempting to shed more light on the motivations for tanning-seeking behaviors may pave the way to targeted and impactful strategies to decrease indoor tanning. Clear messages by policy makers, health care systems, mass media campaigns, school curricula, and parents are necessary to raise awareness on the carcinogenicity of indoor UVR tanning and the greater vulnerability of younger people to this carcinogenic impact, and to discourage such exposure. Multicomponent interventions, including educational, mass media, and policy strategies, combined with the use of social media may be more effective towards these ends.
The world has been struggling with an unforeseen viral pandemic. While COVID-19 has put considerable pressure on the health systems and created fear and uncertainty, it might in parallel provide a window of opportunity to put previously cemented beliefs and priorities into question. The preservation of health seems to come more into focus. Through this new lens, the public may come to question the social constructs of beauty produced by magazines, advertisements, social media, and collective opinion. The cost of tanning on health is extremely high to pay.
Funding Statement
This research received no external funding.
Author Contributions
Writing—original draft preparation, C.D.; writing—review and editing, supervision, A.J.S. All authors have read and agreed to the published version of the manuscript.
Conflicts of Interest
Clio Dessinioti: None reported. Alexander J Stratigos: Advisory Board: Regeneron, Novartis. Honoraria: LeoPharma, Novartis, MSD. Research Support: Roche, Genesis Pharma, Janssen Cilag, Abbvie, unrelated to the content of this work.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Home › Risk Factors › Tanning
Tanning & Your Skin
The facts. the risks. how they affect you., indoor tanning dangers.
75% increased risk of developing life-threatening melanoma from just one indoor tanning session before age 35.
Tanning outside or indoors can have dangerous consequences. What is tanning? In short, tanning is a sign of skin damage. While often associated with good health, the “glow” of a tan is the very opposite of healthy; it is evidence of DNA injury to your skin. Tanning damages your skin cells and speeds up visible signs of aging. Worst of all, tanning can lead to skin cancer .
It’s a fact: There is no such thing as a safe or healthy tan. Tanning increases your risk of basal cell carcinoma , squamous cell carcinoma and melanoma .
Your best defense is to avoid tanning altogether .
What causes tanning?
What is at stake.
- Tanning facts & risks
Tanning FAQs
Protect yourself & look great.
Tanning is caused by exposure to ultraviolet (UV) radiation from the sun or tanning beds that causes genetic damage to cells on your outmost layer of skin. The skin tries to prevent further injury by producing melanin (the pigment that gives our skin its color) that results in darkening – what we call a tan.
This damage is cumulative, starting from the very first tan .
Your Health
- One in five Americans will develop skin cancer by the age of 70.
- Worldwide, there are more skin cancer cases due to indoor tanning than there are lung cancer cases due to smoking.
Your Appearance
- Tanning changes and ages your skin.
- It’s a visible signal of damage that accelerates the appearance of wrinkles, dark spots and weathered skin.
- If you do develop skin cancer, you run the risk of further, sometimes unsightly changes to your appearance.
Nonmelanoma skin cancer
Melanoma skin cancer.
MOST nonmelanoma skin cancers (NMSC) and a large percentage of melanomas are associated with exposure to UV rays from natural sunlight and/or indoor tanning.
Tanning facts and risks
Skin damage starts with your very first tan . Each time you tan, the damage builds up, creating more genetic mutations and greater risk.
Indoor tanning is dangerous : Tanning beds don’t offer a safe alternative to sunlight; they raise the risk for skin cancers. One study observing 63 women diagnosed with melanoma before age 30 found that 61 of them – that’s 97 percent — used tanning beds.
Tanning damages all types of skin: Even if your skin type is not fair, tanning causes DNA injury that can lead to premature aging and skin cancer.
You can easily reduce your likelihood of developing skin cancer by practicing sun safety .
Are tanning beds as harmful as the sun?
YES. Tanning, whether indoors or outdoors, is dangerous. In fact, UVA rays used in tanning beds might increase your risk of developing melanoma.
Is tanning a good way to get vitamin D?
NO . The truth is that UVB radiation leads to the production of vitamin D. Tanning is mostly caused by UVA rays. This means that tanning delivers almost no vitamin D benefit while increasing the risk of skin cancer. Meet your daily vitamin D requirement the safe way — with food or supplements.
Should I get a “base tan” indoors before a tropical vacation to prevent burning?
NO! Tanning does not protect against sunburn; it simply exposes you to more harmful UV rays. The best way to prevent sunburn is to seek the shade, wear protective clothing, a wide-brimmed hat and UV blocking sunglasses, and apply sunscreen every day.
Does tanning help with Seasonal Affective Disorder (SAD)
NO. Tanning does not help treat SAD , and UV light from tanning beds is proven to cause you harm.
- Avoid tanning entirely : It’s the best way to safeguard against unhealthy, unsightly skin damage.
- Fake, don’t bake : If you want a golden glow, consider sunless tanning products. There are many options that can give you a bronzed look, but you still need sun protection!
- Tone, don’t tan : Get radiant skin by doing aerobic or high-intensity exercises. Working out feels good and boosts your mood.
- Hydrate, eat great : Drink lots of water and choose whole, unprocessed foods. Your skin will thank you!
Make healthy skin a way of life. Get the details here: Your Daily Sun Protection Guide
Reviewed by: Anna Chien, MD Heidi Jacobe, MD
Last updated: July 2022
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Tanning Beds and Skin Cancer: Heeding the Call to Action
Dr. Carolyn Heckman discusses indoor tanning and skin cancer.
Newswise — New Brunswick, N.J. April 28, 2021 – There is substantial evidence that indoor tanning is associated with increased risk of skin cancer – the most common type of cancer nationwide according to the American Cancer Society. Public health officials and researchers have become increasingly concerned about the health risks posed by indoor tanning. Researchers at Rutgers Cancer Institute of New Jersey recently addressed the importance of increasing efforts to limit indoor tanning among minors in a viewpoint paper published in the April 28 2021 online edition of JAMA Dermatology . ( doi:10.1001/jamadermatol.2021.0874 )
Carolyn J. Heckman, PhD , co-leader of the Cancer Prevention and Control Program at Rutgers Cancer Institute and an associate professor of medicine at Rutgers Robert Wood Johnson Medical School, is corresponding author and shares some insight.
Why is legislation limiting indoor tanning important – especially for minors?
Skin cancer can be disfiguring, debilitating, and deadly, but it is largely preventable. Ultraviolet (UV) radiation from indoor tanning (and the sun) is a well-established carcinogen that causes most skin cancers. Research has shown that even one session of indoor tanning at a young age greatly increases risk for melanoma, the most deadly form of skin cancer. Studies have also shown that compared to bans, less restrictive types of legislation such as requiring parental consent or accompaniment are not effective because they are not well-enforced, and many parents do not fully understand the risks of indoor tanning.
What are the key challenges you describe relating to regulations for indoor tanning?
Even when there is legislation addressing indoor tanning restrictions, resources for enforcement may be inadequate. Additionally, some people take part in indoor tanning in facilities other than tanning salons that may not be as well-regulated. For example, several large gym chains offer indoor tanning. Calling these facilities “fitness” or “health” clubs is a misnomer when they offer indoor tanning. Many people do not understand that this practice poses health risks and some even think that it is healthful.
What do you hope to achieve through this work and what is the takeaway message?
We are hopeful that FDA’s proposed rule to federally ban indoor tanning for minors will be enacted this year, after being on hold during the last administration. In the meantime, we can all educate our family and friends (particularly young women) about the risks of indoor tanning and advocate for stricter legislation and enforcement of regulations on this carcinogen.
The work was supported in parts by grants from the National Institutes of Health (R01CA244370) and a Cancer Center Support Grant (P30CA072720). Disclosures and other information can be found here .
Journal Link: JAMA Dermatology
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Introduction
Materials and methods, disclosure of potential conflicts of interest, acknowledgments, indoor tanning and risk of melanoma: a case-control study in a highly exposed population.
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DeAnn Lazovich, Rachel Isaksson Vogel, Marianne Berwick, Martin A. Weinstock, Kristin E. Anderson, Erin M. Warshaw; Indoor Tanning and Risk of Melanoma: A Case-Control Study in a Highly Exposed Population. Cancer Epidemiol Biomarkers Prev 1 June 2010; 19 (6): 1557–1568. https://doi.org/10.1158/1055-9965.EPI-09-1249
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Background: Indoor tanning has been only weakly associated with melanoma risk; most reports were unable to adjust for sun exposure, confirm a dose-response, or examine specific tanning devices. A population-based case-control study was conducted to address these limitations.
Methods: Cases of invasive cutaneous melanoma, diagnosed in Minnesota between 2004 and 2007 at ages 25 to 59, were ascertained from a statewide cancer registry; age-matched and gender-matched controls were randomly selected from state driver's license lists. Self-administered questionnaires and telephone interviews included information on ever use of indoor tanning, types of device used, initiation age, period of use, dose, duration, and indoor tanning–related burns. Odds ratios (OR) and 95% confidence intervals (CI) were adjusted for known melanoma risk factors.
Results: Among 1,167 cases and 1,101 controls, 62.9% of cases and 51.1% of controls had tanned indoors (adjusted OR 1.74; 95% CI, 1.42-2.14). Melanoma risk was pronounced among users of UVB-enhanced (adjusted OR, 2.86; 95% CI, 2.03-4.03) and primarily UVA-emitting devices (adjusted OR, 4.44; 95% CI, 2.45-8.02). Risk increased with use: years ( P < 0.006), hours ( P < 0.0001), or sessions ( P = 0.0002). ORs were elevated within each initiation age category; among indoor tanners, years used was more relevant for melanoma development.
Conclusions: In a highly exposed population, frequent indoor tanning increased melanoma risk, regardless of age when indoor tanning began. Elevated risks were observed across devices.
Impact: This study overcomes some of the limitations of earlier reports and provides strong support for the recent declaration by the IARC that tanning devices are carcinogenic in humans. Cancer Epidemiol Biomarkers Prev; 19(6); 1557–68. ©2010 AACR.
Between 1997 and 2006, melanoma incidence increased 2.2% and 2.1% annually in the United States among Caucasian males and females, respectively ( 1 ). These trends have resulted in melanoma ranking first among men and second among women as the fastest increasing cancer for the 10 most common cancers in Caucasians, even as most common cancers are declining or stable. Intense, intermittent solar UV radiation has long been thought to account for the rise in melanoma ( 2 ). Indoor tanning is an artificial source of intermittent UV radiation exposure that has gained in popularity since the early 1980s. The indoor tanning industry estimates that approximately 30 million Americans visit indoor tanning salons each year ( 3 ). A recent report based on data from 116 cities in the United States found that the average number of tanning salons exceeded the average number of Starbucks or McDonald's ( 4 ).
In 2009, the IARC classified tanning devices as carcinogenic to humans ( 5 ). The IARC report may have little effect on indoor tanning use in the United States, in part, because the industry has used limitations of the studies reviewed by the IARC and hypotheses regarding potential health benefits, such as vitamin D, to counter possible health concerns ( 6 ). With at least 29 reports to date ( 7 - 35 ), past history of indoor tanning has been only weakly associated with melanoma (ref. 5 ; the IARC reported a summary odds ratio of 1.15; 95% CI, 1.00-1.31 based on 19 studies), and limitations of these studies include the lack of information on sun exposure (a known correlate of indoor tanning use; ref. 36 ) in the majority of studies, and a low or presumed low prevalence of exposure to indoor tanning. Only 11 studies have provided some detail about the exposure, but none measured dose-response or reported on age of initiation in the same manner ( 11, 17, 21 - 23, 25, 27, 28, 30 - 32 ). Consequently, the evidence that melanoma occurrence increases with frequent indoor tanning use is limited. In addition, only three studies have examined melanomas in relation to indoor tanning use during adolescence ( 30 - 32 ), when indoor tanning is most likely to be initiated ( 37 ). Although moderately strong associations have been reported, point estimates were imprecise, perhaps due to the low frequency of exposure ( 30, 32 ) or number of events ( 31 ).
Information on the risk of melanoma associated with specific devices is also lacking. Tanning devices emit both UVB and UVA. The UVB component has been considered to be the putative factor for skin carcinogenesis, but cutaneous melanocytes absorb both UVB and UVA ( 38 ), and mechanisms have been proposed by which UVA might lead to skin cancer, including indirect damage to DNA via reactive oxygen species ( 39 - 41 ). A complicating factor is that devices have changed over time. For example, devices available prior to the 1980s emitted much higher levels of UVB compared with normal solar UV radiation. These were followed by the introduction in the 1980s of devices emitting primarily UVA to address the public's concern about burning ( 42 - 45 ). In the 1990s, UVB was reintroduced in high-speed or high-intensity devices to produce deeper tans, and high-pressure devices emitting almost exclusively UVA also became available. Year of use or device type could serve as proxies for UVB versus UVA exposure in epidemiologic studies. However, in most studies, cases were diagnosed prior to 1990, and only a few studies have measured device- or period-specific exposure ( 21, 23, 27, 30 - 32 ). Although the IARC report designated UVA as “carcinogenic” in humans, device- and period-specific results from epidemiologic studies have been inconclusive with respect to melanoma.
In 2004, we initiated the Skin Health Study, a population-based case-control study of indoor tanning in relation to risk of melanoma, that was specifically designed to address the limitations of prior research. The study was conducted in Minnesota, a state with documented high prevalence of the behavior ( 37 ). We collected more detailed information than most studies to assess not only melanoma risk associated with frequent use, years of use, and age at which use began, but also with specific devices and period of use to distinguish exposure to UVB or UVA. We also obtained information on known confounders and enrolled a sufficiently large sample size to allow for subgroup analyses which have rarely been possible. Our results are presented here.
Ascertainment and recruitment of cases and controls
The Skin Health Study was approved by the Institutional Review Board at the University of Minnesota. Cases were ascertained by the Minnesota Cancer Surveillance System, a population-based, statewide cancer registry. Individuals with invasive cutaneous melanoma, any histologic type, diagnosed between July 2004 and December 2007, between the ages of 25 and 59, with a state driver's license or state identification card, were eligible to participate. The lower age limit allowed for a latency period for melanoma development among indoor tanning users exposed during adolescence; age was truncated at 59 years because indoor tanning decreases with age. In accordance with state laws, the cancer registry first obtained physician permission for research staff to contact his or her patient before releasing case information to research staff; consent was assumed after allowing sufficient time for physician response. Controls were randomly selected from the Minnesota state driver's license list (which includes persons with state identification cards) and frequency-matched to cases in a 1:1 ratio on age (in 5-year age groups) and gender.
Eligible cases and controls were required to be English-speaking and to have a telephone number. We used several methods for obtaining telephone numbers including hiring companies specializing in locating individuals, manually searching publicly available databases, telephone books, and web sites, or sending a letter requesting a telephone number if these other methods were unsuccessful. Once we located a telephone number, we then sent a letter introducing the research study, followed by a telephone call to invite participation. Data collection began in December 2004 and was completed in March 2009.
Data collection and participation
After receiving a self-administered questionnaire, selected information was entered into a computer-assisted telephone interview system to facilitate a subsequent, detailed 1-hour telephone interview. A reference date was assigned to each participant. For cases, this date was the date of diagnosis, and for controls, this date was the date the invitation letter was sent less the mean time between cases' diagnosis and when cases were released to the study.
Exposure measurement
Because devices varied widely and no standardized instruments to measure exposure to tanning devices were available, we developed and pilot-tested a new tanning device instrument by first conducting in-depth interviews with seven individuals that had tanned indoors to identify device types, determine their common names, and find the best approach for collecting lifetime history of indoor tanning use. From this process, we developed a mixed mode instrument for collecting information about tanning devices used at various ages, which we tested with another 32 individuals. The final instrument, consisting of a self-administered questionnaire and telephone interview, was implemented in this study.
The self-administered portion of the tanning device instrument contained six columns with photographs for each device: regular tanning beds/booths without facial lamps (variable ratios of UVB to UVA), regular tanning beds/booths with facial lamps (similar to devices without facial lamps; facial lamps are primarily UVA emitting), high-speed or high-intensity tanning beds/booths (UVB enhanced), high-pressure tanning beds/booths (primarily UVA emitting), sun lamps, or partial body tanners. Under each column, participants checked the age at which the device had been used, in 5-year age blocks from age 11 to age 59 (the oldest age at reference date). This information was then entered into the computer-assisted telephone interview system to guide device-specific questions during the telephone interview about use in each 5-year age period. These telephone-based questions included the number of years used within each 5-year age period, location of use (home, business, or other), and whether use was “occasional” or “fairly regular.” If the participant was an occasional user, we asked about times per year of use, and if a fairly regular user, we asked about the number of months in which use occurred, and then times used per month. We also asked about the number of minutes of a typical session. We derived the specific years in which use occurred from birth year, year at reference age, age at tanning initiation, and age at tanning cessation. We calculated measures of ever use (based on reported age of initiation), dose (hours, sessions), and duration (years) across all devices, for specific devices, and for specific time periods. We classified regular beds/booths with and without facial lamps as conventional devices, and dropped partial tanners due to infrequent use. We also asked about frequency of burns attributed to an indoor tanning session or to sun after indoor tanning.
Other risk factors
We collected skin, hair and eye color, and presence and pattern of freckles and moles via the self-administered questionnaire. Education, income, family history of melanoma (diagnosed in parents, siblings, children, grandparents, grandchildren), all sun exposure measures, history and number of painful sunburns before and after age 18, and sunscreen use were collected during the telephone interview. Lifetime routine sun exposure was obtained by multiplying the number of days by the number of hours typically spent outside on weekdays and weekends during winter and summer months in the decade years (at age 10, 20, 30, 40, and 50, depending on a person's age), and summing across decades. This instrument was developed by Kricker et al. and found to be reliable and well correlated with skin damage ( 46 - 49 ). Sun exposure during outdoor activities was based on a list of 11 outdoor activities in which the participant had engaged for at least 4 days per year in the decade years. The outdoor activities included time spent at the beach or pool, sunbathing, boating or water-skiing, fishing, playing or coaching outdoor team sports, walking, hiking or jogging, biking, roller skating or rollerblading, golfing, playing tennis, playing outside, and gardening. The total number of days spent in each activity was multiplied by the number of hours for each activity, and summed across activities and decades. We also asked about total hours of sun exposure associated with all outdoor jobs during warmer and cooler months and calculated total hours in a manner similar to total hours for routine and outdoor activity sun exposure. Lifetime sunscreen use was measured by averaging the frequency of sunscreen use (almost always, more than half the time, about half the time, less than half the time, rarely, never) associated with each outdoor activity reported in each decade year.
Assessment of bias
Due to challenges in recruiting controls, we implemented procedures in July 2007 to assess potential for selection bias. Among persons that refused participation at the first recruitment call (excluding persons explicit about no further contact or that we had been unsuccessful in reaching), we randomly selected cases and controls to re-contact and ask six questions. The questions included past use of indoor tanning (“have you ever tanned indoors?”), total number of sessions if used, number of lifetime sunburns, skin sensitivity to sun, sunscreen use, and income. We also attempted to re-contact and query all cases and controls that had not returned the self-administered questionnaire by this point. Going forward, we then asked these questions of all persons during routine reminder calls to return the self-administered questionnaire. Altogether, we obtained this information from 32% of cases and 15% of controls among all nonparticipants. We also assessed recall bias possibly introduced by physicians revealing the study hypothesis to their patients prior to permitting the release of names. So, beginning in May 2008, we asked each participant at the end of the telephone interview (12.9% and 17.3% of all interviewed cases and controls, respectively) if they had talked to a physician about the study before we first made contact with them.
Statistical analysis
Using multiple logistic regression, we calculated odds ratios (OR) and 95% confidence intervals (CI) for the likelihood of melanoma associated with having ever tanned indoors, frequency of use (total hours, sessions, or years), age of initiation, and burns from indoor tanning or sun after indoor tanning. Total hours, sessions, or years were divided into categories comparable with other reports. For these measures, a P value for trend was calculated by treating the categories as ordinal. We compared cases to controls according to the types of indoor tanning devices used and period of use, i.e., before 1990, 1990 or later, or in both periods. The year 1990 was chosen to identify the time period when high-speed/high-intensity and high-pressure devices became more widely available. We also examined use according to tumor location (head and neck, trunk, upper or lower limbs) and gender. All analyses were first adjusted for age at reference date (in years) and gender (if not stratified on this characteristic). In multivariate analyses, ORs and 95% CIs were also adjusted for income (≤$60,000, >$60,000, missing), education (completed college, did not complete college), eye color (gray/blue, green, hazel, or brown), hair color (red, blond, light brown, or dark brown/black), skin color (very fair, fair, light olive versus dark olive, brown, very dark brown, or black), freckles (none, very few, few, some, many, missing), moles (none, few, some, many, missing), family history of melanoma (yes or no, missing), total lifetime painful sunburns lasting more than 1 day (continuous), routine sun exposure (continuous), sun exposure from outdoor activities (continuous), sun exposure from outdoor jobs (continuous), and lifetime sunscreen use (continuous). A total of 16 cases and 12 controls were excluded because of missing data for one or more confounders.
To examine whether indoor tanning exposure initiated at a young age reflected higher cumulative exposure or biological susceptibility among younger persons, we examined age of initiation and duration of use simultaneously (among indoor tanners only), while adjusting for previously mentioned confounders. Similarly, we examined the period of use while controlling for total number of years used to determine whether or not exposure to earlier devices conferred greater risk than later devices, independent of total years of exposure. We compared users relative to nonusers (never tanners, plus nonusers of a specific device) of conventional, high-speed/high-intensity, and high-pressure devices in the same model to assess whether each device contributed independently to melanoma risk. We allowed for latency by estimating the likelihood of melanoma associated with indoor tanning use by stratifying according to use initiated more than or less than 15 years from the reference date. Associations between indoor tanning use and melanoma were examined by tumor characteristics (tumor site, Breslow's depth, presence of ulceration, or histologic subtype) and tested for statistically significant differences by age at diagnosis, gender, and phenotypic characteristics. Finding no evidence that results were modified by these characteristics (e.g., P for interaction by phenotypic characteristics ranged from 0.37 to 0.76), we present results for all cases and controls.
Eligibility was determined for 72.5% of cases and 56.3% of controls ( Table 1 ). Among known eligible cases and controls, 1,167 cases (84.6%) and 1,101 controls (69.2%) completed the self-administered questionnaire and telephone interview between December 2004 and March 2009. Due to frequency matching, cases and controls had similar age and gender distributions ( Table 2 ); 98% of cases and 96% of controls were Caucasian. Phenotypic characteristics known to increase melanoma risk and greater number of sunburns were more common among cases than controls. For sun exposure, we observed no association with case-control status whether we assessed sun exposure from routine, outdoor recreational activities or occupational lifetime exposure. History of sunscreen use was reported more frequently by cases than controls in the crude analysis.
Outcome of recruitment of cases and controls (Skin Health Study)
Comparison of cases and controls in the Skin Health Study
Indoor tanning use was reported by 62.9% of cases and 51.1% of controls ( Table 3 ). Because age- and gender-adjusted ORs varied only slightly from multivariate-adjusted ORs, the latter are described throughout. The multivariate-adjusted OR for the likelihood of melanoma in relation to having ever tanned indoors was 1.74 (95% CI, 1.42-2.14) and confidence intervals excluded the null value. Melanoma risk increased markedly with frequency of use. Adjusted ORs ranged between approximately 2.5 and 3.0 for the highest category of use—50+ hours, more than 100 sessions, 10 or more years—and the P for trend was 0.006 to <0.0001, depending on the measure. A significant trend in the likelihood of melanoma with increasing number of sessions was also observed for melanomas arising on each tumor site (data not shown). When examined by gender, this dose-response pattern held for both men ( P < 0.0001) and women ( P < 0.0001) with melanoma arising on the trunk, among men with melanoma on the head and neck ( P = 0.05), and among women diagnosed with melanoma on the upper ( P = 0.006) or lower limbs ( P < 0.0001). Cases were also more likely than controls to report having experienced painful burns from indoor tanning (adjusted OR, 2.28; 95% CI, 1.71-3.04), a greater number of indoor tanning-related burns ( P trend = 0.01), or painful sunburns at a time when they thought they were protected from the sun by indoor tanning (adjusted OR, 2.00; 95% CI, 1.48-2.70).
The association between indoor tanning history with melanoma risk (Skin Health Study)
NOTE: Frequency totals for indoor tanning measures might not add up to 100% due to missing values.
*Adjusted for age, gender, eye color, natural hair color, skin color, freckles, moles, income, education, family history of melanoma, routine sun exposure, outdoor activity sun exposure, outdoor job exposure, mean sunscreen use, and number of lifetime painful sunburns; an additional 16 cases and 12 controls were excluded because the number of missing values was too small to be included as its own category.
Adjusted ORs for the likelihood of melanoma among users of indoor tanning relative to never users were similarly elevated regardless of the age when indoor tanning began ( Table 3 ; P trend = 0.68). When we restricted the analysis to indoor tanners and simultaneously modeled age of initiation and total years used, ORs were attenuated for each category of age at which use began or according to number of years, but the significant trend associated with duration remained (data not shown). After accounting for age at initiation among indoor tanners, the risk of melanoma was concentrated among users for 10 or more years compared with users for only 1 year (adjusted OR, 1.77; 95% CI, 1.19-2.63).
Controls reported use of different types of devices that generally coincided with their availability over time ( Fig. 1 ); cases were more likely than controls to report use of each type of device shown. The likelihood of melanoma was significantly increased 2.86 and 4.44 times for users of high-speed/high-intensity devices and high-pressure devices, respectively; and 1.76 and 1.85 times for users of conventional devices and sunlamps, respectively, relative to never users ( Table 4 ). When the reference group was changed to be nonusers of a specific device (as opposed to never users), the associations were attenuated, ranging from 1.6 to 1.9 depending on the device, yet confidence intervals for each estimate still excluded 1.0 (data not shown). The risk of melanoma was elevated for use occurring before or after 1990, or in both periods ( Table 4 ). After accounting for the number of years of indoor tanning use in each period, these associations persisted except among cases and controls that reported use in both periods. The associations by device type, dose and duration were similar whether use was initiated at least 15 years prior to or within 15 years of the reference date (data not shown).
Tanning device use by time period among 563 controls (Skin Health Study).
Association between indoor tanning device types and period of indoor tanning use and the likelihood of melanoma (Skin Health Study)
Crude ORs for the likelihood of melanoma among past compared with never users of indoor tanning were similar for participants and nonparticipants ( Table 5 ). Among cases and controls that did and did not report speaking with a physician, crude ORs were each ∼1.2, weaker than what was observed among all study participants. However, multivariate adjustment resulted in an OR of 1.72 among cases and controls that said they did not speak to their physician before enrolling in the study, similar to the overall point estimate of 1.74. The small number of cases and controls that reported speaking to their physician precluded calculation of an adjusted OR in this group.
Association between indoor tanning and risk of melanoma by possible recall and selection bias among cases and controls (Skin Health Study)
*Adjusted for age, gender, eye color, natural hair color, skin color, freckles, moles, income, education, family history of melanoma, routine sun exposure, outdoor activity sun exposure, outdoor job exposure, mean sunscreen use, and number of lifetime painful sunburns; analysis among all participants excludes an additional 16 cases and 12 controls because the number of missing values was too small to be included as its own category. Analysis of recall bias excludes only two additional cases and three controls for the same reason.
† Excludes nine cases and three controls who responded “don't know” or whose response was missing.
‡ Not possible to estimate due to small numbers.
§ Confounders not collected on nonparticipants.
Our study has several important findings. First, we found that melanoma occurred more frequently among indoor tanners compared with persons that never engaged in this activity. Second, we found a strong dose-response relationship between melanoma risk measured by total hours, sessions, or years. Furthermore, this dose-response was also seen for melanomas arising on the trunk, not only in men but also in women, that would not ordinarily expose this site to UV radiation except when tanning or sunbathing. Third, we found an increased risk of melanoma with use of each type of tanning device as well as with each period of tanning use, suggesting that no device could be considered “safe.” In addition, burns from indoor tanning seemed to be fairly common and conferred a similar risk of melanoma to sunburns. These associations remained significant even after adjusting for the potential confounding effects of known risk factors for melanoma.
We did not confirm the IARC report's emphasis on an increased risk of melanoma with first exposure to indoor tanning “in youth”, defined as use before the age of 36 ( 5 ). Except for one cohort and two case-control studies that examined indoor tanning during adolescence in relation to melanoma ( 30 - 32 ), all other reports considered use prior to ages 25 to 30 ( 11, 17, 21 ), or restricted the analysis to cases diagnosed before the age of 36 ( 22, 28 ). This restriction, however, could have resulted in the exclusion of older cases and controls that may have been exposed at a younger age. An elevated risk of melanoma associated with first use at younger ages has been consistently observed across these studies, but this is also the case for indoor tanning used at older ages in some reports reviewed by the IARC ( 11, 17, 22, 28, 31 ). Our study was designed to specifically evaluate indoor tanning use initiated at any age. And by simultaneously accounting for duration of use among indoor tanners, our analysis indicates that early age exposure is most likely a marker for cumulative exposure, the reason for an excess risk of melanoma, not that younger individuals are at increased susceptibility to the effects of UV radiation. Although no other study has analyzed these data in the same manner as we did, three reports provide further support for our observation. One recent report found total hours of sunbed exposure to be much higher (34 versus 9 hours) among persons that first tanned indoors before compared with after age 15 years ( 32 ). And in two studies that stratified frequency of indoor tanning use by age of cases, elevated risks for melanoma were observed for those with 10 or more sessions, regardless of age ( 22 ), or for those with regular use up to the age of 60 ( 28 ).
With our carefully designed questionnaire eliciting the use of specific devices that emit differing amounts of UVB and UVA, we observed considerably stronger ORs for melanoma among users of high-speed or high-pressure devices than among users of conventional devices. We still cannot be certain, however, that these results reflect higher exposure to UVB from high-speed devices or higher exposure to UVA from high-pressure devices. First, the proportion of subjects reporting use of these devices was quite low. Second, studies have shown that the percentage of UVB and UVA emitted depends on the type of lamp, the quality of maintenance, and the level of degradation—information that cannot be collected through retrospective recall ( 50 - 53 ). Recently, inspections of tanning devices in European tanning salons have revealed poor compliance with regulations for the allowable distribution of UVB versus UVA, with a concomitant increase in the proportion of UVB beyond permissible limits over time ( 54 - 56 ). If UVA is carcinogenic in humans, as stated in the IARC report, our findings are biologically plausible. However, it is also possible that the devices we assessed, regardless of our classification scheme, emitted sufficient UVB for that component of UV radiation to be the reason for the observed associations. Similar to our experience, other studies that collected information about device types have not been able to single out any one type as being higher risk than another ( 21, 27, 30, 32 ). Nor have most studies, ours included, found higher risks of melanoma associated with indoor tanning exposure in a specific period, despite changes in emission of UV components over time ( 21, 23, 30, 57 ). Although disentangling which wavelength is responsible for melanoma development might not be possible in epidemiologic studies, the evidence also indicates that all indoor tanning devices are harmful.
We did not find lifetime routine sun exposure or sun exposure via recreational outdoor activities or occupations to be associated with melanoma risk, nor were these results changed by a detailed examination of sun exposure according to season, decade age, type of outdoor activity, indoor tanning status, or tumor site. Indeed, published studies reveal that the relationship between sun exposure and melanoma is complex, and depends on whether the exposure is intermittent or chronic; inconsistencies in its measurement further complicates an understanding of these relationships. A meta-analysis of 57 studies ( 58 ) and a pooled analysis of 15 studies ( 59 ) each reported fairly weak associations between total sun exposure and melanoma, no relationship to chronic exposure (based on outdoor occupations), moderately strong associations with intermittent exposure (usually defined as sunbathing, time spent during sunny vacations, or outdoor recreational activities), and strong associations with sunburn. Thus, our results are in agreement with these reports for chronic exposure and sunburns. To the extent that sunburns are a marker of intermittent sun exposure, then our results adequately represent the independent effect of indoor tanning use on the risk of melanoma. Differential underreporting of sun exposure by cases seems to be a less likely explanation of these trends in our study; had it been operative, we might have expected the same to occur for cases' report of artificial solar exposure. Although our findings could reflect less variation in sun exposure among a relatively homogenous population residing in Minnesota, or the younger age of our study sample in contrast with most case-control studies of melanoma, we cannot exclude the possibility that nondifferential misclassification obscured a relationship between sun exposure and melanoma.
Although the prevalence of indoor tanning among participating controls (51.1%) is high compared with most other reports, we do not think this is due to differential selection of indoor tanners into the study. In a 2002 Minnesota statewide survey of adults, age 18 and older ( 37 ), we found that overall, 36.3% of respondents reported indoor tanning use; prevalence was higher (42%) in the sample with the same age range as the current study. More importantly, the frequency of indoor tanning use was very similar when we compared participating and nonparticipating cases and controls and crude ORs for the association between indoor tanning use and melanoma were identical for participants and nonparticipants. We were also concerned that cases that had discussed the study with their physician might have reported higher frequency of indoor tanning use than cases that did not. We attempted to address this potential bias by querying both cases and controls in the latter part of the study. The fact that several controls (whose physicians were not contacted) reported discussions with their physician about the study prior to participating is also interesting. As the prevalence of overreporting was similar for both cases and controls in this group, and the adjusted OR among cases and controls that did not speak with a physician was similar to what we reported for the entire sample, recall bias seems less likely to explain our results. This conclusion is further supported by a recent nested case-control study, which reported no consistent pattern of recall bias for indoor tanning or other melanoma risk factors ( 60 ).
In summary, our study provides strong evidence that indoor tanning is a risk factor for melanoma. Due to the strength of the association, the dose-response, the results by tumor site (especially the trunk), and the ability to account for known confounders, our results address several limitations of previous studies. Our results also indicate that the number of times an individual is exposed to indoor tanning is more important than exposure to indoor tanning at an early age. Our ancillary studies on bias, although limited in scope, suggest that our results are not explained by selection or recall bias. In conclusion, our results add considerable weight to the IARC report that indoor tanning is carcinogenic in humans and should be avoided to reduce the risk of melanoma.
No potential conflicts of interest were disclosed.
Grant Support: American Cancer Society (RSGPB-04-083-01-CCE) and the National Cancer Institute (5R01CA106807).
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
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Article Contents
Acknowledgments, indoor tanning and melanoma risk: long-term evidence from a prospective population-based cohort study.
Abbreviations: CI, confidence interval; IARC, International Agency for Research on Cancer; NOWAC, Norwegian Women and Cancer; RR, relative risk; UV, ultraviolet; UVA, ultraviolet A; UVB, ultraviolet B.
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Reza Ghiasvand, Corina S. Rueegg, Elisabete Weiderpass, Adele C. Green, Eiliv Lund, Marit B. Veierød, Indoor Tanning and Melanoma Risk: Long-Term Evidence From a Prospective Population-Based Cohort Study, American Journal of Epidemiology , Volume 185, Issue 3, 1 February 2017, Pages 147–156, https://doi.org/10.1093/aje/kww148
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Indoor tanning is associated with increased risk of melanoma, but most evidence comes from case-control studies. Using data from the Norwegian Women and Cancer Study, a large prospective cohort study, we investigated the associations of age at initiation of indoor tanning, duration of tanning-device use, and dose response with melanoma risk and examined the role of indoor tanning in age at melanoma diagnosis. We used Poisson regression to estimate relative risks and 95% confidence intervals for the relationship of indoor tanning to melanoma risk and linear regression to examine age of indoor tanning initiation in relation to age at diagnosis. During follow-up of 141,045 women (1991–2012; mean duration follow-up = 13.7 years), 861 women were diagnosed with melanoma. Melanoma risk increased with increasing cumulative number of tanning sessions (for highest tertile of use vs. never use, adjusted relative risk = 1.32, 95% confidence interval (CI): 1.08, 1.63); P -trend = 0.006. Age at initiation <30 years was associated with a higher risk in comparison with never use (adjusted relative risk = 1.31, 95% CI: 1.07, 1.59). Moreover, women who started indoor tanning prior to 30 years of age were 2.2 years (95% CI: 0.9, 3.4) younger at diagnosis, on average, than never users. This cohort study provides strong evidence of a dose-response association between indoor tanning and risk of melanoma and supports the hypothesis that vulnerability to the harmful effects of indoor tanning is greater at a younger age.
The incidence of cutaneous melanoma (hereafter termed melanoma) has increased dramatically during the past few decades among fair-skinned populations worldwide; there were an estimated 230,000 new cases and 55,000 deaths in 2012 ( 1 ). In Norway, melanoma has gone from being uncommon in the 1950s to being the fourth most common incident cancer among both men and women in the last decade; as of 2014, the incidence rate was 42 cases per 100,000 population per year in men and 37 cases per 100,000 population per year in women ( 2 ).
The relationship between indoor tanning and melanoma has been investigated in several case-control studies and a few cohort studies, and the most recent meta-analyses found that ever users of indoor tanning devices had a 16%–20% higher risk of melanoma than nonusers ( 3 , 4 ). However, these summary estimates were mainly based on case-control studies, and high-quality evidence remains scarce ( 4 , 5 ).
In 2009, the International Agency for Research on Cancer (IARC) classified ultraviolet (UV) radiation from indoor tanning devices as carcinogenic to humans ( 6 , 7 ). Despite this, indoor tanning has remained popular in many Western countries, especially among young people ( 8 ). In a meta-analysis of the most recent international data (2007–2012), past-year prevalence of indoor tanning was 18% among adults and 45% among university students ( 8 ). In a Norwegian survey from 2014, past-year prevalence of indoor tanning was 16% in adults ( 9 ).
The Norwegian Women and Cancer (NOWAC) Study, a large, well-characterized, population-based cohort study with exposure information updated during follow-up, provides a unique opportunity to prospectively examine the long-term risk of melanoma in relation to indoor tanning. We studied the associations of current use, age at indoor tanning initiation, duration of use, and dose response with melanoma risk. In addition, we examined the role of indoor tanning in age at melanoma diagnosis.
The NOWAC study sample
The NOWAC cohort includes women born in 1927–1965. Enrollment started in 1991. Details on the study population and the NOWAC study design have been published previously ( 10 ). Briefly, nationwide random samples of more than 300,000 women aged 30–75 years were drawn from the Norwegian National Population Register. All women received an invitation letter between 1991 and 2007, and 171,725 answered the questionnaire and gave written informed consent to participate (response rate = 54%).
Selection of participants from the Norwegian Women and Cancer (NOWAC) Study cohort for an analysis of indoor tanning and melanoma risk, 1991–2012.
We excluded participants with very dark skin ( n = 2,560), as well as 18,349 women born in 1927–1942 who had spent most of their lives prior to the availability of any indoor tanning devices (the first whole-body sunbed was introduced to the market in 1972 in Norway) ( 13 ). We further excluded participants with prevalent melanoma ( n = 788) and persons who died or emigrated before the date of questionnaire return ( n = 92). Thus, the final study sample comprised 141,045 women born in 1943–1957 (Figure 1 ).
Follow-up and endpoints
The unique 11-digit identity number assigned to Norwegian citizens was used to link individuals from NOWAC to the population register at Statistics Norway for information on postal address and to the Cancer Registry of Norway for follow-up of cancer incidence and vital status (alive, emigrated, or deceased) through December 31, 2012. Melanoma cases are registered according to the International Classification of Diseases, Seventh Revision (codes 190.0–190.9), and 99.9% of melanomas in the registry are morphologically verified ( 2 ). The Norwegian Data Inspectorate and the Regional Committee for Medical Research Ethics in North Norway approved the study.
Indoor tanning exposure
History of using an indoor tanning device was recorded for childhood (ages ≤9 years), adolescence (ages 10–19 years), and various age periods in adulthood, which varied between questionnaires (e.g., 20–29, 30–39, and 40–49 years in some questionnaires and 20–44 and ≥45 years in others). Participants were asked to report the average frequency of use of an indoor tanning device for the respective age periods as never, rarely, 1, 2, or 3–4 times per month, or >1 time per week. We created 5 variables to describe exposure to indoor tanning: cumulative number of indoor tanning sessions, ever/never use of tanning devices, duration of use (never, <10 years, or ≥10 years), current use (yes or no in the most recent age period), and age at indoor tanning initiation (never, <30 years, or ≥30 years, excluding a subsample of women who were asked about indoor tanning at ages 20–44 years ( n = 12,358)).
To calculate the cumulative number of indoor tanning sessions, we converted the observed frequencies for all age periods starting from age 10 years to a yearly amount (never = 0 sessions/year; rarely = 1 session/year; 1 time/month = 12 sessions/year; 2 times/month = 24 sessions/year; 3–4 times/month = 42 sessions/year; and >1 time/week = 60 sessions/year) and multiplied this by the number of years for the given period; results were summed and categorized as never, lowest tertile (≤14 sessions), medium tertile (15–30 sessions), or highest tertile (≥31 sessions). Since very few participants reported indoor tanning before age 10 years (<1%) and many did not answer the question on indoor tanning before age 10 years, we did not include this period in the calculation. Women with missing information for 1 or more age periods were considered to have missing data, and multiple imputations were used to impute missing values.
We categorized region of residence (latitudes 70°N–58°N) according to average number of hours of ambient UV radiation ( 14 ) as low (northern Norway), medium-low (central Norway), medium (southwestern Norway), or high (southeastern Norway). We categorized number of years of education as ≤10, 11–13, or ≥14. Host factors included untanned skin color, hair color (black/dark brown, brown, blond/yellow, or red), freckling when sunbathing (yes, no), and number of asymmetrical nevi greater than 5 mm in diameter on the legs (0, 1, 2–3, 4–6, 7–12, 13–24, or ≥25; categorized as 0, 1, or ≥2). Untanned skin color was self-reported by participants using a 1- × 9-cm color scale graded from 1 (very fair) to 10 (very dark brown; very dark grades (grades 8–10) were excluded from the study) and was categorized as dark (grades 6 and 7), medium (grades 4 and 5), or light (grades 1–3). Annual number of severe sunburns that resulted in pain or blisters and subsequent peeling (never, 1, 2–3, 4–5, or ≥6) and average number of weeks per year spent on sunbathing vacations (never, 1 week/year, 2–3 weeks/year, 4–6 weeks/year, or ≥7 weeks/year) at low latitudes (typically Southern European countries with latitudes below 45°N, such as Spain or Greece) or within Norway or other northern countries were reported for the same age periods as for indoor tanning.
Cumulative number of sunburns was calculated in the same way as cumulative number of indoor tanning sessions but included the age period <10 years, and it was categorized as none, lowest tertile (≤30 sunburns), medium tertile (31–51 sunburns), or highest tertile (≥52 sunburns). Cumulative number of weeks spent on sunbathing vacations was calculated in the same way and was categorized as none, lowest tertile (≤46 weeks), medium tertile (47–87 weeks), or highest tertile (≥88 weeks). Finally, we calculated cumulative number of indoor and outdoor tanning sessions by summing tertiles of cumulative number of indoor tanning sessions and cumulative number of sunbathing vacations (score ranged from 0–6) and categorizing the variable into 4 groups (1 = lowest, 4 = highest).
Information on indoor tanning, sunburns, and sunbathing vacations was updated through the follow-up questionnaires. The reproducibility of most of the questions was assessed and shown to be good/acceptable; reproducibility was not affected by age, education, or skin color ( 15 ). The reliability coefficients for indoor tanning and sunbathing vacations at southern latitudes were 0.70 and 0.71, respectively.
Statistical analysis
Poisson regression analysis with age as the time scale was used to estimate relative risks and 95% confidence intervals for melanoma risk in relation to indoor tanning variables. Person-years were calculated from the date of return of the baseline questionnaire to the date of melanoma diagnosis, emigration, death, or the end of follow-up (December 31, 2012), whichever occurred first. Dynamic exposure variables (i.e., cumulative use, ever use, duration of use, and current use of indoor tanning), as well as cumulative numbers of sunburns and sunbathing vacations, were included as time-varying variables in all models. The association between indoor tanning and melanoma risk was examined by anatomical site (for the trunk and extremities but not the head/neck, because of few cases) and by histological subtype (for superficial spreading melanoma and nodular melanoma but not for other subtypes, because of few cases).
All analyses included adjustment for attained age (in 5-year intervals), birth cohort (1943–1957), and calendar year of study entry (1991, 1992, 1997, 1998, or 2004–2007), since calendar year of indoor tanning exposure may influence the level of UV irradiance ( 16 ). In the second model, we further adjusted for residential ambient UV exposure, hair color, and cumulative numbers of sunburns and sunbathing vacations. Additional adjustment for skin color, number of asymmetrical nevi, and freckling when sunbathing did not change the results.
In calculating the cumulative number of indoor tanning sessions, 15% ( n = 21,037) of the observations had missing information for 1 or more age periods. In addition, in the multivariable analysis, approximately 15% of participants were missing information on 1 or more covariates. Thus, we used multiple imputation with chained equations ( 17 ), imputing 15 data sets to evaluate the influence of missing information on the estimates. The imputation models included all of the covariates included in the second model, and the results are presented as those of model 3. We tested the trend of association with a variable across categories by treating the variable as continuous in the model. Interaction effects between cumulative number of indoor tanning sessions and duration of use (<10 years, ≥10 years), age at initiation (<30 years, ≥30 years), cumulative number of sunburns (never, lowest tertile, or medium/highest tertiles), cumulative number of sunbathing vacations (never, lowest tertile, or medium/highest tertiles), birth cohort, freckling, hair color (dark, light), number of nevi (0, 1, or ≥2), and year of study entry were tested with a likelihood ratio test.
We studied the association between age at indoor tanning initiation and age at diagnosis using linear regression analysis. Results are presented as regression-coefficient estimates ( β ˆ ) and 95% confidence intervals. The multivariable model included birth cohort, year of study entry, hair color, and cumulative numbers of sunburns and sunbathing vacations. We further conducted the same analysis with cases confined to early-onset melanomas (women diagnosed at age <50 years; n = 137). We used 2-sided statistical tests and a 5% significance level. Stata, version 14 (StataCorp LP, College Station, Texas) was used in all analyses.
Study sample and indoor tanning
We included 141,045 women in the analysis, and 861 women were diagnosed with incident melanoma during 1,930,583 person-years of follow-up (mean duration of follow-up = 13.7 years). Mean age at study entry was 48 years (range, 34–64), and mean age at diagnosis was 56 years (range, 34–69). The lower limb was the most common site of melanoma ( n = 343), followed by the trunk ( n = 303), upper limb ( n = 116), head/neck ( n = 52), and multiple sites/unspecified ( n = 47). The majority of cases were superficial spreading melanoma (61%) and nodular melanoma (14%).
Reported frequency of indoor tanning by age of exposure and tertile of cumulative number of tanning sessions among participants in the Norwegian Women and Cancer Study ( n = 120,008), 1991–2012. Women with missing data for 1 or more age periods were excluded ( n = 21,037). White portions of the columns represent never use of tanning devices, light gray portions represent “rare” use (per the questionnaire), black portions represent use once per month, and dark gray portions represent use ≥2 times per month.
Cumulative number of indoor tanning sessions (never, lowest tertile, or medium/highest tertiles) and age at initiation of indoor tanning (<30 years, ≥30 years), by year of birth, among participants in the Norwegian Women and Cancer Study ( n = 104,617), 1991–2012. The stacked columns represent tertile of cumulative number of indoor tanning sessions (white, never use of tanning devices; light gray, lowest tertile of use; black, medium tertile of use; dark gray, highest tertile of use). The dashed line represents the proportion of women who initiated indoor tanning at age ≥30 years; the solid line represents the proportion who initiated indoor tanning at age <30 years.
Characteristics of Participants in an Analysis of Indoor Tanning and Melanoma Risk, According to Cumulative Number of Indoor Tanning Sessions ( n = 120,008), Norwegian Women and Cancer Study, 1991–2012
Abbreviation: UV, ultraviolet.
a Percentages are row percentages.
b The relatively higher amount of missing data was due to the fact that the question was not included in all baseline questionnaires.
Indoor tanning and melanoma risk
Results from complete-case and multiple-imputation analyses were similar. Estimates from the multiple-imputation analysis are reported here, except P values for interaction.
Relative Risk of Melanoma According to Exposure to Indoor Tanning Devices Among Participants in the Norwegian Women and Cancer Study, 1991–2012 a
Abbreviations: CI, confidence interval; RR, relative risk.
a Poisson regression.
b Complete-case analyses with adjustment for attained age, birth cohort, and year of study entry.
c Complete-case analyses with adjustment for attained age, birth cohort, year of study entry, residential ambient ultraviolet radiation exposure, hair color, and cumulative number of sunburns and sunbathing vacations (additional adjustment for skin color, number of nevi, and freckling when sunbathing did not change the results).
d Analysis with multiple imputation of missing covariate data conducted using chained equations and a total of 15 generated data sets ( n = 141,045; 861 cases). Results were adjusted for all of the variables in model 2.
e Test for linear trend conducted by treating the variables as continuous in the model.
f Test of the hypothesis that RR[age of initiation (AOI) ≥30 years and lowest tertile of cumulative sessions (TCS)] + RR(AOI ≥30 years and medium/highest TCS) = RR(AOI <30 years and lowest TCS) + RR(AOI <30 years and medium/highest TCS).
We found increased risks of melanoma for both women who initiated indoor tanning prior to age 30 years (adjusted RR = 1.34, 95% CI: 1.05, 1.66) and women who initiated indoor tanning at ages ≥30 years (adjusted RR = 1.15, 95% CI: 0.96, 1.35) in comparison with never users. Melanoma risk increased with increasing duration of use ( P -trend = 0.009) (Table 2 ). Melanoma risk increased significantly with cumulative number of indoor tanning sessions (for the highest tertile of use compared with never use, adjusted RR = 1.32, 95% CI: 1.08, 1.63; P -trend = 0.006). The relative risk was even higher for a very high cumulative number of tanning sessions—for example, the relative risk was 1.53 (95% CI: 1.12, 2.09) among women with ≥480 sessions (e.g., 1 session per week on average for 10 years) compared with never users (results not shown). Testing for interaction between cumulative number of sessions and age at initiation showed a significantly higher melanoma risk among those with age at initiation <30 years ( P -interaction = 0.02; Table 2 ). When we stratified the cumulative number of sessions by duration of use, the association between cumulative sessions and melanoma risk did not change ( P -interaction = 0.71; results not shown). None of the associations between melanoma risk and cumulative tanning or ever indoor tanning varied by number of sunburns, sunbathing, birth cohort, freckling, number of nevi, hair color, or year of study entry (0.09 < P -interaction < 0.83). A highly significant trend in melanoma risk with increasing cumulative number of indoor and outdoor tanning sessions was observed ( P -trend < 0.001).
Ever use, current use, duration of use, and cumulative number of sessions were associated with significantly increased risk of superficial spreading melanoma but not nodular melanoma, although confidence intervals around the relative risk for nodular melanoma were wide because of the limited number of cases (see Web Table 1 , available at http://aje.oxfordjournals.org/ ). Site-specific analyses gave similar results for the trunk and extremities ( Web Table 2 ).
Age at initiation and age at diagnosis
Mean Age Differences in the Association Between Age at Initiation of Indoor Tanning and Age at Melanoma Diagnosis in the Norwegian Women and Cancer Study, 1991–2012 a
Abbreviations: CI, confidence interval; SD, standard deviation.
a Linear regression analysis.
b Complete-case analysis with adjustment for birth cohort, year of study entry, hair color, and cumulative numbers of sunburns and sunbathing vacations.
c Multiple-imputation analysis with adjustment for all variables in the complete-case analysis ( n = 689 cases). Multiple imputation of missing covariate data was conducted using chained equations and a total of 15 generated data sets.
In this large prospective cohort study of indoor tanning and melanoma risk, we found a significant dose-response association with cumulative number of indoor tanning sessions. Moreover, current use, younger age at initiation of indoor tanning, and longer duration of use were significantly associated with a higher risk of melanoma. Importantly, indoor tanning was associated with younger age at melanoma diagnosis. These associations remained significant after controlling for potential confounders, including age, birth cohort, residential ambient UV exposure, hair color, skin color, and cumulative numbers of sunburns and sunbathing vacations. We found a significantly higher risk of superficial spreading melanoma, the most commonly occurring histological subtype of melanoma in relation to indoor tanning use, but not a higher risk of nodular melanoma; this may have reflected the reduced statistical power to detect an association with the smaller number of cases of nodular melanoma.
We found a 32% increased risk of melanoma for women with cumulative totals of >30 tanning sessions (highest tertile), and risk was 53% higher for those with ≥480 sessions (e.g., once a week or more for 10 years, on average) compared with never use. Our findings support the evidence from 2 recent meta-analyses ( 3 , 4 ). Two cohort studies found a nonsignificant or borderline-significant increased risk of melanoma among indoor tanners; however, those investigators did not have detailed information on indoor tanning, and the sample sizes were quite small ( 18 , 19 ). To our knowledge, this study is the first prospective cohort study to have investigated cumulative number of indoor tanning sessions over several decades of life, as well as the relationship of current use and age at initiation to melanoma risk and average age at melanoma diagnosis.
Any indoor tanning was significantly associated with younger age at diagnosis, with a 2-year decrease in mean age at diagnosis among patients who started indoor tanning prior to 30 years of age. While this is the first study to have examined the association between indoor tanning and mean age at melanoma diagnosis, 2 case-control studies found a significant association between indoor tanning and early-onset melanoma. Those authors reported that participants with more than 10 indoor tanning sessions over the course of a lifetime were at significantly higher risk of being diagnosed with melanoma before age 30 years ( 20 , 21 ). The minimum age at inclusion in our study was 34 years, and we excluded melanomas diagnosed before study entry; thus, the difference in average age at diagnosis for indoor tanners compared with never users is likely to be larger than our estimates suggest. Considering the currently high prevalence of indoor tanning among young people, this finding has important implications for public health. It shows that indoor tanning increases the burden of melanoma not only by increasing its incidence but also by decreasing age at onset. Globally, it is estimated that 1,169,000 years of life were lost due to melanoma in 2010 ( 22 ), and a person dying from melanoma loses an average of 20 years of potential life ( 23 , 24 ).
In Norway, the first whole-body tanning device became available in 1972, and indoor tanning became popular during the 1980s ( 13 ). Thus, most of our study cohort (born in 1943–1957) did not have access to sunbeds during their adolescence. The prevalence of indoor tanning was high among these participants, with 70% reporting ever tanning indoors, but the cumulative number of sessions was quite low, and two-thirds of the indoor tanners reported ≤30 sessions. The proportion of indoor tanners with age at initiation <30 years was approximately 20% in our study, with an increasing trend in the younger cohorts. According to a recent Norwegian survey, 35% of respondents aged 18–24 years reported having engaged in indoor tanning during the past year ( 9 ), and in a recent meta-analysis, Wehner et al. ( 8 ) reported indoor tanning among 55% of university students, with 43% engaging in indoor tanning during the past year and a significant increasing trend over time. At the same time, in a recent systematic review, Nilsen et al. ( 25 ) found a trend toward a significantly higher level of UV radiation being measured in modern indoor tanning devices in recent years in Europe, and the level of this UV radiation is higher than that from natural sunlight. Therefore, younger generations are being exposed to a higher dose of artificial UV radiation than the women in our study cohort, and the negative impact of indoor tanning among them would be expected to be higher than that observed in our cohort.
In 1983, Norway implemented the first regulations on indoor tanning devices. At that time, tanning devices with lamps rich in ultraviolet B (UVB) radiation were replaced by devices with ultraviolet A (UVA)-rich fluorescent lamps ( 13 ). Thus, in our study, older birth cohorts were more exposed to UVB-rich tanning devices and younger birth cohorts were mainly exposed to newer, UVA-rich devices. However, we found no interaction in the association between indoor tanning and melanoma risk by birth cohort, which is in line with the evidence from other studies that newer tanning devices are as hazardous as the older ones ( 19 , 26 , 27 ).
In its 2006 meta-analysis, IARC found a higher melanoma risk associated with younger age at tanning initiation (≤35 years) and suggested that there may be greater susceptibility to harmful effects of indoor tanning during youth ( 28 ). However, the literature is not conclusive in this regard. In a recent report, Lazovich et al. ( 29 ) suggested that early age at initiation of indoor tanning is most likely a marker for cumulative exposure, not an indication of increased susceptibility for younger people. However, in the report by Cust et al. ( 20 ), cumulative exposure did not fully account for the association between earlier age at initiation and melanoma risk. The higher risk of melanoma for initiation at age <30 years compared with initiation at age ≥30 years observed in our study provides supporting evidence of greater susceptibility during youth and young adulthood.
Since it is not ethical to use randomized controlled trials for investigating the association between indoor tanning and melanoma risk, large prospective cohort studies provide the highest level of evidence. NOWAC is a large, well-characterized, population-based prospective cohort study. Possession of detailed exposure information across several decades of life that was updated during follow-up, complete follow-up through high-quality national registries, and the large number of cases, with 99.9% of melanomas being morphologically verified ( 2 ), were some of the strengths of our study. However, a limitation is that the information on exposure at young ages was collected retrospectively. Thus, some misclassification of exposure is likely to have occurred, but it was most probably nondifferential, since all of the information was collected before melanoma diagnosis. We also did not collect information on the types of indoor tanning devices used and the duration of each tanning session; however, other studies found no difference in the risk by type of device ( 29 – 31 ). This study included only women aged ≥34 years. Although indoor tanning is more popular among women than among men ( 32 , 33 ), another study found similar estimates for the association between indoor tanning and melanoma for men and women ( 29 ).
In summary, this large prospective cohort study provides strong supporting evidence on the strength, dose response, and temporality of the association between indoor tanning and melanoma risk. Moreover, our findings support the IARC's conclusion of a higher vulnerability to the harmful effects of indoor tanning before 35 years of age.
Author affiliations: Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway (Reza Ghiasvand, Corina S. Rueegg, Marit B. Veierød); Department of Community Medicine, Faculty of Health Sciences, UiT—The Arctic University of Norway, Tromsø, Norway (Elisabete Weiderpass, Eiliv Lund); Department of Research, Cancer Registry of Norway, Oslo, Norway (Elisabete Weiderpass); Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (Elisabete Weiderpass); Genetic Epidemiology Group, Folkhälsan Research Center, Helsinki, Finland (Elisabete Weiderpass); Cancer and Population Studies Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia (Adele C. Green); and Cancer Research UK Manchester Institute, University of Manchester, Manchester, United Kingdom (Adele C. Green).
This work was supported by the Norwegian Extra Foundation [ExtraStiftelsen] for Health and Rehabilitation through EXTRA funds (project 2011/2/0228) and by the Norwegian Cancer Society (projects 6823329 and 2197685). C.S.R. has received funding from the European Union Seventh Framework Programme under grant agreement 609020 (Scientia Fellows and the Institute of Basic Medical Sciences, University of Oslo).
Portions of these results were presented at the International Agency for Research on Cancer's 50th anniversary scientific conference (“Global Cancer: Occurrence, Causes, and Avenues to Prevention”), Lyon, France, June 7–10, 2016.
Conflict of interest: none declared.
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Author notes
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Supplementary data
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- Invited Commentary: Indoor Tanning—A Melanoma Accelerator?
- Ghiasvand et al. Respond to “Indoor Tanning—A Melanoma Accelerator?”
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Preventive Medicine Reports
Tanning bed use and melanoma: establishing risk and improving prevention interventions ☆.
We present a concise review of current evidence on the risks of indoor tanning.
We identify populations most at risk of negative outcomes from indoor tanning.
We evaluate current legislation aimed to reduce the prevalence of indoor tanning.
We argue for aggressive anti-tanning initiatives targeting specific high risk groups.
We reaffirm the need for widespread public education on the health risks of indoor tanning.
Exposure to ultraviolet radiation (UVR) from indoor tanning devices is thought to cause melanoma and other negative health consequences. Despite these findings, the practice of indoor tanning in the United States remains prevalent. In this paper we aim to present a clear discussion of the relationship between indoor tanning and melanoma risk, and to identify potential strategies for effective melanoma prevention by addressing indoor tanning device use.
Basic procedures
We reviewed relevant literature on the risks of indoor tanning, current indoor tanning legislation, and trends in indoor tanning and melanoma incidence. Study was conducted at the University of Southern California, Los Angeles, CA between the years of 2014 and 2015.
Main findings
Our findings reaffirm the relationship between indoor tanning and melanoma risk, and suggest a widespread public misunderstanding of the negative effects of indoor tanning.
Principal conclusions
This review argues for an aggressive initiative to reduce indoor tanning in the United States, to design prevention efforts tailored towards specific high risk groups, and the need to better inform the public of the risks of indoor tanning.
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Financial support
Dr. Cockburn was supported in part by the National Cancer Institute and the National Institute of Child Health and Human Development under grant R01CA158407 .
IMAGES
VIDEO
COMMENTS
Studies from the past several years have shown a significant association between ever-use of an indoor tanning facility and an increased risk of basal cell
Regarding BCC, sunbed use was a risk factor for sporadic basal cell carcinoma in Germany []. A study from the Icelandic Cancer Registry reported
Tanning is caused by exposure to ultraviolet (UV) radiation from the sun or tanning beds that causes genetic damage to cells on your outmost layer of skin.
2 Even seemingly trivial sun exposure, enough just to turn the skin red, causes considerable damage to both keratinocytes3 and melanocytes and is sufficient for
Ultraviolet (UV) radiation from indoor tanning (and the sun) is a well-established carcinogen that causes most skin cancers. Research has
Conclusions: In a highly exposed population, frequent indoor tanning increased melanoma risk, regardless of age when indoor tanning began. Elevated risks were
The internal reliability of the scale was KR-20 = 0.624. We discovered an improvable level of knowledge in terms of skin cancer among the study population.
The relationship between indoor tanning and melanoma has been investigated in several case-control studies and a few cohort studies, and the
Research has already linked indoor tanning to an increased risk of cutaneous squamous cell carcinoma — a type of skin cancer.
Exposure to UVR from indoor tanning devices has been shown to cause DNA damage in skin cells, and is associated with an increased risk of developing melanoma