NEJM Perspective: Indoor Tanning — Science, Behavior, and Policy

An estimated 1 million times per day, someone in the United States uses ultraviolet (UV) radiation for skin tanning. According to the indoor tanning industry, tanning beds are used by 30 million Americans, or about 10% of the US population, each year (www.theita.com/indoor). These users include minors, who often have ready access to tanning beds. In response to considerable grassroots and political opposition to indoor tanning, in late March the Food and Drug Administration (FDA) convened an advisory panel to review the safety of the procedure. The FDA is expected to announce a decision soon on whether and how to reclassify tanning lamps and possibly to address minors’ access to them.

The concern arises from increases in the incidence of melanoma and its related mortality. In the United States, the incidence of melanoma is increasing more rapidly than that of any other cancer. From 1992 through 2004, there was a particularly alarming trend in new melanoma diagnoses among girls and women between the ages of 15 and 39. Data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results registry show an estimated annual increase of 2.7% in this group. Researchers suspect that the increase results at least partially from the expanded use of tanning beds. The possibility that changes in diagnostic criteria may have contributed to the increased incidence is lessened by the fact that the trend is specific to a certain age range and sex. The incidence of thicker cutaneous melanomas (>1 mm) has also increased, and the incidence of regional and distant tumors has increased at an estimated annual rate of 9.2% — a change that could portend a surge in advanced melanomas in young women. Although substantial advances have been made in melanoma therapies, the risk of death from advanced disease remains high.

Abundant epidemiologic data have been examined to assess potential connections between indoor tanning and both melanoma and non-melanoma cutaneous cancers. According to a 2006 meta-analysis by the International Agency for Research on Cancer (IARC), among people who first used indoor tanning before 35 years of age, the relative risk of melanoma was 1.75 — a finding that prompted the World Health Organization to classify tanning beds as a group I carcinogen. Similarly, a recent case–control study in Minnesota showed an adjusted odds ratio of 1.74; the risk of melanoma increased as the number of years of tanning and hours of tanning sessions increased.

An even more dramatic association has been found between exposure to UV radiation and non-melanoma skin cancers. In the IARC study, history of any indoor tanning was associated with a relative risk of 2.25 for squamous-cell carcinoma. Although most of these lesions are successfully treated at an early stage, metastasis persistently occurs in a small minority of such lesions, at which point cure is rare. Although the overall rate of death from squamous-cell carcinoma is low, the high incidence of this form of cancer means that it accounts for 25 to 35% of skin-cancer–related deaths.

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