Abstract
Objective:
Tattooed individuals have reported reduced access to health care and have a higher prevalence of risky health behaviors compared with individuals without tattoos, but the overall health profile of this population is poorly understood. The objective of this study was to characterize associations between tattooing and health status in Utah.
Methods:
We used data from approximately 27 000 respondents to the 2020, 2021, and 2022 Utah Behavioral Risk Factor Surveillance System surveys. We used multivariable Poisson regression to calculate the prevalence ratios (PRs) and 95% CIs associating ever receiving a tattoo with physical, oral, and mental health status.
Results:
In this cross-sectional study, ever receiving a tattoo was associated with self-reported poor versus excellent overall health, particularly among women (PR = 3.08; 95% CI, 2.26-4.21). Tattooing was also associated with obesity (women: PR = 1.40; 95% CI, 1.22-1.61; men: PR = 1.21; 95% CI, 1.04-1.40) and chronic pain (women: PR = 1.59; 95% CI, 1.43-1.77; men: PR = 1.55; 95% CI, 1.37-1.76). Tattooed individuals (vs not tattooed) were more likely to have been diagnosed with a depressive disorder (women: PR = 1.64; 95% CI, 1.53-1.75; men: PR = 1.55; 95% CI, 1.39-1.73) and to have had ≥6 teeth removed versus none removed (women: PR = 2.18; 95% CI, 1.61-2.96; men: PR = 2.88; 95% CI, 2.10-3.95).
Conclusions:
Public health entities may consider partnering with tattoo studios and conventions to provide information about nutrition, exercise, dental care, mental health resources, and health screenings to individuals with tattoos.
The United States has one of the highest prevalences of tattooing in the world, with approximately 38% of women and 27% of men having at least 1 tattoo. 1 In Utah, adults with tattoos are more likely than adults without tattoos to be unable to see a physician due to cost and less likely to receive an influenza vaccine. 2 Tattooing is also associated with several risky health behaviors, including tobacco smoking3-5 and heavy alcohol use.2,4 The barriers to health care that tattooed individuals may experience, combined with an elevated prevalence of risk behaviors, suggest that tattooed individuals may experience a disproportionate burden of poor health.
Despite these concerns, tattooed individuals represent a uniquely accessible population for public health interventions. Tattoo studios and conventions serve as community gathering spaces where health promotion campaigns, screenings, and educational resources can effectively reach this population. Understanding the health profile of tattooed individuals is therefore critical for developing targeted interventions in these settings. In this study, we aimed to quantify associations between tattooing and health status, including self-reported physical and mental health outcomes, in a population-representative sample of approximately 27 000 adults in Utah.
Methods
We used a cross-sectional study design that included respondents to the 2020, 2021, and 2022 Utah Behavioral Risk Factor Surveillance System (BRFSS) surveys. 6 The BRFSS is a population-based telephone health survey administered throughout the United States. The BRFSS uses a disproportionate stratified sampling design that stratifies by telephone type and region. 7 Design weights and iterative proportional fitting (raking) ensure that the sample reflects the underlying population. The methodology used in this study was described previously. 2 Participants in the 2020, 2021, and 2022 Utah BRFSS surveys were asked about any tattoos they had received with a tattoo machine. Because this study used only secondary, deidentified data from the BRFSS survey, the University of Utah Institutional Review Board determined it to be exempt from review.
We included the following health status variables: overall health (excellent, very good, good, fair, poor), number of days during the past 30 days when physical health was not good, average hours of sleep per night (<7, 7-9, >9), body mass index (BMI), physical activity in the past 30 days (yes/no), chronic pain (yes/no), prescription opioid use for chronic pain (yes/no), visited a dentist in the past year (yes/no), number of permanent teeth removed due to tooth decay or gum disease, ever had a depressive disorder (yes/no), number of days during the past 30 days when mental health was not good, and stress during the past 30 days (never, rarely, sometimes, usually, always).
The chronic health condition variables included in supplemental analyses were ever diagnosis of the following conditions: asthma (current and ever); chronic obstructive pulmonary disease, emphysema, or chronic bronchitis; stroke; heart attack; angina or coronary heart disease; high blood pressure; high cholesterol; kidney disease; diabetes; arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia; and any cancer.
We calculated prevalence ratios (PRs) and 95% CIs associating ever receiving a tattoo (yes/no) with each health status variable, stratified by sex. We fit modified Poisson regression models for binary health status variables and multinomial models for categorical health status variables with 2 or more categories. The use of robust (sandwich) variance estimators provides valid SEs regardless of the underlying variance structure, addressing concerns about overdispersion that can arise with Poisson models. Models were adjusted for age (continuous) and education level (less than high school diploma, high school diploma, some college, college graduate or more). We assessed multicollinearity between age and education through model comparisons and cross-tabulation analyses, confirming both variables were necessary to avoid confounding bias (see eTable 1 in the Supplement for model comparisons). We then fit models further adjusted for ever tobacco smoking (yes/no), heavy drinking (yes/no), BMI (<18.5, 18.5-24.9, 25.0-29.9, ≥30.0 kg/m2), and physical activity in the past 30 days (yes/no) to examine the effect of these variables on the observed associations. The number of individuals reporting specific cancer types was small, so we further fit a multinomial model associating ever receiving a tattoo with cancer type among all individuals, controlling for sex. In supplemental analyses to assess potential residual confounding by tobacco smoking status, we fit comparable models restricted to individuals who reported never smoking.
All models incorporated the BRFSS design weights to account for the complex survey design; while the reported sample sizes were unweighted, the percentages were weighted and, therefore, more accurately reflect the underlying population in Utah. We confirmed that (1) all models converged successfully, (2) sample sizes were adequate across all exposure–outcome categories (minimum cell size = 5), and (3) variance inflation factors (<2.5) indicated no problematic multicollinearity among covariates. We conducted analyses with R Statistical Software version 4.3.1 (R Core Team).
Results
Most participants reported non-Hispanic White race (78.5% of women and 77.3% of men), and approximately 13% reported Hispanic ethnicity (Table 1). The age distribution was similar for women and men. The largest group comprised adults aged ≥60 years (25.8% of women, 23.7% of men), followed by adults aged 30 to 39 years (19.2% of women, 19.4% of men). Most participants were married (~60%) and had attained more than a high school education (69.2% of women and 67.0% of men). The prevalence of ever receiving a tattoo was 24% overall, with 26% of women and 22% of men reporting having at least 1 tattoo.
Demographic characteristics of BRFSS respondents and corresponding prevalence of ever receiving a tattoo among women and men, United States, 2020-2022 a
Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; GED, General Educational Development.
Data source: BRFSS. 6 Numbers are unweighted. Percentages are weighted to reflect the population in Utah; percentages may not add to 100 because of rounding. The prevalence of tattooing was 24% overall.
Includes all racial identities not listed as separate response options in the survey instrument.
Health Status: Physical Health
Among women, those with tattoos were more likely to report poorer overall health status than those without tattoos, after adjustment for age and education level. Specifically, the prevalence of reporting fair versus excellent health was about 1.7 times higher (PR = 1.66; 95% CI, 1.34-2.06) and the prevalence of reporting poor versus excellent health was about 3 times higher (PR = 3.08; 95% CI, 2.26-4.21) among women with tattoos than among women without tattoos (Table 2). Among men, patterns were weaker but had similar trends. Women with tattoos were about 1.3 times more likely (PR = 1.33; 95% CI, 1.03-1.72) and men with tattoos were 1.6 times more likely (PR = 1.60; 95% CI, 1.18-2.16) to report 8 to 14 days (vs 0 d) when their physical health was not good during the past 30 days compared with those without tattoos. Women with tattoos were about 1.7 times more likely (PR = 1.69; 95% CI, 1.42-2.02) and men with tattoos were about 1.5 times more likely (PR = 1.45; 95% CI, 1.17-1.80) than men and women without tattoos to report ≥15 days with poor physical health. Associations with overall health were still 2 times higher among tattooed women after additionally controlling for having ever smoked tobacco, heavy drinking, BMI, and physical activity, but associations were attenuated for men.
Associations between ever receiving a tattoo and physical, oral, and mental health status among women and men, United States, 2020-2022 a
Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; PR, prevalence ratio.
Data source: BRFSS. 6 Numbers are unweighted. Percentages are weighted to reflect the population in Utah. Percentages may not add to 100 because of rounding. Models incorporate BRFSS weights to account for the complex survey design.
Model 1 is adjusted for age and education level.
Model 2 is adjusted for age, education level, ever tobacco smoking, heavy drinking, body mass index, and physical activity in the past 30 days.
Censored due to cell sizes <11.
Not applicable.
Years in parentheses denote the survey years in which that variable was assessed; the number of respondents will not add to the value in the column head. Variables without year indicators were included in all 3 survey years.
Not included as an adjustment variable in model 2.
2020: All participants (both survey legs); 2022: 50% of participants (1 survey leg). The Utah BRFSS uses a 2-leg split-sample design in which certain questions are administered to the full sample (both survey legs) and others to only 1 randomly assigned subgroup (1 survey leg).
Stress defined as a situation in which a person feels tense, restless, nervous, or anxious or is unable to sleep at night because their mind is troubled all the time.
Ever receiving a tattoo was also associated with reporting both <7 hours and >9 hours of sleep per night. Women and men with tattoos were about 1.6 times more likely to sleep <7 hours per night (women: PR = 1.58; 95% CI, 1.36-1.83; men: PR = 1.64; 95% CI, 1.41-1.90) compared with those without tattoos. Tattooed women were about 1.8 times more likely (PR = 1.83; 95% CI, 1.26-2.65) and tattooed men were about 1.4 times more likely (PR = 1.44; 95% CI, 0.91-2.26) to sleep >9 hours per night compared with those without tattoos. Tattooed women were 1.4 times more likely (PR = 1.40; 95% CI, 1.22-1.61) and tattooed men were about 1.2 times more likely (PR = 1.21; 95% CI, 1.04-1.40) to be obese (BMI ≥30) compared with those without tattoos. Tattooed women (but not men) were about 1.2 times more likely to report no physical activity in the past 30 days (PR = 1.21; 95% CI, 1.09-1.36). Tattooed individuals were about 1.6 times more likely to report chronic pain than those without tattoos (women: PR = 1.59; 95% CI, 1.43-1.77; men: PR = 1.55; 95% CI, 1.37-1.76). Tattooed women (but not men) were about 1.6 times more likely to use a prescribed opioid for chronic pain than women without tattoos (PR = 1.62; 95% CI, 1.23-2.12). Tattooed individuals were about 1.2 times less likely to have seen a dentist in the past year than individuals without tattoos (women: PR = 1.21; 95% CI, 1.09-1.35; men: PR = 1.20; 95% CI, 1.09-1.33). Tattooed women and men were about 2 to 3 times more likely to have had ≥6 permanent teeth removed due to tooth decay or gum disease than men and women without tattoos (women: PR = 2.18; 95% CI, 1.61-2.96; men: PR = 2.88; 95% CI, 2.10-3.95). In general, associations were attenuated after further consideration of having ever smoked tobacco, heavy drinking, BMI, and physical activity.
Health Status: Mental Health
Ever receiving a tattoo was associated with depressive disorders, poor mental health, and stress. Tattooed individuals were about 1.6 times more likely than individuals without a tattoo to have ever been diagnosed with a depressive disorder (women: PR = 1.64; 95% CI, 1.53-1.75; men: PR = 1.55; 95% CI, 1.39-1.73). Individuals with tattoos were also more likely to report more days with poor mental health during the past 30 days than individuals without tattoos. Tattooed women were more than 2 times more likely (PR = 2.21; 95% CI, 1.91-2.57) and tattooed men were about 1.9 times more likely (PR = 1.88; 95% CI, 1.59-2.23) to report ≥15 poor mental health days than men and women without tattoos. Tattooed women were more than 2 times more likely and tattooed men were nearly 3 times more likely to report always experiencing stress in the last 30 days, defined as feeling tense, restless, nervous, or anxious, or unable to sleep at night, than women and men without tattoos (women: PR = 2.42; 95% CI, 1.54-3.79; men: PR = 2.97; 95% CI, 1.87-4.72).
Chronic Health Conditions
Ever receiving a tattoo was associated with a higher prevalence of several chronic health conditions compared with individuals who were never tattooed (eTable 2 in the Supplement). Among both women and men, tattooing was associated with asthma (women: PR = 1.37; 95% CI, 1.21-1.55; men: PR = 1.26; 95% CI, 1.10-1.45) and arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia (women: PR = 1.20; 95% CI, 1.09-1.33; men: PR = 1.20; 95% CI, 1.06-1.35). Among men, tattooing was associated with stroke (PR = 1.77; 95% CI, 1.26-2.50). Among women, tattooing was associated with kidney disease (PR = 1.44; 95% CI, 1.03-2.02), breast cancer (PR = 1.87; 95% CI, 1.25-2.80), and cervical cancer (PR = 2.44; 95% CI, 1.32-4.49) (eTable 3 in the Supplement). Tattooed women and men combined were also more likely to have had colorectal cancer (PR = 1.42; 95% CI, 0.78-2.61) and bladder cancer (PR = 2.00; 95% CI, 0.85-4.68), although these estimates were imprecise because they were based on only 20 tattooed individuals with colorectal cancer and 11 individuals with bladder cancer.
Models restricted to never smokers produced similar effect estimates to overall findings (eTables 4-6 in the Supplement). For some variables, such as number of permanent teeth removed due to tooth decay or gum disease, associations were attenuated among never smokers; however, for other variables such as how often they felt stress, the associations were stronger when limited to never smokers.
For chronic conditions, restricting to never smokers generally produced similar or stronger effect estimates rather than attenuating them, suggesting that the associations between ever receiving a tattoo and health status were not primarily explained by confounding from smoking (eTables 2 and 5 in the Supplement).
The associations between cancer and ever receiving a tattoo that were most robust in the overall population (breast and gynecologic cancers in women) persisted or strengthened when restricted to never smokers (eTables 3 and 6 in the Supplement).
Discussion
In this contemporary, cross-sectional study of tattooing and health status among approximately 27 000 men and women in Utah, we observed that tattooing was associated with several physical and mental health conditions. These conditions included poorer overall physical health, ever diagnosis of a depressive disorder, an increase in the number of days during the past 30 days with poor mental health, inadequate or excessive sleep, stress, permanent tooth loss, chronic pain, and asthma. Because tattooing and chronic conditions were assessed simultaneously, we could not establish whether tattoos preceded or followed the health events. In some cases, the tattoo was likely received after the health event. For example, among women with breast cancer, some women may have received a tattoo after cancer treatment if they received reconstructive surgery with nipple tattooing. While biological mechanisms linking the components of tattoo ink to health outcomes cannot be excluded, tattooing is also strongly associated with smoking and other risk-taking behaviors that themselves predict poor health outcomes, 2 making it difficult to disentangle these relationships without temporal data. Therefore, these associations should be interpreted as descriptive rather than causal.
Our findings are consistent with a 2016 online survey of approximately 2000 US adults conducted via Amazon’s Mechanical Turk platform. 3 That study demonstrated a strong relationship between tattooing and ever receiving a diagnosis for a mental health condition as well as difficulty sleeping. 3 While that study did not demonstrate associations between tattooing and overall health status, 3 another online survey of approximately 450 US adults conducted in 2008 found that participants with a tattoo were more likely to have used a sick day from work in the past 30 days than participants without a tattoo. 8 To our knowledge, our study is the first to report on permanent tooth loss, chronic pain, asthma, breast cancer, and gynecologic cancers.
Strengths and Limitations
Strengths of this study included the large population-based design and the ability to examine associations between tattooing and a wide variety of health outcomes. In addition, missing data were minimal for most variables, and the proportion of missing data was comparable between ever and never tattooed individuals.
This study also had several limitations. First, the cross-sectional design prohibited the ability to examine temporality between tattoo exposure and development of health outcomes, because the BRFSS does not collect data on the timing of medical diagnoses. Second, because exposures and outcomes were measured simultaneously, both were subject to potential misclassification (respondents incorrectly classified as exposed or not exposed and/or respondents incorrectly classified as having or not having the condition). Third, our reliance on self-reported medical diagnoses could have led to misclassification. If tattooed individuals face greater barriers to health care access (as prior literature suggests 2 ), they may be less likely to receive formal diagnoses, potentially biasing our estimates toward the null and underestimating true associations. Conversely, differential reporting accuracy could bias estimates in either direction. Fourth, this study may also have been affected by selection bias because nonrespondents may have been less healthy than respondents. Despite these limitations, to our knowledge, this is the largest population-based study to date that describes associations between the prevalence of ever receiving a tattoo and health status, providing justification for future studies to evaluate potential causal relationships.
Conclusion
These findings suggest that tattooing is correlated with several poor physical and mental health outcomes. Given that individuals with tattoos face documented barriers to health care access, 2 tattoo conventions and studios present opportunities for partnerships to reach individuals with tattoos through health promotion activities, disease screening programs, and linkage to care services. Such venues may be particularly well-suited for interventions targeting modifiable risk factors, including tobacco use, alcohol consumption, and physical inactivity.
Supplemental Material
sj-docx-1-phr-10.1177_00333549261445868 – Supplemental material for Associations Between Tattooing and Health Status: A Population-Based Cross-Sectional Study of Adults in Utah, 2020-2022
Supplemental material, sj-docx-1-phr-10.1177_00333549261445868 for Associations Between Tattooing and Health Status: A Population-Based Cross-Sectional Study of Adults in Utah, 2020-2022 by Rachel D. McCarty, Britton Trabert, Morgan M. Millar, David Kriebel, Laurie Grieshober, Mollie E. Barnard, Lindsay J. Collin, Jeffrey A. Gilreath, Paul J. Shami and Jennifer A. Doherty in Public Health Reports®
Footnotes
Acknowledgements
The authors thank the participants in this study who dedicated their time to make this research possible. We also thank Anna Dillingham, MPH; Lynne MacLeod, MStat; MaryAnne Hunter, MPH; Lin-Marie Wright, BA; and Shige Onda, BA, at the Utah Department of Health and Human Services, whose work facilitating the Behavioral Risk Factor Surveillance System (BRFSS) made this study possible.
ORCID iDs
Funding
The authors received the following financial support for the research, authorship, and/or publication of this article: Rachel D. McCarty was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under award no. T32TR004392. Lindsay J. Collin was supported by K99CA277580 from the National Cancer Institute of NIH. We acknowledge the direct financial support for the research reported in this article provided by the Huntsman Cancer Foundation and the Cancer Control and Population Sciences Program at Huntsman Cancer Institute. We also acknowledge support by the National Cancer Institute of NIH under award no. P30CA042014.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Jeffrey A. Gilreath is employed by Sanofi.
Data Availability Statement
The BRFSS data used in this study are available from the Utah Department of Health and Human Services. Restrictions apply to data availability.
Disclaimer
Where authors are identified as personnel of the International Agency for Research on Cancer or the World Health Organization, the authors alone are responsible for the views expressed in this article; the views do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer or the World Health Organization.
Supplemental Material
Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.
References
Supplementary Material
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