Controversy remains over the risks involved with indoor tanning, especially in children and young adults. Since sunburn serves as a marker for excessive and skin-cell damaging ultraviolet (UV) exposure -- which can eventually lead to the development of skin cancer -- investigators at The Cancer Institute of New Jersey (CINJ) took a closer look at a college-aged sample of females and their indoor tanning habits. What they found was that sunburn was a frequently reported experience by these young women when they engaged in this activity. CINJ is a Center of Excellence of the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

Previous research on erythema -- or redness of the skin/sunburn -- in relation to tanning bed use has relied on study participants' long-term memory in recalling if and how often they experienced this effect from indoor tanning. In this study, participants were required to make a series of diary entries over a course of 12 weeks to document whether sunburn was a result of their tanning bed use during that period. Diary data were utilized to determine how often sunburn occurred and whether there were certain characteristics specific to both the session and the user that would predict outcomes of sunburn following tanning bed use. The research, conducted by investigators from CINJ and colleagues from East Tennessee State University, The Pennsylvania State University and Northwestern University, appears in the current online edition of Translational Behavioral Medicine.

The study, Erythema and Ultraviolet Indoor Tanning: Findings from a Diary Study, looked at 198 female college students, with a mean age of approximately 19, from two universities in the northeastern and southeastern United States. All participants reported engaging in an indoor tanning session at least once in the year prior to the study. Participants were asked to recall their indoor tanning behavior over a previous two-week period and indicated if and how often during that period they tanned. Questions included how long each individual session was and whether goggles were worn. They also were asked whether they "burned" or experienced "red skin" related to a tanning session.

During the study period, just over a third of participants (37 percent) did not engage in indoor tanning during the assessment period. An additional third of the sample group used indoor tanning one to ten times, while nearly 12 percent reported more than 20 sessions. Two-thirds of participants reported at least one case of sunburn related to an indoor tanning session. Half of respondents reported two or more episodes, while 36 percent reported three or more instances. Thus the authors note a positive association between the number of indoor tanning sessions and number of sunburn cases. The duration of the sessions however, was not significantly associated with sunburn risk.

Among those who did use indoor tanning, 1,429 indoor tanning sessions were reported, with one in five sessions resulting in sunburn. In addition, while the study did not specifically measure eye damage incurred by participants, the data reveal that in 39 percent of the sessions, study participants did not wear goggles to shield their eyes from radiation. That frequent lack of eye protection raises concerns that participants may be at risk of injuring their eyes in addition to their skin.

Jerod L. Stapleton, PhD, behavioral scientist at CINJ and assistant professor of medicine at UMDNJ-Robert Wood Johnson Medical School, is the lead author of the study. "What our findings show is that indoor tanning -- advertised by the indoor tanning industry as a 'controlled' ultraviolet radiation exposure resulting in minimal risk of burn -- results in quite the opposite. Despite these claims, our results show that sunburn is a common occurrence related to tanning bed use. This is particularly worrisome given data that suggest sunburns increase future skin cancer risk," noted Dr. Stapleton.

As far as predictors, those who reported tanning-bed use at the highest levels prior to the study had a "significantly lower risk of experiencing indoor tanning-related erythema despite reporting the highest mean number of sessions during the study period." The authors say this finding suggests that perhaps those who are heavy users of tanning beds learn to adjust their tanning patterns in a manner that prevents burning despite their excessive exposure. While the authors say this approach presents somewhat less risk than one that induces burning, they also emphasize that there is no such thing as a safe tan.

Results also showed that a perceived susceptibility to burning from indoor tanning was positively associated with risk of burning. To further clarify, investigators examined the relationship between those with a sensitive skin type and their perceived susceptibility to burning and found a significant moderate correlation. For instance, they note that those more susceptible to burning because of their sensitive skin know this, but are unable to do anything to prevent such burns. The authors also note that some with sensitive skin may think it is necessary to burn first before achieving a tan. With such perceptions, the team notes that prevention efforts should seek to understand why individuals make the decisions they do, when they know they put themselves at an increased risk of burning.

"The biology of the skin-tanning response shows that any tanning or darkening of the skin is a sign of skin damage, and refraining from indoor tanning should be an overall goal for users to protect their skin's health and appearance. However, health professionals know there are many indoor tanning users who refuse to give it up. In developing interventions for this population, clinicians may want to focus on the importance of avoiding sunburn as part of a harm-reduction approach, as previous intervention methods have not focused on that aspect before," Stapleton added.

The authors note there were limitations to the study, including a sole focus on a female college sample, although research indicates this population has a high rate of indoor tanning use. "Even though this study focused on young adults, our findings support the need to discourage tanning bed use by minors, since previous studies have shown that their skin is more prone to damage from UV exposure," said Stapleton. The authors also cite a potential for inaccuracies in reporting behavior in using the diary method, but say that because sunburn is a distinct and memorable event, it reduces the likelihood of misreporting.

With regard to future studies, the authors say information should be collected about the type of indoor tanning device used (ie: whether the device has high- or low-intensity UV light bulbs), saying that specific knowledge may determine user behavior as to how long the user chooses to tan.

Along with Stapleton, the authors include Joel Hillhouse, East Tennessee State University; Rob Turrisi, The Pennsylvania State University; June K. Robinson, Northwestern University; Katie Baker, East Tennessee State University; Sharon L. Manne, CINJ and UMDNJ-Robert Wood Johnson Medical School; and Elliot J. Coups, CINJ and UMDNJ-Robert Wood Johnson Medical School.

The study was supported by funding from the American Cancer Society: RSGPB-05-011-01-CPPB (Hillhouse).