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Original Investigation |

International Prevalence of Indoor Tanning:  A Systematic Review and Meta-analysis

Mackenzie R. Wehner, MPhil1,2,3; Mary-Margaret Chren, MD1,4; Danielle Nameth, BA5; Aditi Choudhry, MD6; Matthew Gaskins, MPH3; Kevin T. Nead, MPhil2; W. John Boscardin, PhD7; Eleni Linos, MD, DrPH1
[+] Author Affiliations
1Department of Dermatology, University of California, San Francisco
2Stanford University School of Medicine, Stanford, California
3Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
4Department of Dermatology, San Francisco Veterans Affairs Medical Center, San Francisco, California
5University of California, Berkeley
6Department of Internal Medicine, John Muir Medical Center, Walnut Creek, California
7Department of Epidemiology and Biostatistics, University of California, San Francisco
JAMA Dermatol. 2014;150(4):390-400. doi:10.1001/jamadermatol.2013.6896.
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Importance  Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known.

Objective  To summarize the international prevalence of exposure to indoor tanning.

Data Sources  Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature.

Study Selection  Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included.

Data Extraction and Synthesis  Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma.

Main Outcomes and Measures  Ever and past-year exposure to indoor tanning.

Results  The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia.

Conclusions and Relevance  Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

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Figures

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Figure 1.
Study Selection Flow Diagram

This flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection.

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Figure 2.
Forest Plots of Primary Analyses: Ever Exposure in Adults

Ever exposure in adults. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.)

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Figure 3.
Forest Plots of Primary Analyses: Ever Exposure in University Students

Ever exposure in university students. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.)

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Figure 4.
Forest Plots of Primary Analyses: Ever Exposure in Adolescents

Ever exposure in adolescents. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.)

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Figure 5.
Forest Plots of Primary Analyses: Past-Year Exposure in Adults

Past-year exposure in adults. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.) CDC indicates Centers for Disease Control and Prevention; CER, Centre for Epidemiology and Research; NCI, National Cancer Institute; NSW, New South Wales.

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Figure 6.
Forest Plots of Primary Analyses: Past-Year Exposure in University Students

Past-year exposure in university students. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.)

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.
Forest Plots of Primary Analyses: Past-Year Exposure in Adolescents

Past-year exposure in adolescents. Plots show point prevalence (squares), 95% CIs (horizontal lines), summary prevalence and 95% CIs for each region and overall (diamonds, the width of which represents the 95% CIs), and summary prevalence estimate (dotted line). Records are listed by date of publication and then by date of data collection. (See eTable 1 in the Supplement for full citations and descriptions.) CDC indicates Centers for Disease Control and Prevention; CER, Centre for Epidemiology and Research; NCI, National Cancer Institute; NSW, New South Wales.

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