Dermatologists undaunted by indoor tanning industry's claims
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Under-18 bans, public education campaigns move forward

The Indoor Tanning Association (ITA) may be prohibited from making false health and safety claims about indoor tanning by a settlement with the Federal Trade Commission (FTC), but that isn’t stopping the industry from pursuing other strategies to promote this $5 billion business. (It isn’t stopping individual operators from making false statements about tanning’s risks to potential customers, either — see sidebar, "Congressional committee looks at tanning industry claims," for details.)

Those strategies include criticizing study findings, downplaying the link between tanning bed use and the increased incidence of melanoma, claiming that indoor tanning produces vitamin D, and suggesting hardship for small businesses.

The indoor tanning industry will use any tactic it can to promote and preserve indoor tanning for people, and young people, in particular, said Bruce A. Brod, MD, clinical associate professor of dermatology at the University of Pennsylvania School of Medicine in Philadelphia. “The bottom line is for every one of those points there is good hard data to refute it,” noted Allan Halpern, MD, chief of dermatology at Sloan-Kettering Cancer Center in New York. 

Misrepresent data, blame others

The tanning industry often tries to discredit study findings that suggest indoor tanning increases the risk of skin cancer. Tanning salon owners opposed to a proposed ban on tanning for minors sent a letter to a state senator claiming to have strong evidence that false information had been provided to the state legislature to promote passage of a bill to ban minors from indoor tanning. They singled out for criticism the International Agency for Research on Cancer (IARC) 2009 report, which found that first exposure to tanning beds before the age of 35 increases an individual’s lifetime risk of melanoma by as much as 75 percent; the ITA used a similar tactic at the Food and Drug Administration’s March 2010 hearing to consider modifying the classification of indoor tanning beds. The ITA argued that a meta-analysis, such as the IARC study, is a flawed methodology. But Henry W. Lim, MD, chairman and C.S. Livingood chair of the department of dermatology at Henry Ford Hospital in Detroit, who attended and testified at the hearing, noted that several other studies have since been published —  in Cancer Epidemiology, Biomarkers & Prevention, the International Journal of Cancer, and the American Journal of Epidemiology — and all conclude that exposure to indoor tanning increases one’s risk of developing skin cancers. All of these studies have looked exclusively at the use of indoor tanning beds, so the ITA can’t argue that dermatology-supervised phototherapy is included, Dr. Lim added.

Blaming sunscreens for increased melanoma is another common strategy. It’s true that some earlier studies have questioned whether sunscreen use is associated with an increase in melanoma, Dr. Lim said, but these studies evaluated first-generation sunscreens, which had good UVB protection, but lacked UVA protection. Most of today’s sunscreens have both good UVA and UVB protection, he noted.[pagebreak]

Tout health benefits

The ITA maintains that vitamin D production is a positive side effect of indoor tanning and notes a potential epidemic of vitamin D deficiency in North America. Dermatologists argue that the ITA overplays the potential health benefits of vitamin D. “The key point about vitamin D is that you don’t need ultraviolet light to get it,” said Martin A. Weinstock, MD, PhD, professor of dermatology and epidemiology at Brown University in Providence, R.I. Vitamin D can be obtained more reliably through diet and supplements, neither of which is associated with carcinogenic risk. Plus, these options are cheaper than indoor tanning.

The indoor tanning industry’s argument is further undermined by the fact that it started using primarily UVA-emitting light bulbs when confronted with growing evidence that UVB rays are carcinogenic and cause burns. The industry argues that today’s tanning beds emit almost exclusively UVA light, said William D. James, MD, director of the residency program, Paul Gross Professor, and vice chair in the department of dermatology at the University of Pennsylvania Health System in Philadelphia. However, UVA is not the wavelength that produces vitamin D. Moreover, the skin can convert only so much vitamin D from UV light and it happens quickly, Dr. Brod said, so getting excessive amounts of any kind of UV light doesn’t translate into higher vitamin D levels.

Claim business hardship

Additionally, the ITA argues that regulation of the indoor tanning industry will cause small businesses to close. This argument was emphasized in New York, according to Liz Dears Kent, executive director of the New York State Society of Dermatology and Dermatologic Surgery and senior vice president for legislative and regulatory affairs for the Medical Society of the State of New York. This is similar to the owners of restaurants and bars who claimed that they would lose customers and be forced out of business if a smoking ban was put into effect, she said. That didn’t happen and neither will tanning salons be put out of business should this bill become law, Kent added.

Using this same argument, the ITA has urged Congress to repeal the 10 percent tax on indoor tanning services enacted as part of health system reform. Some anti-UV tanning advocates have suggested that indoor tanning facilities can grow their spray-on tanning services as a reasonable and safe way to sustain their business.[pagebreak]

Support legislation

The dermatology community combats efforts of the indoor tanning industry primarily by supporting the passage of state laws to ban indoor tanning for minors or restrict its use while educating the public about the known health risks associated with UV radiation exposure from indoor tanning.

To date, 36 states regulate the indoor tanning industry in some way. During the last several years, tanning bills have been introduced in approximately half of the states across the country, said Kathryn Chandra, assistant director of state policy for the AADA. She expects roughly that many to be introduced in 2012, as well.

The difference between legislation introduced in years past and this year is that many of the current proposals call for a ban on indoor tanning for individuals under the age of 18. “We’re seeing more states calling for an under-age ban whereas previously new legislation was for parental consent,” said Dr. Brod, who attributes this shift largely to California, which became the first state to prohibit anyone under 18 from using indoor tanning beds as of Jan. 1. “California is often the frontrunner on legislative initiatives,” he added. When dermatologists are trying to get tanning legislation passed in their respective states, they can let legislators know that California has a law banning minors from using tanning beds. That gets the attention of legislators,” Dr. Brod said.

This difference is also a reflection of the growing scientific evidence, including growing evidence in animal models and human studies that tanning is an addictive behavior. “That’s becoming a very powerful message,” Dr. Lim said. Dr. Weinstock summed up that message: “By preventing children from indoor tanning, you prevent them from becoming addicted to it,” he said. “By the time these minors are 18 years of age, their judgment may be more developed and they may choose not to tan when they get older.”

The message is getting stronger, but credit is also due to those who have been pushing for better laws for years, according to Dr. James. “It takes a while to gain momentum,” he said. “Previous efforts have made inroads that brought this issue to the forefront for legislators.”

Each state, however, will have its own political realities to overcome, warned Ann Haas, MD, who testified before multiple committees of both houses in advance of the California bill’s passage. “What defeats these bills is politics. Things happen for political reasons, not necessarily merit,” she said. The only way to know the political inner workings is by hiring a lobbyist. “You need a lobbyist because dermatologists don’t have the time or political knowledge to do this,” Dr. Haas said. The lobbyist for the California Society of Dermatology and Dermatologic Surgery worked tirelessly with both CalDerm and the bill’s other cosponsor, the AIM at Melanoma Foundation, to get it passed, she said.

In New York, the political reality is that the small business concern is a significant threat to passage of an under-18 ban. Legislators, in particular senators from upstate New York, need to be assured that these businesses have alternative options that they can offer, Kent said.

Even as states enact laws, lack of enforcement is an issue. Including more enforcement language and building in funding mechanisms to allow for conducting routine annual inspections and levying penalties for violations can help. For instance, Dr. Brod explained, in some states, parental consent laws do not require the consenting parent to prove that he/she is the parent. “The language can be strengthened to require the parent to show identification and to stay on site as opposed to providing a note that can easily be forged,” he said. A look at New Hampshire, where there was an attempt to overturn the parental consent law because of a lack of funding, points to the importance of incorporating funding mechanisms in proposed bills. If the regulations had both licensing fees and financial penalties, states could set up systems that were financially self-sufficient, Dr. Halpern said.[pagebreak]

Enlist others

Overall, more dermatologists are taking an active role in getting legislation passed and they are becoming more savvy in doing so, Dr. Brod said. Instead of starting from scratch, they are using model legislation drafted by the AADA and working with other advocacy organizations, including the American Society for Dermatologic Surgery Association, other state medical societies, and other specialty societies, including pediatrics. In some states, dermatologists are trying to build relationships with the Department of Health, reasoning that if the health department supports passage of a bill, it will be more inclined to enforce a law.

But it’s not just dermatologists taking a more active role. “We are seeing more state medical societies, which represent all medical specialties, supporting indoor tanning legislation,” Dr. Brod said. Some medical specialty groups have used their capitol visits, which are extremely important because they get media coverage, to advocate for indoor tanning legislation, something pediatricians did last year in Pennsylvania, he added.

As a core member of the National Council for Skin Cancer Prevention, the AADA knows the value of working with other skin cancer stakeholder groups. Many of the 50 organizations that comprise the council have been very vocal in supporting tanning legislation across the country. In California, the state medical society, medical specialty associations, and nurses organizations all played a major role in getting the under-18 ban passed, Dr. Haas said. The American Cancer Society Cancer Action Network was instrumental as a grassroots organization. Similar collaborative efforts have been ongoing in New York, Kent said, adding that, “All of medicine needs to be united in this effort.”

Besides the AADA, probably the most vocal is the American Academy of Pediatrics, which last year issued a policy statement supporting a ban on tanning bed use by minors. “Pediatricians have taken a strong stand, and we would like to have more physicians and medical societies come out with that kind of statement,” noted Dr. James, who is a past president of the AAD. The Academy continues to reach out to other specialists, such as opthalmologists and plastic surgeons, who see the effects of chronic UV light in their respective patients.

Many believe that passage of the Tanning Bed Cancer Control Act, which calls for the FDA to examine the classification of indoor tanning beds, would also serve to support state-based legislation. Reclassification might lead to a youth ban as well as the ability to enforce warning signs, implement labeling recommendations included in the Tanning Accountability and Notification Act, which became law in 2007, and encourage more enforcement of state regulations, Dr. Brod said. The AADA continues its efforts on Capitol Hill to add more members of Congress to the list of cosponsors of the federal bill that was reintroduced last year.[pagebreak]

Provide public education, awareness

In addition to supporting passage of tanning legislation, the primary goal of the dermatology community has been to raise public awareness and provide education about the risks of tanning in general and the use of tanning beds in particular, Dr. Halpern said. “It’s not an attack on the indoor tanning industry. It’s a concerted effort to help the public better understand how to protect themselves from the ravages of UV exposure.”

Dr. Weinstock likened the dermatology community’s efforts to those involved in reducing tobacco consumption. When the Surgeon General’s report on tobacco was published in 1964, it created an opportunity to educate the public about the perils of smoking and led to the tobacco industry being prohibited from making claims that smoking was healthy. Similarly, the FTC settlement with the ITA and the multitude of studies linking indoor tanning to the increase in skin cancers have laid the groundwork for public education about tanning, he said.

But passing tanning legislation would enhance this drive for public education and awareness, Dr. Halpern said, because the current lack of regulation can be interpreted by the public to mean that indoor tanning is not that dangerous. “Legislation not only impacts public perception, but has the potential to directly impact behaviors through the enforcement of regulations,” he added. “[But] even if enforcement is lacking, having the legislation still accomplishes a great deal in terms of setting the proper tone for public education.”

Next on the agenda is to change the public’s perception about having a tan. “The truth is that young people care more about being tan for the prom than getting melanoma when they’re 50,” said James M. Spencer, MD, a Florida dermatologist and chair of the American Academy of Dermatology’s Melanoma/Skin Cancer Committee. “We’re losing that battle. We need to make tanning uncool.” Dr. Weinstock concurs. “We need to change glorification of the tan so that a larger variety of skin tones would be considered attractive,” he said. That is why public education must address both cultural norms and health concerns. These messages must be targeted to various demographics and use a variety of media to reach the different audiences, Dr. Lim added.

Dermatologists are undaunted by the ongoing battle they face. “This won’t be easy and it won’t go away anytime soon,” Dr. Spencer concluded. “We have our work cut out for us, but we’re in it for the long haul.” 

Congressional committee looks at tanning industry claims

Dermatologists have heard anecdotes for years about what indoor tanning salons tell potential customers regarding the risks and benefits of tanning. A report released Feb. 1 by the Democratic minority of the House Energy and Commerce Committee confirmed what many dermatologists have long suspected  — customers are not hearing the truth about tanning from salons.

The committee’s investigation consisted of contacting more than 300 tanning salons around the country, including at least three in every state, and asking each salon about the benefits and risks of indoor tanning and how frequently customers could use tanning beds. Investigators found that:

  • 90 percent of salons said tanning did not pose a health risk.
  • nearly 80 percent said tanning would have health benefits for a fair-skinned teenage girl several said it would prevent cancer.
  • about 75 percent of salons allow daily tanning, though the FDA recommends limiting indoor tanning to three visits the first week.

“The results of this investigation point to the need for policymakers to increase regulation of indoor tanning devices to help protect the health and safety of our young people,” the American Academy of Dermatology said in a statement following the report’s release. “This report demonstrates that when asked direct, simple questions about the safety of indoor tanning, the industry willfully misleads potential customers, putting their health in jeopardy.”

The full report is available online in the Academy’s State Advocacy Toolkit on indoor tanning, along with a fact sheet on indoor tanning, documents to use in meetings with legislators, and templates for communicating with the media on the issue. Visit member-tools-and-benefits/aada-advocacy/state-affairs/advocacy-toolkit.



Congressional committee looks at tanning industry claims