 |
|
Characteristics Associated With Use or Intention to Use Indoor Tanning Among Adolescents
DeAnn Lazovich, PhD;
Jean Forster, PhD, MPH;
Glorian Sorensen, PhD;
Karen Emmons, PhD;
Jo Stryker, PhD;
Marie-France Demierre, MD;
Andrea Hickle, MPH;
Natania Remba, EdM
Arch Pediatr Adolesc Med. 2004;158:918-924.
ABSTRACT
| |
Background Indoor tanning is a popular behavior that may increase skin cancer risk.
Objective To examine characteristics associated with use or intention to use indoor tanning among adolescents.
Methods A telephone interview was conducted with 1273 adolescents, aged 14 to 17 years, in the Minneapolis– St Paul, Minn, and Boston, Mass, metropolitan areas. Questions included demographic and phenotypic characteristics, knowledge, attitudes, social factors, use of indoor tanning, and intention to tan indoors.
Results Twelve percent of boys and 42% of girls had tanned indoors. Among nontanners, 22.4% planned to start, and 77.2% of tanners planned to continue tanning indoors. Nontanners and tanners at risk for future indoor tanning use were each significantly more likely to be female, less likely to use sun protection, less knowledgeable about skin cancer risks, more likely to agree that tans were attractive, and more strongly influenced by social factors compared with their low-risk counterparts.
Conclusions Our data suggest that intention to tan indoors may identify a group of adolescents at risk for adopting the behavior; prospective studies are needed for confirmation.
INTRODUCTION
The incidence of squamous cell, basal cell, and melanoma skin cancers has risen dramatically since the mid 1950s.1-4 Solar UV radiation is an established risk factor for these cancers, with the magnitude of the risk depending on patterns of sun exposure, intermittent or cumulative, and frequency of sunburn.5 Despite recommendations to avoid all sources of UV radiation,6-9 the desire for a tan and the availability of artificial sources of UV radiation from tanning beds and booths has given rise to the indoor tanning industry, estimated to be a $5 billion enterprise.10 The tanning industry estimates that 28 million Americans have used indoor tanning facilities, with about 1 million visits each day.11
Typical indoor tanners in the United States today (20 sessions per year) could add anywhere from 0.20% to 24% more UV-B radiation (S. A. Miller, written communication, March 2003) but as much as 30% to 300% more UV-A radiation12 to their annual solar exposures by tanning indoors, depending on the tanning device. While UV-B has generally been viewed as the component of UV radiation responsible for skin cancer development, laboratory studies, experiments in animals, case reports of skin cancer following tanning bed exposure, and increased incidence of skin cancer among patients with psoriasis treated with UV-A and psoralen strongly suggest that UV-A may also be carcinogenic.13-27 The majority of epidemiologic studies of indoor tanning and skin cancer predate the current availability of low UV-B–, high UV-A–emitting tanning devices or have insufficient information on indoor tanning use to draw conclusions.28-33 However, a recent study from Sweden29 among individuals primarily exposed to tanning devices in use today reported a strong positive association for melanoma, thus providing preliminary epidemiologic evidence that currently available tanning devices could increase the risk of melanoma.
Given the carcinogenic potential and the popularity of indoor tanning, we conducted a comprehensive assessment of indoor tanning–related practices among public health agencies and tanning businesses and among adolescents and their parents in the metropolitan regions of Minnesota and Massachusetts. Herein, we report our findings for characteristics associated with indoor tanning use among adolescents, as others have recently done,34-36 and then we examine whether these characteristics are also related to intention to either initiate indoor tanning use among nontanners or to continue use among tanners. The model for this approach was developed by Pierce et al,37-38 who defined adolescents' "susceptibility" to tobacco use according to their intention to smoke in the near or long term or their ability to refuse a cigarette from friends. Adolescent nonsmokers who met the definition of susceptibility shared characteristics with current smokers in cross-sectional analyses,37 and a prospective assessment confirmed that the probability of subsequent smoking increased according to susceptibility and past smoking experience.38-39 This concept is now used to describe stages of smoking acquisition among adolescents40 but has not been routinely applied to other adolescent behaviors. Second, we examine practices and attitudes specific to indoor tanning use among adolescents who had tanned indoors.
METHODS
PARTICIPANTS
We identified adolescents aged 14-17 years in fall 2000 from a targeted age list purchased from Survey Sampling, Inc, Fairfield, Conn, for the Boston, Mass, and Minneapolis–St Paul, Minn, metropolitan statistical areas. Randomly selected households were called to determine if a teenager resided at that number, selecting 1 at random if more than 1 adolescent in the age range was in the household. We oversampled girls relative to boys in a 2:1 ratio. In the Boston area, 33.0% of households (n = 2699) were found to have an adolescent in the desired age range; in the Minneapolis–St Paul area, 44.7% of 1650 households had an adolescent in the desired age range (37.4% overall). Among eligible households, 651 adolescents (73.1%) in Boston and 647 adolescents (87.8%) in Minneapolis–St Paul completed a telephone interview with their parents' consent. Because we were interested in the use of commercial tanning facilities, we excluded 23 adolescents (1.8%) who reported home use only and 2 adolescents who did not provide information about intention to tan, for a total of 1273 participants. The study was approved by the institutional review boards at the University of Minnesota, Minneapolis–St Paul, and Harvard University School of Public Health, Boston.
MEASURES
We collected information about personal characteristics including age, sex, smoking history, use of sun protection, skin cancer risk factors (eg, color of hair, eyes, skin, propensity to sunburn, and history of severe sunburns), body satisfaction (eg, how often are you happy with the way you look), and depression (eg, how often have you been bothered by feeling unhappy, sad, and depressed41). From the risk factors for skin cancer, we created a skin cancer risk summary score (range, 4-17; the higher the score, the higher the risk). A knowledge summary score was created by giving 1 point for each correct answer (0-5 points possible) to questions about tans being a marker of skin damage, indoor tanning being a possible cause of skin cancer, whether indoor tanning is safer than the sun or protects one from sunburn, and that medications could make one more sensitive to the effects of UV radiation. Positive attitudes toward tans were measured by the percentage of teens who agreed or strongly agreed that people with tans looked more attractive or healthier than those without a tan. Social influences were assessed by agreement with the statements that most of their friends liked to be tan or that their parents allowed them to tan indoors, and perceived norms were based on adolescents' estimates of the proportion of their friends or adults who tan indoors (dichotomized at the median value, specific to each measure).
Age at tanning initiation and recency of indoor tanning use was asked of adolescents who had ever tanned. Those who had tanned in the past year were asked detailed questions about tanning frequency, parental consent (required by law in each state, depending on age), perceived difficulty to stop tanning indoors, indoor tanning practices (eg, wearing goggles), and adverse effects experienced from tanning (from a list including itching, red/painful skin, eye problems, warts, medication reaction, other). We also asked these teens to indicate their level of agreement with 3 positive (compliments about indoor tan, indoor tanning helps lift spirits, or is relaxing) and 5 negative (feeling claustrophobic in a tanning bed, getting hot and sweaty from indoor tanning, and indoor tans look fake, are expensive, or make skin smell) attitudes about indoor tanning. Items were reordered so that a high value indicated positive attitudes toward indoor tanning, and a summary score was created by taking the mean of values across items (Cronbach  = .55).
For outcome measures, we first classified all adolescents according to whether they had ever tanned indoors. We defined our second outcome according to adolescents' self-reported intention to use indoor tanning. Intention was asked slightly differently depending on an adolescent's previous indoor tanning experience. Adolescents who had tanned indoors and reported being very or somewhat likely to do so again in the next year (298 tanners [77.2%]) were classified as being at risk to continue the behavior relative to tanners who responded not very or not at all likely to tan in the next year. Nontanners who answered yes to a question about plans to tan indoors sometime in the future (198 nontanners [22.3%]) were considered to be at risk to initiate indoor tanning, while those who answered no were classified as being at low risk for future indoor tanning use.
STATISTICAL ANALYSIS
Although the prevalence of indoor tanning was higher in the Minneapolis–St Paul area than the Boston area (40.0% vs 20.7%), preliminary analyses indicated no important differences between cities in the associations of interest nor did our results differ by sex or age. Therefore, all analyses are presented for the combined sample. We first compared adolescents who had ever tanned indoors with those who never had for each characteristic described earlier. We then repeated the analysis separately among nontanners and tanners, comparing adolescents who were at risk for future indoor tanning use (ie, those reporting intention to initiate or continue the behavior) with those in the respective low-risk group. Among tanners, we also assessed the relationship between tanning practices and attitudes about the practice with intention to continue indoor tanning use.
We used logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of interest. The significance of the observed associations was assessed by the likelihood ratio test; linear trends were evaluated by the Wald test. For personal characteristics associated with use or future use and for indoor tanning practices associated with intention to continue use, ORs were adjusted for age, sex, and city. For knowledge, attitudes (about tans, about indoor tanning), or social factors, we first obtained ORs adjusted for these confounders (data not shown). Then, for those found to be significantly associated with use and/or intention to use indoor tanning, we identified which factors were independent predictors of past or future indoor tanning by including all related characteristics simultaneously in logistic regression models. Odds ratios were not adjusted for socioeconomic status because only the parent's education was available and was missing for adolescents whose parent was not interviewed. However, ORs based on the subset of the sample that included parent education were unchanged from the results presented here.
RESULTS
Girls were more likely than boys to have ever tanned indoors and to report intention to either initiate or continue indoor tanning use (Table 1). In contrast, adolescents who reported using sun protection most of the time were the least likely to report indoor tanning use or be at risk for future use relative to adolescents who never used sun protection. For other personal characteristics, however, the associations were not consistent across outcomes. The prevalence of indoor tanning use increased with each additional year of age (P trend <.001). Among adolescents who had never tanned indoors, however, intention to initiate indoor tanning was less likely with increasing age (P trend = .09), while age was not a factor for intention to continue indoor tanning if adolescents had previously tanned indoors (P trend = .76). Smoking history was positively associated with having ever tanned indoors and with being at risk for future tanning among nontanners but not among tanners, whereas the observation that the likelihood of future indoor tanning decreased with higher skin cancer risk scores was found only among tanners. Neither body satisfaction nor depression were associated with any outcome (data not shown).
|
|
|
|
Table 1. Personal Characteristics Associated With Past Use or Intention to Use Indoor Tanning Among Adolescents Aged 14 to 17 Years
|
|
|
Knowledge, positive attitudes toward tans, and social factors were all significantly associated with having ever tanned indoors or with intention to tan indoors when we adjusted for age, sex, and city. When we considered all these characteristics simultaneously (Table 2), social influences (friends like to be tan, parents allow tanning) and perceived norms (proportion of friends or adults who have tanned indoors) generally remained strong predictors of ever use of indoor tanning as well as intention to initiate or to continue the behavior. For knowledge and positive attitudes, however, the results depended on whether we considered past use or intention to use indoor tanning. Among all adolescents, neither knowledge nor positive attitudes toward tans were associated with having ever tanned indoors once social factors were considered. Among nontanners and tanners, however, adolescents who were more knowledgeable about the potential risks of indoor tanning were still less likely to be at risk for initiation or continuation of indoor tanning, while those holding the view that people with tans look more attractive (but not healthier) were still more likely to be at risk for future indoor tanning after adjusting for social factors.
|
|
|
|
Table 2. Knowledge, Attitudes, and Social Factors Associated With Past Use or Intention to Use Indoor Tanning Among Adolescents Aged 14 to 17 Years
|
|
|
Recent or frequent use of indoor tanning were each strongly predictive of intention to continue the practice among adolescent tanners (Table 3). In addition, tanners who reported medium to extreme difficulty to stop tanning indoors were more likely to be at risk for future indoor tanning (adjusted OR, 11.52 [95% CI, 1.53-86.60]). However, neither asking a parent for consent to tan indoors nor having experienced adverse effects from indoor tanning appeared to decrease intention to continue tanning indoors, whereas compliance with regulations, such as wearing goggles, did. Among tanners, 2 of the 5 negative attitudes toward indoor tanning—agreement that tanning indoors is expensive or that it makes skin smell bad—were not associated with intention to continue indoor tanning after accounting for age, sex, and city. When we simultaneously considered all other attitudes found to be related to future indoor tanning (Table 4), only the 3 positive attitudes toward indoor tanning (compliments, lifts spirits, relaxation) remained independently associated with the likelihood of being in the at-risk group. When all 8 attitudes toward indoor tanning were combined into a summary scale, higher scores were strongly associated with intention to continue to tan indoors.
|
|
|
|
Table 3. Indoor Tanning Practices Associated With Intention to Continue to Tan Indoors Among Adolescent Tanners
|
|
|
|
|
|
|
Table 4. Attitudes Toward Indoor Tanning Associated With Intention to Continue to Tan Indoors Among Adolescent Tanners
|
|
|
COMMENT
To our knowledge, our report is the first to examine predictors of indoor tanning among adolescents in relation to their stated intention to tan indoors. Although cross-sectional data limit us from concluding that our measure of intention predicts future indoor tanning, our results are notable for their consistency with early work to define adolescent "susceptibility" to tobacco use.37 Just as adolescents susceptible to tobacco use resembled adolescent smokers, we found that at-risk nontanners and tanners were each more likely to be female, less likely to be frequent sunscreen users, less knowledgeable about skin cancer risks, more likely to agree that tans were attractive, and strongly influenced by social factors compared with their low-risk counterparts. Other studies have prospectively linked behavioral intention to indoor tanning among college students42 and sunscreen use among fourth graders and college students,43-44 strengthening the possibility that self-reported intention to tan indoors may identify a group of adolescents who are likely to tan indoors sometime in the future.
Our findings also add further evidence to the growing recognition that indoor tanning is a socially determined behavior. In 2 recent national surveys of US adolescents, the probability of tanning indoors was much higher among adolescents whose friends34 or parents36 also tanned. Others have reported that social relationships influence the likelihood of sunbathing among adolescents45-46 and that friends, parents, and social norms are important for encouraging adolescent sunscreen use47 or intention to protect oneself from the sun.48 Our data suggest that social influences and perceived norms may also be critical to initiating and maintaining the behavior. In particular, the perception of being surrounded by friends and adults who tan and believing that the behavior is sanctioned by their parents were each strongly predictive of indoor tanning behavior beyond the contribution of positive attitudes toward a tan.
Anecdotal reports suggest that some adolescents may be "addicted" to indoor tanning.49 We found that tanners at risk to continue tanning indoors were much more likely to report difficulty giving up indoor tanning compared with low-risk tanners, warranting further investigation in longitudinal studies. The most common reasons for tanning indoors include relaxation50-52 and appearance.50, 53 Appearance, relaxation, and social benefits have been correlated with the frequency of visits to tanning salons54; being female or a recent tanner have been associated with intention to continue to tan indoors but experiencing adverse effects has not53; and being female and believing that tans represent a healthy appearance or that tanning beds are safe distinguished current from past users.55 Although these studies were conducted in college-aged or older populations, the observations are consistent with our own.
Our analysis of attitudes toward indoor tanning is more comprehensive than what has been previously reported and provides guidance for interventions to dissuade adolescents from continuing to tan indoors. Appearance, relaxation, and mood elevation outweighed negative reasons for continued tanning; thus, adolescents may benefit from alternative activities that provide similar benefits. Increasing the cost of indoor tanning through taxation56 might be another strategy since clearly the cost of tanning was not a barrier to adolescents' intention to continue tanning. Although none of the negative attitudes toward indoor tanning was significant in the fully adjusted model, the view that indoor tans look fake almost approached statistical significance (fully adjusted OR, 0.62 [95% CI, 0.35-1.09]), and the strength of the relationship suggests that it may retain some merit as a message to counter the view that tans are attractive.
In recent national reports,34-36 indoor tanning prevalence ranged from 2% to 11% among boys and from 12% to 37% among girls. Despite the use of a targeted list for sampling that could yield a more select group, our prevalence estimates are comparable with the upper range of prior studies. Our findings for age, sex, other health behaviors, positive attitudes, and social factors in relation to indoor tanning use are similar to other reports,34-36,45-48,52, 57-59 providing additional evidence that our associations were not biased by sample selection methods. Other limitations include reliance on self-report to ascertain the behavior and the effect of nonresponse on the point estimates. However, high correspondence (r = 0.78) between self-report of indoor tanning and events recorded in diaries has been reported,60 and our response rates were high—73% in Boston and 88% in Minnesota. If nonresponders were more likely to be indoor tanners, as might be expected since this behavior seems to parallel other high-risk behaviors associated with nonresponse such as smoking, then the strength of the associations reported herein may be underestimated.
Recommendations and interventions for skin cancer prevention have focused almost exclusively on reducing children's and adults' sun exposure,6-8,61-62 understandably, because sun is ubiquitous and an established risk factor for skin cancer. Although the indoor tanning industry is subject to federal regulation and, in addition, about 27 states have some form of regulations on indoor tanning businesses, only 18 states limit adolescent use of indoor tanning,63 and low industry compliance with such rules has been reported.64-65 Our findings that a high proportion of adolescents believe that their parents would allow them to tan indoors and that parents often tan indoors themselves36, 66 suggest that public awareness of the dangers posed by indoor tanning is limited. In addition to increasing awareness of the potential risks of indoor tanning, our data provide support for interventions that increase knowledge and consider the social aspects of indoor tanning to prevent initiation or continuation of indoor tanning use. Until such time that epidemiologic studies can confirm or refute the link between modern indoor tanning devices and skin cancer, in particular melanoma, it would be prudent to find effective ways to limit adolescents' use of indoor tanning.
| What This Study Adds
When this study was undertaken, little information was available about adolescent use of indoor tanning in the United States. Since then, 3 recently published articles have reported indoor tanning to be more prevalent among girls or older adolescents, among teens whose friends or parents tanned or who held positive attitudes toward the behavior, and among teens with other high-risk behaviors, such as alcohol or tobacco use. This report confirms earlier findings and extends this work by examining for the first time adolescent intention to initiate or continue to tan indoors among nontanners and tanners, respectively, based on a model of "susceptibility" to the behavior first proposed to identify adolescents at risk for tobacco use. Similar to the tobacco model, nontanners at risk for initiating and tanners at risk for continuing the behavior shared characteristics that may help to identify adolescents at risk for future indoor tanning. Associations between indoor tanning practices (eg, number of sessions, experience of symptoms, infrequent use of goggles) and attitudes related to intention to continue to tan indoors provide new evidence for concern about potential harmful effects of indoor tanning and possible messages to dissuade adolescents from the practice.
|
|
AUTHOR INFORMATION
Correspondence: DeAnn Lazovich, PhD, Division of Epidemiology, University of Minnesota, 1300 S 2nd St, Suite 300, Minneapolis, MN 55454 (lazovich{at}epi.umn.edu).
Accepted for publication April 19, 2004.
This study was supported by grant 1 RO1 CA079593 from the National Cancer Institute, Bethesda, Md.
From the Division of Epidemiology, University of Minnesota, Minneapolis– St Paul (Drs Lazovich, Forster, and Hickle); Dana Farber Cancer Center and Harvard School of Public Health, Harvard University, (Drs Sorensen, Emmons, and Stryker and Ms Remba), and the Department of Dermatology, Boston University (Dr Demierre) Boston, Boston, Mass.
REFERENCES
1. Jemal A, Devesa SS, Hartge P, Tucker MA. Recent trends in cutaneous melanoma incidence among whites in the United States. J Natl Cancer Inst. 2001;93:678-683.
FREE FULL TEXT
2. Howe HL, Wingo PA, Thun MJ, et al. Annual report to the nation on the status of cancer (1973 through 1998), featuring cancers with recent increasing trends. J Natl Cancer Inst. 2001;93:824-842.
FREE FULL TEXT
3. Karagas MR, Greenberg ER, Spencer SK, Stukel TA, Mott LA. Increase in incidence rates of basal cell and squamous cell skin cancer in New Hampshire, USA. Int J Cancer. 1999;81:555-559.
FULL TEXT
|
ISI
| PUBMED
4. Joseph AK, Mark TL, Mueller C. The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by Medicare. Dermatol Surg. 2001;27:955-959.
FULL TEXT
|
ISI
| PUBMED
5. Armstrong BK, Kricker A. The epidemiology of UV induced skin cancer. J Photochem Photobiol B. 2001;63:8-18.
FULL TEXT
| PUBMED
6. Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine practice policy statement: skin protection from ultraviolet light exposure. Am J Prev Med. 1998;14:83-86.
FULL TEXT
|
ISI
| PUBMED
7. Robinson JK, Amonette RA, Wright SW, Bewerse BA, Bergfeld WF, Farris PK. Executive summary of the national "Sun Safety: Protecting our Future" conference: American Academy of Dermatology and Centers for Disease Control and Prevention. J Am Acad Dermatol. 1998;38:774-780.
FULL TEXT
|
ISI
| PUBMED
8. Glanz K, Saraiya K, Wechsler H. Guidelines for school programs to prevent skin cancer. MMWR. 2002;51:1-18.
PUBMED
9. Council on Scientific Affairs. Harmful effects of ultraviolet radiation. JAMA. 1989;262:380-384.
FREE FULL TEXT
10. Winning moves for tanning and equipment: a comprehensive report on the state of the industry. Looking Fit. 2002;17:38-48.
11. American Academy of Dermatology. Facts about indoor tanning [press kit]. Schaumburg, Ill: American Academy of Dermatology; 1997.
12. Miller SA, Hamilton SL, Wester UG, Cyr WH. An analysis of UVA emissions from sunlamps and the potential importance for melanoma. Photochem Photobiol. 1998;68:63-70.
FULL TEXT
|
ISI
| PUBMED
13. Linge C. Relevance of in vitro melanocytic cell studies to the understanding of melanoma. Cancer Surv. 1996;26:71-87.
ISI
| PUBMED
14. Wang SQ, Setlow R, Berwick M, et al. Ultraviolet A and melanoma: a review. J Am Acad Dermatol. 2001;44:837-846.
FULL TEXT
|
ISI
| PUBMED
15. Runger TM. Role of UVA in the pathogenesis of melanoma and non-melanoma skin cancer: a short review. Photodermatol Photoimmunol Photomed. 1999;15:212-216.
ISI
| PUBMED
16. Woollons A, Kipp C, Young AR, et al. The 0.8% ultraviolet B content of an ultraviolet A sunlamp induces 75% of cyclobutane pyrimidine dimers in human keratinocytes in vitro. Br J Dermatol. 1999;140:1023-1030.
FULL TEXT
|
ISI
| PUBMED
17. Marrot L, Belaidi JP, Meunier JR, Perez P, Agapakis-Causse C. The human melanocyte as a particular target for UVA radiation and an endpoint for photoprotection assessment. Photochem Photobiol. 1999;69:686-693.
FULL TEXT
|
ISI
| PUBMED
18. Burren R, Scaletta C, Frenk E, Panizzon RG, Applegate LA. Sunlight and carcinogenesis: expression of p53 and pyrimidine dimers in human skin following UVA I, UVA I + II and solar simulating radiations. Int J Cancer. 1998;76:201-206.
FULL TEXT
|
ISI
| PUBMED
19. Kvam E, Tyrrell RM. Induction of oxidative DNA base damage in human skin cells by UV and near visible radiation. Carcinogenesis. 1997;18:2379-2384.
FREE FULL TEXT
20. Ley RD. Ultraviolet radiation A-induced precursors of cutaneous melanoma in Monodelphis domestica. Cancer Res. 1997;57:3682-3684.
FREE FULL TEXT
21. Setlow RB, Grist E, Thompson K, Woodhead AD. Wavelengths effective in induction of malignant melanoma. Proc Natl Acad Sci U S A. 1993;90:6666-6670.
FREE FULL TEXT
22. Lindelof B, Sigurgiersson B, Tegner E, et al. PUVA and cancer risk: the Swedish follow-up study. Br J Dermatol. 1999;141:108-112.
FULL TEXT
|
ISI
| PUBMED
23. Katz KA, Marcil I, Stern RS. Incidence and risk factors associated with a second squamous cell carcinoma or basal cell carcinoma in psoralen + ultraviolet A light-treated psoriasis patients. J Invest Dermatol. 2002;118:1038-1043.
FULL TEXT
|
ISI
| PUBMED
24. Stern RS, Nichols KT, Vakeva LH. Malignant melanoma in patients treated for psoriasis with methoxsalen (psoralen) and ultraviolet A radiation (PUVA): the PUVA Follow-Up Study. N Engl J Med. 1997;336:1041-1045.
FREE FULL TEXT
25. Roest MAB, Keane FM, Agnew K, Hawk JLM, Griffiths WAD. Multiple squamous skin carcinomas following excess sunbed use. J R Soc Med. 2001;94:636-637.
FREE FULL TEXT
26. Lever LR, Lawrence CM. Nonmelanoma skin cancer associated with use of a tanning bed. N Engl J Med. 1995;332:1450-1451.
FREE FULL TEXT
27. Higgins EM, du Vivier AWP. Possible induction of malignant melanoma by sunbed use. Clin Exp Dermatol. 1992;17:357-359.
FULL TEXT
|
ISI
| PUBMED
28. Swerdlow AJ, Weinstock MA. Do tanning lamps cause melanoma? an epidemiologic assessment. J Am Acad Dermatol. 1998;38:89-98.
FULL TEXT
|
ISI
| PUBMED
29. Westerdahl J, Ingvar C, Masback A, Jonsson N, Olsson H. Risk of cutaneous malignant melanoma in relation to use of sunbeds: further evidence for UV-A carcinogenicity. Br J Cancer. 2000;82:1593-1599.
FULL TEXT
|
ISI
| PUBMED
30. Loria D, Matos E. Risk factors for cutaneous melanoma: a case-control study in Argentina. Int J Dermatol. 2001;40:108-114.
FULL TEXT
|
ISI
| PUBMED
31. Landi MT, Baccarelli A, Calista D, et al. Combined risk factors for melanoma in a Mediterranean population. Br J Cancer. 2001;85:1304-1310.
FULL TEXT
|
ISI
| PUBMED
32. Kaskel P, Sander S, Kron M, Kind P, Peter RU, Krahn G. Outdoor activities in childhood: a protective factor for cutaneous melanoma? results of a case-control study in 271 matched pairs. Br J Dermatol. 2001;145:602-609.
FULL TEXT
|
ISI
| PUBMED
33. Naldi L, Gallus S, Imberti GL, Cainelli T, Negri E, La Vecchia C. Sunlamps and sunbeds and the risk of cutaneous melanoma. Eur J Cancer Prev. 2000;9:133-134.
FULL TEXT
|
ISI
| PUBMED
34. Geller AC, Colditz GA, Oliveria S, et al. Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics. 2002;109:1009-1014.
FREE FULL TEXT
35. Demko CA, Borawski EA, Debanne SM, Cooper KD, Stange KC. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med. 2003;157:854-860.
FREE FULL TEXT
36. Cokkinides VE, Weinstock MA, O'Connell MC, Thun MJ. Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: prevalence and correlates. Pediatrics. 2002;109:1124-1130.
FREE FULL TEXT
37. Pierce JP, Farkas AJ, Evans N, Gilpin E. An improved surveillance measure for adolescent smoking? Tob Control. 1995;4(suppl 1):S47-S56.
38. Pierce JP, Choi WS, Gilpin EA, Farkas AJ. Validation of susceptibility as a predictor of which adolescents take up smoking in the United States. Health Psychol. 1996;15:355-361.
FULL TEXT
|
ISI
| PUBMED
39. Choi WS, Gilpin E, Farkas AJ, Pierce JP. Determining the probability of future smoking among adolescents. Addiction. 2001;96:313-323.
FULL TEXT
|
ISI
| PUBMED
40. Mayhew KP, Flay BR, Mott JA. Stages in the development of adolescent smoking. Drug Alcohol Depend. 2000;59(suppl 1):S61-S81.
41. Kandel DB, Davies M. Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry. 1986;43:255-262.
FREE FULL TEXT
42. Hillhouse JJ, Adler CM, Drinnon J, Turrisi R. Application of Azjen's theory of planned behavior to predict sunbathing, tanning salon use, and sunscreen use intentions and behaviors. J Behav Med. 1997;20:365-378.
FULL TEXT
|
ISI
| PUBMED
43. Martin SC, Jacobsen PB, Lucas DJ, Branch KA, Ferron JM. Predicting children's sunscreen use: application of the theories of reasoned action and planned behavior. Prev Med. 1999;29:37-44.
FULL TEXT
|
ISI
| PUBMED
44. Jackson KM, Aiken LS. A psychological model of sun protection and sunbathing in young women: the impact of health beliefs, attitudes, norms, and self-efficacy for sun protection. Health Psychol. 2000;19:469-478.
FULL TEXT
|
ISI
| PUBMED
45. Wichstrom L. Predictors of Norwegian adolescents' sunbathing and use of sunscreen. Health Psychol. 1994;13:412-420.
FULL TEXT
|
ISI
| PUBMED
46. Brandberg Y, Ullen H, Sjoberg L, Holm LE. Sunbathing and sunbed use related to self-image in a randomized sample of Swedish adolescents. Eur J Cancer Prev. 1998;7:321-329.
ISI
| PUBMED
47. Banks BA, Silverman RA, Schwartz RH, Tunnessen WW Jr. Attitudes of teenagers toward sun exposure and sunscreen use. Pediatrics. 1992;89:40-42.
FREE FULL TEXT
48. Mermelstein RJ, Riesenberg LA. Changing knowledge and attitudes about skin cancer risk factors in adolescents. Health Psychol. 1992;11:371-376.
FULL TEXT
|
ISI
| PUBMED
49. Netburn D. Young, carefree and hooked on sunlamps. New York Times. May 26, 2002;9.
50. Dougherty MA, McDermott RJ, Hawkins MJ. A profile of users of commercial tanning salons. Health Values. 1988;12:21-29.
PUBMED
51. Mawn VB, Fleischer AB. A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing and sunscreen use. J Am Acad Dermatol. 1993;29:959-962.
ISI
| PUBMED
52. Boldeman C, Jansson B, Nilsson B, Ullen H. Sunbed use in Swedish urban adolescents related to behavioral characteristics. Prev Med. 1997;26:114-119.
FULL TEXT
|
ISI
| PUBMED
53. Rhainds M, DeGuire L, Claveau J. A population-based survey on the use of artificial tanning devices in the province of Quebec, Canada. J Am Acad Dermatol. 1999;40:572-576.
FULL TEXT
|
ISI
| PUBMED
54. Beasley TM, Kittel BS. Factors that influence health risk behaviors among tanning salon patrons. Eval Health Prof. 1997;20:371-388.
FREE FULL TEXT
55. Knight JM, Kirincich AN, Farmer ER, Hood AF. Awareness of the risks of tanning lamps does not influence behavior among college students. Arch Dermatol. 2002;138:1311-1315.
FREE FULL TEXT
56. Dellavalle RP, Schilling LM, Chen AK, Hester RJ. Teenagers in the UV tanning booth: tax the tan. Arch Pediatr Adolesc Med. 2003;157:845-846.
FREE FULL TEXT
57. Oliphant JA, Forster JL, McBride CM. The use of commercial tanning facilities by suburban Minnesota adolescents. Am J Public Health. 1994;84:476-478.
FREE FULL TEXT
58. Boldeman C, Branstrom R, Dal H, et al. Tanning habits and sunburn in a Swedish population age 13-50 years. Eur J Cancer. 2001;37:2441-2448.
59. Robinson JK, Rademaker AW, Sylvester JA, Cook B. Summer sun exposure: knowledge, attitudes, and behaviors of Midwest adolescents. Prev Med. 1997;26:364-372.
FULL TEXT
|
ISI
| PUBMED
60. Hillhouse JJ, Turrisi R, Kastner M. Modeling tanning salon behavioral tendencies using appearance motivation, self-monitoring and the theory of planned behavior. Health Educ Res. 2000;15:405-414.
FREE FULL TEXT
61. Davy L, Boyett T, Weathers L, Campbell RJ, Roetzheim RG. Sun protection counseling by pediatricians. Ambul Pediatr. 2002;2:207-211.
FULL TEXT
|
ISI
| PUBMED
62. Buller DB, Borland R. Skin cancer prevention for children: a critical review. Health Educ Behav. 1999;26:317-343.
FREE FULL TEXT
63. Dellavalle RP, Parker ER, Cersonsky N, et al. Youth access laws? in the dark at the tanning salon? Arch Dermatol. 2003;139:443-448.
FREE FULL TEXT
64. Ross RN, Phillips B. Twenty questions for tanning facility operators: a survey of operator knowledge. Can J Public Health. 1994;85:393-396.
ISI
| PUBMED
65. Culley CA, Mayer JA, Eckhardt L, et al. Compliance with federal and state legislation by indoor tanning facilities in San Diego. J Am Acad Dermatol. 2001;44:53-60.
FULL TEXT
|
ISI
| PUBMED
66. Stryker JE, Lazovich D, Forster JL, Emmons KM, Sorensen G, Demierre MF. Parental influences on adolescent indoor tanning. J Adol Health. In press.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Peer Crowd Identification and Indoor Artificial UV Tanning Behavioral Tendencies
Stapleton et al.
J Health Psychol 2008;13:940-945.
ABSTRACT
Patterns of Indoor Tanning Use: Implications for Clinical Interventions
Hillhouse et al.
Arch Dermatol 2007;143:1530-1535.
ABSTRACT
| FULL TEXT
Teens and Tans: Implementing Behavioral Change
Haas
Arch Dermatol 2007;143:1058-1061.
FULL TEXT
Appearance Reasons for Tanning Mediate the Relationship Between Media Influence and UV Exposure and Sun Protection.
Cafri et al.
Arch Dermatol 2006;142:1067-1069.
FULL TEXT
Shedding More Light on Adolescent Tanning
JWatch Pediatrics 2004;2004:5-5.
FULL TEXT
|
