By Ruth Carol, contributing writer, May 02, 2011
The majority of states have enacted indoor tanning regulations, but they are not proving to be game changers when it comes to curtailing the use of such facilities. Still, dermatologists say the legislation sends a strong message about the dangers of indoor tanning to the public that they believe is essential to stopping behavior that is contributing to the rise in skin cancer.
In this year’s legislative sessions across the country, dermatologists proposed or re-introduced bills to restrict tanning bed use. They were cautiously optimistic about passage as steps are being taken on the federal level to more closely monitor the indoor tanning industry — and they were armed with a growing body of evidence linking tanning bed use with an increased lifetime risk of melanoma.
To date, 36 states have regulations that range from banning the use of tanning beds for minors to restricting their use by requiring parental consent or accompaniment. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island are considered to have the most stringent overall regulations based on factors such as minors’ access, ultraviolet (UV) exposure control, operator training, violation penalties, and sanitation, according to a 2007 study published in the Journal of the American Academy of Dermatology. Specifically, Texas and New Hampshire were the most restrictive regarding minors’ access. (Wisconsin has joined them with a law that bans tanning under the age of 16.) More recently, bills prohibiting the use of tanning beds by minors have been introduced in Iowa, Illinois, Maryland, New Jersey, New Mexico, New York, Ohio, Pennsylvania, Rhode Island, Washington, and Vermont. Parental consent bills have been introduced in California, Florida, Minnesota, Nevada, South Dakota, and West Virginia. Legislation is expected to be proposed in Massachusetts and North Carolina this year, said Kathryn Chandra, assistant director of state policy for the American Academy of Dermatology Association. [pagebreak]
While all of this legislative activity is encouraging, what is not is the limited effect that regulation appears to have on tanning salon patrons. According to a 2009 study published in Cancer, the prevalence of indoor tanning use among U.S. adolescents barely changed between 1998 and 2004, despite more states restricting tanning bed use by minors. The authors suggest one reason the laws have had such little impact is that many states permit use with parental consent. Two of the five factors significantly associated with indoor tanning use cited were parental permission and having a parent/guardian who used indoor tanning within the previous year.
The Cancer study did note that the use of indoor tanning by minors decreased slightly in states that enacted youth access policies while use by minors increased slightly in states that lacked such policies. These findings are consistent with other study findings and speak to the argument that more restrictive legislation may be more effective in reducing tanning bed use. “Studies have shown that tanning salons in states with legislation, and in particular tanning bans for minors, tend to be more compliant with providing informed consent, restricting youth, and obtaining parental consent,” said Bruce A. Brod, MD, clinical associate professor of dermatology at the University of Pennsylvania School of Medicine in Philadelphia. “So the legislation is having an impact, but not as much as we would like.” The easiest thing to change about regulation is youth access, said Robin L. Hornung, MD, MPH, a pediatric dermatologist at the Everett Clinic and clinical associate professor in the division of dermatology at the University of Washington in Seattle. [pagebreak]
Another reason that state regulations may have limited impact is because they are not being enforced. A 2008 study published in Preventing Chronic Disease found that routine annual inspections were not conducted in 64 percent of cities required to do so. Specifically, 32 percent of the cities did not inspect indoor tanning salons for compliance with state law and another 32 percent conducted inspections less than annually. Slightly less than half of the cities issued citations to tanning salons that violated state law. The good news is that when conducted on an unannounced basis, these inspections were more likely to be effective.
Why are indoor tanning facilities not being more closely monitored? For starters, it’s easier to enforce a ban rather than a complicated regulation. “The more complex the regulation gets, the more difficult it is to enforce it,” said Martin A. Weinstock, MD, PhD, professor of dermatology and community health at Brown University in Providence, R.I.
But the primary reason is lack of funding. “The focus has been on licensing, regulations, youth bans, and parental consent, and maybe not enough on how to fund those,” said Dr. Brod, who pointed out that in New Hampshire a bill was recently introduced that would reverse its existing regulations to save the state money.
Last year in Dr. Brod’s home state of Pennsylvania, legislation banning tanning bed use for individuals under the age of 14 and requiring parental accompaniment for those under 18 made it through two senate committees — the furthest it has ever progressed — but didn’t pass for partisan and fiscal reasons, he said. Moving forward, the bill may include amended language to allow for the state to accumulate funding from the licensing fees in order to pay for enforcement efforts. In prior years, the public health department was resistant to taking on additional regulatory activity, but that resistance has subsided as knowledge about the dangers of indoor tanning has grown, Dr. Brod added. [pagebreak]
Given the budgetary constraints faced by many states across the country, it is not surprising that they aren’t dedicating a lot of money toward enforcing these regulations, stated Allan Halpern, MD, chief of dermatology at Sloan-Kettering Cancer Center in New York. Consequently, he suggested, these regulations should be written to be self-sustaining from a budgetary perspective.
When indoor tanning regulation is re-introduced in Massachusetts this year, the bill will propose that tanning salon operators and employees pay a licensing fee to each of the state’s 351 local public health departments to be used toward enforcement, said Martin Cohn, associate director of the Massachusetts Academy of Dermatology.
To combat another argument that the bill will hurt small businesses, the language will be changed to regulate “tanning beds” and not “tanning devices” so that it won’t preclude the use of tanning sprays, Cohn said. He is confident that these revisions will be enough to pass the bill, which proposes to ban individuals under the age of 16 from using indoor tanning salons and requires parental consent for those between 16 and 18. This bill has consistently passed the state Senate and almost passed in the House, but then a member of the House introduced an amendment to retain the ages in the current legislation at 14 and 16, respectively, Cohn explained. That amendment was enough to send the bill for reconciliation to the conference committee where it remained until the legislative session ended in 2010. In February, the same House member filed a bill using the ages in the current regulation. “So this year, we’re trying to pass one bill and kill another,” he said. [pagebreak]
The Academy offers a wealth of information for dermatologists to navigate through the regulatory process, Dr. Brod said, including model legislation, examples of letters to legislatures, and talking points, as well as knowledgeable staff in the Washington, D.C. office. “States don’t have to reinvent the wheel,” he said. “The Academy can also put you in touch with others who are working on this in their respective states.”
Body of evidence grows
Another reason that dermatologists are optimistic about the passage of regulations is the growing body of evidence that links exposure to UV radiation from indoor tanning devices with an increased risk of skin cancer. “Recent studies make it very clear that tanning beds are definitely contributing to the rise in melanoma,” Dr. Halpern said. In the past year alone, there has been a huge accumulation of evidence, Dr. Weinstock concurred.
In 2010, two population-based studies found that the use of indoor tanning devices increase the risk of developing melanoma. The Skin Health Study published in Cancer Epidemiology, Biomarkers & Prevention determined that this risk increased with frequency of use measured by hours, sessions, and years. As an example, an individual with more than 50 hours, 100 sessions, or 10 or more years of tanning was up to three times more likely to develop melanoma than a person who never tanned indoors. Similarly, the use of tanning beds was associated with an increased risk of early-onset melanoma the risk increasing with greater use in the Australian Melanoma Family Study published in the International Journal of Cancer. Among those who ever used indoor tanning and who were diagnosed with melanoma between the ages of 18 and 29 years, 76 percent of melanomas were attributable to tanning bed use. Furthermore, a sharp increase in melanoma incidence was linked to the increase in the number of indoor tanning salons in Iceland in a 2010 study published in the American Journal of Epidemiology. [pagebreak]
All of these studies support the findings by the World Health Organization’s International Agency for Research on Cancer that noted first exposure to tanning beds before the age of 35 increases an individual’s lifetime risk of melanoma by as much as 75 percent. It was the agency’s 2007 systematic review, published in the International Journal of Cancer that prompted the WHO to categorize tanning beds as carcinogenic to human beings in 2009. That pronouncement has been echoed by the U.S. Department of Health and Human Services.
Federal efforts multiply
In 2007, the Tanning Accountability and Notification (TAN) Act, sponsored by Rep. Carolyn Maloney (D-N.Y.), called on the Food and Drug Administration (FDA) to examine the effectiveness of warning labels on tanning bed devices. Although consumer panels were convened to assess the appropriateness of the current labels and their comments in support of alternate labeling were reported by the FDA, the agency has not yet implemented new regulations to change the required labels.
Three years later, Rep. Maloney introduced the Tanning Bed Cancer Control Act of 2010. It calls for the FDA to examine the classification of indoor tanning beds. Proponents would like to see them re-classified as Class II or III devices. They are currently Class I devices along with bandages, tongue depressors, and gauze, with very little oversight, Dr. Brod noted. If tanning beds are categorized as Class II devices, the FDA could require more stringent performance standards regarding the strength of UV rays being emitted and amount of exposure time. It has been decades since tanning bed classification was last examined by the FDA, Chandra said. Although the legislation did not pass, it will be re-introduced this May. [pagebreak]
However, in an ongoing effort to address indoor tanning, the FDA’s Medical Devices Advisory Committee met last March and sent its recommendations to the agency. Among the committee’s recommendations was that tanning lamps and beds should not be Class I devices and do not have to be regulated or classified separately based on whether they emit UVA or UVB radiation. The panel members favored patient information beyond labels and more prominent posting of such warnings. The majority of panel members favored an age restriction for tanning. The FDA is expected to issue a proposed ruling soon.
Also in 2010, the Federal Trade Commission limited the Indoor Tanning Association’s ability to make false health and safety claims about indoor tanning. Dr. Halpern believes that this has had the greatest impact on the industry during the last couple of years. Every bit of pressure the FDA receives in the form of academic endorsement of the science behind this issue — such as that issued by the American Academy of Pediatrics in its call for an indoor tanning ban for minors this spring — will help move the agency in the right direction, he added.
Ban the tan
Ideally, that move would be in the form of federal regulation. While states are making great strides in enacting legislation, regulation needs to be consistent across the board, Cohn said. “We need to look at this as a society and see the danger and understand the public health impact of the rise of melanoma.” He believes that a national public education campaign should be undertaken with public health messages issued by the Ad Council. Having regulation that varies state-by-state is confusing, Dr. Hornung added. Plus, having federal regulation would make enforcement easier, Dr. Halpern noted.
Dr. Brod would like to see minors banned from indoor tanning in the same way that they are banned from purchasing cigarettes and alcohol. Those opposed to a ban argue against legislating behavior, he said, but the more important argument is that children and adolescents don’t have the experience and knowledge to always make the best choices. “It’s a time of life in which peer pressure and immediate gratification have a lot of influence,” noted Dr. Brod, who said a ban also will take the pressure off of parents to give their consent. [pagebreak]
In addition to supporting regulation, dermatologists must continue their efforts to educate the public in order to impact behavior. “The dermatology community is in a position to leverage these regulations into a teachable moment,” Dr. Halpern said. “It’s important to enforce the message, even if it’s hard to enforce the actual regulations.”
Greater efforts must be made to inform parents about the dangers of indoor tanning, including the myths regarding vitamin D and the addictive nature of tanning that has been cited in several studies, Dr. Weinstock said. In addition, the motivation to use tanning beds must be addressed. The other three factors that were significantly associated with indoor tanning use were age — 16 to 18 years of age — being female, and having a positive attitude about a tan, according to the Cancer study.
Going to the tanning salon is a bonding experience for some mothers and daughters, Dr. Halpern said. Young women are especially susceptible to buying into the aesthetic of being tanned. “Ultimately we need the aesthetic sense to change. It won’t change by regulations or nerdy dermatologists,” he said, adding, “We need those who set the fashion trends to change this.”
Dermatologists also are looking to educate other health care professionals. For example, the Massachusetts Academy of Dermatology is working with the Melanoma Foundation of New England on an outreach campaign to educate pediatricians about the dangers of indoor tanning.
The bottom line is that the indoor tanning industry is large, and it’s difficult to make rapid change when a $5 billion industry is involved, Dr. Hornung concluded. There is a little momentum now and the goal is to keep it moving forward, she said.
According to the AAD’s indoor tanning resources for the media:
- On an average day in the United States, more than 1 million people use tanning salons.
- Nearly 70 percent of tanning salon patrons are Caucasian girls and women, primarily aged 16 to 29 years.
- Melanoma, the deadliest form of skin cancer, is now the second most common cancer in women ages 20 to 29 years of age.
- The FDA estimates that 3,000 hospital emergency room cases a year are due to indoor tanning bed and lamp exposure.
For more statistics on tanning, visit www.aad.org/media-resources/stats-and-facts/prevention-and-care/indoor-tanning. For more details on the prevalence of tanning in young women and their attitudes about it, read the Facts at Your Fingertips column.
JAAD study supports banning tanning
One year after a hearing of the FDA’s General and Plastic Surgery Devices Panel regarding indoor tanning, the agency continues to work on a proposed rule to carry out the panel’s opinion that more regulation of tanning is needed. In a new article in the Journal of the American Academy of Dermatology, authors Henry W. Lim, MD, William D. James, MD, Darrell S. Rigel, MD, Mary E. Maloney, MD, James M. Spencer, MD, MS, and Reva Bhushan, PhD, lay out the evidence regarding the adverse effects of ultraviolet radiation from the use of indoor tanning equipment and suggest it is “Time to ban the tan.” The article lays out the links between indoor tanning and skin cancer and recaps the evidence presented at the March 25, 2010 FDA hearing to make the case that the FDA should reclassify tanning devices. The full text of the article is available online at www.eblue.org/article/S0190-9622(10)02138-9/fulltext.