Double exposure: natural and artificial ultraviolet radiation exposure in beachgoers. (Original Article).

Background: Although the beach is a high-risk environment for ultraviolet light exposure and subsequent skin damage, little is known about beachgoer tanning habits outside the beach setting. Our purpose was to evaluate indoor tanning and additional, nonbeach sunlight exposure in a beachgoing population.

Methods: We conducted an epidemiologic survey.

Results: There was more use of indoor tanning salons among sunbathing beachgoers who applied little or no skin protection from the sun (50.8% [31 of 61 respondents]) compared with nonsunbathing beachgoers (22.7% [5 of 22 respondents]). In addition to increased use of tanning salons, we observed that poorly protected sunbathers tanned at locations other than the beach on a regular basis (50.8% [31 of 61 respondents]) more than nonsunbathers did (9.1% [2 of 22 respondents]).

Conclusion: Beachgoing sunbathers often used both natural sunlight and tanning beds, subjecting themselves to two forms of ultraviolet radiation exposure.

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Every year, more than 1 million new cases of skin cancer are diagnosed in the United States. Current evidence suggests that acute and chronic exposure to ultraviolet (UV) radiation is a major risk factor for the development of skin cancer, regardless of whether it is emitted naturally from the sun or artificially from sources such as indoor tanning beds. (1) The public has been going to the beach and other recreation areas to sunbathe for many years, dating from the emergent popularity of tan skin in the early 1920s. (2) More recently, the advent and subsequent increasing popularity of indoor tanning salons have provided a widely available alternative source of UV exposure. Whereas previous research focused primarily on the attitudes and behaviors of beachgoers at the beach, (3-6) we investigated their indoor tanning habits in this study. We compared sunbathing and nonsunbathing beach-goers with regard to their indoor (ie, tanning salon) and outdoor (ie, sunlight) tanning habits.

Materials and Methods

With Institutional Review Board approval, the investigators collected data at popular public beaches on Galveston Island, TX, with the use of a questionnaire (Table 1). The data were collected for approximately 2 h/d between noon and 6:00 PM for a 6-week period during the summer of 2001. Individuals who were at least 18 years old and had Fitzpatrick skin Types I through IV (increased risk of skin cancer) were asked if they would like to participate in this research project. Ninety-nine people completed the survey about sun exposure, skin protection, and tanning habits. The following topics were included in the questionnaire:

* Self-assessment of Fitzpatrick skin type

* Intent with regard to their beachgoing (eg, tanning, leisure, sport)

* Current use of sunscreen 

* Current use of other skin protection items (ie, hats, umbrella, clothing)

* Tanning salon use and other types of tanning activities

* Survey of additional health risk behaviors

* Body Dysmorphic Disorder Questionnaire (Dermatology Version) and Clinician-administered Diagnostic Module (7)

Beachgoers were classified into one of three groups: sunbathers with one or no means of UV protection, sunbathers with two or more means of UV protection, and nonsunbathers (individuals who were not at the beach to obtain a tan). Indoor tanning salon frequency was classified into one of three groups: no salon use, occasional salon use (<4 sessions/mo), or frequent salon use ([less than or equal to]4 sessions/mo). Data were analyzed by performing the Pearson [X.sup.2] test.

Results

The 99 people who participated comprised 32 men and 67 women ranging from 18 to 61 years of age (mean age, 29.0 yr). The association between beachgoers' UV exposure or skin protection level and their indoor tanning salon use is summarized in Table 2. Beachgoers who used less sun protection tended to use indoor tanning salons more often (P = 0.047). Of the sunbathers with one or no means of sun protection, 50.8% (31 of 61 respondents) reported using tanning salons (22.9% [14 of 61 respondents] occasional use, 27.9% (17 of 61 respondents] frequent use). Of the sunbathers with two or more means of sun protection, 43.7% (7 of 16 respondents) reported using salons (31.2% [5 of 16 respondents] occasional, 12.5% [2 of 16 respondents] frequent], compared with 22.7% (5 of 22 respondents) of nonsunbathers that reported the use of tanning salons (all of which were just occasional users). Subjects were also asked whether they tan elsewhere on a regular basis (Table 3). Beachgoers using less sun protection tended to obta in additional natural UV light exposure elsewhere (P = 0.003). Of the sunbathers with less than two means of sun protection, 50.8% (31 of 61 respondents) tanned elsewhere on a regular basis, whereas 37.5% (6 of 16 respondents) of more protected sunbathers and 9.1% (2 of 22 respondents) of nonsunbathers reported doing so. Consistent. with previous psychological literature, in contrast to nonsunbathers, sunbathers in this survey were found to be younger, to have tattoos and body piercing, to drink alcohol and then drive a car, to use illegal drugs, and to fail to wear a seatbelt while driving in a car. However, the differences were not statistically significant (Table 4). No individuals with possible body dysmorphic disorder were identified on the basis of the Body Dysmorphic Disorder Questionnaire (Dermatology Version). (7)

Discussion

Although many factors play a role in the development of skin cancer, UV radiation exposure is known to be a common risk. It is recognized that the molecular skin changes that occur with exposure to solar UV radiation also occur in skin that has been UV-irradiated during indoor tanning salon use. (1) These molecular changes have been demonstrated to precede skin cancer. (8) A recent epidemiologic study showed that tanning device use increased the risk of nonmelanorna skin cancer by a factor of 2.5. (9)

It was hypothesized that a subset of beachgoers were at higher risk for sustaining dual UV radiation exposure from indoor and outdoor sources. Among beachgoers, sunbathers were more likely than nonsunbathers to use tanning salons and to use them with greater frequency. Beachgoing sunbathers who took few or no precautions against solar exposure reported more frequent use of tanning salons than other sunbathers, who took two or more measures to protect themselves from the sun. This tan-seeking behavior held true when these two groups of sunbathers were asked whether they tanned at sites other than the beach and indoor salons. Once again, the least-protected sunbathers reported the most supplemental outdoor tanning.

Preoccupation with body image as a motivation for tanning to change physical appearance could not be identified in these individuals on the basis of a recently developed instrument, the Body Dysmorphic Disorder Questionnaire (Dermatology Version). (7) This questionnaire was developed for dermatology patients seeking clinical care, however, and not as an epidemiologic research tool for nonclinical settings. The motivation behind tanning behavior remains poorly understood but is important if successful interventions are to be developed.

Texas sunbathers, like sunbathers studied in California, are prone to engage in other behaviors that may be harmful to their health. (4) Risk takers are likely to ignore warnings about skin cancer (4) or other health-compromising behaviors, even though the spectrum of risk may be understood. Until the utility of tanning and other risky behaviors is diminished, such behavior is likely to continue, despite educational efforts to the contrary. (10) Regulatory barriers to indoor tanning bed use, such as prohibiting use by minors and requiring formal informed consent of adults, have been suggested. (9)

Double exposure to UV radiation from different sources increases cumulative UV radiation exposure in a subset of beachgoers. We hope that as more is learned about this type of multicentric UV light exposure behavior, health care educators and providers can better identify this high-risk group and provide targeted educational and behavioral interventions to decrease people's future risk for, and to facilitate early detection of, skin cancer.

Table 1

Survey


Group [circle 1]: Burned Tanned Neither (ie, protccted)
Age:
Medicines:
Intentions [circle 1): Tan Leisure Other
How often do you come to the beach?
Main reason for coming to the beach?
Ever go to tanning salons?
  How often and how long?
Tan anywhere else on a regular basis?
  How often and how long?
How often do you get a sunburn?
Fitzpatrick skin type:
Currently using sunscreen?
  What SPF level?
Using baby oil or suntan oil?
How long have you been at the beach today?
How many times did you reapply sunscreen?
Have you been in the water today?
  Reapply sunscreen after coming out?
Use any other skin protection items (ic, hats, umbrella, clothing)?
Tattoos?
  How many?
Body piercing?
  How many?
Use anabolic steroids?
Cosmetic surgical procedures?
Ever not wear seatbelt?
  Why?
Do you wear a helmet while riding a motorcycle?
  Why?
Ever drink and drive?
Use illegal drugs?

Table 2

Beachgoer use of indoor tanning salons (a)

                                 Indoor tanning salon use


Category                             0         <4/mo

Beachgoer ultraviolet radiation
    protection
  One or less                    30 (49.2%)  14 (22.9%)
  Two or more                     9 (56.3%)   5 (31.2%)
Nonsunbathing beachgoer          17 (77.3%)   5 (22.7%)
  Total                          56          24

                                    Indoor tanning salon use

                                 [greater than or equal
Category                               to]4/mo        Total

Beachgoer ultraviolet radiation
    protection
  One or less                        17 (27.9%)        61
  Two or more                         2 (12.5%)        16
Nonsunbathing beachgoer               0 (0.0%)         22
  Total                              19                99

(a) [chi square] = 9.6;

P = 0.047.

Table 3

Nonbeach outdoor tanning by beachgoers (a)

                              Nonbeach outdoor tanning

Category                     No         Yes       Total
Beachgoer ultraviolet
    rdiation protection
  One or less            30 (49.2%)  31 (50.8%)     61
  Two or more            10 (62.5%)   6 (37.5%)     16
Nonsunbathing beachgoer  20 (90.9%)   2 (9.1%)      22
  Total                  60          39             99

(a) [chi square] = 11.8;

P = 0.003.

Table 4

Health risk behaviors involving beachgoers (a)

                                    Beachgoers with one
                                     or no means of UV
                                    protection (n = 61)

Mean age (yr)                           27.6
Females                                 43 (70.5%)
Has one or more tattoos                 22 (36.1%)
Has body piercing (excluding cars)      15 (24.6%)
Sometimes fails to wear seatbelt        15 (24.6%)
 when driving a car
Has ever drank alcohol and then         24 (39.3%)
 driven an automobile
Use of illegal drugs                    17 (27.9%)

                                    Beachgoers with two  Nonsunbating
                                    or more means of UV   Beachgoers
                                    protection (n = 16)    (n = 22)

Mean age (yr)                            27.6             31.5
Females                                  11 (68.8%)       10 (45.5%)
Has one or more tattoos                   5 (3 1.3%)       2 (9.1%)
Has body piercing (excluding cars)        5 (31.3%)        3 (13.6%)
Sometimes fails to wear seatbelt          7 (43.8%)        5 (22.7%)
 when driving a car
Has ever drank alcohol and then           5 (3 1.3%)       5 (22.7%)
 driven an automobile
Use of illegal drugs                      3 (18.8%)        2 (9.1%)



                                    P value

Mean age (yr)                        0.19
Females                              0.10
Has one or more tattoos              0.06
Has body piercing (excluding cars)   0.41
Sometimes fails to wear seatbelt     0.27
 when driving a car
Has ever drank alcohol and then      0.36
 driven an automobile
Use of illegal drugs                 0.18

(a) UV, ultraviolet.

Accepted November 5, 2002.

References

(1.) Whitmore SE, Morison WL, Potten CS, Chadwick C. Tanning salon exposure and molecular alterations. J Am Acad Dermatol 2001;44:775-780.

(2.) Lencek L, Bosker G. The Beach: The History of Paradise on Earth. New York, Penguin Books, 1998, p 203.

(3.) Arthey S, Clarke VA. Suntanning and sun protection: A review of the psychological literature. Soc Sci Med 1995;40:265-274.

(4.) Keesling B, Friedman HS. Psychosocial factors in sunbathing and sunscreen use. Health Psycho! 1987;6477-493.

(5.) McCarthy EM, Ethridge KP, Wagner RF Jr. Beach holiday sunburn: The sunscrccn paradox and gender differences. Cutis 1999;64:37-42.

(6.) Wright MW, Wright ST, Wagner RF. Mechanisms of sunscreen failure. J Am Acad Dermatol 2001;44:781-784.

(7.) Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001;27:457-462.

(8.) Wang SQ, Setlow R, Berwick M, Polsky D, Marghoob AA, Kopf A W, et al. Ultraviolet A and melanoma: A review. J Am Acad Dermatol 2001;44:837-846.

(9.) Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst 2002;94:224-226.

(10.) Feldman SR, Dempsey JR, Grummer S, Chen JG, Fleiseher AB. Implications of a utility model for ultraviolet exposure behavior. J Am Acad Dermatol 2001;45:718-722.

RELATED ARTICLE: Key Points

* Beachgoers who take few or no precautions to prevent injury from natural ultraviolet (UV) radiation are more likely than nonsunbathing beachgoers to use indoor tanning salons.

* Beachgoers who take few or no precautions to prevent injury from natural UV radiation are more likely than nonsunbathing beachgoers to seek nonbeach locations for additional exposure to natural UV radiation.

* Sunbathing beachgoers are at increased risk for skin cancers caused by natural and artificial UV radiation exposure, and efforts to decrease their exposure may decrease their risk for skin cancer.

* Periodic skin surveillance of sunbathing beachgoers for skin cancer is likely to decrease patient morbidity and mortality through early detection, diagnosis, and treatment.

From the Department of Dermatology and Office of Biostatistics, The University of Texas Medical Branch at Galveston, Galveston, TX.

Supported in part by a grant from the American Academy of Dermatology Minority Medical Student Mentorship Program (MAR), Schaumburg, IL, and the Department of Dermatology of the University of Texas Medical Branch at Galveston, Galveston, TX.

Presented in part at The University of Texas Medical Branch Medical Student Summer Research Program Poster Session, June 28, 2001, Galveston, TX; at the National Student Research Forum, April 26, 2002, Galveston, TX; and at the 60th annual meeting of the American Academy of Dermatology, February 23-26, 2002, New Orleans, LA.

Reprint requests to Richard F. Wagner, Jr., MD, Department of Dermatology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555-0783. Email: [e-mail]

Copyright [C] 2003 by The Southern Medical Association

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