Although the prevalence of recent indoor tanning in our entire sample was approximately 10%, the prevalence for older adolescent girls was substantially higher—nearly 27%. This sex–age pattern has been found previously in national US samples.4–7
Our multivariate test results regarding indoor tanning and parental and peer influences were consistent with our preliminary report, in which only psychosocial and demographic variables were evaluated,12
and also were comparable to the findings of Stryker et al.34
The adolescent’s belief that indoor tanning may cause skin cancer was positively associated with indoor tanning use. Although this finding initially may seem counterintuitive, it is based on cross-sectional data, and it is possible that adolescents who use indoor tanning have had greater exposure to health-risk messages on tanning equipment and consent forms.
In addition to psychosocial and demographic variables, indoor tanning also was significantly associated with the built-environment variable of the adolescent’s proximity to tanning facilities from their home. In other health areas, such as alcohol and tobacco control, availability of built-environmental resources also has been linked to healthy or unhealthy behaviors.38–42
The relationship between city-based tanning facility density and indoor tanning, significant in the univariate test, may not have been significant in the multivariate test because of multicollinearity, with a strong correlation between the proximity and density variables (data not shown). Proximity to individual adolescents’ homes was likely a more sensitive and precise measure of tanning salon availability.
At the policy level, we recently reported that tanning facility personnel in states with (vs without) indoor tanning youth-access laws were significantly more likely to tell our study confederates that they would need parental consent.30
However, this finding does not appear to translate into reduced indoor tanning by adolescents; the current multivariate analyses found no significant difference in indoor tanning behavior among adolescents in states with adolescent indoor tanning access laws versus states without such laws (e.g., parental consent or accompaniment). A recent report also found a lack of association between these variables, and concluded that “the presence of state legislation restricting minors’ access to indoor tanning has limited effectiveness, perhaps because most state policies permit use with parental consent.”43
(p190) We agree with this interpretation.
Limitations of our study include reliance on adolescents’ self-reported indoor tanning behavior, a cross-sectional study design, using a telephone (vs in-person) data collection strategy by young women posing as 15-year-old girls to obtain facility practice data, and omitting smaller cities and rural areas from our sampling sites. An important methodological strength included careful pilot testing,28
sampling, and quality control procedures for each data set, which yielded respectable levels of reliability. Moreover, to our knowledge this study represents the most comprehensive attempt to examine potential correlates of indoor tanning by adolescents, simultaneously examining demographics, psychosocial variables, tanning facility availability, and policy-related factors such as legislation and practices by tanning facility operators.
As noted before, a key finding was the lack of a significant association between whether a state had an indoor tanning youth-access law and whether adolescents in that state were using indoor tanning. Our data, as well as those of others,43
suggest that the current laws, most of which involve parental consent requirements, are not working. Possible reasons for this ineffectiveness are
- parents may be providing their consent,
- adolescents may be falsifying their parents’ signatures,
- adolescents may be visiting the (less compliant) facilities that have a history of not requiring parental consent,
- parents and adolescents may be unaware of the laws, or
- the age limit in some of the states requiring parental consent may be too low.
The high rate of indoor tanning by older adolescent girls suggests that better laws are needed, preferably in the form of bans for those younger than 18 years as recommended by the World Health Organization.44
Such laws already have been passed in several European countries,45
several states in Australia,45
and Howard County, Maryland.46
Results of statistical modeling have suggested that effective regulation of the indoor tanning industry in Australia, including banning minors’ use, could substantially reduce skin cancer incidence and associated costs.47
Additionally, in the meantime and in conjunction with stronger laws, our data show that parents who influence their adolescents’ indoor tanning behavior both by modeling this behavior themselves and by granting their permission for their adolescents to tan could play an important role in lowering their adolescents’ melanoma risk. More specifically, they could discontinue their own use of indoor tanning, withhold their consent for their child to tan, place restrictions on their child’s use of his or her allowance, or lobby for the passage of effective indoor tanning laws in their state and nationally.