Abstract

Objective

To explore the motivations, experiences and views of female regular sunbed users aged 15–17 and consider the implications of legislation seeking to restrict sunbed use among the under-18s.

Design

Qualitative study of 12 focus groups.

Method

Participants were recruited opportunistically through community and social networks, around tanning salons, leisure and educational facilities in six English towns and cities. Interviews were transcribed, a thematic framework generated and a validation exercise conducted.

Setting

Urban communities in England.

Participants

Sixty-nine female regular sunbed users aged 15–18.

Results

Respondents consistently valued tanning and attached considerable personal and social importance to it. They showed an awareness of the risks of sunbed use that they accepted, downplayed and/or ignored. While experiences and responses to supervision varied, respondents were resistant to any measures that restricted their use and expressed willingness to find ways around such restrictions.

Conclusions

The sunbed users interviewed in this study attached considerable significance to tanning, rationalized the risks of sunbed use and expressed their determination to continue using them. The impact of legislation to limit sunbed access may be weakened without requirements to ensure supervision of salons.

Introduction

With the increasing global incidence of malignant melanoma and recognition of ultraviolet radiation (UV) as a carcinogen,1 there has been growing attention given to preventive measures, including attempts to reduce sunburn and exposure to both natural and artificial UV radiation sources. Sunbed use before the age of 35 increases the risk of developing malignant melanoma by 59%.2 Worryingly, almost a third of UK patients diagnosed with malignant melanoma are <55 years old and it is now the second most common cancer in those aged 15–34.3

The Cancer Reform Strategy for England4 set out to establish the number and distribution of sunbeds, and the scale of their use by minors. Subsequently, the National Cancer Action Team, supported by the Department of Health, commissioned Cancer Research UK to undertake two quantitative studies and one qualitative study to explore the use of sunbeds among minors. The two quantitative studies reported that 6% of 11–17-year-olds across England had used a sunbed with marked variation by age and sex. For example, 11.2% of 15–17-year-olds had used a sunbed compared with 1.8% of 11–14-year-olds and 8.6% of girls compared with 3.5% of boys. There was also marked geographical variation with the highest rates in Liverpool and Sunderland, where half of 15–17-year-old girls used sunbeds, 40% of these on a weekly basis. Nearly a quarter of users reported that they had not been supervised, and a quarter that they had used a sunbed in their own or a friend's home.5,6

The Committee on Medical Aspects of Radiation in the Environment7 has identified that legislation controlling the use of sunbeds was in place in 2009 in Belgium, Finland, France, Norway, Portugal, Spain, Sweden, a number of US states and Australia. The nature of this varied from voluntary controls, licensing arrangements, manufacturing guidelines, marketing standards, point of sales directions and requirements for information and supervision. A private members bill with cross party support imposing a duty on sunbed businesses to prevent use among under-18 s entered into law in England and Wales in 2010 and came into force in April 2011.8 This followed Scottish legislation in 20099 and was followed by legislation in Northern Ireland in 2012.10 In Scotland, Wales and Northern Ireland, the legislation also requires salons to be supervised by trained staff. While this provision is also in the legislation in England, the regulations requiring supervision were not implemented, which means that there is currently no requirement for the salons to be supervised by trained staff in England. This raises the prospect that without a legal requirement for supervision in England, the impact of the legislation may be reduced.

This study is the third part of the research into sunbed use by minors undertaken by Cancer Research UK. Its primary aim was to explore in depth the motivations, experiences and views of female sunbed users aged 15–17, given that the highest prevalence of use was identified in this group. At the time of the focus group interviews in early 2009, there were no legal restrictions on the use of sunbeds, as it predated the introductions of the law in England and Wales.8 Instead regulations were primarily limited to Health & Safety Executive guidance, which only recommended that under-18 s do not use sunbeds, that any sunbed use by any age group should be supervised and information provided to users, but had no real powers to enforce this. The analysis conducted here was therefore extended to consider the implications of the responses from the girls in the context of the recent introduction of legislation restricting sunbed use among those <18 years old.

Methods

Cancer Research UK commissioned CM Insight,11 an experienced qualitative research partnership, to conduct 12 focus groups of four to six females aged 15–17 years who reported using sunbeds monthly or on over nine occasions in the previous 9 months. The decision to focus on females in this age group was taken because of their far higher prevalence of sunbed use as reported above.5

Two focus groups were held in each of six English towns and cities from the South Coast to the North East of England, including Brighton, Bushey, Liverpool, Newcastle upon Tyne, Solihull, and Stoke on Trent between 7 and 15 January 2009, i.e. before the introduction of the legislation banning sunbed use by under-18 s. These locations were selected to include areas with high and low densities of sunbed outlets and varying levels of deprivation. The population, deprivation, number of outlets and their density are summarized in Table 1.

Table 1

Focus group location characteristics

 Number of outlets Number per 100 000 total population Index of multiple deprivation rank (1 = most deprived, 326 = least deprived) Population (‘000s) Office of National Statistics 2010 estimate 
Brighton and Hove 21 8.4 84 258.8 
Newcastle upon Tyne 56 20.8 35 292.2 
Liverpool 73 16.7 445.2 
Solihull 15 7.4 119 206.1 
Stoke on Trent 36 15 15 240.1 
Busheya 6.3 231 25.9 
 Number of outlets Number per 100 000 total population Index of multiple deprivation rank (1 = most deprived, 326 = least deprived) Population (‘000s) Office of National Statistics 2010 estimate 
Brighton and Hove 21 8.4 84 258.8 
Newcastle upon Tyne 56 20.8 35 292.2 
Liverpool 73 16.7 445.2 
Solihull 15 7.4 119 206.1 
Stoke on Trent 36 15 15 240.1 
Busheya 6.3 231 25.9 

Outlet and density data taken from SWPHO (2009).23

aFigures are for Watford, of which Bushey is a part, except final population column, which is for Bushey.

Participants were recruited opportunistically, sunbed users being identified among CM Insight's recruiters' networks, and also around sunbed salons, leisure facilities and educational establishments. Participants were informed of the purpose of the study and assured that their views would remain confidential and be reported anonymously. Each received £25 for their involvement.

In total, 69 participants were recruited, of whom six were aged 15 years, 24 aged 16, 37 aged 17 years and two aged 18 years. The recruitment of the two 18-year-olds was erroneous as the intention was to concentrate on children and in particular those in the high-use category as previously determined5; nevertheless, we judged it appropriate to analyse their data once recruited. Each focus group lasted ∼1 h 30 min and comprised open-ended discussions exploring (i) motivations and experiences of sunbed use; (ii) knowledge of/response to the risks and (iii) experiences of/attitudes towards supervision at sunbed facilities. Interviewers were supported by an outline of prompt questions and began each session with a ‘draw and talk’ exercise.

Interviews were transcribed verbatim and the initial informal analysis by CM Insight reported to Cancer Research UK, the National Cancer Action Team and the Department of Health. The current systematic analysis employed methods of qualitative thematic analysis12 to confirm the findings of the informal analysis undertaken by CM Insight and extend the analysis in light of the recent legislation to ban the use of sunbeds by under-18 s.

The first phase of this analysis employed a realistic inductivist approach assuming an unproblematic relationship between respondents' experiences and meanings and the language they used to express them, building up thematic description from coding of responses without applying any pre-existing analysis structure. JRL openly coded four transcripts before rationalizing those codes to generate an initial thematic framework. JRL then carried out a divergent case analysis that involved indexing the remaining transcripts with further open coding and refinement of the thematic framework to accommodate any data that were inconsistent or inadequately summarized. A refinement and validation exercise was then conducted with the remaining authors. A thematic summary and collations of extracts for each theme were shared with CST, CJT and EAD, who independently reviewed four transcripts to verify the completeness of the collated extracts and the appropriateness of codes and themes. The analysis was then discussed before reaching a consensus on its content.

Legislation had recently been introduced in England to restrict the use of sunbeds among those <18 years of age,8 and the decision was made to adopt a theoretical and researcher-driven interest rather than an inductive approach to further analysis, which allowed us to consider the implications of the findings in this context. The thematic areas most relevant to this around experiences and responses to supervision were initially identified by JRL. These were then shared with the other researchers and refined before reaching a consensus on their implications for sunbed legislation. These were: reasons for sunbed use, knowledge and responses to risks and experiences and responses to supervision.

Ethics

We sought advice on the ethics of using transcript data for this analysis and were advised that formal ethical review was not required since the transcript data were anonymized.13

Results

Seventy coding labels were used in analysing the responses, which were organized into eight themes as follows: Those selected as most informative in considering the potential response to legislation, i.e. themes 3–7, are presented below.

  • Initiation

  • Patterns of use (including addiction)

  • Reason

  • Risks

  • Responses to risks

  • Experiences of supervision

  • Responses to supervision

  • Alternatives to sunbed use (including sun exposure and fake tanning)

Reasons for sunbed use

Tanning was a very clear reason for sunbed use as one respondent explained:

The main reason really is actually just to get a tan. (Newcastle FG1)

Some identified that this was because of their concern with appearance:

It just looks better. (Solihull FG1)

Others reported that they felt more attractive to others with a tan:

I don’t know, I think boys probably go for you a bit more if you have a bit of colour. (Liverpool FG2)

Respondents reported feeling negatively about their appearance when they lost their tan:

But you can't just stop going on them because when you lose your tan you think you look crap, so you've to go on them to make yourself feel better otherwise you look at yourself and you think ‘urgh’. (Brighton FG1)

Respondents also reported feeling better and more confident with a tan:

It makes you feel better having a tan. (Newcastle FG2)

It makes you feel more confident. (Liverpool FG2)

The comparative element of these feelings was recognized:

I was looking at other people and I was like ‘I feel great’ because I was so dark. (Newcastle FG2)

I don't want to be the odd one out, like looking dead pale. (Liverpool FG1)

Social influences on tanning behaviour were also reflected in its association with celebrities:

And like celebrities and stuff … on the red carpet they've got the nice glow and like a tan, and so we kind of look to them and they look pretty. (Liverpool FG2)

A range of reports demonstrated some association between tanning and health:

Well you look more healthy with a tan, you look like you've got more life to you. (Newcastle FG2)

You feel more healthy don't you? (Newcastle FG2)

It was suggested that tanning can be protective and help to relieve some health problems:

It helps you not burn (Brighton FG1)

I do it to stop prickly heat (Newcastle FG1)

It's good for muscle problems. (Solihull FG1)

Acne or spots, it helps clear them up. (Liverpool FG2)

Responses indicated that sunbed use provides time for oneself or something to do with friends:

It's like a bit of me time (Solihull FG1)

It's like to get out of the house for an hour just to go and see my friend and get a sunbed. (Bushey FG1)

Reports indicated that sunbed use was prompted by special events:

It's like when you go to a party, and you usually go on a sunbed before it (Liverpool FG2)

If I'm going to a wedding or something and I don't want to be too pale. (Bushey FG1)

You don't really want to go on holiday and be white, you want some tan (Newcastle FG2)

Other responses suggested intrinsic enjoyment of sunbed use:

It's a nice time to relax and think about stuff (Liverpool FG2)

I think it's just nice to feel warm as well in the winter. (Newcastle FG1)

Finally, sunbeds offered a sense of control:

With a sunbed you are in control and it’s much quicker [than sunbathing] and it's at your convenience. (Liverpool FG2)

Knowledge of risks

There was widespread recognition of the damaging effects of sunbed use and recognition of the risk of cancer:

It ages your skin though (Newcastle FG2)

I always feel mean on my skin when I come out I feel like I've frazzled it (Liverpool FG1)

You all know about the links to skin cancer. (Stoke FG1)

There was also mention of an effect on moles and freckles and one respondent mentioned cataracts:

If you've got like a mole, if it gets more raised or changes colour (Newcastle FG1)

Since I got burnt I've had like loads of like permanent freckles (Solihull FG1)

It can cause like cataracts. (Stoke FG2)

Other risks concerned facilities and equipment:

Someone might be able to see me (Liverpool FG2)

I'm like dead scared I'm going to get trapped (Liverpool FG2)

One of the bulbs might blow. (Solihull FG2)

Response to risks

Responses to risks varied with some indicating an acceptance of risks and others downplaying or ignoring them. Acceptance was reflected in responses such as:

We know all like the risks and that and you know how bad it is but we all still go on them (Liverpool FG1)

Yeah we'll all realise it when we're 30. (Liverpool FG1)

Consistent with these reports, there was also recognition that current priorities outweigh future concerns:

She [mother] says ‘You're stupid’ because in 30 years time I'll be moaning a lot … I said ‘I'll deal with it then’. (Solihull FG1)

Downplaying the significance of skin cancer was reflected in reports such as the following:

If you've got skin cancer you can get over it quick. (Liverpool FG2)

Respondents also reported that media coverage could be unduly pessimistic:

I think magazines … like make stories look ten times worse than they usually are. (Liverpool FG2)

It was noted that risk is often reported simplistically:

I know they're trying to stop cancer, but instead of them saying like ‘Yes there's limitations where they are good’ they'd probably just say ‘They're bad full stop, just don't risk it’ because you risk going inside a car every day, like car crash accident, so you might as well just risk your life. (Solihull FG1)

There were also suggestions that sunbed risks were emphasized far more strongly than the risks of natural sun exposure:

Like somebody's not going to say, don't go on holiday because you're going to get skin cancer (Newcastle FG1)

Another reported the belief that it was inevitable that some people developed cancer:

If people have got cancer they're born with it. (Newcastle FG2)

Others reported that they didn't retain negative messages about the risks of sunbed use:

You don't take it in (Liverpool FG1)

I feel bad then when people have told me about it but then it really goes out of my head really and then I don't really think about it. (Liverpool FG1)

You need something that has happened to yourself really before you really realise it. (Liverpool FG1)

Some reports suggested that only extremes of use were regarded as risky:

I think if you go on for 15 minutes like the maximum minutes every day for the rest of your life that's taking it too far, but twice a week? (Liverpool FG2)

Weekly usage was regarded as moderate:

I think you can say we all use it in moderation, once a week or, and then in the summer say twice a week if we want to. (Solihull FG1)

One respondent reported that they didn't believe sunbed use was risky as their expectation was that they were protected:

I don't think they can be that harmful or they wouldn't provide them. (Solihull FG1)

Experience of supervision

Reports showed varying degrees of attention at different facilities to the age of users, skin type, the duration and frequency of sunbed usage, use of creams and use of goggles.

At one extreme, respondents reported entirely unsupervised facilities:

It was just a machine and no-one worked there … Just put a coin in and jump on. (Newcastle FG2)

Others reported facilities that displayed posters and disclaimers:

There are like posters and that (Liverpool FG1)

Saying they are not responsible if you burn or anything. (Liverpool FG1)

Some respondents reported that there were rules in operation at sunbed facilities but that they were not enforced:

They've asked me a few times how old I was when I was younger and I just said I was 16 and they just said okay go in they wouldn't ask for any proof of age or anything. (Liverpool FG1)

Others reported using facilities that had more formalized procedures and maintained oversight:

You've to fill out a form saying if you've any medical problems or anything (Bushey FG2)

Even though I've been there more than once, they'll always go through step by step what you have to do. (Newcastle FG1)

Responses to supervision

Some respondents reported valuing supervisory advice:

The woman who owns our one she's lovely and she does advise you. She was saying to me you've got fair skin and so I wouldn't go on for nine [minutes] because they are new tubes and stuff. (Liverpool FG1)

but others found it unwelcome:

You don't need to be supervised they're so simple to use (Bushey FG1)

Yeah, it's not up to them is it? (Stoke FG2)

Some respondents felt that rules were appropriate; for example, one said:

I think they [salons] should be able to say ‘you're not having another one until whenever (Solihull FG2)

Another reported:

I wouldn't let kids go in there

(Interviewer) Kids being how old? Under 16, maybe even under 18. Like even though I've had them before I don't think I should have been allowed to do that. (Bushey FG1)

Nevertheless, some users reported that they found ways around limitations on their use, for example, by identifying staff who were less strict:

One could say no and one could say yeah. (Liverpool FG1)

or by shifting their use to sunbeds at a friend's home:

I was talking to my friends about it and they were like ‘well I know somebody who's got a sunbed at home’ and I was ‘well I'll use that.’ (Newcastle FG2)

Some responses suggested that supervision was considered customer care:

Some people will advise you but some just don't really care (Liverpool FG1)

While others felt supervision was offered to protect the provider:

If they just let you go on and something goes wrong then it's their fault (Bushey FG2)

Reminders of the risks of sunbed use are not necessarily welcome:

We don't need to be reminded every time we go on the sunbed that we can get skin cancer, that's highly depressing. You go there to make yourself look better and not be told ‘you're going to get skin cancer’, nice one, cheers. (Solihull FG1)

Discussion

Main findings

This study provides insights into the motivations of regular female sunbed users aged <18 years; their understandings of and responses to risks and experiences of and responses to supervision. In some areas, respondents' reports were consistent, whereas in others divergent views were expressed. Importantly, this study highlights motives and attitudes of minors that may reduce the impact of recent legislation seeking to limit the use of sunbeds unless supervision is required in all salons.

The value and social significance given to tanning was reflected universally with respondents reporting a desire to conform to social expectations and ideals on the one hand and, on the other hand, to distinguish themselves from others. Sunbed use was also associated with being healthy; it was reported to confer a sense of control and for some was intrinsically enjoyable.

Our results suggest that users may be receptive to harm-reduction messages. There was widespread recognition of the damaging effects and health risks of sunbed use such as burning, ageing skin and increased risk of skin cancer. There was also mention of the early warning signs of malignant melanoma—change in colour or size of a mole. The short-term benefits of tanning outweighed these longer term risks in the view of the teenage users. Although some respondents accepted the risks associated with sunbed use, others ignored or underestimated them by concluding that risks were exaggerated in the media and that any benefits were not reported. It was also suggested that you can recover quickly from skin cancer with no acknowledgement that it can be fatal. Although non-melanoma skin cancer is not commonly fatal, malignant melanoma is the most serious type with a higher mortality rate. In 2010, there were >2700 deaths from skin cancer in the UK—2200 of which were caused by malignant melanoma.3

A number of misconceptions about the health effects of sunbed use and/or tanning were uncovered. These included protection from sunburn, therapy for muscle problems and clearing up acne. In reality, a tan offers very limited protection from the sun or sunburn, with some studies showing that tans only offer protection equivalent to using factor 3 sunscreen.14 Far from being a sign of health, a tan is a sign that the body is trying to repair DNA damage in the skin. Sunbeds have been used medically to provide artificial sources of UV radiation to treat certain skin conditions, such as psoriasis, but in these cases it is normally combined with a chemical which sensitizes the skin, and given under medical supervision. Commercial tanning facilities do not follow this practice and are less effective than medically controlled treatments.

While some respondents welcomed supervision of their use, they did not accept restrictions that impinged on their freedom to use sunbeds and reported how they would actively circumvent such measures if they could. Interestingly, some respondents who had used sunbeds at a younger age said they favoured limiting the use of sunbeds by others of that age, while others felt that supervision was offered in the providers' interests, rather than their own. There was some evidence that rules or procedures were in place in some facilities, for example some respondents were asked their age or to fill in forms about their medical history, but even in these facilities they were not always enforced. While some respondents felt that rules were appropriate and tanning facilities should be responsible, others felt that it was ultimately the user's choice or responsibility.

What is already known on this topic

Previous research has established that teenage sunbed users are positive about tanning believing it to be attractive and of social significance, as for example reported in Schneider and Krämer's15 systematic review. The association of tanning with health has also been noted previously as Garside et al.'s16 review demonstrates.

There have been relatively few qualitative studies but some studies have reported the value given to tanning by young Australians;17 the status afforded to tanning among Canadian women18 and the peer influences that provide positive reinforcement when tanned, and negative responses when tanning fades among women in Merseyside.19 Qualitative studies have also shown that Australian children associated skin cancer with adults and had variable perceptions of its severity.20

The requirements of legislation regarding sunbed use have varied internationally and in the UK. Although in all the four countries in the UK, sunbed use by under-18 s is now banned, the legislation in Scotland, Wales and Northern Ireland includes measures that have been fully implemented to ensure the supervision of salons, the provision of health information by salons, and in Northern Ireland the requirements also include the need for the provision of specified health information to buyers and hirers of sunbeds.

However, in England because the regulations including the mandatory supervision of sunbed use have not been implemented, the effectiveness of the ban in England may be significantly compromised. This is because such regulations help to ensure that sunbeds are not used by, or offered for use to under-18 s and we have shown that users <18 have demonstrated a clear willingness to find ways around measures that seek to limit their use. Therefore, it is important at national level that the Government introduces further regulations such as mandatory supervision, but it is also important that Local Authorities ensure that existing regulations are fully enforced.

It should also be noted, however, that while supervisory arrangements may limit underage salon use, almost a quarter of children in England previously using sunbeds did so either at their own or a friend/relative's home.6 Only in Northern Ireland has legislation incorporated the requirement to provide advice at the point of sale.

What this study adds

We are not aware of any previous qualitative studies that have focussed specifically on sunbed use in this age group or on their responses to supervision. Also, the study is unique in considering how these views might influence the impact of legislation.

Some of our findings, particularly regarding the reasons for sunbed use, are consistent with previous research as summarized above. In other areas, however, our results contradict or extend previous research. For example, Schneider and Krämer's15 review suggested that sunbed users were likely to know relatively little about the health risks of sunbed use. While the relative awareness of the risks of sunbed use between users and non users was beyond the scope of this study, our results do suggest that sunbed users have a clear awareness of risks, but often choose to ignore them. This is similar to the findings from Monfrecola et al.21 in their survey of Italian high school students aged 16–21.

Elsewhere, Elwood and Gallagher22 considered sunbed users' understandings of risk and suggested that since females appear to have a stronger tendency than men towards both sun protection and sunbed use, they might regard sunbeds as protective. In our study some respondents mentioned that their sunbed use prevented burning, but others recognized that sunbed use increased rather than reduced the risk of skin cancer.

The quantitative survey research conducted by CRUK5,6 provided an overview of the availability and level of supervision at sunbed outlets in the UK. This study further considers the responses of sunbed users to that supervision and may inform future research on this topic, such in the development of survey instruments in support of quantitative studies. It was notable that additional to its nature and content, the spirit in which supervision was provided appeared significant.

Limitations of this study

This was a large qualitative study that involved 69 female 15–18-year-old regular female sunbed users in England and provided open and in-depth investigation of their views. The intention was to recruit participants under the age of 18 only but two who had become 18 were included in error. Given that these two recruits took part in, and therefore had a degree of influence on, focus groups, we did not consider it appropriate to attempt to remove their responses from the analysis.

Since the sample was not randomly selected, the results cannot be taken to be representative of all teenage sunbed users. Nevertheless, we believe that the views and experiences of the participants of this study warrant serious consideration as being those of regular female 15–18-year-old sunbed users in England. It is recognized that while prevalence surveys have consistently found higher sunbed use among females,15 as we found in the UK, and this informed focus group recruitment in this study, there may not be as much disparity in the use of sunbeds between the sexes or age groups elsewhere.

Conclusions and policy implications

Female teenage sunbed users place significant priority to tanning, rationalize the risks of their use and are generally resistant to measures that seek to limit it. Legislative measures regarding sunbed use have varied internationally and in the UK. The legislation introduced in England and Wales in April 2010 and implemented from 2011 placed a duty on sunbed businesses to prevent use of sunbeds by under-18 s.8 The legislation, however, is unlikely to alter the social desirability of tanned skin for many people; and so the lack of enforced supervision in England may mean that the impact of the legislation is significantly compromised and diminished, teenagers being able to gain entry to salons that are not manned or adequately supervised as Elwood & Gallagher16 have previously argued.

Our results suggest that legislation is likely to be negatively received by some sunbed users who may seek ways around the rules, including the use of home sunbeds. This emphasizes the need to fully implement all the regulations in the Sunbed Act in England, including making it mandatory for all salons to be staffed. Further investigation of the provision of health information at point of sale and of the impact of sunbed legislation internationally would be merited.

Acknowledgements

We thank Clare Mansfield and Catherine Millican from CM Insight for their background context around the focus groups and their helpful comments on the draft paper; Sarah Woolnough and Chit Selvarajah for their help with understanding the legislation; Yinka Ebo for her comments on the health risks and Sara Hiom for useful comments on the text.

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