Research
Original Investigation
Availability of Tanning Beds on US College Campuses Sherry L. Pagoto, PhD; Stephenie C. Lemon, PhD; Jessica L. Oleski, MA; Jonathan M. Scully, BA; Gin-Fei Olendzki, MS; Martinus M. Evans, BS; Wenjun Li, PhD; L. Carter Florence, MPH; Brittany Kirkland, BS; Joel J. Hillhouse, PhD
IMPORTANCE Indoor tanning is widespread among young adults in the United States despite
evidence establishing it as a risk factor for skin cancer. The availability of tanning salons on or near college campuses has not been formally evaluated. OBJECTIVE To evaluate the availability of indoor tanning facilities on US college and university campuses (colleges) and in off-campus housing surrounding but not owned by the college. DESIGN, SETTING, AND PARTICIPANTS This observational study sampled the top 125 US colleges and universities listed in US News and World Report. Investigators searched websites of the colleges and nearby housing and contacted them by telephone inquiring about tanning services. MAIN OUTCOMES AND MEASURES Frequency of indoor tanning facilities on college campus and in off-campus housing facilities, as well as payment options for tanning. RESULTS Of the 125 colleges, 48.0% had indoor tanning facilities either on campus or in off-campus housing, and 14.4% of colleges allow campus cash cards to be used to pay for tanning. Indoor tanning was available on campus in 12.0% of colleges and in off-campus housing in 42.4% of colleges. Most off-campus housing facilities with indoor tanning (96%) provide it free to tenants. Midwestern colleges had the highest prevalence of indoor tanning on campus (26.9%), whereas Southern colleges had the highest prevalence of indoor tanning in off-campus housing facilities (67.7%). Presence of on-campus tanning facilities was significantly associated with enrollment (P = .01), region (P = .02), and presence of a school of public health (P = .01) but not private vs public status (P = .18) or presence of a tobacco policy (P = .16). Presence of tanning facilities in off-campus housing was significantly associated with region (P = .002) and private vs public status (P = .01) but not enrollment (P = .38), tobacco policy (P = .80), or presence of a school of public health (P = .69). CONCLUSIONS AND RELEVANCE Reducing the availability of indoor tanning on and around college campuses is an important public health target. JAMA Dermatol. 2015;151(1):59-63. doi:10.1001/jamadermatol.2014.3590 Published online October 29, 2014.
D
espite evidence establishing indoor tanning as a risk factor for skin cancer,1 this habit is widespread among young adults in the United States, especially nonLatino white women. Almost one-quarter of white women aged 18 to 35 years have used a tanning salon in the past year, and 15% tan indoors frequently.2 Tanning salons are ubiquitous in US cities,3 and 1 study showed that tanning salons are particularly concentrated near colleges.4 Although parental consent laws have not curbed tanning bed use by minors, laws banning indoor tanning by minors have been effective.5 However, young adults aged 18 and older are not directly affected by policies targeting minors. Research is needed to inform targeted public health and policy interventions for indoor tanjamadermatology.com
Author Affiliations: Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts (Pagoto, Lemon, Oleski, Scully, Olendzki, Evans, Li); College of Public Health, East Tennessee State University, Johnson City, Tennessee (Florence, Kirkland, Hillhouse). Corresponding Author: Sherry L. Pagoto, PhD, Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655 ([email protected]).
ning by young adults given that this age group has higher rates of indoor tanning than any other age group.6 Although a great deal of research has examined the tanning habits of college students, to our knowledge, no study has examined the availability of tanning salons on or near college campuses. Research has also shown that tanning salons are more plentiful in areas with a greater percentage of girls and women aged 15 to 29 years.4 A recent ABC news story covered the emergence of luxury accommodations in college campus housing, including tanning beds, as a move to court incoming students.7 This potential trend would make indoor tanning highly accessible to young adults. The purpose of our investigation was to evaluate the presence of tanning facilities on JAMA Dermatology January 2015 Volume 151, Number 1
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Tanning Bed Availability on US College Campuses
campus and in off-campus housing in the top 125 colleges and universities on the US News and World Report8 list of best colleges in 2013. We also explored the extent to which the cost of tanning is included in rent and/or college fees and to what extent students could use their campus cash cards to pay for indoor tanning at local salons. We compared colleges with indoor tanning on campus and/or in off-campus housing on region and college characteristics, including public or private status, college ranking, enrollment, tobacco use policy, and presence of a school of public health. We hypothesized that colleges with higher enrollment and lower ranking and those that are public and have no school of public health would be more likely to have tanning beds on campus and/or in offcampus housing.
Methods Human subjects review was waived by the institutional review board of University of Massachusetts Medical School because no human participants were recruited for this study.
Sample The first 125 colleges in the US News and World Report8 list of the best colleges and universities for undergraduate education in the United States in 2013 were used for this investigation. College and housing facility websites were used to access information about services available, and when the information was not found online, colleges and housing facilities were telephoned to inquire about services. Offcampus housing was defined as a house, condominium, apartment building, or community living center that caters to students attending a particular college but is not owned by the college or located on campus property. An off-campus housing facility was deemed “college referred” if it was listed on the college’s housing website. Some colleges noted that their posted housing list was for informational purposes and not necessarily an endorsement.
Search Strategy Multiple search methods were used to evaluate the presence of indoor tanning facilities on campus. College websites were explored by looking at the links for housing, campus activities, student life, and gyms or fitness centers and by performing a search using the search term “tanning” in the college website search tool. If the presence of tanning was not clear via the website, the offices of student housing were contacted by telephone and an investigator asked, “are there any tanning salons or tanning beds on campus?” Additional searches were performed using Google maps of tanning salons in proximity to each campus. If a tanning salon appeared to be located on campus property via the Google map, an investigator telephoned and asked whether the salon was on campus, in an offcampus housing facility, or neither. When indoor tanning facilities were discovered on campus, they were called and asked, “How much does it cost per session? Can students pay with campus cash cards?” Campus cash cards are debit cards that students use on campus and at local participating busi60
nesses. Local businesses can apply to be a cash card merchant, which may bring them student business and a listing on the university website. To determine whether campus cash cards could be used for local tanning salons, we looked at the college website and located a list of local businesses where cash cards were accepted and noted when a tanning salon was on that list. To evaluate the presence of tanning facilities in offcampus housing, off-campus housing links on the college websites were explored. When off-campus housing locations were listed, their websites were explored to determine whether they had indoor tanning facilities, and if so, the housing location was called to determine what payment methods were accepted (eg, campus cash, free for residents, fee per use). Tanning facilities in off-campus housing not linked from college websites were found via searches in online search engines using the terms “tanning [college name],” “tanning [college name] off campus,” “tanning [college name] off campus housing,” and “tanning [college name] housing.” These businesses do not have formal relationships with the college. The presence of a tobacco-free policy was determined by examining the college website or calling the college when this information could not be determined from the website.
Indoor Tanning Availability Outcome variables included presence of indoor tanning facilities on campus, presence of indoor tanning facilities in offcampus housing to which the college refers students, and presence of indoor tanning facilities in off-campus student housing that is not college referred. For each category, we evaluated whether tanning was offered for free or with unlimited use included in rent and/or college fees and whether students could use campus cash cards to pay for tanning.
College Characteristics Basic characteristics of colleges were collected including public or private status, enrollment, geographic region (West, South, Midwest, Northeast), US News and World Report8 ranking (with 1 being the highest ranked college), and presence of a school of public health. The range in the number of students enrolled was high (ie, 2243-56 387), so we converted enrollment into tertiles of 12 904 or fewer students (small), 12 905 to 28 033 students (medium), and 28 034 students or more (large) because extreme scores would make means difficult to interpret.
Analytic Plan Descriptive statistics including means and frequencies were calculated for all variables of interest. Mann-Whitney U tests were used to compare colleges with and without indoor tanning facilities on median US News and World Report8 rankings. For the remaining variables, we were unable to conduct multivariable analyses of the associations between college characteristics and the availability of on-campus indoor tanning because of small cell sizes. As such, Fisher exact tests were used to test for statistically significant differences in oncampus indoor tanning by categorical variables. A multivariate logistic regression model was used to test the association
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Tanning Bed Availability on US College Campuses
of each of the college characteristics with off-campus housing tanning availability. This model included enrollment, region, private vs public status, tobacco policy, and presence of schools of public health. For the enrollment variable, large enrollment was the reference category. For the region variable, the South was the reference category given that a previous study revealed the highest rates of indoor tanning in the South.2
Original Investigation Research
Table 1. Characteristics of the Top 125 Colleges Rated by US News and World Report8 Characteristic
Value
Rank, median (IQR) Enrollment, median (IQR) Public, %
62.0 (31.5-91.0) 20 447.0 (10 865.0-31 086.5) 49.6
Region, % South
Results Description of Colleges Table 1 describes the characteristics of the 125 colleges assessed. Overall, the median (interquartile range) enrollment was 20 447 (10 865-31 086), and 49.6% were public colleges.
24.8
Northeast
36.8
West
17.6
Midwest
20.8
Tobacco-free policy, %
36.8
School of public health, %
64.0
Campus cards can be used for local tanning salons, %
14.4
Indoor tanning, %
Availability of Tanning On-campus indoor tanning facilities were available in 12.0% of colleges. In 42.4% of colleges, indoor tanning was observed in off-campus housing and among those, the mean (SD; range) number of housing facilities with indoor tanning was 2.79 (2.72; 1-14). Thirty-six percent of colleges that had offcampus housing with indoor tanning referred students to those housing facilities on their website. This represents 15.0% of colleges in the overall sample. A total of 48.0% of colleges had indoor tanning facilities either on campus, in off-campus housing, or both. Among colleges with indoor tanning facilities, 53% had indoor tanning in off-campus housing (Table 1).
On campus
12.0
Off-campus housing
42.4
Either on campus or in off-campus housing
48.0
Colleges referring students to housing with indoor tanning, %
15.2
Abbreviation: IQR, interquartile range.
observed according to public vs private status or tobacco policy (see Table 2). Colleges with and without on-campus indoor tanning also did not significantly differ in median ranking on the US News and World Report8 list (P = .85) (data not shown).
Tanning Payment Options Of colleges with indoor tanning facilities on campus (n = 15), none provided tanning to students for free. Of colleges with indoor tanning facilities in college-referred off-campus housing (n = 19), 100% of housing facilities provided unlimited tanning to residents as part of the rental agreement (ie, it was an included amenity for no extra charge). In colleges that had offcampus housing with indoor tanning facilities to which they did not directly refer students (n = 26), 96% of housing facilities provided unlimited tanning to residents as part of the rental agreement. We could not determine referral status for 8 colleges because student login information was required to view the housing list. Campus cash cards could be used to pay for indoor tanning at local salons for 18 colleges (14.4%).
College Characteristics Associated With On-Campus Tanning Availability Table 2 describes the bivariate associations of college characteristics with on-campus tanning availability. Colleges with and without indoor tanning facilities on campus were significantly different in enrollment (Fisher exact test P = .01), region (Fisher exact test P = .02), and presence of schools of public health (Fisher exact test P = .01). On-campus tanning was more prevalent in colleges in the high-enrollment category (23.8%) than those in the medium-enrollment (10.5%) or lowenrollment (2.5%) categories. Indoor tanning was more prevalent on campuses in the Midwest (26.9%), followed by the Northeast (13.0%) and South (6.5%), with no colleges offering on-campus tanning in the West. No significant differences were jamadermatology.com
College Characteristics Associated With Off-Campus Housing Tanning Availability Table 2 describes the bivariate associations of college characteristics with tanning availability in off-campus housing. A multivariable logistic regression model indicated that public colleges were more likely to have tanning facilities in offcampus housing than private colleges (64.5% vs 20.6%, respectively; OR, 4.33 [95% CI, 1.38-13.58]). Region was also associated with tanning facilities in off-campus housing, with colleges in the Northeast (OR, 0.16 [95% CI, 0.05-0.51]) and West (OR, 0.15 [95% CI, 0.40-0.59]) having lower odds of tanning facilities in off-campus housing compared with colleges in the South. Tanning facilities were available in off-campus housing at 67.7% of colleges in the South, 61.5% in the Midwest, 31.8% in the West, and 19.6% in the Northeast (P = .002). Associations between enrollment, tobacco-free campus policy, presence of schools of public health, and off-campus tanning facilities were not statistically significant. Finally, colleges with tanning facilities in off-campus housing also did not have significantly different median ranking from those with no tanning facilities in off-campus housing (P = .20) (data not shown).
Discussion The present study shows that approximately half of the top 125 colleges on the US News and World Report8 list of colleges have JAMA Dermatology January 2015 Volume 151, Number 1
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Table 2. Prevalence of Indoor Tanning on Campus and in Off-Campus Housing by Enrollment, Region, Private vs Public Status, Tobacco Policy, and Presence of School of Public Health Variable
On-Campus Tanning, %
P Value
Off-Campus Housing Tanning, %
P Value
Enrollment Low
2.5
24.4
Medium
10.5
High
23.8
69.0
13.0
19.6
.01
33.3
.38
Region Northeast West Midwest South
0.0 26.9
31.8 .02
6.5
61.5
.002
67.7
Private vs public status Public
16.2
Private
7.9
64.5 .18
20.6
.01
Tobacco policy Yes
17.3
No
8.8
52.2 .16
36.7
.80
School of public health Yes
17.5
No
2.2
46.3 .01
indoor tanning facilities on campus and/or in off-campus housing. Twelve percent of colleges offer indoor tanning on campus property, whereas for 42% of the colleges, off-campus housing offering indoor tanning facilities was found. Almost half (48%) of colleges had indoor tanning facilities either on campus, in off-campus housing, or both. Campus cash cards could be used to purchase tanning locally for 14.4% of colleges. Whereas indoor tanning facilities were found on a small minority of campuses (12%), the total enrollment for these colleges is 523 610 students. If this sample is representative of the 2870 colleges in the United States, then several million young adults have access to indoor tanning facilities on their college campuses.9 Colleges could take steps to ban indoor tanning on campus. Public health efforts are needed to raise university administration and student population awareness of the harms that indoor tanning poses to young adults in order to increase demand for policy-related action. Our findings showed that colleges with higher enrollment and those in the Midwest and Northeast have the highest prevalence of on-campus indoor tanning, which may suggest a place to start prevention efforts. Indoor tanning facilities were more prevalent in offcampus housing than on campus property and were almost always (in 96% of cases) provided as a free, unlimited amenity to residents as part of their rental agreement. Research is needed to explore how free access to indoor tanning might affect tanning behavior. Free access could potentially encourage tanning among people who would only be willing to tan if it is free, as well as possibly leading to even higher rates of tanning among frequent tanners. To the extent that tanning is included in rental fees or can be paid for with campus cash cards, parents may be absorbing the cost of their child’s tanning habit, possibly unknowingly. Dermatologists and pediatricians can play a role in informing par62
35.6
.69
ents about the possibility of indoor tanning on college campuses and in off-campus housing, the dangers associated with such access, and the possibility that they may be unknowingly paying for it. Results also showed that 15% of colleges referred students to off-campus housing that had indoor tanning facilities. Although colleges do not have direct control over indoor tanning facilities in off-campus housing, they likely have some influence over these facilities. Colleges could take some steps to discourage indoor tanning in off-campus housing, such as by referring students only to off-campus housing that embraces their campus health policies, publicly condemning the practice of placing indoor tanning facilities in off-campus housing, and prohibiting tanning salons from being campus cash merchants. Skin cancer prevention efforts should also directly target owners of offcampus housing. We examined differences in tanning availability according to campus tobacco-free policy status because we hypothesized that these colleges may have greater awareness of public health risks and/or place greater priority on cultivating healthier environments. Whereas 36.8% of colleges in our sample have policies that ban both the sale and use of tobacco 10 on campus, these colleges were not less likely to have indoor tanning on campus and in off-campus housing. The lack of a difference according to tobacco-free status may be due to inherent differences in regulation of tobacco, which has a direct impact on others via secondhand smoke. Our results ran counter to the hypothesis that colleges with schools of public health would be less likely to have tanning on campus. This suggests a possible disconnect between university health policy and academic public health programs. It also points to an important potential role for schools of public health in advocating for tanning-free policies.
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Tanning Bed Availability on US College Campuses
Original Investigation Research
The present study has several limitations. The top 125 colleges and universities in US News and World Report8 are not likely representative of all US colleges and universities. We chose this list because it represents the most highly regarded colleges in the United States, ones that may be viewed as trendsetters for US undergraduate education. Also, our estimates of indoor tanning, particularly in off-campus housing, may be underestimates because our search strategy (eg, telephone inquiries, website searches) was more vulnerable to missing existing facilities than counting ones that did not exist. For 8 colleges (6%), the amenities of off-campus housing facilities could not be viewed without entering a student identification number. More systematic means of retrieving information about amenities are not available to our knowledge. Also, our data do not account for the presence of independent indoor tanning businesses surrounding college campuses. One study showed that the number of tanning salons in a census tract was predicted by a greater number of young females (ages 15-29 years) residing in that area,4 which suggests that these businesses may be heavily concentrated near college campuses. Our data likely provide an incomplete picture of the availability of indoor tanning facilities local to college campuses because our focus was primarily on indoor tanning either on campus or in student housing because these are in stu-
ARTICLE INFORMATION Accepted for Publication: September 3, 2014. Published Online: October 29, 2014. doi:10.1001/jamadermatol.2014.3590. Author Contributions: Dr Pagoto had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Pagoto, Lemon, Hillhouse. Acquisition, analysis, or interpretation of data: Pagoto, Oleski, Scully, Olendzki, Evans, Li, Florence, Kirkland. Drafting of the manuscript: Pagoto, Li, Hillhouse. Critical revision of the manuscript for important intellectual content: Pagoto, Lemon, Oleski, Scully, Olendzki, Li, Florence, Kirkland. Statistical analysis: Pagoto, Li. Obtained funding: Pagoto, Lemon, Li, Hillhouse. Administrative, technical, or material support: Pagoto, Oleski, Scully, Olendzki, Florence, Kirkland. Study supervision: Pagoto, Oleski. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by Centers for Disease Control and Prevention grant DP09-901 U48 DP001933 to Drs Pagoto and Hillhouse. This study was supported by the Cooperative Agreement 3U48DP001933-04W1 SIP12-054 from the Centers for Disease Control and Prevention.
jamadermatology.com
dents’ immediate environment. Future research should explore the proximity and density of tanning businesses off campus.
Conclusions Recent research has shown that indoor tanning bans for minors have reduced adolescent tanning in states where bans are in place,5 and to date 11 states have adopted indoor tanning bans for minors.11 The presence of indoor tanning on and around university campuses may offset the progress made by policies banning tanning by minors, especially given that college-aged persons have the highest rate of tanning. 6 While a minority of colleges (12%) in our sample had indoor tanning facilities on campus, just under half had facilities either on campus or in off-campus housing. The presence of indoor tanning facilities on and near college campuses may passively reinforce indoor tanning in college students, thereby facilitating behavior that will increase their risk for skin cancer both in the short term and later in life. In step with tobacco-free policies, tanning-free policies on college campuses may have high potential to reduce skin cancer risk in young adults.
Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. REFERENCES 1. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757. 2. Guy GP Jr, Berkowitz Z, Watson M, Holman DM, Richardson LC. Indoor tanning among young non-Hispanic white females. JAMA Intern Med. 2013;173(20):1920-1922. 3. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large US cities. Am J Prev Med. 2009;36(3):243-246. 4. Patel MR, Mayer JA, Slymen DJ, Weeks JR, Hurd AL. Correlates of tanning facility prevalence within San Diego County, California census tracts. J Community Health. 2007;32(6):391-400. 5. Guy GP Jr, Berkowitz Z, Jones SE, et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health. 2014;104(4):e69-e74.
6. Wehner MR, Chren MM, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol. 2014;150(4):390-400. 7. Kim S. Luxury college dorms offer upscale amenities. ABC News website. September 9, 2013. http://abcnews.go.com/Business/luxury-college -dorms-offer-rooftop-pool-tanning-bed/story?id =20180564. Accessed March 28, 2014. 8. US News Rankings and Reviews. US News and World Report. 2013. http://colleges.usnews .rankingsandreviews.com/best-colleges. Accessed August 1, 2013. 9. Institute of Education Sciences. Fast Facts: Educational Institutions. National Center for Education Statistics website. 2013. http://nces.ed.gov/fastfacts/display.asp?id=84. Accessed August 4, 2014. 10. American Nonsmokers’ Rights Foundation. Smokefree and Tobacco-Free US and Tribal Colleges and Universities. 2014. http://www.no-smoke.org /pdf/smokefreecollegesuniversities.pdf. Accessed April 1, 2014. 11. National Conference of State Legislatures. Indoor tanning restrictions for minors: a state-by-state comparison. 2013. http://www.ncsl .org/research/health/indoor -tanning-restrictions.aspx. Accessed September 17, 2014.
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Original Investigation
Availability of Tanning Beds on US College Campuses Sherry L. Pagoto, PhD; Stephenie C. Lemon, PhD; Jessica L. Oleski, MA; Jonathan M. Scully, BA; Gin-Fei Olendzki, MS; Martinus M. Evans, BS; Wenjun Li, PhD; L. Carter Florence, MPH; Brittany Kirkland, BS; Joel J. Hillhouse, PhD
IMPORTANCE Indoor tanning is widespread among young adults in the United States despite
evidence establishing it as a risk factor for skin cancer. The availability of tanning salons on or near college campuses has not been formally evaluated. OBJECTIVE To evaluate the availability of indoor tanning facilities on US college and university campuses (colleges) and in off-campus housing surrounding but not owned by the college. DESIGN, SETTING, AND PARTICIPANTS This observational study sampled the top 125 US colleges and universities listed in US News and World Report. Investigators searched websites of the colleges and nearby housing and contacted them by telephone inquiring about tanning services. MAIN OUTCOMES AND MEASURES Frequency of indoor tanning facilities on college campus and in off-campus housing facilities, as well as payment options for tanning. RESULTS Of the 125 colleges, 48.0% had indoor tanning facilities either on campus or in off-campus housing, and 14.4% of colleges allow campus cash cards to be used to pay for tanning. Indoor tanning was available on campus in 12.0% of colleges and in off-campus housing in 42.4% of colleges. Most off-campus housing facilities with indoor tanning (96%) provide it free to tenants. Midwestern colleges had the highest prevalence of indoor tanning on campus (26.9%), whereas Southern colleges had the highest prevalence of indoor tanning in off-campus housing facilities (67.7%). Presence of on-campus tanning facilities was significantly associated with enrollment (P = .01), region (P = .02), and presence of a school of public health (P = .01) but not private vs public status (P = .18) or presence of a tobacco policy (P = .16). Presence of tanning facilities in off-campus housing was significantly associated with region (P = .002) and private vs public status (P = .01) but not enrollment (P = .38), tobacco policy (P = .80), or presence of a school of public health (P = .69). CONCLUSIONS AND RELEVANCE Reducing the availability of indoor tanning on and around college campuses is an important public health target. JAMA Dermatol. 2015;151(1):59-63. doi:10.1001/jamadermatol.2014.3590 Published online October 29, 2014.
D
espite evidence establishing indoor tanning as a risk factor for skin cancer,1 this habit is widespread among young adults in the United States, especially nonLatino white women. Almost one-quarter of white women aged 18 to 35 years have used a tanning salon in the past year, and 15% tan indoors frequently.2 Tanning salons are ubiquitous in US cities,3 and 1 study showed that tanning salons are particularly concentrated near colleges.4 Although parental consent laws have not curbed tanning bed use by minors, laws banning indoor tanning by minors have been effective.5 However, young adults aged 18 and older are not directly affected by policies targeting minors. Research is needed to inform targeted public health and policy interventions for indoor tanjamadermatology.com
Author Affiliations: Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts (Pagoto, Lemon, Oleski, Scully, Olendzki, Evans, Li); College of Public Health, East Tennessee State University, Johnson City, Tennessee (Florence, Kirkland, Hillhouse). Corresponding Author: Sherry L. Pagoto, PhD, Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655 ([email protected]).
ning by young adults given that this age group has higher rates of indoor tanning than any other age group.6 Although a great deal of research has examined the tanning habits of college students, to our knowledge, no study has examined the availability of tanning salons on or near college campuses. Research has also shown that tanning salons are more plentiful in areas with a greater percentage of girls and women aged 15 to 29 years.4 A recent ABC news story covered the emergence of luxury accommodations in college campus housing, including tanning beds, as a move to court incoming students.7 This potential trend would make indoor tanning highly accessible to young adults. The purpose of our investigation was to evaluate the presence of tanning facilities on JAMA Dermatology January 2015 Volume 151, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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Tanning Bed Availability on US College Campuses
campus and in off-campus housing in the top 125 colleges and universities on the US News and World Report8 list of best colleges in 2013. We also explored the extent to which the cost of tanning is included in rent and/or college fees and to what extent students could use their campus cash cards to pay for indoor tanning at local salons. We compared colleges with indoor tanning on campus and/or in off-campus housing on region and college characteristics, including public or private status, college ranking, enrollment, tobacco use policy, and presence of a school of public health. We hypothesized that colleges with higher enrollment and lower ranking and those that are public and have no school of public health would be more likely to have tanning beds on campus and/or in offcampus housing.
Methods Human subjects review was waived by the institutional review board of University of Massachusetts Medical School because no human participants were recruited for this study.
Sample The first 125 colleges in the US News and World Report8 list of the best colleges and universities for undergraduate education in the United States in 2013 were used for this investigation. College and housing facility websites were used to access information about services available, and when the information was not found online, colleges and housing facilities were telephoned to inquire about services. Offcampus housing was defined as a house, condominium, apartment building, or community living center that caters to students attending a particular college but is not owned by the college or located on campus property. An off-campus housing facility was deemed “college referred” if it was listed on the college’s housing website. Some colleges noted that their posted housing list was for informational purposes and not necessarily an endorsement.
Search Strategy Multiple search methods were used to evaluate the presence of indoor tanning facilities on campus. College websites were explored by looking at the links for housing, campus activities, student life, and gyms or fitness centers and by performing a search using the search term “tanning” in the college website search tool. If the presence of tanning was not clear via the website, the offices of student housing were contacted by telephone and an investigator asked, “are there any tanning salons or tanning beds on campus?” Additional searches were performed using Google maps of tanning salons in proximity to each campus. If a tanning salon appeared to be located on campus property via the Google map, an investigator telephoned and asked whether the salon was on campus, in an offcampus housing facility, or neither. When indoor tanning facilities were discovered on campus, they were called and asked, “How much does it cost per session? Can students pay with campus cash cards?” Campus cash cards are debit cards that students use on campus and at local participating busi60
nesses. Local businesses can apply to be a cash card merchant, which may bring them student business and a listing on the university website. To determine whether campus cash cards could be used for local tanning salons, we looked at the college website and located a list of local businesses where cash cards were accepted and noted when a tanning salon was on that list. To evaluate the presence of tanning facilities in offcampus housing, off-campus housing links on the college websites were explored. When off-campus housing locations were listed, their websites were explored to determine whether they had indoor tanning facilities, and if so, the housing location was called to determine what payment methods were accepted (eg, campus cash, free for residents, fee per use). Tanning facilities in off-campus housing not linked from college websites were found via searches in online search engines using the terms “tanning [college name],” “tanning [college name] off campus,” “tanning [college name] off campus housing,” and “tanning [college name] housing.” These businesses do not have formal relationships with the college. The presence of a tobacco-free policy was determined by examining the college website or calling the college when this information could not be determined from the website.
Indoor Tanning Availability Outcome variables included presence of indoor tanning facilities on campus, presence of indoor tanning facilities in offcampus housing to which the college refers students, and presence of indoor tanning facilities in off-campus student housing that is not college referred. For each category, we evaluated whether tanning was offered for free or with unlimited use included in rent and/or college fees and whether students could use campus cash cards to pay for tanning.
College Characteristics Basic characteristics of colleges were collected including public or private status, enrollment, geographic region (West, South, Midwest, Northeast), US News and World Report8 ranking (with 1 being the highest ranked college), and presence of a school of public health. The range in the number of students enrolled was high (ie, 2243-56 387), so we converted enrollment into tertiles of 12 904 or fewer students (small), 12 905 to 28 033 students (medium), and 28 034 students or more (large) because extreme scores would make means difficult to interpret.
Analytic Plan Descriptive statistics including means and frequencies were calculated for all variables of interest. Mann-Whitney U tests were used to compare colleges with and without indoor tanning facilities on median US News and World Report8 rankings. For the remaining variables, we were unable to conduct multivariable analyses of the associations between college characteristics and the availability of on-campus indoor tanning because of small cell sizes. As such, Fisher exact tests were used to test for statistically significant differences in oncampus indoor tanning by categorical variables. A multivariate logistic regression model was used to test the association
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Tanning Bed Availability on US College Campuses
of each of the college characteristics with off-campus housing tanning availability. This model included enrollment, region, private vs public status, tobacco policy, and presence of schools of public health. For the enrollment variable, large enrollment was the reference category. For the region variable, the South was the reference category given that a previous study revealed the highest rates of indoor tanning in the South.2
Original Investigation Research
Table 1. Characteristics of the Top 125 Colleges Rated by US News and World Report8 Characteristic
Value
Rank, median (IQR) Enrollment, median (IQR) Public, %
62.0 (31.5-91.0) 20 447.0 (10 865.0-31 086.5) 49.6
Region, % South
Results Description of Colleges Table 1 describes the characteristics of the 125 colleges assessed. Overall, the median (interquartile range) enrollment was 20 447 (10 865-31 086), and 49.6% were public colleges.
24.8
Northeast
36.8
West
17.6
Midwest
20.8
Tobacco-free policy, %
36.8
School of public health, %
64.0
Campus cards can be used for local tanning salons, %
14.4
Indoor tanning, %
Availability of Tanning On-campus indoor tanning facilities were available in 12.0% of colleges. In 42.4% of colleges, indoor tanning was observed in off-campus housing and among those, the mean (SD; range) number of housing facilities with indoor tanning was 2.79 (2.72; 1-14). Thirty-six percent of colleges that had offcampus housing with indoor tanning referred students to those housing facilities on their website. This represents 15.0% of colleges in the overall sample. A total of 48.0% of colleges had indoor tanning facilities either on campus, in off-campus housing, or both. Among colleges with indoor tanning facilities, 53% had indoor tanning in off-campus housing (Table 1).
On campus
12.0
Off-campus housing
42.4
Either on campus or in off-campus housing
48.0
Colleges referring students to housing with indoor tanning, %
15.2
Abbreviation: IQR, interquartile range.
observed according to public vs private status or tobacco policy (see Table 2). Colleges with and without on-campus indoor tanning also did not significantly differ in median ranking on the US News and World Report8 list (P = .85) (data not shown).
Tanning Payment Options Of colleges with indoor tanning facilities on campus (n = 15), none provided tanning to students for free. Of colleges with indoor tanning facilities in college-referred off-campus housing (n = 19), 100% of housing facilities provided unlimited tanning to residents as part of the rental agreement (ie, it was an included amenity for no extra charge). In colleges that had offcampus housing with indoor tanning facilities to which they did not directly refer students (n = 26), 96% of housing facilities provided unlimited tanning to residents as part of the rental agreement. We could not determine referral status for 8 colleges because student login information was required to view the housing list. Campus cash cards could be used to pay for indoor tanning at local salons for 18 colleges (14.4%).
College Characteristics Associated With On-Campus Tanning Availability Table 2 describes the bivariate associations of college characteristics with on-campus tanning availability. Colleges with and without indoor tanning facilities on campus were significantly different in enrollment (Fisher exact test P = .01), region (Fisher exact test P = .02), and presence of schools of public health (Fisher exact test P = .01). On-campus tanning was more prevalent in colleges in the high-enrollment category (23.8%) than those in the medium-enrollment (10.5%) or lowenrollment (2.5%) categories. Indoor tanning was more prevalent on campuses in the Midwest (26.9%), followed by the Northeast (13.0%) and South (6.5%), with no colleges offering on-campus tanning in the West. No significant differences were jamadermatology.com
College Characteristics Associated With Off-Campus Housing Tanning Availability Table 2 describes the bivariate associations of college characteristics with tanning availability in off-campus housing. A multivariable logistic regression model indicated that public colleges were more likely to have tanning facilities in offcampus housing than private colleges (64.5% vs 20.6%, respectively; OR, 4.33 [95% CI, 1.38-13.58]). Region was also associated with tanning facilities in off-campus housing, with colleges in the Northeast (OR, 0.16 [95% CI, 0.05-0.51]) and West (OR, 0.15 [95% CI, 0.40-0.59]) having lower odds of tanning facilities in off-campus housing compared with colleges in the South. Tanning facilities were available in off-campus housing at 67.7% of colleges in the South, 61.5% in the Midwest, 31.8% in the West, and 19.6% in the Northeast (P = .002). Associations between enrollment, tobacco-free campus policy, presence of schools of public health, and off-campus tanning facilities were not statistically significant. Finally, colleges with tanning facilities in off-campus housing also did not have significantly different median ranking from those with no tanning facilities in off-campus housing (P = .20) (data not shown).
Discussion The present study shows that approximately half of the top 125 colleges on the US News and World Report8 list of colleges have JAMA Dermatology January 2015 Volume 151, Number 1
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Research Original Investigation
Tanning Bed Availability on US College Campuses
Table 2. Prevalence of Indoor Tanning on Campus and in Off-Campus Housing by Enrollment, Region, Private vs Public Status, Tobacco Policy, and Presence of School of Public Health Variable
On-Campus Tanning, %
P Value
Off-Campus Housing Tanning, %
P Value
Enrollment Low
2.5
24.4
Medium
10.5
High
23.8
69.0
13.0
19.6
.01
33.3
.38
Region Northeast West Midwest South
0.0 26.9
31.8 .02
6.5
61.5
.002
67.7
Private vs public status Public
16.2
Private
7.9
64.5 .18
20.6
.01
Tobacco policy Yes
17.3
No
8.8
52.2 .16
36.7
.80
School of public health Yes
17.5
No
2.2
46.3 .01
indoor tanning facilities on campus and/or in off-campus housing. Twelve percent of colleges offer indoor tanning on campus property, whereas for 42% of the colleges, off-campus housing offering indoor tanning facilities was found. Almost half (48%) of colleges had indoor tanning facilities either on campus, in off-campus housing, or both. Campus cash cards could be used to purchase tanning locally for 14.4% of colleges. Whereas indoor tanning facilities were found on a small minority of campuses (12%), the total enrollment for these colleges is 523 610 students. If this sample is representative of the 2870 colleges in the United States, then several million young adults have access to indoor tanning facilities on their college campuses.9 Colleges could take steps to ban indoor tanning on campus. Public health efforts are needed to raise university administration and student population awareness of the harms that indoor tanning poses to young adults in order to increase demand for policy-related action. Our findings showed that colleges with higher enrollment and those in the Midwest and Northeast have the highest prevalence of on-campus indoor tanning, which may suggest a place to start prevention efforts. Indoor tanning facilities were more prevalent in offcampus housing than on campus property and were almost always (in 96% of cases) provided as a free, unlimited amenity to residents as part of their rental agreement. Research is needed to explore how free access to indoor tanning might affect tanning behavior. Free access could potentially encourage tanning among people who would only be willing to tan if it is free, as well as possibly leading to even higher rates of tanning among frequent tanners. To the extent that tanning is included in rental fees or can be paid for with campus cash cards, parents may be absorbing the cost of their child’s tanning habit, possibly unknowingly. Dermatologists and pediatricians can play a role in informing par62
35.6
.69
ents about the possibility of indoor tanning on college campuses and in off-campus housing, the dangers associated with such access, and the possibility that they may be unknowingly paying for it. Results also showed that 15% of colleges referred students to off-campus housing that had indoor tanning facilities. Although colleges do not have direct control over indoor tanning facilities in off-campus housing, they likely have some influence over these facilities. Colleges could take some steps to discourage indoor tanning in off-campus housing, such as by referring students only to off-campus housing that embraces their campus health policies, publicly condemning the practice of placing indoor tanning facilities in off-campus housing, and prohibiting tanning salons from being campus cash merchants. Skin cancer prevention efforts should also directly target owners of offcampus housing. We examined differences in tanning availability according to campus tobacco-free policy status because we hypothesized that these colleges may have greater awareness of public health risks and/or place greater priority on cultivating healthier environments. Whereas 36.8% of colleges in our sample have policies that ban both the sale and use of tobacco 10 on campus, these colleges were not less likely to have indoor tanning on campus and in off-campus housing. The lack of a difference according to tobacco-free status may be due to inherent differences in regulation of tobacco, which has a direct impact on others via secondhand smoke. Our results ran counter to the hypothesis that colleges with schools of public health would be less likely to have tanning on campus. This suggests a possible disconnect between university health policy and academic public health programs. It also points to an important potential role for schools of public health in advocating for tanning-free policies.
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Original Investigation Research
The present study has several limitations. The top 125 colleges and universities in US News and World Report8 are not likely representative of all US colleges and universities. We chose this list because it represents the most highly regarded colleges in the United States, ones that may be viewed as trendsetters for US undergraduate education. Also, our estimates of indoor tanning, particularly in off-campus housing, may be underestimates because our search strategy (eg, telephone inquiries, website searches) was more vulnerable to missing existing facilities than counting ones that did not exist. For 8 colleges (6%), the amenities of off-campus housing facilities could not be viewed without entering a student identification number. More systematic means of retrieving information about amenities are not available to our knowledge. Also, our data do not account for the presence of independent indoor tanning businesses surrounding college campuses. One study showed that the number of tanning salons in a census tract was predicted by a greater number of young females (ages 15-29 years) residing in that area,4 which suggests that these businesses may be heavily concentrated near college campuses. Our data likely provide an incomplete picture of the availability of indoor tanning facilities local to college campuses because our focus was primarily on indoor tanning either on campus or in student housing because these are in stu-
ARTICLE INFORMATION Accepted for Publication: September 3, 2014. Published Online: October 29, 2014. doi:10.1001/jamadermatol.2014.3590. Author Contributions: Dr Pagoto had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Pagoto, Lemon, Hillhouse. Acquisition, analysis, or interpretation of data: Pagoto, Oleski, Scully, Olendzki, Evans, Li, Florence, Kirkland. Drafting of the manuscript: Pagoto, Li, Hillhouse. Critical revision of the manuscript for important intellectual content: Pagoto, Lemon, Oleski, Scully, Olendzki, Li, Florence, Kirkland. Statistical analysis: Pagoto, Li. Obtained funding: Pagoto, Lemon, Li, Hillhouse. Administrative, technical, or material support: Pagoto, Oleski, Scully, Olendzki, Florence, Kirkland. Study supervision: Pagoto, Oleski. Conflict of Interest Disclosures: None reported. Funding/Support: This study was supported by Centers for Disease Control and Prevention grant DP09-901 U48 DP001933 to Drs Pagoto and Hillhouse. This study was supported by the Cooperative Agreement 3U48DP001933-04W1 SIP12-054 from the Centers for Disease Control and Prevention.
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dents’ immediate environment. Future research should explore the proximity and density of tanning businesses off campus.
Conclusions Recent research has shown that indoor tanning bans for minors have reduced adolescent tanning in states where bans are in place,5 and to date 11 states have adopted indoor tanning bans for minors.11 The presence of indoor tanning on and around university campuses may offset the progress made by policies banning tanning by minors, especially given that college-aged persons have the highest rate of tanning. 6 While a minority of colleges (12%) in our sample had indoor tanning facilities on campus, just under half had facilities either on campus or in off-campus housing. The presence of indoor tanning facilities on and near college campuses may passively reinforce indoor tanning in college students, thereby facilitating behavior that will increase their risk for skin cancer both in the short term and later in life. In step with tobacco-free policies, tanning-free policies on college campuses may have high potential to reduce skin cancer risk in young adults.
Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Disclaimer: The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. REFERENCES 1. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757. 2. Guy GP Jr, Berkowitz Z, Watson M, Holman DM, Richardson LC. Indoor tanning among young non-Hispanic white females. JAMA Intern Med. 2013;173(20):1920-1922. 3. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large US cities. Am J Prev Med. 2009;36(3):243-246. 4. Patel MR, Mayer JA, Slymen DJ, Weeks JR, Hurd AL. Correlates of tanning facility prevalence within San Diego County, California census tracts. J Community Health. 2007;32(6):391-400. 5. Guy GP Jr, Berkowitz Z, Jones SE, et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health. 2014;104(4):e69-e74.
6. Wehner MR, Chren MM, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol. 2014;150(4):390-400. 7. Kim S. Luxury college dorms offer upscale amenities. ABC News website. September 9, 2013. http://abcnews.go.com/Business/luxury-college -dorms-offer-rooftop-pool-tanning-bed/story?id =20180564. Accessed March 28, 2014. 8. US News Rankings and Reviews. US News and World Report. 2013. http://colleges.usnews .rankingsandreviews.com/best-colleges. Accessed August 1, 2013. 9. Institute of Education Sciences. Fast Facts: Educational Institutions. National Center for Education Statistics website. 2013. http://nces.ed.gov/fastfacts/display.asp?id=84. Accessed August 4, 2014. 10. American Nonsmokers’ Rights Foundation. Smokefree and Tobacco-Free US and Tribal Colleges and Universities. 2014. http://www.no-smoke.org /pdf/smokefreecollegesuniversities.pdf. Accessed April 1, 2014. 11. National Conference of State Legislatures. Indoor tanning restrictions for minors: a state-by-state comparison. 2013. http://www.ncsl .org/research/health/indoor -tanning-restrictions.aspx. Accessed September 17, 2014.
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