From an evolutionary perspective, fair skin is seen as a selection advantage in regions with low solar intensity by preventing vitamin D deficiency, thus, increasing longevity and fertility as well as preventing autoimmune diseases and cancer development [1
]. Exposure to natural and artificial ultraviolet radiation (UVR) initiates the physiological process of skin tanning, which is associated with epidermal cells damage [3
]. A growing body of scientific evidence argues for the carcinogenic properties of indoor exposure to ultraviolet radiation [4
]. However, the popularity of indoor tanning as recreational pastimes is hardly on the wane in Western countries with mainly fair-skinned populations [10
]. Wehner et al.
estimated that over 400,000 non-melanoma and 10,000 melanoma cases each year are attributable to sunbed use in the U.S., Europe, and Australia [13
Worldwide, several countries implemented more stringent policies and programs to mitigate sunbed use, increase customer stewardship, raise awareness, and provoke action by government and industry [14
]. Recently, the number of countries restricting underage youth access to indoor tanning facilities increased from two countries (Brazil, France) in 2003 to eleven countries in 2011, now including Austria, Belgium, Germany, Portugal, Spain, and the U.K. in Europe, and parts of Canada, the U.S, and Australia [15
Limiting UVR exposure and increasing sun protection could reduce skin cancer incidence rates and associated healthcare costs [16
]. Awareness campaigns as an important tool for skin cancer prevention influence tanning attitudes and educate the public about appropriate photo-protection [18
]. The effect of these campaigns in diminishing recreational sunbed use, potentially due to vast media and public policy attention, seems encouraging [20
Based on the broader concept of Public Health, the umbrella term Public (Skin) Health refers to skin health-related activities aimed at lowering incidence rates of photo-induced skin manifestations [22
]. By encouraging individuals to adopt skin health-sensitive behaviors, Public (Skin) Health has practical implications for community-based skin health promotion. Focusing on potential risks accompanied with recreational exposure to solar and artificial UVR, the respective research activities define risk groups as target for according educative campaigns and public policies. In this context, Bock et al.
identified a need for studies examining behavioral patterns related to sunbed use on a national level to develop successful skin health promotion strategies [21
Similar to other countries, Austrian melanoma incidence rates (1983: 4.8; 2012: 12.3/100,000) and mortality rates (1983: 1.9, 2012: 2.2/100,000) have constantly increased over the last decades [28
]. Despite these rising skin cancer rates, little is known about the national prevalence of sunbed use and the associated skin health burden in Austria as a potential lifestyle factor influencing the individual skin cancer risk. To close this knowledge gap, we conducted the population-based UV Skin Risk survey to assess prevailing intentional tanning behaviors including sunbed exposure as well as sunless tanning product use. Thus, this article specifically analyzed socio-demographic characteristics, knowledge, and attitudes of sunbed users in comparison to non-users.
In total, 1500 study subjects (50.5% females, 18–74 years, mean 44.7, SD 15.4 years) participated in this questionnaire survey. Table 1
presents the overall distribution of seasonal prevalence of sunbed use during winter and summer months. As expected, sunbed use was statistically significantly more common and frequent during winter (p
shows basic characteristics of the study population in relation to sunbed use. Overall one-year prevalence of sunbed use was 8.9% (95% CI 7.5%–10.4%). We found a slightly higher prevalence in females (9.2%, 95% CI 7.3%–11.2%) compared to males (8.6%, 95% CI 6.7%–10.6%), but this gender difference did not reach statistical significance. Prevalences were highest in the youngest age group (18–29 years, 13.4% (95% CI 9.5%–17.7%), with a statistically significant linear decrease with age: 30–39 years: 11.9% (7.9%–15.8%), 40–49 years: 9.1% (6.2%–12.4%), 50-59 years: 7.3% (4.2%–10.8%), and 60–74 years: 3.2% (1.3%–5.4%), respectively (p
< 0.001). Also, participants living in the East of Austria were more likely to be among the group of sunbed users (p
shows prevalent sunbed use according to individual skin health characteristics and habits. Compared to non-users, sunbed users were more likely to smoke, have darker skin pigmentation (skin type III+), low connectedness to nature (all p
< 0.05), outdoor sun exposure, more motives to tan, and also use of UV-free tanning products (all p
Item-based specifications showed that besides more consumption of UV-free tanning products in general, sunbed users also reported more use of temporary bronzers and tanning accelerators/tan enhancers (Table 4
). However, non-recent sunbed users were more likely to consume nutritional supplements as endogenous tanning agents (p
< 0.04). Furthermore, skin health information by healthcare providers was more often gathered among non-recent sunbed users (p
< 0.012), whereas indoor tanning studios as information source was more common among users (p
< 0.001). Knowledge on risk of sunbed use was higher among non-users (p
< 0.001), while users were more aware of skin aging due to sun exposure (p
< 0.028). Agreements with statements regarding motives to tan were consistently higher in the sunbed user group (all p
< 0.05), except for concerns about acne (p
= n.s.). Regarding sun protection habits, sunbed users were less likely to seek shade and wear a hat or sun-protective garments (all p
depicts the results of the adjusted binary regression model (Hosmer-Lemeshow-Test: chi² = 2.965, p
= 0.937). Nagelkerke’s R² suggested that the model explains 13% of the variation in the outcome and that the model was a good fit to the data (p
> 0.05). The overall model predictive ability was about 91%. Factors predicting sunbed use were age, by trend decreasing with older age (for 60–74 year olds: OR = 0.30, 95% CI 0.14–0.62, p
< 0.001), place of living by geographic regions of Austria (East vs.
South, OR = 1.58, 95% CI 1.04–2.41, p
< 0.032), smoking (non-smoking vs.
current smoking, OR = 1.87, 95% CI 1.22–2.87, p
< 0.004), skin type (skin type I vs.
darker skin, by trend increasing with darker skin, p
< 0.026), more sun exposure (OR = 1.69, 95% CI 1.13–2.51, p
< 0.01), more motives to tan (OR = 2.10, 95% CI 1.40–3.15, p
< 0.001), use of UV-free tanning products (OR = 1.82, 95% CI 1.11–2.98, p
So far, little is known on potential lifestyle-associated explanations for rising skin cancer incidence and mortality rates in Austria. A considerable amount of studies have investigated prevalence of sunbed use, characteristics, attitudes, and knowledge of sunbed users in other European countries [8
]. To close this knowledge gap, the present population-based study assessed prevalent general and seasonal sunbed use as well as skin health knowledge, attitudes, and habits among Austrian citizens. The practical and theoretical implications of these findings are discussed from a Public (Skin) Health perspective.
In a recently published meta-analysis including U.S., European, and Australian studies, prevalence of past-year sunbed use was 14% for adults, 18% for adolescents, and as high as 43% for university students [13
]. In our sample, past-year sunbed use prevalence was 9% in general and 13% among the youngest age group (18–29 years). However, varying prevalence rates of ever sunbed use were reported across Europe. Schneider et al.
identified as many as 47% ever and 21% current users among German adults [40
]. These rates were higher compared to French data, where 13% of the general population reported having tanned indoors at least once in their lifetime and 4% in the past year, with higher rates (10%) among the younger population (20–25 years) [39
To assess predictors of sunbed use, we employed an adjusted regression model showing both an adequate goodness-of-fit to the data and strong predictive power. Sunbed users were typically younger, lived in the Eastern region of Austria, smoked cigarettes, used UV-free tanning products, and reported darker skin, outdoor sun exposure, and more motives to tan. These socio-economic profiles of recent sunbed users have not been addressed in national skin health awareness campaigns in Austria so far. Approaches sensitive to recipients’ socio-economic background and educational level might more successfully increase general skin cancer risk awareness and also reduce sunbed use.
Sunbed exposure is a risk factor for melanoma even among persons who never experienced sunburns from indoor or outdoor UVR contact [41
]. Although a tan does not protect against sunburn, individuals often tan indoors before planned sun exposure, presumably to prevent sunburns [10
]. Alternatively, a wide range of UV-free tanning products are commercially available and commonly used to boost the tanning process. Their consumption is associated with more frequent use and higher risk for tanning addiction [36
We found a respective prevalence of about 11% and statistically significant higher use of UV-free tanning products among sunbed users compared to non-users. Also, their self-reported consumption predicted sunbed use in our regression model. To our knowledge, this is the first study evaluating the prevailing use of these products among Austrian citizens. This finding is of relevance for skin health counseling and could be further integrated in future implementation of labeling requirements for these products, e.g., showing skin health messages. Day et al.
differentiated between three distinct types of tanning behavior: outdoor tanners, fake tanners, and tan avoiders [35
]. This differentiation was beyond the scope of our study, as we aimed at providing so far lacking baseline data on recreational skin health behavior among the Austrian population. However, evaluating personal tanning preferences and their interaction with long-term skin health outcomes may reveal novel Public (Skin) Health strategies.
Recently, we reported on geographic differences in melanoma incidence and mortality trends in Austria [29
]. In addition to this, the current analysis revealed that prevalence of sunbed use among Austria citizens followed an East-West gradient. This regional gradient has already been shown for various lifestyle-associated health determinants such as cardiovascular diseases, diabetes mellitus, and obesity [42
]. Urban-rural influences on socio-economic status and recreational habits might explain this well-established association. However, a South-North gradient with higher prevalence of sunbed exposure in the North compared to the South was found in several European countries [34
]. This so far unknown result on geographical associations with sun exposure habits in Austria could motivate future hypothesis-driven evaluations to identify novel strategies and risk groups for targeted awareness campaigns.
Ezzedine et al.
found a correlation between indoor and outdoor UVR exposure habits and lifestyle habits [34
]. In agreement with Grange et al.
, our analysis showed that sunbed users were less likely to use sun-protective measures such as hats or clothes than non-users [11
]. Further, we observed higher sunbed use prevalence in younger study subjects. Accordingly, several publications identified the typical sunbed user as being female, of younger age and—beyond this—having a higher socio-professional category and a fairer phototype [11
]. Nevertheless, Schneider et al.
found higher prevalence rates among individuals with medium education, whereas age, partnership status, and nationality were not associated with sunbed use [40
]. Exposure to artificial UVR increases the risk of skin cancer, irrespective of age of initial indoor tanning [7
]. Boniol and colleagues reported that melanoma risk was higher if first exposure to indoor tanning equipment occurred before the age of 35 years [8
]. Initiation of sunbed use at young adult age suggests the need for targeted interventions. In particular, adolescents should be made aware of the long-term skin health risks of sunbed use when used for short-term cosmetic tanning purposes [15
Our analysis also found that sunbed use was associated with smoking habits and outdoor sun exposure. This is in line with vast scientific evidence, showing that sunbed use is correlated with risky lifestyle habits including smoking cigarettes, drinking alcohol, eating unhealthy food, and sunbathing and thus, accumulating risk factors for skin health [11
]. In this context, Gunn et al.
verified that smoking and sunbed use are strongly associated with photoaging and wrinkling in both genders, while a reasonable lifestyle preserves youthful looks on the long run [47
Appearance- and emotion-based motives to tan influence both solar and indoor tanning habits [48
]. Although sunbed users were shown to know that sun exposure reduces the skin’s regenerative capacity, they consider that a tan makes a person look more attractive and protects the skin [11
]. In our survey, sunbed users compared to non-users were more aware of the risk of photo-induced skin aging, but they perceived a lower skin health risk in connection with sunbed use. Likewise, agreements with statements regarding motives to tan were consistently higher in the sunbed user group. This observation suggests that research entangling motives of indoor tanners could provide valuable input for larger-scale skin cancer prevention policies and monitoring programs [7
Knowledge, attitudes, and intentions of individuals are vital targets for public education programs. However, there is still a lack of information among consumers regarding the safety of sunbeds use [46
]. Schneider et al.
reported alarmingly poor quality of services provided by tanning parlors [40
]. In our study, non-recent sunbed users more often received skin health information by healthcare providers, whereas users more often mentioned indoor tanning studios as a source of information. Given the known publishing source bias of information material, these finding suggests the need for standardizing the content of skin health educative information [23
Sunbed users experience positive emotions and relaxation during frequent and intentional exposure to artificial UVR, potentially leading to tanning addiction, also referred to as tanorexia [49
]. This concept of tanorexia is supported by the observation that the annual exposure remained constant over time among German sunbed users [21
]. Contrarily, Guy et al.
reported a recent decrease in sunbed use among U.S. adults [20
]. This decline might reflect increased public awareness of the carcinogenic potential sunbed use due to respective skin health campaigns and implementation of laws restricting sunbed access among minors [14
]. Characteristics associated with sunbed use cessation include greater awareness of skin cancer risk and higher educational level [21
]. Evidence suggests that positive attitudes towards tanning are a key barrier to adopt measures towards preventing skin health hazards [21
]. In addition to tackling these pro-tanning societal framing and motives to tan, awareness campaigns focusing on sunbed use cessation should also account for gender—and age—specific requirements.
Besides the aforementioned Public (Skin) Health aspects of sunbed use, there is evidence of detrimental risks of UVR exposure avoidance contributing to a higher risk for all-cause mortality [50
]. These photo-induced benefits are probably due to the still controversially discussed Vitamin D-associated health effects [52
]. Nevertheless, according to Woo et al.
, Vitamin D supplementation is a feasible means for adequate Vitamin D supply while avoiding sunbed exposure as a the risk factor for skin cancer and skin aging [54
The present survey is the first empirical study that collected data from a large, community-based sample representing the Austrian census data [26
]. Amount of participants (n
= 1500) was equal to comparable European studies such as the French EDIFICE Melanoma survey (n
= 1502), although France has a far larger population size [11
]. Public (Skin) Health research has wide implications for clinical practice and community skin health promotion. Closing the knowledge gap regarding sunbed use in Austria, the current study theoretically advances the understanding of prevailing skin health habits in the general Austrian population.
However, the findings of this study are subject to several limitations, mainly related to the cross-sectional design. Thus, the survey data do not allow for causal relations of individual characteristics and indoor tanning behaviors. We used stratified random sampling on the basis of the official national telephone directory list to ensure representativeness of the study population. However, as in every telephone-based survey, potential study participants needed to have a valid telephone number when contacted, thus introducing selection bias and limiting generalizability of the study results to the general adult population. Also, we assessed self-reported data, which might be subject to non-response, reporting, and recall bias. Nevertheless, recall bias regarding UVR exposure seems to be small and self-reported data on phenotypic characteristics, sunburn history, and sun protection behavior were shown to be reproducible [56
]. We assume that these data represent a trustworthy picture of actual skin health habits executed by the Austrian population. Although our data on recent sunbed users were based on the respective group of only about 9% of study participants, they were comparable with sunbed use prevalence reported in other studies, e.g., Grange et al.
]. Thus, we also used the bootstrapping method based on 1000 bootstrap samples to additionally provide prevalence estimates for sunbed use in Austria. The herein presented data may serve as a baseline for tracking progress achieved by future Public (Skin) Health campaigns, as suggested by Davis et al.
]. Since September 2010, Austria has implemented a legislation to ban indoor tanning bed use for minors nationwide [59
]. Further research could analyze the impact of this ban on skin health-related longitudinal trends and behavior changes in the general population.