Letters to the Editor On the potential beneficial effects of indoor tanning DOI: 10.1111/bjd.21829 Linked Article: Eden et al. Br J Dermatol 2022; 187:105–14. DEAR EDITOR, We read with great interest the article by Eden et al. 1 entitled ‘Cost-effectiveness of a policy-based intervention to reduce melanoma and other skin cancers associated with indoor tanning’, concluding that banning of indoor tanning would save lives. We agree with the Eden et al. 1 that a cost-effectiveness anal- ysis of indoor tanning is needed. A key limitation of their paper is that they included only the hazardous events and not the beneficial effects of indoor tanning. 2 In our large prospec- tive cohort, indoor tanning was associated with a 20% increased risk of malignant melanoma mortality (hazard ratio 1Á2, 95% confidence interval 1Á0–1Á6), but at the same time a 23% lower all-cause mortality risk (hazard ratio 0Á77, 95% confidence interval 0Á7–0Á8) during the study interval. 3 Thus, indoor tanning seems to give a survival advantage, at least in a low ultraviolet radiation (UV) region. We are well aware that the findings of a prospective obser- vational study do not give causal results. However, the dose- dependent relationship, plausible mechanisms, and supporting findings in experimental studies increase the likelihood of a causal relationship between active sun exposure habits and a decreased rate of all-cause mortality. We agree that the greater the UV exposure, the higher the rate of keratinocytic skin cancer. However, as the UV risk fac- tor for malignant melanoma is mainly overexposure, proper targeted guidelines should keep the risk low and optimize health. Furthermore, as indoor tanning is a source of sunlight for underprivileged groups, a ban on indoor tanning might increase health inequalities. We agree with Eden et al. 1 that policymakers need robust economic knowledge when making decisions. Unfortunately, the paper by Eden et al. only gives information on one side of the coin. In addition, there is no proof that banning indoor tanning would save lives in Northern Europe; it is only hypo- thetical. On the contrary, there is evidence that banning indoor tanning would instead increase the mortality rate due other causes, such as hypertension, thromboembolism and type 2 diabetes mellitus. 2,3 Thus, a quick fix of a complex problem like banning indoor tanning is unlikely to save lives in the UK or Sweden. Data available in prior papers. A multidisciplinary approach to optimize sun exposure for maximal health benefit, and minimize the risk of malignant melanoma will supposedly be a winning concept. It should be possible to target guidelines against (episodic) overexposure of UV and indoor tanning abuse, and to question the reliance on sun blockers, and still get UV exposure for optimal health. Pelle G. Lindqvist iD , 1 Elisabeth Epstein iD 1 and Mona Landin-Olsson iD 2 1 Department of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden; and 2 Department of Endocrinology, Lund University, Lund, Sweden Email: pelle.lindqvist@ki.se Funding sources: none. Conflicts of interest: the authors declare they have no conflicts of interest. References 1 Eden M, Hainsworth R, Gordon LG et al. Cost-effectiveness of a pol- icy-based intervention to reduce melanoma and other skin cancers associated with indoor tanning. Br J Dermatol 2022; 187:105–14. 2 Lindqvist PG, Epstein E, Landin-Olsson M. Sun exposure – hazards and benefits. Anticancer Res 2022; 42:1671–7. 3 Lindqvist PG, Epstein E, Landin-Olsson M et al. Avoidance of sun exposure is a risk factor for all-cause mortality: results from the Mela- noma in Southern Sweden cohort. J Intern Med 2014; 276:77–86. On the potential beneficial effects of indoor tanning: reply from the authors DOI: 10.1111/bjd.21854 DEAR EDITOR, Lindqvist et al. 1 claim that our model-based eco- nomic evaluation does not account for beneficial effects of indoor tanning. 2 Their contention that indoor tanning is asso- ciated with reduced mortality is based on a prospective cohort study conducted by them. We appreciate their motivation to understand the implications of ultraviolet exposure for health and longevity. However, their methodological approach 3,4 has been criticized elsewhere and we support that criticism. 5,6 In particular, Hoffmann et al. commented that the statistical methods used do not sufficiently control for confounding fac- tors such as older age, higher prevalence of comorbidities and Ó 2022 British Association of Dermatologists. British Journal of Dermatology (2022) 187, pp1057–1059 1057 Downloaded from https://academic.oup.com/bjd/article/187/6/1057/6972522 by guest on 10 January 2023