PUBLIC HEALTH POLICY BRIEF
Enforcement Provisions of Indoor Tanning Bans for Minors: An Analysis of the First 6 US States Several states have passed legislation banning minors from indoor tanning; however, concern has been raised regarding enforcement. We explored the statutes pertaining to enforcement in the first 6 US states to pass legislation banning minors younger than 18 years from indoor tanning. The findings reflect significant variability in enforcement provisions across the 6 states. Further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce skin cancer incidence. (Am J Public Health. 2015;105:e10–e12. doi:10. 2105/AJPH.2015.302684)
Amy L. Bulger, RN, MPH, Jonathan E. Mayer, MD, MPH, Jeffrey E. Gershenwald, MD, Samantha R. Guild, JD, Mark A. Gottlieb, JD, and Alan C. Geller, RN, MPH
SINCE 2011, 11 US STATES have passed indoor tanning bans for minors younger than 18, and many other states are currently considering similar legislation.1 Although there is unprecedented momentum for indoor tanning legislation that protects youths, the recent US Surgeon General’s Call to Action, among others, has raised concerns over whether these new statutes will be enforced.2 Policy initiatives for tobacco control can provide important lessons for control of indoor tanning, including enforcement.3 Federal tobacco enforcement policies are set forth in the Synar Amendment, an amendment to the Alcohol, Drug Abuse, and Mental Health Administration Act enacted in 1992 and implemented by the Substance Abuse and Mental Health Services Administration in 1996.4 Notably, the amendment tasks US states with enacting and enforcing legislation aimed at prohibiting the sale and distribution of tobacco to minors younger than 18 years.4 In addition to laws banning tobacco sales to people younger than 18 years, states have enacted legislation requiring licensure of tobacco retailers; random, unannounced inspections; specification of state enforcement authority; and creation of a graduated system of civil or criminal penalties for outlet owners and clerks.4 Similar to age restrictions on tobacco sales, legislation banning minors from indoor tanning may play an important role in educating the public about the risks
e10 | Public Health Policy Brief | Peer Reviewed | Bulger et al.
posed by indoor tanning and may denormalize indoor tanning by children. Legislation can also counter the indoor tanning industry’s history of deceptive marketing claims that tend to understate risks and broadly overstate any potential benefits of tanning.5
METHODS Drawing on tobacco enforcement policies and emerging tanning device policies, we assessed the enforcement provisions contained within the statutes for the first 6 states to enact bans on indoor tanning for minors younger than 18 years. Enforcement of these statutes is important to ensure compliance and decrease the potential harm to youths who seek to tan indoors with sunlamps.
provisions. We used Internet searches and telephone calls to identify state agencies and individuals responsible for enforcement of the relevant statutes. We used the same instrument that was used to review statutes to interview officials in each state by telephone or in writing between April and June 2014. We conducted the surveys to confirm that the information in statutes and on state Web sites was reliable and accurately reflected postban enforcement practices. Five of the 6 states contacted responded to the survey. For the single state where we were unable to make a personal contact, we obtained relevant information from the text of the statute and from the state’s Web site.
Measures Procedure We developed an instrument to analyze statutes and interview state officials. The enforcement measures included in the survey were compiled from tobacco youth access4,6---8 and indoor tanning literature.9,10 We used this instrument to examine the statutes and Web sites of the first 6 states enacting indoor tanning bans for children younger than 18 years that became law as of April 2014: California, Vermont, Nevada, Texas, Illinois, and Oregon. We used the National Conference of State Legislatures Web site (http:// www.ncsl.org) and Internet searches to document legislation; all 6 state Web sites contained information about the statutes and enforcement
Most of the items were derived from enforcement measures used for tobacco control,4,6---8 and the remainder were derived from the indoor tanning literature that generally consists of exploratory studies conducted in recent years.9,10 The instrument included the following items: declares use of tanning devices by those younger than 18 years illegal,4,7,9 requires tanning salon registration or licensure,4,6,9,10 clearly names the specific statewide agency or department in charge of enforcement,4,6---9 establishes tanning facility inspections,4,7---10 establishes unannounced facility inspections,4,7,8,10 declares penalties for violations,4,6,7,9,10 requires specific signage to be posted indicating
American Journal of Public Health | August 2015, Vol 105, No. 8
PUBLIC HEALTH POLICY BRIEF
TABLE 1—Enforcement Provisions in Statutes for the First 6 US States to Enact Bans on Indoor Tanning for Minors Younger Than 18 Years and Dates Law Went Into Effect California: January 20121 Vermont: May 20121 Nevada: July 20131 Texas: September 20131 Illinois: January 20141 Oregon: January 20141 Enforcement Items Declares use of tanning devices
Statute/Web
Survey
✔
✔
Statute/Web Survey Statute/Web Survey Statute/Web ✔
Survey
Statute/Web
Survey
Statute/Web
Survey
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
by those < 18 y illegal4,7,9 Requires tanning salon registration or licensure4,6,9,10 Clearly names the specific statewide agency or department in charge of enforcement4,6–9 Establishes tanning facility inspections4,7–10 Establishes unannounced
✔
INO
✔
✔
facility inspections4,7,8,10 Declares penalties for violations4,6,7,9,10
✔
✔
Requires specific signage to
✔
INO
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔+
✔+
10
11
be posted indicating ban for those < 18 y4,7,8 Opens salon to loss of license or
INO
✔
✔
✔
✔
✔
✔
✔
✔
9
10
✔
✔
permit for repeated noncompliance7 State’s requirement of salon
✔
✔
INO
✔
✔
INO
to verify client’s age7–9 Requires salon to maintain
✔
✔
✔
✔
documentation on all clients9,10 Maintains public online access to violations6 Total no. (of 11 items)
INO 4
4
3
NA
4
4
7
8
Note. INO = information not obtained; NA = not applicable; ✔ = item included in statute, online, or affirmative “yes” from surveyed official; ✔+ = item was being implemented but not yet active at time of survey.
ban for those younger than 18 years,4,7,8 opens salon to loss of license or permit for repeated noncompliance,7 states requirement of salon to verify client’s age,7---9 requires salon to maintain documentation on all clients,9,10 and maintains public online access to violations.6 The results from the statutes, Web sites, and surveys were independently evaluated (A. L. B., J. E. M.), and any differences in interpretation were resolved.
RESULTS The results are presented in Table 1. We found that all 6
statutes contain some enforcement provisions, including declaring penalties for salons that violate the statutes. Among the 6 states for which we reviewed enforcement provisions, the fourth, fifth, and sixth states (Texas, Illinois, and Oregon) had the most comprehensive enforcement provisions: requiring tanning salon registration or licensure, naming the specific agency or department in charge of enforcement, establishing tanning facility inspections, and opening salons to loss of license or permit for repeated noncompliance. By contrast, the first 3 states enacting legislation (California, Vermont,
August 2015, Vol 105, No. 8 | American Journal of Public Health
and Nevada) lacked many of these enforcement provisions.
DISCUSSION Eleven states have passed legislation banning indoor tanning for youths younger than 18 years (as of April 17, 2015).1 We analyzed enforcement provisions in the months after the sixth state enacted new legislation in January 2014. Enacting such legislation is both laudable and noteworthy, but the potential reduction of youth indoor tanning and risk of skin cancer cannot be fully realized without proper enforcement. As
such, we were concerned that current statutes and those yet to be proposed would lack essential enforcement provisions. After comparing enforcement provisions in each state with the components listed in Table 1, substantial variation among states in the comprehensiveness of enforcement policies was noted. There is room for cautious optimism because the 3 states— Texas, Illinois, and Oregon—that built bans on indoor tanning for those younger than 18 years on top of preexisting tanning legislation have stronger enforcement provisions. Advocates considering new indoor tanning legislation for
Bulger et al. | Peer Reviewed | Public Health Policy Brief | e11
PUBLIC HEALTH POLICY BRIEF
those younger than 18 years should insist on the inclusion of comprehensive enforcement provisions, such as delegating authority to a particular agency that is best equipped for regulation and enforcement of these devices. Going forward, advocates and legislators in the first 3 states should seek to amend current statutes to match the stronger provisions in Texas, Illinois, and Oregon. After the completion of the telephone surveys and investigation of statutes in the first 6 states, 5 new states passed similar legislation banning underage tanning: Washington (June 2014), Hawaii and Minnesota (July 2014), Louisiana (August 2014), and Delaware (January 2015).1 With resource constraints, we were unable to survey officials in these states. However, 2 themes emerged on examination of the statutes. In 3 of the 5 states (Washington, Hawaii, and Delaware), monetary fines were proposed, starting at $250 for the first offense. In addition, 3 of the 5 states (Minnesota, Hawaii, and Louisiana) require signage to be displayed at the entrance of the facility or in a conspicuous place specifically stating that it is unlawful for minors (younger than 18 years) to use tanning equipment. Future research is needed to investigate the actual enforcement of the provisions in the first 6 states and in the 5 states that have enacted legislation most recently. It is also important to study whether tanning rates are more likely to decline in states with local versus state enforcement of provisions. Methodologically, it also may be useful to experiment with other grading systems such as the equal weighting approach used herein. It is also important to study whether the severity of the sanctions correlates with the effectiveness of the enforcement and whether
lessons learned from the latter stages of antitobacco enforcement for youths can be applied more rigorously to tanning device legislation. Finally, further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce the incidence of skin cancer. j
About the Authors Amy L. Bulger, Jonathan E. Mayer, and Alan C. Geller are with Harvard T. H. Chan School of Public Health, Boston, MA. Jeffrey E. Gershenwald is with the Departments of Surgical Oncology and Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston. Samantha R. Guild is with AIM at Melanoma, Richmond, CA. Mark A. Gottlieb is with Public Health Advocacy Institute at Northeastern University School of Law, Boston. Correspondence should be sent to Alan C. Geller, MPH, RN, Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, 677 Huntington Ave, Boston, MA 02115 (e-mail: ageller@hsph. harvard.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This brief was accepted March 23, 2015.
Contributors A. L. Bulger and J. E. Mayer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. A. L. Bulger, J. E. Mayer, and A. C. Geller originated the study concept and design and drafted the brief. A. C. Geller supervised the study. All authors analyzed and interpreted the data and critically revised the brief for important intellectual content.
2. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2014. 3. Seidenberg AB, Mahalingam-dhingra A, Weinstock MA, Sinclair C, Geller AC. Youth indoor tanning and skin cancer prevention. Am J Prev Med. 2015;48 (2):188---194. 4. Substance Abuse and Mental Health Services Administration. Evidence of the Synar Program’s success. 2014. Available at: http://beta.samhsa.gov/synar/success. Accessed October 5, 2014. 5. Federal Trade Commission. In the matter of Indoor Tanning Association. May 19, 2010. Available at: http://www. ftc.gov/enforcement/cases-proceedings/ 082-3159/indoor-tanning-associationmatter. Accessed February 2, 2015. 6. DiFranza JR. Best practices for enforcing state laws prohibiting the sale of tobacco to minors. J Public Health Manag Pract. 2005;11(6):559---565. 7. Alciati MH, Frosh M, Green SB, et al. State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system. Tob Control. 1998;7(4):345---352. 8. Grucza RA, Plunk AD, Hipp PR, et al. Long-term effects of laws governing youth access to tobacco. Am J Public Health. 2013;103(8):1493---1499. 9. Gosis B, Sampson BP, Seidenberg AB, Balk SJ, Gottlieb M, Geller AC. Comprehensive evaluation of indoor tanning regulations: a 50-state analysis, 2012. J Invest Dermatol. 2014;134(3):620---627. 10. Mayer JA, Hoerster KD, Pichon LC, Rubio DA, Woodruff SI, Forster JL. Enforcement of state indoor tanning laws in the United States. Prev Chronic Dis. 2008;5(4):A125.
Human Participant Protection The study protocol was approved by the Harvard University institutional review board.
References 1. National Conference of State Legislatures. Indoor tanning restrictions for minors: a state-by-state comparison. 2014. Available at: http://www.ncsl. org/research/health/indoor-tanningrestrictions.aspx. Accessed August 1, 2014.
e12 | Public Health Policy Brief | Peer Reviewed | Bulger et al.
American Journal of Public Health | August 2015, Vol 105, No. 8
Enforcement Provisions of Indoor Tanning Bans for Minors: An Analysis of the First 6 US States Several states have passed legislation banning minors from indoor tanning; however, concern has been raised regarding enforcement. We explored the statutes pertaining to enforcement in the first 6 US states to pass legislation banning minors younger than 18 years from indoor tanning. The findings reflect significant variability in enforcement provisions across the 6 states. Further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce skin cancer incidence. (Am J Public Health. 2015;105:e10–e12. doi:10. 2105/AJPH.2015.302684)
Amy L. Bulger, RN, MPH, Jonathan E. Mayer, MD, MPH, Jeffrey E. Gershenwald, MD, Samantha R. Guild, JD, Mark A. Gottlieb, JD, and Alan C. Geller, RN, MPH
SINCE 2011, 11 US STATES have passed indoor tanning bans for minors younger than 18, and many other states are currently considering similar legislation.1 Although there is unprecedented momentum for indoor tanning legislation that protects youths, the recent US Surgeon General’s Call to Action, among others, has raised concerns over whether these new statutes will be enforced.2 Policy initiatives for tobacco control can provide important lessons for control of indoor tanning, including enforcement.3 Federal tobacco enforcement policies are set forth in the Synar Amendment, an amendment to the Alcohol, Drug Abuse, and Mental Health Administration Act enacted in 1992 and implemented by the Substance Abuse and Mental Health Services Administration in 1996.4 Notably, the amendment tasks US states with enacting and enforcing legislation aimed at prohibiting the sale and distribution of tobacco to minors younger than 18 years.4 In addition to laws banning tobacco sales to people younger than 18 years, states have enacted legislation requiring licensure of tobacco retailers; random, unannounced inspections; specification of state enforcement authority; and creation of a graduated system of civil or criminal penalties for outlet owners and clerks.4 Similar to age restrictions on tobacco sales, legislation banning minors from indoor tanning may play an important role in educating the public about the risks
e10 | Public Health Policy Brief | Peer Reviewed | Bulger et al.
posed by indoor tanning and may denormalize indoor tanning by children. Legislation can also counter the indoor tanning industry’s history of deceptive marketing claims that tend to understate risks and broadly overstate any potential benefits of tanning.5
METHODS Drawing on tobacco enforcement policies and emerging tanning device policies, we assessed the enforcement provisions contained within the statutes for the first 6 states to enact bans on indoor tanning for minors younger than 18 years. Enforcement of these statutes is important to ensure compliance and decrease the potential harm to youths who seek to tan indoors with sunlamps.
provisions. We used Internet searches and telephone calls to identify state agencies and individuals responsible for enforcement of the relevant statutes. We used the same instrument that was used to review statutes to interview officials in each state by telephone or in writing between April and June 2014. We conducted the surveys to confirm that the information in statutes and on state Web sites was reliable and accurately reflected postban enforcement practices. Five of the 6 states contacted responded to the survey. For the single state where we were unable to make a personal contact, we obtained relevant information from the text of the statute and from the state’s Web site.
Measures Procedure We developed an instrument to analyze statutes and interview state officials. The enforcement measures included in the survey were compiled from tobacco youth access4,6---8 and indoor tanning literature.9,10 We used this instrument to examine the statutes and Web sites of the first 6 states enacting indoor tanning bans for children younger than 18 years that became law as of April 2014: California, Vermont, Nevada, Texas, Illinois, and Oregon. We used the National Conference of State Legislatures Web site (http:// www.ncsl.org) and Internet searches to document legislation; all 6 state Web sites contained information about the statutes and enforcement
Most of the items were derived from enforcement measures used for tobacco control,4,6---8 and the remainder were derived from the indoor tanning literature that generally consists of exploratory studies conducted in recent years.9,10 The instrument included the following items: declares use of tanning devices by those younger than 18 years illegal,4,7,9 requires tanning salon registration or licensure,4,6,9,10 clearly names the specific statewide agency or department in charge of enforcement,4,6---9 establishes tanning facility inspections,4,7---10 establishes unannounced facility inspections,4,7,8,10 declares penalties for violations,4,6,7,9,10 requires specific signage to be posted indicating
American Journal of Public Health | August 2015, Vol 105, No. 8
PUBLIC HEALTH POLICY BRIEF
TABLE 1—Enforcement Provisions in Statutes for the First 6 US States to Enact Bans on Indoor Tanning for Minors Younger Than 18 Years and Dates Law Went Into Effect California: January 20121 Vermont: May 20121 Nevada: July 20131 Texas: September 20131 Illinois: January 20141 Oregon: January 20141 Enforcement Items Declares use of tanning devices
Statute/Web
Survey
✔
✔
Statute/Web Survey Statute/Web Survey Statute/Web ✔
Survey
Statute/Web
Survey
Statute/Web
Survey
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
INO
✔
✔
by those < 18 y illegal4,7,9 Requires tanning salon registration or licensure4,6,9,10 Clearly names the specific statewide agency or department in charge of enforcement4,6–9 Establishes tanning facility inspections4,7–10 Establishes unannounced
✔
INO
✔
✔
facility inspections4,7,8,10 Declares penalties for violations4,6,7,9,10
✔
✔
Requires specific signage to
✔
INO
✔
✔
✔
INO
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔+
✔+
10
11
be posted indicating ban for those < 18 y4,7,8 Opens salon to loss of license or
INO
✔
✔
✔
✔
✔
✔
✔
✔
9
10
✔
✔
permit for repeated noncompliance7 State’s requirement of salon
✔
✔
INO
✔
✔
INO
to verify client’s age7–9 Requires salon to maintain
✔
✔
✔
✔
documentation on all clients9,10 Maintains public online access to violations6 Total no. (of 11 items)
INO 4
4
3
NA
4
4
7
8
Note. INO = information not obtained; NA = not applicable; ✔ = item included in statute, online, or affirmative “yes” from surveyed official; ✔+ = item was being implemented but not yet active at time of survey.
ban for those younger than 18 years,4,7,8 opens salon to loss of license or permit for repeated noncompliance,7 states requirement of salon to verify client’s age,7---9 requires salon to maintain documentation on all clients,9,10 and maintains public online access to violations.6 The results from the statutes, Web sites, and surveys were independently evaluated (A. L. B., J. E. M.), and any differences in interpretation were resolved.
RESULTS The results are presented in Table 1. We found that all 6
statutes contain some enforcement provisions, including declaring penalties for salons that violate the statutes. Among the 6 states for which we reviewed enforcement provisions, the fourth, fifth, and sixth states (Texas, Illinois, and Oregon) had the most comprehensive enforcement provisions: requiring tanning salon registration or licensure, naming the specific agency or department in charge of enforcement, establishing tanning facility inspections, and opening salons to loss of license or permit for repeated noncompliance. By contrast, the first 3 states enacting legislation (California, Vermont,
August 2015, Vol 105, No. 8 | American Journal of Public Health
and Nevada) lacked many of these enforcement provisions.
DISCUSSION Eleven states have passed legislation banning indoor tanning for youths younger than 18 years (as of April 17, 2015).1 We analyzed enforcement provisions in the months after the sixth state enacted new legislation in January 2014. Enacting such legislation is both laudable and noteworthy, but the potential reduction of youth indoor tanning and risk of skin cancer cannot be fully realized without proper enforcement. As
such, we were concerned that current statutes and those yet to be proposed would lack essential enforcement provisions. After comparing enforcement provisions in each state with the components listed in Table 1, substantial variation among states in the comprehensiveness of enforcement policies was noted. There is room for cautious optimism because the 3 states— Texas, Illinois, and Oregon—that built bans on indoor tanning for those younger than 18 years on top of preexisting tanning legislation have stronger enforcement provisions. Advocates considering new indoor tanning legislation for
Bulger et al. | Peer Reviewed | Public Health Policy Brief | e11
PUBLIC HEALTH POLICY BRIEF
those younger than 18 years should insist on the inclusion of comprehensive enforcement provisions, such as delegating authority to a particular agency that is best equipped for regulation and enforcement of these devices. Going forward, advocates and legislators in the first 3 states should seek to amend current statutes to match the stronger provisions in Texas, Illinois, and Oregon. After the completion of the telephone surveys and investigation of statutes in the first 6 states, 5 new states passed similar legislation banning underage tanning: Washington (June 2014), Hawaii and Minnesota (July 2014), Louisiana (August 2014), and Delaware (January 2015).1 With resource constraints, we were unable to survey officials in these states. However, 2 themes emerged on examination of the statutes. In 3 of the 5 states (Washington, Hawaii, and Delaware), monetary fines were proposed, starting at $250 for the first offense. In addition, 3 of the 5 states (Minnesota, Hawaii, and Louisiana) require signage to be displayed at the entrance of the facility or in a conspicuous place specifically stating that it is unlawful for minors (younger than 18 years) to use tanning equipment. Future research is needed to investigate the actual enforcement of the provisions in the first 6 states and in the 5 states that have enacted legislation most recently. It is also important to study whether tanning rates are more likely to decline in states with local versus state enforcement of provisions. Methodologically, it also may be useful to experiment with other grading systems such as the equal weighting approach used herein. It is also important to study whether the severity of the sanctions correlates with the effectiveness of the enforcement and whether
lessons learned from the latter stages of antitobacco enforcement for youths can be applied more rigorously to tanning device legislation. Finally, further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce the incidence of skin cancer. j
About the Authors Amy L. Bulger, Jonathan E. Mayer, and Alan C. Geller are with Harvard T. H. Chan School of Public Health, Boston, MA. Jeffrey E. Gershenwald is with the Departments of Surgical Oncology and Cancer Biology, The University of Texas MD Anderson Cancer Center, Houston. Samantha R. Guild is with AIM at Melanoma, Richmond, CA. Mark A. Gottlieb is with Public Health Advocacy Institute at Northeastern University School of Law, Boston. Correspondence should be sent to Alan C. Geller, MPH, RN, Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, 677 Huntington Ave, Boston, MA 02115 (e-mail: ageller@hsph. harvard.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This brief was accepted March 23, 2015.
Contributors A. L. Bulger and J. E. Mayer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. A. L. Bulger, J. E. Mayer, and A. C. Geller originated the study concept and design and drafted the brief. A. C. Geller supervised the study. All authors analyzed and interpreted the data and critically revised the brief for important intellectual content.
2. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2014. 3. Seidenberg AB, Mahalingam-dhingra A, Weinstock MA, Sinclair C, Geller AC. Youth indoor tanning and skin cancer prevention. Am J Prev Med. 2015;48 (2):188---194. 4. Substance Abuse and Mental Health Services Administration. Evidence of the Synar Program’s success. 2014. Available at: http://beta.samhsa.gov/synar/success. Accessed October 5, 2014. 5. Federal Trade Commission. In the matter of Indoor Tanning Association. May 19, 2010. Available at: http://www. ftc.gov/enforcement/cases-proceedings/ 082-3159/indoor-tanning-associationmatter. Accessed February 2, 2015. 6. DiFranza JR. Best practices for enforcing state laws prohibiting the sale of tobacco to minors. J Public Health Manag Pract. 2005;11(6):559---565. 7. Alciati MH, Frosh M, Green SB, et al. State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system. Tob Control. 1998;7(4):345---352. 8. Grucza RA, Plunk AD, Hipp PR, et al. Long-term effects of laws governing youth access to tobacco. Am J Public Health. 2013;103(8):1493---1499. 9. Gosis B, Sampson BP, Seidenberg AB, Balk SJ, Gottlieb M, Geller AC. Comprehensive evaluation of indoor tanning regulations: a 50-state analysis, 2012. J Invest Dermatol. 2014;134(3):620---627. 10. Mayer JA, Hoerster KD, Pichon LC, Rubio DA, Woodruff SI, Forster JL. Enforcement of state indoor tanning laws in the United States. Prev Chronic Dis. 2008;5(4):A125.
Human Participant Protection The study protocol was approved by the Harvard University institutional review board.
References 1. National Conference of State Legislatures. Indoor tanning restrictions for minors: a state-by-state comparison. 2014. Available at: http://www.ncsl. org/research/health/indoor-tanningrestrictions.aspx. Accessed August 1, 2014.
e12 | Public Health Policy Brief | Peer Reviewed | Bulger et al.
American Journal of Public Health | August 2015, Vol 105, No. 8
