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Background People increase their risk of melanoma unless they are protected from the harmful effects of sun exposure during childhood and adolescence. We aimed to assess the feasibility of a three-component sun protection intervention- presentation, action planning, and SMS messages - and trial parameters. Methods This feasibility wait-list trial was conducted in the United Kingdom in 2018. Students aged 13–15 years were eligible. Feasibility outcomes were collected for recruitment rates; data availability rates for objective measurements of melanin and erythema using a Mexameter and self-reported sunburn occurrences, severity and body location, tanning, sun protection behaviours and Skin Self-Examination (SSE) collected before (baseline) and after the school summer holidays (follow-up); intervention reach, adherence, perceived impact and acceptability. Quantitative data were analysed using descriptive statistics; qualitative data were analysed thematically. Results Five out of eight schools expressing an interest in participating with four allocated to act as intervention and one control. Four parents/carers opted their child out of the study. Four hundred and eighty-seven out of 724 students on the school register consented to the study at baseline (67%). Three hundred and eighty-five were in intervention group schools. Objective skin measurements were available for 255 (66%) of the intervention group at baseline and 237 (61%) of the group at follow up. Melanin increased; erythema decreased. Complete self-report data were available for 247 (64%) students in the intervention group. The number of students on the school register who attended the presentation and given the booklet was 379 (98%) and gave their mobile phone number was 155 (40%). No intervention component was perceived as more impactful on sun protection behaviours. Adolescents did not see the relevance of sun protection in the UK or for their age group. Conclusions This is the first study to use a Mexameter to measure skin colour in adolescents. Erythema (visible redness) lasts no more than three days and its measurement before and after a six week summer holiday may not yield relevant or meaningful data. A major challenge is that adolescents do not see the relevance of sun protection and SSE. Trial registration International Standard Randomised Controlled Trial Number ISRCTN11141528 . Date registered 0/2/03/2018; last edited 31/05/2018. Retrospectively registered.

Adolescent and young adult men are a potentially overlooked population with respect to risky tanning behaviors. This study sought to determine the prevalence of various modes of tanning and associated variables among young men in a university setting in the southeastern United States. Undergraduate students at a public institution in Mobile, Alabama were surveyed electronically in March 2016. Of the 818 undergraduate men surveyed, over 90% reported tanning behaviors, with 37% reporting engaging in indoor tanning. Additionally, over 25% reported engaging in two or more types of tanning concurrently. These findings indicate that early intervention efforts targeting young men are needed to reduce risky tanning behaviors and associated negative health outcomes.

Objectives. Recently, several state indoor tanning laws, including age restrictions, were promulgated to reduce indoor tanning among minors. We examined the effects of these laws on adolescent indoor tanning. Methods. We used nationally representative data from the 2009 and 2011 national Youth Risk Behavior Surveys (n = 31 835). Using multivariable logistic regression, we examined the association between state indoor tanning laws and indoor tanning among US high school students. Results. Female students in states with indoor tanning laws were less likely to engage in indoor tanning than those in states without any laws. We observed a stronger association among female students in states with systems access, parental permission, and age restriction laws than among those in states without any laws. We found no significant association among female students in states with only systems access and parental permission laws or among male students. Conclusions. Indoor tanning laws, particularly those including age restrictions, may be effective in reducing indoor tanning among female high school students, for whom rates are the highest. Such reductions have the potential to reduce the health and economic burden of skin cancer.

Objectives To quantify the use of sunbeds in young people across England, identify geographical variation, and explore patterns of use, including supervision.Design Two random location sampling surveys.Setting National Prevalence Study in England; Six Cities Study in Liverpool, Stoke/Stafford, Sunderland, Bath/Gloucester, Oxford/Cambridge, and Southampton.Participants 3101 children aged 11-17 in the National Prevalence study and 6209 in the Six Cities study.Results In the National Prevalence Study 6.0% (95% confidence interval 5.1% to 6.8%) of those aged 11-17 had used a sunbed. Use was higher in girls than in boys (8.6% (7.2% to 10.0%) v 3.5% (2.6% to 4.4%), respectively), in those aged 15-17 compared with those aged 11-14 (11.2% (9.5% to 12.9%) v 1.8% (1.2% to 2.4%), respectively), and in those from lower rather than higher social grades (7.6% (5.7% to 9.5%) v 5.4% (4.5% to 6.3%), respectively). Sunbed use was higher in the “north” (11.0%, 8.9% to 13.0%) than in the “midlands” (4.2%, 2.5% to 5.8%) and the “south” (4.2%, 3.3% to 5.2%). In the Six Cities Study, sunbed use was highest in Liverpool and Sunderland (20.0% (17.5% to 22.4%) and 18.0% (15.6% to 20.3%), respectively), with rates especially high in girls, those aged 15-17, or from lower social grades. Mean age of first use was 14, and 38.4% (34.7% to 42.1%) of children used a sunbed at least once a week. Nearly a quarter (23.0%, 19.8% to 26.1%) of children had used a sunbed at home (including home of friends/relatives), and 24.7% (21.0% to 28.4%) said they had used sunbeds unsupervised in a tanning/beauty salon or gym/leisure centre.Conclusions Sunbed use by children is widespread in England, is often inadequately supervised, and is a health risk. National legislation is needed to control sunbed outlets.

Purpose Gender nonconformity (GNC) describes the degree of misalignment between individual’s gender expression and gender norms and is often linked to negative health outcomes. We aimed to investigate the association between GNC and adolescent indoor tanning, the most preventable cause of skin cancer, among U.S. high school students. Methods This study examined cross-sectional data from the 2017 state Youth Risk Behavior Survey in Maryland. Participants included 25,432 female and 25,060 male students in grades 9 through 12. The primary outcome was the prevalence of self-reported 12-month history of indoor tanning before survey. The GNC was measured by self-perceived gender expression (from “very feminine” to “very masculine”) and sex (“female” or “male”). The logistic regression analysis for weighted survey data was performed to estimate the association between GNC and adolescent indoor tanning. Results Among 50,492 high school students in Maryland, the prevalence of indoor tanning was 6.8(95% CI, 6.4-7.3), and varied by demographic characteristics and sexual orientation. Among male students, indoor tanning was significantly associated with moderate GNC (AOR, 1.55; 95% CI, 1.13-2.13; P=0.007) and high GNC (AOR, 4.92; 95% CI, 4.04-5.99; P<0.001). However, among female students, indoor tanning was not associated with moderate and high GNC in the adjusted models. Furthermore, indoor tanning was also significantly associated with transgender identity, the AOR was 7.16 (95% CI, 5.89-8.72; P<0.001) compared with cisgender female students, and 9.31(7.44-11.64; P<0.001) compared with cisgender male students. Conclusions Gender nonconforming adolescent males and transgender adolescents report higher risk of indoor tanning than gender conforming adolescent males and cisgender adolescents respectively. Skin cancer prevention efforts targeted at gender minorities might reduce indoor tanning, a preventable risk factor for skin cancer.

Background Skin cancer is the most prevalent yet most preventable cancer in the US. While protecting oneself from ultraviolet radiation (UVR) can largely reduce risk, rates of unprotected sun exposure remain high. Because the desire to be tan often outweighs health concerns among sunbathers, very few interventions have been successful at reducing sunbathing behavior. Sunless tanning (self-tanners and spray tans), a method of achieving the suntanned look without UVR exposure, might be an effective supplement to prevention interventions. Methods and Design This cluster randomized trial will examine whether a beach-based intervention that promotes sunless tanning as a substitute for sunbathing and includes sun damage imaging and sun safety recommendations is superior to a questionnaire only control group in reducing sunbathing frequency. Female beach visitors (N = 250) will be recruited from 2 public beaches in eastern Massachusetts. Beach site will be the unit of randomization. Follow-up assessment will occur at the end of the summer (1-month following intervention) and 1 year later. The primary outcome is average sunbathing time per week. The study was designed to provide 90% power for detecting a difference of .70 hours between conditions (standard deviation of 2.0) at 1-year with an intra-cluster correlation coefficient of 0.01 and assuming a 25% rate of loss to follow-up. Secondary outcomes include frequency of sunburns, use of sunless tanning products, and sun protection behavior. Discussion Interventions might be improved by promoting behavioral substitutes for sun exposure, such as sunless tanners, that create a tanned look without exposure to UVR. Trial registration NCT00403377

Introduction Adolescents increase their skin cancer risk through exposure to ultraviolet radiation, tanning, and poor use of sun-safety practices. Past studies documented that adolescent indoor tanning is associated with substance use. However, these did not examine e-cigarette use as many were conducted prior to their widespread popularity nor were most studies focused on areas with high environmental risk for skin cancer. The present study examined the current relationship between indoor tanning and substance use, including e-cigarettes, in an area with high skin cancer burden. Methods Data for the current study stem from a statewide survey of middle and high school students in a high melanoma burden state of the United States ( N  = 22,141). The survey assessed student’s reported indoor tanning, alcohol use, cigarette smoking, and e-cigarette and marijuana usage. Results Across all student participants, 3.5% reported indoor tanning one or more times in the past 12 months. Weighted chi-square tests revealed statistically significant associations between indoor tanning and other health risk behaviors ( p  < 0.001). Specifically, higher alcohol consumption, e-cigarette use, marijuana use, and cigarette use were all significantly associated with more frequent indoor tanning. Female and older adolescents were more likely to report indoor tanning. Conclusions Indoor tanning among adolescents is associated with increased odds of engaging in substance use behaviors, including e-cigarette use. Health interventions for adolescents may benefit from addressing multiple health risk behaviors concurrently and targeting adolescents most in need for health interventions. Future work to better understand the common mechanisms underlying co-occurring health risk behaviors could inform development of such interventions.

Although personal melanoma risk factors are well established, the contribution of socioeconomic factors, including clothing styles, social norms, medical paradigms, perceptions of tanned skin, economic trends, and travel patterns, to melanoma incidence has not been fully explored. We analyzed artwork, advertisements, fashion trends, and data regarding leisure-time activities to estimate historical changes in UV skin exposure. We used data from national cancer registries to compare melanoma incidence rates with estimated skin exposure and found that they rose in parallel. Although firm conclusions about melanoma causation cannot be made in an analysis such as this, we provide a cross-disciplinary, historical framework in which to consider public health and educational measures that may ultimately help reverse melanoma incidence trends.

Tanning bed location and distribution Tanning salon Beauty Gyms & fitness Laundromats Health services Other n (%) n (%) n (%) n (%) n (%) n (%) 8105 (60.7) 2857 (21.4) 1999 (15.0) 48 (0.4) 28 (0.2) 306 (2.3) State Alaska 38 (65.5) 9 (15.5) 6 (10.3) 1 (1.7) 0 (0.0) 4 (6.9) Alabama 134 (55.1) 62 (25.5) 38 (15.6) 0 (0.0) 0 (0.0) 9 (3.7) Arkansas 88 (61.1) 31 (21.5) 19 (13.2) 0 (0.0) 0 (0.0) 6 (4.2) Arizona 128 (59.5) 26 (12.1) 53 (24.7) 0 (0.0) 0 (0.0) 8 (3.7) California 629 (65.6) 155 (16.2) 148 (15.4) 0 (0.0) 3 (0.3) 24 (2.5) Colorado 128 (61.2) 47 (22.5) 27 (12.9) 0 (0.0) 1 (0.5) 6 (2.9) Connecticut 82 (53.3) 30 (19.5) 36 (23.4) 0 (0.0) 0 (0.0) 6 (3.9) Washington D.C 6 (66.7) 1 (11.1) 2 (22.2) 0 (0.0) 0 (0.0) 0 (0.0) Delaware 21 (55.3) 7 (18.4) 9 (23.7) 0 (0.0) 0 (0.0) 1 (2.6) Florida 412 (65.6) 91 (14.5) 107 (17.0) 0 (0.0) 4 (0.6) 14 (2.2) Georgia 258 (61.4) 80 (19.1) 76 (18.1) 0 (0.0) 1 (0.2) 5 (1.2) Hawaii 9 (69.2) 1 (7.7) 3 (1.2) 0 (0.0) 0 (0.0) 0 (0.0) Iowa 122 (49.4) 89 (36.0) 24 (9.7) 1 (0.4) 0 (0.0) 11 (4.5) Idaho 49 (56.3) 26 (29.9) 10 (11.5) 0 (0.0) 0 (0.0) 2 (2.3) Illinois 330 (63.1) 101 (19.3) 83 (15.9) 0 (0.0) 2 (0.4) 7 (1.3) Indiana 316 (67.7) 82 (17.6) 48 (10.3) 15 (3.2) 1 (0.2) 5 (1.1) Kansas 90 (53.6) 52 (31.0) 24 (14.3) 0 (0.0) 0 (0.0) 2 (1.2) Kentucky 195 (69.4) 35 (12.5) 37 (13.2) 3 (1.1) 1 (0.4) 10 (3.6) Louisiana 109 (50.2) 69 (31.8) 34 (15.7) 0 (0.0) 0 (0.0) 5 (2.3) Massachusetts 156 (55.1) 61 (21.6) 63 (22.3) 0 (0.0) 0 (0.0) 3 (1.1) Maryland 97 (58.1) 29 (17.2) 41 (24.3) 0 (0.0) 0 (0.0) 2 (1.2) Maine 41 (44.6) 32 (34.8) 12 (13.0) 1 (1.1) 0 (0.0) 6 (6.5) Michigan 342 (60.5) 131 (23.2) 73 (12.9) 3 (0.5) 1 (0.2) 15 (2.7) Minnesota 164 (54.7) 89 (29.7) 29 (9.7) 4 (1.3) 2 (0.7) 12 (4.0) Missouri 210 (62.0) 77 (22.7) 39 (11.5) 0 (0.0) 1 (0.3) 12 (3.5) Mississippi 75 (56.4) 33 (24.8) 21 (15.8) 0 (0.0) 0 (0.0) 4 (3.0) Montana 30 (47.6) 25 (39.7) 5 (7.9) 0 (0.0) 0 (0.0) 3 (4.8) North Carolina 269 (62.1) 96 (22.2) 58 (13.4) 0 (0.0) 1 (0.2) 9 (2.1) North Dakota 38 (56.7) 22 (32.8) 4 (6.0) 3 (4.5) 0 (0.0) 0 (0.0) Nebraska 57 (47.1) 40 (33.1) 18 (14.9) 2 (1.7) 0 (0.0) 4 (3.3) New Hampshire 54 (59.3) 18 (19.8) 17 (18.7) 1 (1.1) 0 (0.0) 1 (1.1) New Jersey 187 (63.8) 39 (13.3) 60 (20.5) 0 (0.0) 1 (0.3) 6 (2.1) New Mexico 29 (40.9) 23 (32.4) 18 (25.4) 0 (0.0) 0 (0.0) 1 (1.4) Nevada 75 (65.2) 21 (18.3) 16 (13.9) 0 (0.0) 0 (0.0) 3 (2.6) New York 345 (61.7) 100 (17.9) 105 (18.8) 1 (0.2) 2 (0.4) 6 (1.1) Ohio 431 (63.7) 137 (20.2) 85 (12.6) 4 (0.6) 2 (0.3) 18 (2.7) Oklahoma 148 (65.5) 46 (20.4) 23 (10.2) 2 (0.9) 0 (0.0) 7 (3.1) Oregon 144 (62.6) 52 (22.6) 26 (11.3) 0 (0.0) 1 (0.4) 7 (3.0) Pennsylvania 357 (52.4) 198 (29.1) 112 (16.5) 4 (0.6) 0 (0.0) 10 (1.5) Rhode Island 39 (66.1) 6 (10.2) 14 (23.7) 0 (0.0) 0 (0.0) 0 (0.0) South Carolina 160 (68.1) 34 (14.5) 40 (17.0) 0 (0.0) 1 (0.4) 0 (0.0) South Dakota 20 (48.8) 13 (31.7) 5 (12.2) 0 (0.0) 0 (0.0) 3 (7.3) Tennessee 198 (63.3) 51 (16.3) 56 (17.9) 0 (0.0) 1 (0.3) 7 (2.2) Texas 574 (71.0) 114 (14.1) 112 (13.9) 0 (0.0) 0 (0.0) 8 (1.0) Utah 69 (69.0) 12 (12.0) 17 (17.0) 0 (0.0) 0 (0.0) 2 (2.0) Virginia 164 (62.6) 56 (21.4) 40 (15.3) 0 (0.0) 0 (0.0) 2 (0.8) Vermont 11 (31.4) 13 (37.1) 8 (22.9) 1 (2.9) 0 (0.0) 2 (5.7) Washington 201 (65.3) 62 (20.1) 38 (12.3) 0 (0.0) 0 (0.0) 7 (2.3) Wisconsin 195 (43.8) 187 (42.0) 43 (9.7) 2 (0.5) 2 (0.5) 16 (3.6) West Virginia 68 (59.7) 31 (27.2) 10 (8.8) 0 (0.0) 0 (0.0) 5 (5.4) Wyoming 13 (37.1) 15 (42.9) 7 (20.0) 0 (0.0) 0 (0.0) 0 (0.0) Numbers in parentheses are the percentage of tanning bed location per state Of 13,343 businesses with tanning bed services, the majority were traditional tanning salons (60.7%). A smaller percentage were laundromats (0.4%) and health services (0.2%) (see Table 1). Florida had the most in health services (4), and Minnesota had the greatest rate (0.04 per 100,000). Number of businesses per 100,000 residents. a Tanning Salons b Beauty Salons c Gyms and Fitness Businesses d Laundromats e Health Services Our study demonstrates the a variety of businesses in the US provide indoor tanning. Data availability Limitations included self-reporting of SIC descriptions and the possibility of missing businesses that are not not captured in the Data Axle’s Business Database Declarations Conflict of interest The authors have no conflicts of interest or financial disclosures, and all authors had access to the data and a role in writing the manuscript.

Objectives. We evaluated psychosocial, built-environmental, and policy-related correlates of adolescents’ indoor tanning use. Methods. We developed 5 discrete data sets in the 100 most populous US cities, based on interviews of 6125 adolescents (aged 14–17 years) and their parents, analysis of state indoor tanning laws, interviews with enforcement experts, computed density of tanning facilities, and evaluations of these 3399 facilities’ practices regarding access by youths. After univariate analyses, we constructed multilevel models with generalized linear mixed models (GLMMs). Results. In the past year, 17.1% of girls and 3.2% of boys had used indoor tanning. The GLMMs indicated that several psychosocial or demographic variables significantly predicted use, including being female, older, and White; having a larger allowance and a parent who used indoor tanning and allowed their adolescent to use it; and holding certain beliefs about indoor tanning's consequences. Living within 2 miles of a tanning facility also was a significant predictor. Residing in a state with youth-access legislation was not significantly associated with use. Conclusions. Current laws appear ineffective in reducing indoor tanning; bans likely are needed. Parents have an important role in prevention efforts.