Original Article

Adolescent Indoor Tanning Use and Unhealthy Weight Control Behaviors Stephen M. Amrock, SM,* Michael Weitzman, MD*† ABSTRACT: Objective: Youth indoor tanning rates remain high despite the potential for increased melanoma risk. No previous study has assessed the prevalence of unhealthy weight control behaviors in both male and female adolescent indoor tanning users using a nationally representative survey. Methods: Pooled data on high school students from the 2009 and 2011 Youth Risk Behavior Survey were used (n 5 26,951). Multivariate logistic regression was used to assess associations between the recent indoor tanning use and recently doing the following to lose weight: fasting for more than 24 hours; taking a pill, powder, or liquid without a doctor’s consent; and vomiting or taking a laxative. Results: Pooled data showed 23.3% of females reported indoor tanning within the past year; 6.5% of males did so as well. Adjusted multivariate results show that females who indoor tan were, on average, more likely to have fasted (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0–1.5), taken a pill, powder, or liquid (OR, 2.4; 95% CI, 1.9–3.0), and vomited or taken a laxative to lose weight (OR, 1.4; 95% CI, 1.1–1.7) within the past 30 days than those who did not. Males who indoor tanned within the past year were, on average, more likely to have fasted (OR, 2.3; 95% CI, 1.7–3.1), taken a pill, powder, or liquid (OR, 4.4; 95% CI, 3.3–6.0), and vomited or taken a laxative to lose weight (OR, 7.1; 95% CI, 4.4–11.4) within the past 30 days. Conclusions: Significant associations between indoor tanning use and unhealthy weight control behaviors exist for both male and female adolescents, with a stronger association observed among males. (J Dev Behav Pediatr 35:165–171, 2014) Index terms: indoor tanning, melanoma, adolescents, eating disorder, healthy people.

R

ates of melanoma, the deadliest form of skin cancer, have increased over the past few decades.1,2 Children and young adults have not been excepted, with melanoma rates among the pediatric population also increasing rapidly.3,4 Indoor tanning once in one’s youth nearly doubles melanoma risk5–7 and a dose-response relationship between indoor tanning and melanoma has been confirmed by meta-analysis.7 Assessing populations that may indoor tan at higher rates remains critical; reducing adolescent indoor tanning exposure has become a national priority with Healthy People 2020.8 Despite legislative efforts to curb this behavior,9 tanning booths remain ubiquitous10 and youth indoor tanning rates remain high.11,12 Moreover, adolescents seem less likely to appreciate melanoma risk than in the past, evidenced by declining sunscreen use rates.13 The cause of why individuals indoor tan may be multifaceted. Prior research has linked indoor tanning use with other risky behaviors, including substance abuse and anxiety.14–16 Individuals’ body image conFrom the Departments of *Pediatrics; and †Environmental Medicine, New York University School of Medicine, New York, NY. Received October 2013; accepted January 2014. Disclosure: The authors declare no conflict of interest. Address for reprints: Stephen M. Amrock, SM, Department of Pediatrics, New York University School of Medicine, 550 First Avenue, NBV-8 South 4-11, New York, NY 10016; e-mail: [email protected]. Copyright Ó 2014 Lippincott Williams & Wilkins

Vol. 35, No. 3, April 2014

cerns, though, may prove as or more important for many individuals as a reason underlying their decision to indoor tan. Research characterizing individuals’ indoor tanning use has often focused on concerns over skin attractiveness (e.g., acne, skin aging17) and, to a lesser extent, on concerns regarding perceived weight and body shame.15,16,18–21 Individuals who indoor tan may be at an increased risk for disordered or unhealthy weight control behaviors (e.g., fasting, vomiting, taking laxatives), even after considering individuals’ other risky behaviors.16,19–21 Such unhealthy weight control behaviors have been linked to subsequent diagnosis of eating disorders22 and increased rates of suicidal behavior.23 Prior research on this topic has not been without limitations. The association between unhealthy weight control behaviors and indoor tanning has not been previously described in a nationally representative sample of female adolescents, nor has prior research compared male and female adolescents from the same sample. Importantly, some prior literature has not considered other, potentially confounding, sun-related behavior or individuals’ overall psychological well-being.19,20 In this study, we attempt to address these limitations using newly released federal data. In a series of analyses, we examine if adolescent indoor tanning users display unhealthy weight control behaviors at higher rates than those who do not indoor tan. For comparison with prior research, we present results stratified by sex and additionally assess whether these associations differ between males and females. www.jdbp.org | 165

METHODS Study Population The National Youth Risk Behavior Survey (YRBS) is a biennial, nationally representative, high school–based cross-sectional study conducted by the Centers for Disease Control and Prevention (CDC). The survey monitors priority health risks and, in 2009 and 2011, included questions regarding adolescents’ use of indoor tanning and other risky health behaviors. The survey’s methodology has been previously described,24 as has the rationale for study question inclusion.25 In brief, the YRBS used a stratified, multistage sample design and oversampled high schools with large minority populations to generate nationally representative estimates. Participation was voluntary and local parental permission procedures were used. For 2009 and 2011, student response rates were 88% and 87%, respectively; the school response rates were 81% for both the years. Students completed anonymous, self-administered penciland-paper questionnaires. Data are publicly available, and the study design was approved by the institutional review board at the CDC.

Variables Dependent Variables Three dichotomous variables served as outcome measures. They assessed a recent history of unhealthy weight control behaviors. Respondents were asked, in the past 30 days: (1) “did you go without eating for 24 hours or more (also called fasting) to lose weight or to keep from gaining weight?”; (2) “did you take any diet pills, powders, or liquids without a doctor’s advice to lose weight or to keep from gaining weight?”; and (3) “did you vomit or take laxatives to lose weight or keep from gaining weight?” Independent Variable Respondents were asked, “During the past 12 months, how many times did you use an indoor tanning device such as a sunlamp, sunbed, or tanning booth? (Do not include getting a spray-on tan).” Results were dichotomized, and a variable indicating whether or not an individual indoor tanned within the past year was used. Control Variables Additional variables were used in the multivariate logistic regressions. These included individuals’ selfperception of their weight. Individuals were asked to assess their weight status on a 5-point Likert scale as “very overweight,” “slightly overweight,” “about the right weight,” “slightly underweight,” and “very underweight”; responses were grouped as overweight, normal, or underweight. BMI percentile for child age and gender was calculated from self-reported height and weight. It was included as a categorical variable to reflect normal weight, overweight, and obese status (,85th, 85th–95th, $95th age and gender-specific percentiles, respectively). A variable indicating whether an individual was currently attempting to lose weight was also included, derived from 166 Indoor Tanning and Unhealthy Weight Control Behaviors

a question asking, “Which of the following are you trying to do about your weight?” to which respondents could answer that they were attempting to, “lose weight,” “gain weight,” “stay the same weight,” or “not trying to do anything about my weight.” Because previous research has suggested that individuals’ actual body weight, perceived body weight, and current attempts to change their weight may be associated with indoor tanning use,15,16,18–21 these measures were included as potential confounding factors. Because prior studies have also suggested that demographics may influence dieting and tanning behaviors,26 variables for academic grade, age, and ethnicity (non-Hispanic white, non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic, other/multiple) were included. Included as well were variables indicating whether or not an adolescent had, within the past 12 months, felt sad or hopeless, or reported having been bullied at school because, as discussed above, mental health has been previously linked with unhealthy eating behaviors.23 Variables indicating whether or not a respondent reported having ever had sex or having smoked, drunk alcohol, or drunk more than 5 alcoholic drinks in a row within the past 30 days were also included as potential confounders following prior research’s suggestion that indoor tanning users may be risk taking.14–16,18–21 Additionally, a variable indicating an individual’s routine use of sunscreen was included. Respondents were asked whether, when in the sun for over an hour, they wore sunscreen (SPF $15); following prior research,27 responses were grouped to indicate those individuals who used sunscreen always or most of the time.

Statistical Methods Analyses were weighted and account for clustering of responses; standard errors were calculated by Taylor series linearization. Cross tabulations were assessed by x2 tests that adjust for the complex survey design.28 Multivariate logistic analysis of pooled data was conducted. Analyses were stratified by respondent gender. All analyses were conducted using Stata 11.2 (StataCorp LP, College Station, Texas).

RESULTS In 2009 and 2011, 31,835 high school students were surveyed by the Youth Risk Behavior Survey (YRBS). Of these, 85% (n 5 26,951) responded to questions regarding indoor tanning use and were included in the analysis. Those who did not were less likely to be non-Hispanic white and more likely to be non-Hispanic Asian or Hispanic. Only 4% of non-Hispanic whites had missing data for indoor tanning use, whereas 16%, 26%, and 32% of non-Hispanic blacks, Hispanics, and non-Hispanic Asians did. Of females who indoor tanned, 87% were non-Hispanic whites; 67% of male tanners were non-Hispanic whites. The sample’s demographic characteristics are described in Table 1. Rates of indoor tanning use by adolescent characteristics are shown in Table 2. Data reveal 23.3% of females Journal of Developmental & Behavioral Pediatrics

used indoor tanning within the past year; 6.5% of males did so as well. Rates increased by age and grade. Only 13.2% of girls aged #14 years reported indoor tanning within the past year, whereas 33.0% of women aged $18 years reported that they had done so. A similar increase was observed in males; 4.9% of those aged #14 years had used indoor tanning within the past year, whereas 10.7% of those aged $18 years reported that they had. Differences existed between racial groups, though differences were larger in females than in males. NonHispanic white (33.7%) and Hispanic (10.3%) females were most likely to have indoor tanned within the past year. Non-Hispanic black females were least likely (3.0%). For males, those of multiple or other races (7.0%) and non-Hispanic whites (6.7%) were most likely to report indoor tanning within the past year, whereas nonHispanic blacks were least likely (5.1%). Only among non-Hispanic blacks did males report indoor tanning use in higher numbers than females, though this difference was not statistically significant. Table 3 displays that among both males and females, those who indoor tanned had higher rates of unhealthy weight control behaviors. They were more likely to report, within the past 30 days: having fasted for more than 24 hours; having taken a pill, powder, or liquid; and having vomited or taken a laxative to lose weight.

Table 1. Sample Demographics Characteristic

%

95% CI

Female

47.9

46.1–49.7

Male

52.1

50.3–53.9

#14

11.2

10.2–12.3

15

24.5

23.5–25.6

16

26.4

25.3–27.4

17

24.3

23.4–25.3

$18

13.6

12.7–14.6

61.6

56.9–66.0

2.8

2.0–3.9

DISCUSSION

Sex

Age (yr)

Ethnicity NH white NH Asian/PI NH black

13.7

11.1–16.7

Hispanic

17.1

14.7–19.8

4.9

4.1–5.9

9th

27.1

25.6–28.7

10th

26.3

24.9–27.6

11th

24.2

23.3–25.1

12th

22.4

21.4–23.5

Other/multiple Grade

Youth Risk Behavior Survey data from 2009 and 2011 (n 5 26,951). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. CI, confidence interval; NH, non-Hispanic; PI, Pacific Islander.

Vol. 35, No. 3, April 2014

Females who indoor tanned were more likely than those females who did not to perceive themselves as normal weight (60.2 vs 55.1%). Self-perception of one’s weight did not differ between males who indoor tanned and those who did not. Females who indoor tanned were more likely than females who did not to report attempting to lose weight (67.7 vs 58.7%); male indoor tan users were, by contrast, less likely to do so (25.5 vs 31.1%). Results from the gender-stratified multivariate logistic regression models assessing the association between indoor tanning and unhealthy weight control behaviors are displayed in Table 4. In all cases, adjusted results show statistically significant associations for both males and females, and results from sex-aggregated models confirm a statistically significant difference in these relationships by sex. All else equal, it was more likely that a female had fasted (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0–1.5), taken a pill, powder, or liquid (OR, 2.4; 95% CI, 1.9–3.0), or vomited or taken a laxative to lose weight (OR, 1.4; 95% CI, 1.1–1.7) within the past 30 days if she had indoor tanned within the past year. The estimated magnitudes of these associations were even greater for males. Males who indoor tanned within the past year were, on average, more likely to have fasted (OR, 2.3; 95% CI, 1.7–3.1), taken a pill, powder, or liquid (OR, 4.4; 95% CI, 3.3–6.0), or vomited or taken a laxative to lose weight (OR, 7.1; 95% CI, 4.4–11.4) within the past 30 days.

Indoor tanning is a preventable cause of melanoma, the incidence of which is increasing in epidemic proportions.1,29 Prior studies on the motivations of those who indoor tan suggest that users perceive tanned skin as healthy,30 have skin or body image concerns,15,16,18 and may be risk taking, frequently engaging in other risky behaviors.14–16,18–21 Yet, a comparison of whether male and female patrons of indoor tanning salons engage in unhealthy weight control behaviors at similar rates has not been previously assessed using a nationally representative sample. The results of this study confirm that indoor tanning use is associated with increased rates of unhealthy weight control behaviors and suggest that the association between unhealthy weight control behaviors and indoor tanning is even stronger among males. These results indicate the need to reassess why adolescents indoor tan. Indoor tanning is common, with roughly one-third of high school senior females and nearly 10% of high school senior males reporting tanning within the past year. Of those who indoor tanned, over 1 in 5 had also fasted for more than 24 hours within the past month to lose weight. Indoor tanning users were also much more likely to have, in the past 30 days, taken a pill, powder, or liquid to lose weight, and to have vomited or taken a laxative to lose weight. In stratified adjusted analyses, the odds that a female who indoor © 2014 Lippincott Williams & Wilkins

167

Table 2. Indoor Tanning Use Within the Past Year, by Demographic Attributes and Gender Female

Male

%

95% CI

%

95% CI

23.3

21.0–25.9

6.5

5.6–7.4a

#14

13.2

10.8–16.1

4.9

3.5–6.9a

15

16.1

14.0–18.5

5.3

4.3–6.4a

16

24.0

20.9–27.4

5.2

4.1–6.5a

17

29.9

26.6–33.5

7.1

5.7–8.7a

$18

33.0

29.3–36.9

10.7

8.8–13.0a

33.7

30.7–36.8

6.7

5.6–8.1a

NH Asian/PI

6.4

4.2–9.6

6.0

3.7–9.4

NH black

3.0

2.2–4.0

5.1

3.6–7.2a

Hispanic

10.3

8.8–12.2

6.0

4.9–7.3a

7.7

8.9–17.0

7.0

4.8–10.0a

9th

14.2

12.2–16.3

5.3

4.4–6.4a

10th

19.5

16.5–23.0

4.7

3.6–6.0a

11th

28.4

25.3–31.8

6.8

5.4–8.5a

12th

33.0

29.6–36.5

9.4

7.9–11.3a

Total Age (yr)

Ethnicity NH white

Other/multiple Grade

Youth Risk Behavior Survey data from 2009 and 2011 (n 5 26,951). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. aDenotes statistically significant difference (p , .05) between sex by weighted x2 test. CI, confidence interval; NH, non-Hispanic; PI, Pacific Islander.

tanned also reported recently engaging in an unhealthy weight control behavior were 1.3 to 2.4 times greater, depending on the behavior assessed, than those who did not indoor tan. The association was even stronger for males, with the odds that a male who indoor tanned also reported an unhealthy weight control behavior were, by comparison, 2.3 to 7.1 times greater than those who did not indoor tan. In assessing each unhealthy weight control behavior, the difference between the sexes was statistically significant and greater for men who indoor tanned than women who did so.

That the association between unhealthy weight control behaviors and indoor tanning was even stronger among males merits comment. The population of males who indoor tans may, when compared to those females that do so, constitute a self-selected group of their samesex peers at higher risk for victimization, may be less risk averse, or may be less familiar with the potential risks of indoor tanning. Prior research, for example, has reported that, compared to their male peers, males who indoor tan engage in risky steroid use at higher rates and also report being targets of victimization at higher rates.19

Table 3. Risk Behaviors Among Youth Who Do and Do Not Indoor Tan, by Gender Indoor Tanning Use, Females No (%)

Yes (%)

p

Indoor Tanning Use, Males a

No (%)

Yes (%)

pa

In the past 30 d, to lose weight Fasted for over 24 hr Took pill, power, or liquid Vomited or took laxative Currently attempting to lose weight

14.3

21.8

,.001

6.0

20.8

,.001

4.3

12.3

,.001

2.9

17.2

,.001

4.7

9.6

,.001

1.5

15.5

,.001

58.7

67.7

,.001

31.1

25.5

.024

10.4

8.1

17.4

20.4

,.001

Self-description of weight Underweight

.361

Normal

55.1

60.2

59.2

57.9

Overweight

34.5

31.7

23.4

21.7

Youth Risk Behavior Survey data from 2009 and 2011 (n 5 26,951). Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. aDenotes statistical significance from weighted x2 test that corrects for survey design.

168 Indoor Tanning and Unhealthy Weight Control Behaviors

Journal of Developmental & Behavioral Pediatrics

Vol. 35, No. 3, April 2014

Table 4. Logistic Regression Assessing Association Between Indoor Tanning Use and Eating Disorder–Related Behaviorsa Fasted to Lose Weight Variable

Took Pill, Powder, or Liquid to Lose Weight

Overall

Female

Male







Overall

Female

Male

Vomited or Took Laxative to Lose Weight Overall

Female

Male —

Indoor tan use, past 12 mo No Yes

1.22b (1.01–1.48) 1.23b (1.01–1.49) 2.29b (1.69–3.10)









2.20a (1.76–2.76)

2.37b (1.85–3.04)

4.44b (3.27–6.04)

1.50b (1.20–1.87) 1.39b (1.12–1.72) 7.07b (4.39–11.40)

Sex —





0.40b (0.35–0.46)

0.71b (0.57–0.88)

0.28b (0.21–0.36)

1.96b (1.36–2.82)

2.07b (1.43–2.99)

4.28a (2.49–7.35)

Female Male Sex 3 indoor tan use Age (yr) #14















15

1.31 (0.97–1.76) 1.51b (1.10–2.07)



0.99 (0.57–1.74)

0.87 (0.56–1.35)

0.76 (0.45–1.30)

1.14 (0.55–2.33)

0.94 (0.61–1.44)

0.97 (0.61–1.56)

0.84 (0.35–2.02)

16

1.50b (1.10–2.06) 1.55b (1.09–2.21)

1.49 (0.84–2.64)

1.08 (0.63–1.87)

0.93 (0.48–1.81)

1.51 (0.72–3.19)

1.11 (0.68–1.81)

1.22 (0.68–2.17)

0.91 (0.33–2.50)

b



b

17

1.48 (1.01–2.17) 1.65 (1.03–2.64)

1.28 (0.63–2.61)

0.92 (0.49–1.74)

0.90 (0.43–1.88)

1.02 (0.40–2.60)

0.90 (0.52–1.56)

1.11 (0.58–2.12)

0.58 (0.18–1.90)

$18

1.76b (1.15–2.70) 1.79b (1.08–2.98)

1.70 (0.75–3.87)

0.99 (0.51–1.92)

1.10 (0.52–2.33)

0.93 (0.32–2.75)

0.68 (0.37–1.28)

0.82 (0.38–1.74)

0.49 (0.13–1.82)















0.70 (0.35–1.40)

0.77 (0.36–1.65)

0.37 (0.08–1.78)

Ethnicity —

NH white NH Asian/PI

b

— b

0.53 (0.33–0.87) 0.48 (0.30–0.79)

b

0.65 (0.27–1.54)

0.58 (0.30–1.13)

0.76 (0.36–1.63)

0.40 (0.14–1.15)

NH black

1.16 (0.92–1.48)

1.00 (0.73–1.37) 1.47b (1.07–2.02)

0.83 (0.59–1.17)

0.99 (0.65–1.49)

0.69 (0.42–1.13)

Hispanic

1.18b (1.00–1.40)

1.10 (0.90–1.33) 1.35b (1.08–1.69)

1.29b (1.02–1.63)

1.56b (1.23–1.98)

0.95 (0.63–1.44)

1.31b (1.02–1.69)

1.12 (0.82–1.53) 1.97b (1.26–3.07)

Other/multiple

b

0.88 (0.57–1.38) 0.63b (0.37–1.06) 2.03b (1.14–3.64)

© 2014 Lippincott Williams & Wilkins

1.32 (0.99–1.75)

1.23 (0.90–1.68) 1.48 (0.93–2.35)

1.23 (0.84–1.80)

1.27 (0.78–2.05)

1.17 (0.66–2.10)

1.32 (0.86–2.01)

1.15 (0.72–1.83) 2.07b (1.02–4.21)

1.07 (0.87–1.31)

1.00 (0.75–1.32)

1.10 (0.77–1.57)

0.73 (0.50–1.07)

0.85 (0.51–1.42)

0.64 (0.389–1.09)

1.28 (0.85–1.93)

1.23 (0.77–1.99)

1.45 (0.77–2.70)



















2.80b (2.21–3.53)

3.76b (2.97–4.77)

1.53 (0.98–2.93)

Self-described weight Underweight Normal Overweight

2.32b (1.97–2.73) 2.36b (1.97–2.84) 2.06b (1.51–2.80)

3.35 (2.60–4.31) 3.42b (2.65–4.42) 2.52b (1.38–4.59)

aOdds ratios (ORs) and 95% confidence intervals are displayed. Regression model additionally adjusts for: grade level; feeling sad or hopeless, or being bullied at school, within the past 12 mo; having, within the past 30 d, smoked, drunk alcohol, and having drunk $5 alcoholic drinks in a row; having ever had sex; wearing sunscreen always or most of the time when in sun .1 hr; BMI (normal, overweight, obese); and a year fixed effect. bDenotes statistical significance (p , .05). NH, non-Hispanic; PI, Pacific Islander.

169

Perhaps sex differences in the associations between indoor tanning use and unhealthy weight control behaviors belie different underlying processes motivating these behaviors. Alternatively, such differences might represent different temporal points along a spectrum of disease motivating indoor tanning use. One may note that in this study, females who indoor tanned were more likely than females who did not indoor tan to indicate both that they considered themselves currently of normal weight and that they were attempting to lose weight. Males who indoor tanned, by contrast, were not more likely than other males to indicate they were currently attempting to lose weight and did not describe their weight any differently from their peers who did not indoor tan. Moreover, the number of males who perceived themselves as underweight was increased among indoor tanners, albeit nonsignificantly. This may suggest that, for males, it could be desirable among those of low weight who already engage in unhealthy weight control behaviors to begin to tan. For females, by contrast, indoor tanning may be early evidence of increased risk to develop more frank disease. Although no firm conclusions can be reached from these cross-sectional data alone, they suggest a need to assess the interplay between body weight, self-perception of body weight, and the onset of indoor tanning in a longitudinal cohort. The implications of these findings for child health and pediatric care are manifold. These results lend credence to prior hypotheses that concerns about a negative body image are a more likely cause for indoor tanning use25,28 than are positive ideals about body image (e.g., that tan skin appears healthy).30 Understanding and addressing why these behaviors move in tandem are essential to improved policies and patient counseling strategies to help curb the rising melanoma epidemic. Screening adolescents for indoor tanning use may serve a double purpose. Because melanoma is among the most common cancers in young adulthood,31 screening adolescents serves as an important vehicle for patient education and primary prevention. Yet results of this study suggest that screening for indoor tanning may help identify patients at risk for unhealthy weight control behaviors as well. Health care providers may be able to capitalize on counseling techniques developed to target other problems, like smoking, with negative effects perceived by youth to be far-off consequences.32,33 Adolescents may respond to interventions highlighting shorter term problems like indoor tanning’s negative effects on skin texture, wrinkles, and eye damage5,6; facial aging software may also hold promise as a technique by which to promote skin-healthy behaviors.34 A recent trial on physician counseling highlighting damaged skin increased subsequent sunprotective behaviors,35 providing proof of concept that, when framed appropriately, behavioral change regarding tanning is possible. In the best of circumstances, adolescent screening might identify, or perhaps in light of concerns over tanning’s addictive nature,36,37 prevent adolescents from concomitant unhealthy weight control behaviors. 170 Indoor Tanning and Unhealthy Weight Control Behaviors

Although these results provide cause for already growing concern over indoor tanning, some caution in interpreting these results is needed. No study is without limitations, and data presented here are cross-sectional and cannot be used to infer causality. Data, including respondents’ heights and weights, are self-reported and may be subject to recall or other biases. Unmeasured confounding may remain. Because the sample is nationally representative of high-school students, and not all adolescents, results may not be generalizable to other groups. Of potential theoretical importance and as mentioned above, we cannot assess the temporality between unhealthy weight control behaviors and indoor tanning use. One may precede the other or they may evolve contemporaneously. The corresponding associations of these with self-esteem and body image remain unknown. Nonetheless, we believe this study has important strengths. The link between unhealthy weight control behaviors and indoor tanning has not been previously described in a nationally representative sample of female adolescents, nor has prior research compared male and female adolescents from the same sample. This study uses nationally representative data to do so. Though data are cross-sectional, adjustments have been made for skin and non-skin behavioral characteristics to assess more clearly the independent association of indoor tanning with unhealthy weight control behaviors. Results of this study expand the potential clinical usefulness of screening or counseling adolescents for indoor tanning use. The findings lend credence to prior research assessing potential effects of body image and suggest a need to redouble efforts to understand and target highrisk adolescent groups. An improved understanding of how media, peer networks, and other social influences affect adolescent decisions to indoor tan is much needed. In summary, this study suggests an association exists between indoor tanning use and unhealthy weight control behaviors among both male and female adolescents. An even stronger relationship was observed in males. The number of adolescents at risk for harmful unhealthy weight control behaviors that indoor tan is sizable, and greater attention to these issues by pediatricians may help reduce the number of adolescents risking potentially deadly consequences. REFERENCES 1. Linos E, Swetter SM, Cockburn MG, et al. Increasing burden of melanoma in the United States. J Invest Dermatol. 2009;129:1666– 1674. 2. Jemal A, Saraiya M, Patel P, et al. Recent trends in cutaneous melanoma incidence and death rates in the United States, 19922006. J Am Acad Dermatol. 2011;65(5 suppl 1):S17–S25. e11–e13. 3. Purdue MP, Freeman LE, Anderson WF, et al. Recent trends in incidence of cutaneous melanoma among US Caucasian young adults. J Invest Dermatol. 2008;128:2905–2908. 4. Strouse JJ, Fears TR, Tucker MA, et al. Pediatric melanoma: risk factor and survival analysis of the surveillance, epidemiology and end results database. J Clin Oncol. 2005;23:4735–4741.

Journal of Developmental & Behavioral Pediatrics

5. International Agency for Research on Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2007;120:1116–1122. 6. Lazovich D, Vogel RI, Berwick M, et al. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiol Biomarkers Prev. 2010;19:1557–1568. 7. Boniol M, Autier P, Boyle P, et al. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757. 8. US Department of Health and Human Services. Healthy people 2020 topics and objectives. Available from: http://healthypeople.gov/ 2020/topicsobjectives2020/default.aspx. Accessed August 7, 2012. 9. Pawlak MT, Bui M, Amir M, et al. Legislation restricting access to indoor tanning throughout the world. Arch Dermatol. 2012;148: 1006–1012. doi: 10.1001/archdermatol.2012.2080. 10. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large US cities. Am J Prev Med. 2009;36:243–246. 11. Hartman AM, Guy GP Jr, Holman DM, et al. Use of indoor tanning devices by adults—United States, 2010. MMWR CDC Surveill Summ. 2012;61:323–326. 12. Lostritto K, Ferrucci LM, Cartmel B, et al. Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates. BMC Public Health. 2012;12:118. 13. Jones SE, Saraiya M, Miyamoto J, et al. Trends in sunscreen use among US high school students: 1999-2009. J Adolesc Health. 2012; 50:304–307. 14. Mosher CE, Danoff-Burg S. Addiction to indoor tanning: relation to anxiety, depression, and substance use. Arch Dermatol. 2010;146:412–417. 15. Demko CA, Borawski EA, Debanne SM, et al. Use of indoor tanning facilities by white adolescents in the United States. Arch Pediatr Adolesc Med. 2003;157:854–860. 16. O’Riordan DL, Field AE, Geller AC, et al. Frequent tanning bed use, weight concerns, and other health risk behaviors in adolescent females (United States). Cancer Causes Control. 2006;17:679–686. 17. Cafri G, Thompson JK, Jacobsen PB, et al. Investigating the role of appearance-based factors in predicting sunbathing and tanning salon use. J Behav Med. 2009;32:532–544. 18. Stapleton J, Turrisi R, Todaro A, et al. Objectification theory and our understanding of indoor tanning. Arch Dermatol. 2009;145: 1059–1060. 19. Blashill AJ. Psychosocial correlates of frequent indoor tanning among adolescent boys. Body Image. 2013;10:259–262. 20. Blashill AJ, Traeger L. Indoor tanning use among adolescent males: the role of perceived weight and bullying. Ann Behav Med. 2013; 46:232–236. 21. Miyamoto J, Berkowitz Z, Jones SE, et al. Indoor tanning device use among male high school students in the United States. J Adolesc Health. 2012;50:308–310.

22. Neumark-Sztainer D, Wall M, Guo J, et al. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc. 2006;106:559–568. 23. Crow S, Eisenberg ME, Story M, et al. Suicidal behavior in adolescents: relationship to weight status, weight control behaviors, and body dissatisfaction. Int J Eat Disord. 2008;41: 82–87. 24. Brener ND, Kann L, Kinchen SA, et al. Methodology of the youth risk behavior surveillance system. MMWR Recomm Rep. 2004;53:1. 25. Centers for Disease Control and Prevention (CDC). Youth Risk Behavior Survey (YRBS): Item Rationale for the 2009 Core Questionnaire. CDC: Atlanta, GA; 2010. Available at: http://www. cdc.gov/healthyyouth/yrbs/pdf/questionnaire/2009ItemRationale.pdf. 26. Story M, French SA, Resnick MD, et al. Ethnic/racial and socioeconomic differences in dieting behaviors and body image perceptions in adolescents. Int J Eat Disord. 1995;18:173–179. 27. Jones SE, Saraiya M. Sunscreen use among US high school students, 1999-2003. J Sch Health. 2006;76:150–153. 28. Rao JNK, Scott AJ. On chi-squared tests for multiway contingency tables with cell proportions estimated from survey data. Ann Stat. 1984;12:46–60. 29. Beddingfield FC III. The melanoma epidemic: res ipsa loquitur. Oncologist. 2003;8:459–465. 30. Poorsattar SP, Hornung RL. UV light abuse and high-risk tanning behavior among undergraduate college students. J Am Acad Dermatol. 2007;56:375–379. 31. Weir HK, Marrett LD, Cokkinides V, et al. Melanoma in adolescents and young adults (ages 15-39 years): United States, 1999-2006. J Am Acad Dermatol. 2011;65(5 suppl 1):S38–S49. 32. Reyna VF, Farley F. Risk and rationality in adolescent decision making: implications for theory, practice, and public policy. Psychol Sci Public Interest. 2006;7:1–44. 33. Spradlin K, Bass M, Hyman W, et al. Skin cancer: knowledge, behaviors, and attitudes of college students. South Med J. 2010;103: 999–1003. 34. Williams AL, Grogan S, Buckley E, et al. A qualitative study examining women’s experiences of an appearance-focussed facialageing sun protection intervention. Body Image. 2012;9:417–420. 35. Emmons KM, Geller AC, Puleo E, et al. Skin cancer education and early detection at the beach: a randomized trial of dermatologist examination and biometric feedback. J Am Acad Dermatol. 2011; 64:282–289. 36. Heckman CJ, Egleston BL, Wilson DB, et al. A preliminary investigation of the predictors of tanning dependence. Am J Health Behav. 2008;32:451–464. 37. Zeller S, Lazovich D, Forster J, et al. Do adolescent indoor tanners exhibit dependency? J Am Acad Dermatol. 2006;54:589–596.

See related commentary in this issue: Schwebel DC: Adolescent tanning, disordered eating, and risk taking. J Devel Behav Pediatr. 2014;35:225–227.

Vol. 35, No. 3, April 2014

© 2014 Lippincott Williams & Wilkins

171

Adolescent indoor tanning use and unhealthy weight control behaviors.

Youth indoor tanning rates remain high despite the potential for increased melanoma risk. No previous study has assessed the prevalence of unhealthy w...
157KB Sizes 2 Downloads 3 Views