Indoor tanning and poor mental health among adolescents in New York City (2015)

Abstract

This study explored relationships between mental health and indoor tanning among high school students in New York City using 2015 data from the Youth Risk Behavior Surveillance System. Those more likely to use indoor tanning were females (odds ratio = 6.26, 95% confidence interval = 6.08–6.45) and non-Hispanic White (odds ratio = 1.10, 95% confidence interval = 1.06–1.14). Being bullied on school property (odds ratio = 1.30, 95% confidence interval = 1.25–1.34), having attempted suicide (odds ratio = 2.08, 95% confidence interval = 1.99–2.18), and having sought counseling (odds ratio = 1.22, 95% confidence interval = 1.18–1.26) were significantly associated with indoor tanning. This study indicates that engaging in indoor tanning is associated with a number of mental health factors.

Keywords

Adolescents indoor tanning mental health skin cancer Youth Risk Behavior Surveillance System

Introduction

Skin cancer is the most common cancer in the United States (American Cancer Society, 2018). Skin cancer has increased over time, and 91,270 new cases resulting in 9320 deaths from melanoma (the most virulent form of skin cancer) were expected in 2018 (American Cancer Society, 2018). Exposure to ultraviolet (UV) radiation is a major risk factor in the development of skin cancer (US Department of Health and Human Services, 2014). While cumulative exposure to UV radiation is thought to drive skin cancer rates in older populations (American Cancer Society, 2018), patterns of excessive UV exposure such as indoor tanning are thought to influence rates in younger populations (Christenson et al., 2005; Purdue et al., 2008). Several case–control studies (Ferrucci et al., 2014; Lazovich et al., 2010, 2016) as well as meta-analyses (Boniol et al., 2012; Colantonio et al., 2014; Wehner et al., 2014) confirm the link between indoor tanning and incidence of skin cancer, and the US Surgeon General has called for a reduction in indoor tanning (US Department of Health and Human Services, 2014).

While there has been progress in limiting adolescents’ access to indoor tanning in some states, there is no national policy prohibiting adolescents from indoor tanning (National Conference of State Legislators, 2018). Knowledge alone may not prevent indoor tanning among youth (Dennis et al., 2009). Risks are not consistently demarcated on machines (Brouse et al., 2011a), and several promotional strategies have been used to encourage consumers to engage in tanning (Brouse et al., 2011b). Although indoor tanning among American high school students has declined from 2009 to 2015 (Basch et al., 2014; Guy et al., 2017; Kann et al., 2018), in 2015 7.3% still reported tanning behaviors (including use of a tanning booth, sunbed, or sunlamp) in the past year, and rates were much higher among some subgroups such as white females (15.2%) (Kann et al., 2018).

Being tan has been equated to feeling good and looking healthy (Basch et al., 2012, 2017; Cho et al., 2010; Daniel et al., 2018; Dennis et al., 2009; Joel Hillhouse et al., 2009; Peacey et al., 2006), and media has been noted as an influence on vanity and body image, particularly among females (Mays et al., 2017; Mills et al., 2018; Raggatt et al., 2018). Mays et al. (2017) found that, in some cases young, non-Hispanic white women were dependent on indoor tanning, which was associated with their depressed mood (Mays et al., 2017), while others have suggested that frequent use indoor indoor tanning is associated with psychiatric disorders (Banerjee et al., 2012; Heckman et al., 2014a, 2016; Petit et al., 2014). This study explores relationships between mental health issues and indoor tanning practices among a probability sample of high school students in New York City (NYC), where indoor tanning facilities are prevalent (Brouse et al., 2011a).

Methods

Data from the 2015 New York City Youth Risk Behavior Surveillance System (NYC YRBSS) were analyzed. The NYC YRBSS is conducted by the NYC Department of Health, NYC Department of Education, and the US Centers for Disease Control and Prevention (CDC). Data are collected in odd-numbered years among a probability sample of public high school students in grades 9 through 12 using a self-administered, anonymous questionnaire. Prevalence data are derived for each of the five boroughs and are weighted to adjust for the cluster sampling design. Weighting procedures were followed in accordance with the CDC procedures (Brener et al., 2004). Sampling weights were applied to each record of the 2015 NYC YRBSS to adjust for non-response and oversampling.

Variables

The outcome variable of interest was the use of indoor tanning, assessed by the question “During the past 12 months, how many times did you go tanning in a tanning salon, nail salon, or health club?” Response options included “0 times,” “1 to 2 times,” “3 to 9 times,” “10 to 19 times,” “20 to 39 times,” and “40 or more times.” Demographic covariates included age (continuous variable ⩾ 12 years through ⩽ 18 years), sex (female or male), and race/ethnicity (non-Hispanic American Indian/Alaskan Native, non-Hispanic Asian, non-Hispanic Black or African American, non-Hispanic Native Hawaiian/other Pacific Islander, non-Hispanic White, Hispanic/Latino, multiple Hispanic, and multiple non-Hispanic). Mental health-related questions asked if any of the following events occurred in the past 12 months: “Have you ever been bullied on school property?” “Have you ever been electronically bullied?” “Did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?” Suicide ideation was assessed by the question: “Did you ever seriously consider attempting suicide?” followed by “Did you get help from a professional counselor, social worker, or therapist for an emotional or personal issue that you could not face alone?” Responses to these questions were “Yes” or “No.” In addition, those who answered “Yes” to suicide ideation were asked: “How many times did you actually attempt suicide?” and “How many times did you do something to purposely hurt yourself?” with responses “0 times,” “1 time,” “2 or 3 times,” “4 or 5 times,” and “6 or more times.”

Analysis

Only those who responded to the outcome variable question about indoor tanning were included in the analysis (n = 198,954; 76,584 non-respondents were excluded from the analysis). Descriptive analyses included frequency distributions and crosstabs. Chi-square analysis was used to examine whether there were differences in mental health-related variables by demographic characteristics. Age was dichotomized as “<17 years” = 0 and “⩾17 years” = 1, and race/ethnicity was recoded as “other than White, non-Hispanic” = 0 and “non-Hispanic White” = 1. This was done because at the time these data were collected, 17-year olds were permitted to use a tasing facility with written parental consent (Gromley, 2018). Categorical variables were dichotomized with “0 times going indoor tanning” = indoor tanning “no” otherwise, indoor tanning = “yes”; “zero times considered attempting suicide” and “zero times purposely hurt oneself” = “no,” otherwise “yes.” Multicollinearity between mental health-related variables was evaluated using Pearson correlations (r). When the correlation between variables was medium to large (r ⩾ 0.3), one variable in the pair was excluded from the multivariable analysis (bullied on school property and bullied on electronically, r = 0.448; feeling sad/hopeless and considering suicide, r = 0.360; considering suicide and attempting suicide, r = 0.479; considering suicide and purposely hurting oneself, r = 0.386; and attempting suicide and purposely hurting oneself, r = 0.398). Unadjusted binary logistic regression analyses were performed to assess the crude association between indoor tanning behavior and mental health-related variables and demographic covariates. Multivariable logistic regression was then performed to examine associations of indoor tanning with independent variables controlling for demographic covariates age, race/ethnicity, and sex. The Institutional Review Board at William Paterson University does not review studies that use publicly available data sets. The Institutional Review Board at Teachers College, Columbia University deemed this study exempt.

Results

Descriptive statistics are presented in Table 1. Slightly more than one-quarter (26.3%) of all respondents indicated that they engaged in indoor tanning at least one to two times in the past 12 months. Over one-quarter of the participants were non-Hispanic Black/African American (26.7%), and 13.6% were non-Hispanic White. Being bullied on school property, or electronically, in the past 12 months was reported by 14.0% and 12.1% of the participants, respectively. Nearly 30% stated that they had felt sad/hopeless, 13.4% considered attempting suicide, while 6.6% actually attempted suicide one or more times; 13.9% had purposely hurt themselves; and 17.4% sought out a counselor, social worker, or therapist in the past year. Compared with males, females more often reported engaging in indoor tanning at least one to two times in the past 12 months (39.1% vs 12.2%, p < 0.001), being bullied on school property (16.5% vs 11.8%, p < 0.001) or electronically (15.1% vs 9.2%, p < 0.001), feeling sad/hopeless (37.8% vs 21.8%, p < 0.001), considered (17.5% vs 9.3%, p < 0.001) and attempted suicide (8.5% vs 6.2%, p < 0.001), purposely hurt themselves (18.2% vs 6.3%, p < 0.001), and sought counseling (22.0% vs 14.0%, p < 0.001).

Table 1.

Characteristics of New York City YBRSS (2015) respondents by sex.

	Total (n = 198,954)	Sex
	Total (n = 198,954)	Female (n = 97,629)	Male (n = 90,048)	p
Tanning behavior in the past 12 months
Indoor tanning				<0.001
0 times	146,543 (73.7)	62,141 (60.8)	83,475 (87.8)
1–2 times	21,615 (10.9)	15,773 (15.4)	5681 (6.0)
3–9 times	17,066 (8.6)	14,057 (13.7)	2795 (2.9)
10–19 times	6314 (3.2)	4958 (4.8)	1278 (1.3)
20–29 times	3559 (1.9)	2768 (2.7)	622 (0.7)
40 or more times	3857 (1.9)	2591 (2.5)	1260 (1.3)
Demographics
Age (years)				<0.001
⩽12	986 (0.5)	298 (0.3)	606 (0.6)
13	4900 (2.5)	2603 (2.5)	2194 (2.3)
14	42,842 (21.5)	22,339 (21.8)	20,141 (21.2)
15	50,679 (25.5)	26,491 (25.9)	24,146 (25.5)
16	46,346 (23.3)	23,288 (22.8)	22,773 (24.0)
17	42,071 (21.1)	22,269 (21.8)	19,635 (20.7)
⩾18	10,431 (5.2)	4968 (4.9)	5362 (5.7)
Missing	698 (0.4)
Sex				−
Female	102,288 (51.4)	−	−
Male	95,110 (47.8)	−	−
Missing	1556 (0.8)	−	−
Race				<0.001
Non-Hispanic American Indian/Alaska Native	882 (0.4)	498 (0.5)	385 (0.4)
Non-Hispanic Asian	37,340 (18.8)	17,744 (18.2)	19,452 (21.6)
Non-Hispanic Black/African American	53,127 (26.7)	30,295 (31.0)	22,745 (25.3)
Non-Hispanic Native Hawaiian/Pacific Islander	988 (0.5)	505 (0.5)	483 (0.5)
Non-Hispanic White	27,009 (13.6)	12,902 (13.2)	13,914 (15.5)
Hispanic	32,688 (16.4)	17,304 (17.7)	15,288 (17.0)
Mixed Hispanic	34,547 (17.4)	17,214 (17.6)	17,113 (19.0)
Mixed non-Hispanic	1835 (0.9)	1167 (1.2)	668 (0.7)
Missing	10,536 (5.3)	−	−
Mental health issues
Bullied on school property				<0.001
Yes	27,890 (14.0)	16,645 (16.5)	11,009 (11.8)
No	167,736 (84.3)	84,218 (83.5)	82,591 (88.2)
Missing	3328 (1.7)
Electronically bullied				<0.001
Yes	24,060 (12.1)	15,293 (15.1)	8548 (9.2)
No	171,291 (86.1)	85,837 (84.9)	84,684 (90.8)
Missing	3602 (1.8)	−	−
Sad/hopeless				<0.001
Yes	58,879 (29.6)	38,106 (37.8)	20,407 (21.8)
No	136,128 (68.4)	62,573 (62.2)	72,993 (78.2)
Missing	3947 (2.0)
Considered attempting suicide				<0.001
Yes	26,607 (13.4)	17,613 (17.5)	8623 (9.3)
No	167,536 (84.2)	82,752 (82.5)	84,092 (90.7)
Missing	4811 (2.4)	−	−
Attempted suicide				<0.001
0 times	156,376 (78.6)	80,125 (91.5)	75,484 (93.7)
1 time	7061 (3.5)	4195 (4.8)	2853 (3.5)
2 or 3 times	3791 (1.9)	2640 (3.0)	1062 (1.3)
4 or 5 times	817 (0.4)	286 (0.3)	355 (0.4)
6 or more times	1386 (0.7)	351 (0.4)	846 (1.0)
Missing	29,523 (14.8)	−	−
Purposely hurt oneself				<0.001
None	169,401 (85.1)	82,864 (81.8)	85,754 (90.8)
1 time	10,993 (5.5)	6720 (6.6)	4058 (4.3)
2–3 times	7474 (3.8)	5549 (5.5)	1749 (1.9)
4–5 times	2981 (1.5)	1937 (1.9)	1020 (1.1)
⩾6 times	6132 (3.1)	4182 (4.1)	1899 (2.0)
Missing	1973 (1.0)	−	−
Sought counselor, social worker, or therapist				<0.001
Yes	34,611 (17.4)	21,790 (22.0)	12,638 (14.0)
No	156,050 (78.4)	77,346 (78.0)	77,717 (86.0)
Missing	8292 (4.2)	−	−

YRBSS: Youth Risk Behavior Surveillance System.

In the unadjusted logistic regression, older respondents (⩾17 years) were less likely than younger respondent to engage in indoor tanning (odds ratio (OR) = 0.87, 95% confidence interval (CI) = 0.85–0.89), and race/ethnicity was not independently associated with indoor tanning behavior (Table 2). Compared with males, females were 4.6 times more likely to reportedly engage in indoor tanning (unadjusted OR = 4.64, 95% CI = 4.53–4.74). All mental health-related variables were associated with a greater likelihood of indoor tanning. In the multivariable analysis, older respondents (⩾17 years vs <17 years) remained less likely than younger respondents to use indoor tanning (OR = 0.86, 95% CI = 0.84–0.89). Those more likely to use indoor tanning were females (OR = 6.26, 95% CI = 6.08–6.45) and non-Hispanic White (OR = 1.10, 95% CI = 1.06–1.14). Being bullied on school property (OR = 1.30, 95% CI = 1.25–1.34), having attempted suicide (OR = 2.08, 95% CI = 1.99–2.18), and having sought counseling (OR = 1.22, 95% CI = 1.18–1.26), remained significantly associated with indoor tanning. Feeling sad/hopeless was no longer statistically significant in the adjusted model controlling for age, race/ethnicity, and sex (OR = 0.99, 95% CI = 0.96–1.02).

Table 2.

Mental health-related factors associated with indoor tanning behavior adjusted for demographic covariates.

	Crude OR, 95% CI	Adjusted OR, 95% CI
Age (years)
<17	1.00	1.00
⩾17	0.87 (0.85–0.89)	0.86 (0.84–0.89)
Sex
Male	1.00	1.00
Female	4.64 (4.53–4.74)	6.26 (6.08–6.45)
Race
Other than White, non-Hispanic	1.00	1.00
White, non-Hispanic	0.97 (0.94–1.00)	1.10 (1.06–1.14)
Bullied in school
No	1.00	1.00
Yes	1.48 (1.44–1.52)	1.30 (1.25–1.34)
Bullied electronically
No	1.00	−
Yes	1.72 (1.67–1.77)	−
Sad/hopeless
No	1.00	1.00
Yes	1.65 (1.62–1.69)	0.99 (0.96–1.02)
Contemplated suicide
No	1.00	−
Yes	1.63 (1.58–1.67)	−
Attempted suicide
No	1.00	1.0
Yes	2.94 (2.83–3.05)	2.08 (1.99–2.18)
Purposely hurt oneself
No	1.00	−
Yes	1.85 (1.81–1.90)	−
Sought counseling
No	1.00	1.00
Yes	1.45 (1.42–1.49)	1.22 (1.18–1.26)

OR: odds ratio; CI: confidence interval.

Discussion

A number of studies have identified detrimental effects of indoor tanning particularly in relation to skin cancer (Boniol et al., 2012; Colantonio et al., 2014; Lazovich et al., 2016; Wehner et al., 2014). Although many understand risks associated with indoor tanning, a significant number of adolescents and young adults still perceive indoor tanning as desirable (Banerjee et al., 2012; Hillhouse et al., 2016). The purpose of this study was to assess relationships between selected mental health-related variables and indoor tanning among a probability sample of high school students in NYC. Compared with rates of indoor tanning in the nation (7.3%) (Guy et al., 2017), our findings indicate that the prevalence of indoor tanning was much higher in our sample of NYC high school students (26.3%). Although speculative, his may be due, in part, to the prevalence of tanning facilities in NYC (Basch et al., 2014).

Despite recommendations by the US Food and Drug Administration (FDA, n.d.) against use of indoor tanning devices by individuals younger than 18 years, and in contradiction to the 2012 New York State law that prohibited tanning salons from serving anyone under 17 years (New York State Department of Health, 2018), we found that a significant number of adolescents under age of 17 years reportedly engaged in indoor tanning. It should be noted that a loophole in the 2012 law permitted 17-year olds to use a tanning facility with written parental consent (Gromley, 2018). In 2018, the New York Governor signed the law banning anyone under the age of 18 years from using indoor tanning facilities. While this bill represents an important step in reducing serious and detrimental health risks of indoor tanning, the true effect of this bill on the reported prevalence of adolescent tanning remains to be seen. Further research is warranted on the role that the parental consent loophole and facility acquiescence may have contributed to such large differences in rates of non-compliance. Systematic reviews suggest that the reasons for non-compliance are multifactorial (Reimann et al., 2018, 2019).

Similar to previous findings (Guy et al., 2014), the prevalence of indoor tanning was higher among females than males. The results of this study are also consistent with previous reports (Guy et al., 2014) that compared with students who report being non-White, indoor tanning was more common among students who report being non-Hispanic White.

Identifying factors that are associated with indoor tanning is important for guiding prevention strategies for this population. Previous research indicates that the reasons for seeking an indoor tan are multifactorial, including appearance (Asvat et al., 2010; Gillen and Markey, 2017; Prior et al., 2014) and the addictive properties of UV exposure (Feldman et al., 2004; Heckman et al., 2014b, 2016). This study indicates that engaging in indoor tanning is associated with a number of mental health factors, including being bullied, experiencing sadness and hopelessness, seeking mental health counseling, suicide ideation, and attempting to commit suicide. These findings add to the literature indicating that indoor tanning may be associated with the suboptimal mental health (Gillen and Markey, 2012; Hillhouse et al., 2005; Mosher and Danoff-Burg, 2010). For example, this study indicates a strong association of bullying victimization with tanning behaviors, corroborating previous findings of positive association between indoor tanning and bullying victimization among adolescent males (Blashill and Traeger, 2013). Bullying victimization has been correlated with appearance dissatisfaction among adolescents (Lawler and Nixon, 2011), so it is possible that indoor tanning represents an effort to reduce displeasure with one’s appearance.

In a 2015 study using YRBSS data, sadness and/or hopelessness and suicidal ideation were associated with increased odds of indoor tanning among Hispanic students (Gonzales and Blashill, 2018). Our univariate analysis indicated a significant association of sadness and hopelessness with indoor tanning; however, the strength of association was non-significant after controlling for other covariates. Furthermore, we observed the clustering of negative mental health-related indicators indicating increased vulnerability of the subset of adolescents in this sample. It is possible that the feelings of sadness or hopelessness act as intermediary in the relationship between bullying and tanning. Although bullying victimization and seeking mental health counseling were associated with tanning behaviors, attempted suicide had the highest OR of indoor tanning among NYC high school students. The adjusted odds of engaging in indoor tanning were 2.08 times higher among those (6.5%) who attempted suicide than among those who did not. Previous research has found a positive association between attempted suicide and indoor tanning among male but not among female students (Guy et al., 2014). Additional research is needed to investigate a possible relationship between attempted suicide (and other mental health factors) and tanning.

Limitations

It is important to address the limitations of this study. It is important to reiterate that these data are from 2015, which is not as recent as preferred. In addition, the survey did not measure indoor tanning in 2017, thus limiting our ability to compare over time. There was a comparatively large amount of missing data, which could have had an influential effect on sampling errors and biases. All the results were based on self-reports. Data were cross-sectional, thus precluding any causal inferences. In addition, the survey had a standard set of fixed demographic questions, which does not allow for exploration of further relationships. Our sample was one single school jurisdiction, thus the results cannot be generalized to all adolescents in the United States. This study only examined indoor (not outdoor) tanning. As noted previously, this study was exploratory in nature and contributes to generating a hypothesis between two behaviors. The directionality and causality cannot be determined. Nevertheless, this study illustrates that, while the YRBSS is clearly a valuable tool on the national level, researching specific localities can influence intervention efforts more directly. Additional studies are necessary to confirm our findings and improve understanding about whether there are causal relationships between mental health and tanning behaviors. More specifically, to assess if there is a causal relationship between tanning and subsequent development of mental health problems, prospective studies would be needed. Such studies would require accurate classification of individuals based on the nature and extent of tanning behavior and ability to follow these individuals over time and measure incidence rates of various mental health problems, while at the same time, controlling for the wide variety of variables known to be associated with mental health risks.

Conclusion

Despite these limitations, the results are consistent with previous studies suggesting that suboptimal mental health is associated with adolescents’ engagement in indoor tanning. Future research is needed to identify behavioral profiles of adolescents who partake in indoor tanning and clarify motives for engaging in tanning behavior. Additional research is also needed to examine if there are any effects of the 2018 New York State legislation prohibiting indoor tanning for individuals younger than 18 years.

Footnotes

Acknowledgements

The authors would like to thank Tamar Marder and Tony He from the New York City Department of Health of Health and Mental Hygiene for providing their feedback on the data analysis/result aspects of this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Corey H Basch

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