Prevalence and Location of Indoor Tanning Among High School Students in New Jersey 5 Years After the Enactment of Youth Access Restrictions

Key Points

Question

Are state restrictions that ban minors from using indoor tanning beds effective in reducing the prevalence of indoor tanning among high school students?

Finding

Data from cross-sectional surveys conducted between 2012, the year prior to indoor tanning restrictions, and 2018 showed that the prevalence of tanning decreased among all minors younger than the legal tanning age and among female students older than the legal tanning age. The prevalence among minors of tanning in salons and nonsalon unregulated locations was similar.

Meaning

This study provides unique evidence supporting the benefit of enacting new regulatory efforts that restrict indoor tanning access among minors and extending existing restrictions to address unsupervised nonsalon tanning.

Abstract

Importance

Several state governments have enacted bans on the use of indoor tanning beds at tanning salons among minors, but studies of the association of such restrictions with tanning behavior have produced mixed results. Little is known about the prevalence of tanning in nonsalon locations that are typically not covered by restrictions. Evidence that age bans are associated with a reduction in tanning bed use is needed to support policy makers’ efforts to expand tanning regulations.

Objective

To determine the prevalence and location of indoor tanning among New Jersey youths after a 2013 statewide indoor tanning ban for minors younger than 17 years.

Design, Setting, and Participants

This survey study comprised 4 biennial (2012-2018) and representative cross-sectional surveys conducted among 12 659 high school students (grades 9-12) in New Jersey.

Main Outcomes and Measures

The main outcome was the frequency of indoor tanning in the past year. Location of tanning bed use (ie, tanning salons or nonsalon locations, such as private residences or gyms) was also assessed.

Results

Survey responses from a total of 12 659 high school students (6499 female [51%]; mean [SD] age, 15.8 [1.3] years) were analyzed across the 4 survey waves. Tanning prevalence among students younger than 17 years (ie, younger than the legal tanning age) was 48% lower in 2018 compared with 2012 (adjusted odds ratio, 0.52; 95% CI, 0.33-0.81; P = .002). Tanning prevalence was 72% lower among female students 17 years or older (adjusted odds ratio, 0.28; 95% CI, 0.18-0.44; P < .001). Prevalence rates were not significantly different for male students 17 years or older and for racial/ethnic minority students. The prevalence of tanning in salons and private residences was similar among students younger than 17 years.

Conclusions and Relevance

This study suggests that the prevalence of tanning in New Jersey has begun to decrease among all youths younger than the legal tanning age and among female students of legal age in the 5 years after a statewide tanning ban. These findings provide valuable evidence to policy makers to support ongoing state-level efforts to enact age-specific bans on indoor tanning. The unique assessment of tanning location demonstrates the need for both greater enforcement of existing tanning salon regulations to ensure compliance and broadening restrictions to cover nonsalon tanning locations.

This survey study examines the prevalence and location of indoor tanning among New Jersey youths after a 2013 statewide indoor tanning ban for minors younger than 17 years.

Introduction

Cumulative lifetime exposure to indoor tanning beds and younger age at first use of indoor tanning are associated with increased risk of melanoma.¹ Recent reductions in indoor tanning among youths are likely a result of increased public health attention and the proliferation of age restrictions on indoor tanning in many US states.² National data have shown that tanning prevalence among youths is lower in states with the most restrictive laws,^3,4 but state-specific studies of indoor tanning restrictions have produced inconsistent evidence.^5,6,7 For example, New Jersey legislators passed a statewide ban on indoor tanning for youths younger than 17 years in 2013, but 1 study found negligible reductions in statewide youth indoor tanning rates 1 year later.⁶ This persistence of indoor tanning among youths may be due to a lack of indoor tanning salon compliance⁸ or increased tanning in nonsalon locations not covered by regulations (eg, gyms and private residences). However, data on the locations of youth tanning have not been systematically reported, to our knowledge. In this study, we examine the prevalence and location of indoor tanning among New Jersey youths several years after the ban. We also report changes in tanning among students of legal age (ie, ≥17 years) to explore whether restrictions intended to delay the initiation of indoor tanning may reduce the prevalence of indoor tanning among older students.

Methods

We analyzed data from 12 659 New Jersey high school students (6499 female [51%]; mean [SD] age, 15.8 [1.3] years) from 4 repeated cross-sectional surveys. The New Jersey Youth Tobacco Survey (NJYTS), which is administered every 2 years to high school students (grades 9-12), uses a 2-stage cluster sample design. In each survey year, schools were sampled with probability proportional to size, and then a probability sample of approximately 4 classes was selected within each participating school. Data are weighted to account for the complex sampling design, yielding estimates representative of public high school students in New Jersey. Yearly response rates ranged from 60.3% to 70.2%. Further NJYTS details can be found elsewhere.⁹ The Rutgers University Health Sciences Institutional Review Board approved the survey and present analyses. Participating schools chose from 2 consent procedures approved by the institutional review board. In schools that chose a waiver of written consent, parents returned a form to the school if they declined participation for their child. In schools that chose written consent, parents returned a consent form for their child to participate. Prior to administering the survey, staff informed students that survey participation was voluntary and anonymous and survey completion was considered an indication of assent.

Indoor Tanning

The NJYTS began incorporating self-reported indoor tanning behavior questions in 2012, prior to the 2013 ban. Students were asked, “How many times in the last 12 months have you used a tanning bed or booth with tanning lamps?” Response options ranged from “0 times” to “40 or more times.” Indoor tanning in the past year was defined as indicating the use of indoor tanning at least 1 time. In 2016 and 2018, students indicated “where you used tanning beds or booths in the last 12 months,” with responses including “at a tanning salon,” “in my home,” “in someone else’s home,” and “at a gym or health club.” Location data from 2016 and 2018 were combined to allow for stratification of location prevalence by age.

Statistical Analysis

Analyses, conducted with SAS, version 9 (SAS Institute Inc), accounted for the complex sampling design and weighting to adjust for nonresponse and the varying probabilities of selection to produce representative prevalence estimates. Weighted sample prevalence rates are calculated as predictive marginals from multivariable logistic regression models, adjusting for covariates, and stratified by sex, race/ethnicity, and age. Multivariable logistic regression analyses with weights and covariates were used to compare the odds of using indoor tanning by survey year. Pairwise deletion was used for missing data.

Results

The overall prevalence of indoor tanning in the past year was 8.5% (95% CI, 5.9%-11.1%) in 2012, which significantly decreased to 4.6% (95% CI, 3.7%-5.5%) in 2018 (adjusted odds ratio, [AOR], 0.50; 95% CI, 0.36-0.70; P < .001; Table 1). The prevalence of indoor tanning decreased significantly from 11.2% (95% CI, 7.0%-15.5%) in 2012 to 4.5% (95% CI, 3.3%-5.6%) in 2018 among all female students (AOR, 0.35; 95% CI, 0.22-0.54; P < .001) and decreased from 5.7% (95% CI, 4.1%-7.4) in 2012 to 4.7% (95% CI, 3.5%-6.0%) in 2018 among all male students (AOR, 0.80; 95% CI, 0.53-1.20; P = .02). For female students, the prevalence of indoor tanning decreased among those younger than 17 years from 8.1% (95% CI, 4.4%-11.9%) in 2012 to 3.6% (95% CI, 2.3%-5.0%) in 2018 (AOR, 0.41; 95% CI, 0.23-0.75; P = .03), as well as among those 17 years or older from 19.3% (95% CI, 11.7%-27.0%) in 2012 to 6.5% (95% CI, 4.7%-8.2%) in 2018 (AOR, 0.28; 95% CI, 0.18-0.44; P < .001). For male students, the prevalence decreased only among those younger than 17 years from 5.2% (95% CI, 3.5%-7.0%) in 2012 to 3.7% (95% CI, 2.3%-5.1%) in 2018 (AOR, 0.68; 95% CI, 0.41-1.14; P = .02). The prevalence of indoor tanning decreased significantly from 10.3% (95% CI, 6.6%-14.1%) in 2012 to 4.0% (95% CI, 3.0%-5.0%) among non-Hispanic White students (AOR, 0.36; 95% CI, 0.23-0.56; P < .001) but not among students identifying as Hispanic or those reporting other race/ethnicity. Tanning prevalence among students younger than 17 years (ie, younger than the legal tanning age) was 48% lower in 2018 compared with 2012 (adjusted odds ratio, 0.52; 95% CI, 0.33-0.81; P = .002).

Table 1. Weighted Prevalence of Indoor Tanning in Past Year Among New Jersey High School Students^a.

Variable	Sample size, No.	2012		2014		2016		2018		2018 [Reference: 2012]b
		No.c	% (95% CI)d	No.c	% (95% CI)d	No.c	% (95% CI)d	No.c	% (95% CI)d	AOR (95% CI)	P valuee
Overall	12 659	145	8.5 (5.9-11.1)	311	8.9 (6.8-11.1)	198	5.6 (4.0-7.3)	192	4.6 (3.7-5.5)	0.50 (0.36-0.70)	<.001
Sex
Female	6499	93	11.2 (7.0-15.5)	164	9.2 (6.6-11.8)	87	4.7 (3.3-6.2)	92	4.5 (3.3-5.6)	0.35 (0.22-0.54)	<.001
Male	6160	52	5.7 (4.1-7.4)	147	8.7 (6.4-10.9)	111	6.5 (4.1-9.0)	100	4.7 (3.5-6.0)	0.80 (0.53-1.20)	.02
Students <17 y
Female	4395	51	8.1 (4.4-11.9)	79	6.1 (3.7-8.5)	43	3.4 (2.3-4.5)	44	3.6 (2.3-5.0)	0.41 (0.23-0.75)	.03
Male	4024	35	5.2 (3.5-7.0)	85	7.7 (5.1-10.3)	65	5.7 (3.4-7.9)	47	3.7 (2.3-5.1)	0.68 (0.41-1.14)	.02
Both sexes	8419	86	6.7 (4.2-9.2)	164	6.9 (4.8-9.0)	108	4.5 (3.1-5.9)	91	3.7 (2.7-4.6)	0.52 (0.33-0.81)	.002
Students ≥17 y
Female	2104	42	19.3 (11.7-27.0)	85	16.4 (12.1-20.8)	44	7.9 (4.7-11.1)	48	6.5 (4.7-8.2)	0.28 (0.18-0.44)	<.001
Male	2136	17	6.9 (3.5-10.4)	62	10.8 (8.5-13.1)	46	8.5 (4.3-12.8)	53	7.1 (5.0-9.1)	1.02 (0.57-1.83)	.28
Both sexes	4240	59	12.8 (8.1-17.5)	147	13.5 (10.8-16.2)	90	8.2 (5.1-11.3)	101	6.8 (5.4-8.2)	0.49 (0.33-0.74)	<.001
Race/ethnicity
Hispanic	3748	37	9.1 (5.4-12.9)	89	9.4 (6.5-12.3)	78	7.9 (5.0-10.8)	87	6.7 (4.6-8.8)	0.71 (0.42-1.21)	.14
Non-Hispanic White	5676	90	10.3 (6.6-14.1)	162	9.9 (7.4-12.3)	76	4.9 (3.4-6.5)	67	4.0 (3.0-5.0)	0.36 (0.23-0.56)	<.001
Other	3235	18	4.5 (2.5-6.4)	60	6.9 (4.1-9.7)	44	5.1 (2.6-7.6)	38	3.9 (2.3-5.5)	0.85 (0.45-1.61)	.15

Abbreviation: AOR, adjusted odds ratio.

^aIndoor tanning was defined as using a tanning booth or bed with tanning lamps 1 or more times in the past year.

^bCompares 2018 tanning prevalence with 2012, the year prior to the tanning ban.

^cAll numbers in the table are unweighted.

^dWeighted prevalence with race/ethnicity, sex, or age included as model covariates.

^eUsing Satterthwaite-adjusted F tests from each multivariable regression analysis.

Students younger than 17 years reported similar prevalence rates for salon tanning (1.5%; 95% CI, 1.1%-1.9%) and private residence tanning (ie, “in my home” or “in someone else’s home”) (1.5%; 95% CI, 1.0%-1.9%) (Table 2). Among students 17 years or older, tanning in salons was more prevalent (3.4%; 95% CI, 2.7%-4.1%) than in private residences (2.1%; 95% CI, 1.2%-2.9%). Indoor tanning at a gym was most prevalent among students 17 years or older (1.1%; 95% CI, 0.4%-1.7%).

Table 2. Weighted Prevalence of Indoor Tanning Location in Past Year Among New Jersey High School Students^a.

Tanning location	Students <17 y		Students ≥17 y
	No.b	% (95% CI)c	No.b	% (95% CI)c
Salon	75	1.5 (1.1-1.9)	85	3.4 (2.7-4.1)
Homed	70	1.5 (1.0-1.9)	57	2.1 (1.2-2.9)
Gym	12	0.3 (0.1-0.4)	31	1.1 (0.4-1.7)
Othere	39	0.8 (0.6-1.1)	34	1.3 (0.9-1.7)

^aIndoor tanning was defined as using a tanning booth or bed with tanning lamps 1 or more times in the past year.

^bAll numbers in the table are unweighted.

^cWeighted prevalence with race/ethnicity and sex as model covariates.

^dResponse options of “in my home” and “in someone else’s home” were combined.

^eResponse options of “in an apartment complex,” “at a beauty shop or salon,” and “somewhere else” were combined.

Discussion

A previous study reported a nonsignificant change in the prevalence of indoor tanning among New Jersey youths in the year after a 2013 state ban on indoor tanning among youths younger than 17 years.⁶ This study shows that, 5 years later, the odds of reporting tanning in 2018 were 48% lower compared with 2012 among all students younger than 17 years. Our longitudinal, representative state health surveillance data provide among the strongest evidence to date of the benefit of indoor tanning bans and suggests that their intended outcome may not be observed until laws have been in place for some time. The ban on youths younger than 17 years allowed us to explore the association between the ban and the prevalence of tanning among older students. Among female students 17 years or older, the prevalence of indoor tanning was 72% lower in 2018 compared with 2012. These data suggest that age restrictions intended to delay the initiation of indoor tanning may have a spillover effect in reducing rates among older youths.

Despite the ban prohibiting minors younger than 17 years from using tanning salons, approximately half of students in this age group who reported tanning in the past year used a tanning bed at a salon location. To our knowledge, our study is the first to capture the location of underage tanning and demonstrates the need for increased enforcement to ensure tanning salon compliance with restrictions. Tanning in private residences was reported by more than half of students younger than 17 years who reported tanning in the past year. Nonsalon use is associated with more frequent, high-risk tanning among adults,¹⁰ highlighting the need for research to understand factors associated with nonsalon tanning bed use among youths. The World Health Organization recommends that policy makers prohibit unsupervised tanning given the concomitant regulatory challenges.¹ Finally, the largely unchanged tanning prevalence rates after the ban among male students older than 17 years and those identifying as Hispanic or other race/ethnicity is consistent with recent national data.^3,4,11 There appears to be a shifting landscape of youth tanning and a need to expand indoor tanning prevention efforts to high-risk groups, such as sexual minority boys.¹²

Limitations

This study has some limitations, including the use of self-reported data subject to recall or self-report bias and a lack of data on youths who do not attend public school. The portion of White students in New Jersey high schools decreased by approximately 5% from 2012 to 2018, which has implications for overall prevalence estimates at each survey. However, we controlled for race/ethnicity in our model comparing 2012 with 2018 tanning rates and also provide specific estimates of tanning by race/ethnicity.

Conclusions

A 2020 economic analysis estimated that an indoor tanning ban among individuals younger than 18 years implemented across North America, assuming it was indeed effective in nearly eliminating minors’ indoor tanning, would prevent 25 000 melanoma deaths and save nearly $9 billion across the lifetime of individuals currently between the ages of 12 and 35 years.¹³ This study adds novel evidence from state-specific data that a ban on indoor tanning among youths may produce the intended reductions in indoor tanning. Although state legislators should be lauded for existing indoor tanning restrictions in several states, most states have not prohibited tanning for minors younger than 18 years, and federal regulatory effects have stalled. This study supports the value of pursuing new regulatory efforts in states currently without them and broadening existing restrictions to extend beyond indoor tanning salons to cover unsupervised nonsalon locations, such as large gym chains or hair and nail salons. Although likely challenging, policy efforts could also be directed toward limiting the production or sale of home tanning devices (eg, requiring a physician’s prescription).