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State Indoor Tanning Laws and Adolescent Indoor Tanning Gery P. Guy Jr, PhD, MPH, Zahava Berkowitz, MSc, MSPH, Sherry Everett Jones, PhD, JD, MPH, Emily O’Malley Olsen, MSPH, Justin N. Miyamoto, MD, Shannon L. Michael, PhD, MPH, and Mona Saraiya, MD, MPH
Skin cancer is the most common cancer in the United States. Approximately 3.5 million cases of nonmelanoma skin cancers are treated annually, while more than 60 000 melanomas are diagnosed annually.1,2 In addition, skin cancer poses a substantial economic burden, with annual direct medical costs of treatment estimated at $1.7 billion in 2004.3 During the past decade, while most cancers decreased, melanoma increased, especially among young adult women.4 Indoor tanning is thought to be partially responsible for this increase.4---6 Indoor tanning before age 35 years increases the risk of melanoma by 59%,5,7 and indoor tanning before age 25 years increases the risk of basal cell carcinoma by 40% and squamous cell carcinoma by 102%.8 Despite these known health risks, indoor tanning is common among adolescents—6.2% of male high school students and 20.9% of female high school students engaged in indoor tanning in 2011.9 In recent years, several states have enacted laws restricting youth access to indoor tanning and laws aimed at reducing consumers’ risk, including facility and operator responsibilities, safety and equipment standards, enforcement authority, and penalties.10 Previous studies that were primarily focused on youth access laws found poor compliance rates among tanning facilities for parental permission laws.11---13 In addition, such laws were ineffective in reducing indoor tanning among adolescents.14,15 Since these earlier studies were conducted, the number of states implementing youth access laws, particularly age restrictions, has increased substantially.16 Although some evidence has suggested that age restrictions may reduce access to indoor tanning among minors,17 no national or international studies have examined the effects these laws have on adolescent indoor tanning behavior. We examined the association between state indoor tanning laws, including age restrictions, and indoor tanning among high school students.
Objectives. Recently, several state indoor tanning laws, including age restrictions, were promulgated to reduce indoor tanning among minors. We examined the effects of these laws on adolescent indoor tanning. Methods. We used nationally representative data from the 2009 and 2011 national Youth Risk Behavior Surveys (n = 31 835). Using multivariable logistic regression, we examined the association between state indoor tanning laws and indoor tanning among US high school students. Results. Female students in states with indoor tanning laws were less likely to engage in indoor tanning than those in states without any laws. We observed a stronger association among female students in states with systems access, parental permission, and age restriction laws than among those in states without any laws. We found no significant association among female students in states with only systems access and parental permission laws or among male students. Conclusions. Indoor tanning laws, particularly those including age restrictions, may be effective in reducing indoor tanning among female high school students, for whom rates are the highest. Such reductions have the potential to reduce the health and economic burden of skin cancer. (Am J Public Health. 2014;104: e69–e74. doi:10.2105/AJPH.2013.301850)
METHODS The national Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention, is a cross-sectional survey conducted biennially since 1991. In each survey year, an independent, 3-stage, cluster sample design is used to obtain a nationally representative sample of public and private school students in grades 9 through 12.18 Student participation in the YRBS is anonymous and voluntary, and the YRBS is conducted in accordance with parental permission procedures in each locality. Because data used in these analyses contain no personal identifying information, this study was exempt from institutional review board review. Participants complete a self-administered questionnaire during a regular class period and record their responses on a computer-scannable questionnaire booklet or answer sheet. The overall response rates were 71% for both 2009 and 2011, and sample sizes were 16 410 and 15 425, respectively. Weights were applied to adjust for school and student nonresponse and oversampling of Black and Hispanic students.
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Data from the 2009 and 2011 YRBS were combined to increase the number of states represented by student respondents. State identifiers were attached to each student record. During 2009 and 2011, 32 states had students selected for the YRBS and asked about indoor tanning; students were from 18 states in both years, 6 states were included only in 2009, and 8 states were included only in 2011. The national YRBS sample is designed to obtain nationally representative estimates for US high school students during any given year; it is not designed to produce state estimates of student behavior and does not select students from every state. Further details on the YRBS have been reported elsewhere.9,18---20
Indoor Tanning In both 2009 and 2011, students were asked, “During the past 12 months, how many times did you use an indoor tanning device, such as a sunlamp, sunbed, or tanning booth? (Do not include getting a spray-on tan.)” Responses included “0 times,” “1 or 2 times,” “3 to 9 times,” “10 to 19 times,” “20 to 39 times,” and “40 or more times.” Indoor tanning was
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defined as having used an indoor tanning device 1 or more times during the 12 months before the survey.
these law-type categories from the analysis using the 3-level law variable.
Analysis State Indoor Tanning Laws We compiled details about each state’s indoor tanning laws by using the National Conference of State Legislatures Web site, 21 the National Cancer Institute State Cancer Legislative Database Program, 22 and published reports,16,23 and these details were confirmed by using each state’s legislative Web site. We included laws in effect at the beginning of each survey year in our analyses. State indoor tanning laws were classified as addressing either youth access or systems access to indoor tanning. Detailed descriptions of the laws are presented in the box on this page. For the analysis, we first examined the association between indoor tanning and the presence of any indoor tanning law, either systems access or youth access. To further examine the role of different types of youth access laws on indoor tanning, we developed a 3-level law variable, categorizing states into 3 law-type groups: those with no state indoor tanning laws, those with only systems access laws and parental permission laws, and those with systems access laws, parental permission laws, and age restrictions. We excluded students from 3 states that did not fit into any of
To account for the complex sample design of the survey and weighting of student records, we conducted all analyses with SUDAAN statistical software version 10.1 (Research Triangle Institute, Research Triangle Park, NC). Given the differences in indoor tanning by gender, race/ethnicity, and grade,9,19 we stratified all analyses by gender and controlled multivariable analyses for race/ethnicity and grade. Differences in the unadjusted prevalence of indoor tanning by state tanning laws were assessed with linear contrasts. We used multivariable logistic regression models to examine the association between state indoor tanning laws and indoor tanning among female and male students. A 2-sided P value of < .05 was considered statistically significant. Because national YRBS data are not designed to be representative below the national level, we conducted sensitivity analyses to examine the stability of the relationship between state indoor tanning laws and indoor tanning. We used a jackknife procedure in which we ran 32 multivariable logistic regression models, iteratively removing all students from 1 state and comparing the new model results to the base model results with all students included.
RESULTS A total of 25 758 high school students were included in our analysis, of whom 12 914 were female and 12 844 were male.
Female High School Students Overall, 23.4% of female high school students engaged in indoor tanning. The prevalence was lower in states with any indoor tanning laws (21.2%) than in states without any indoor tanning laws (30.1%). In the analysis using the 3-level law variable, the prevalence of indoor tanning was lowest among female students in states with systems access, parental permission, and age restrictions (17.1%; Table 1). In the multivariable logistic regression models, indoor tanning was negatively associated with the presence of any state indoor tanning law (adjusted odds ratio [AOR] = 0.70; 95% confidence interval [CI] = 0.51, 0.97; P = .03; Table 2). In the analysis that used the 3-level law variable, indoor tanning among female students was negatively associated with the combination of systems access, parental permission, and age restriction laws compared with those states with no indoor tanning laws (AOR = 0.58, 95% CI = 0.41, 0.83, P = .003). We found no statistically significant difference in the odds of indoor tanning among female students in states with only systems access and parental permission laws compared with those
Definitions of State Indoor Tanning Laws by Category Systems Access Warning statement Any requirement of indoor tanning device operator to obtain signed
Youth Access Parental permission Laws that prohibit minors younger than a certain age from using an indoor tanning
warning statement from patron Warning sign Any requirement of indoor tanning device operator to post warning sign Restricted advertising Hazard-free, safe, and medically beneficial advertising prohibited Mandatory protective eyewear
device without d
Parental consent
d
Parental accompaniment
Age restrictions Laws that prohibit minors younger than a certain age from using an indoor tanning device
Any protective eyewear requirement Mandatory operator-required incident reports Any incident report requirement Penalty for violation Any civil or financial penalty or licensing suspension
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TABLE 1—Prevalence of Indoor Tanning Among High School Students by State Indoor Tanning Laws: National Youth Risk Behavior Survey, United States, 2009 and 2011 Type of Indoor Tanning Lawb
No.
Systems Access and Parental Permission Law (n = 13), % (95% CI)
Systems Access, Parental Permission, and Age Restriction Law (n = 8), % (95% CI)
21.2c (18.8, 23.9)
11 821
26.3 (20.9, 32.5)
17.1c,d (14.4, 20.2)
Presence of Any Indoor Tanning Lawa Variable
No.
All Study States (n = 32), % (95% CI)
No State Laws (n = 11), % (95% CI)
12 914
23.4 (21.1, 25.7)
30.1 (24.3, 36.7)
Any Indoor Tanning Law (n = 23), % (95% CI) Female
Overall School grade 9th
3229
14.0 (12.1, 16.1)
19.5 (14.6, 25.7)
12.4c (10.5, 14.6)
2956
15.3 (11.7, 19.8)
10.5c (8.1, 13.4)
10th 11th
3186 3286
19.8 (17.0, 23.0) 28.6 (25.5, 31.9)
29.8 (22.7, 38.0) 34.0 (27.3, 41.3)
16.7c (13.9, 19.9) 26.9 (23.2, 30.8)
2893 3002
22.1 (15.2, 31.1) 34.2 (26.8, 42.5)
13.4c,d (10.5, 16.8) 20.5c,d (16.6, 25.0)
12th
3174
32.9 (29.5, 36.4)
38.2 (30.8, 46.2)
31.1 (27.2, 35.3)
2937
35.3 (28.4, 42.9)
26.0c (21.0, 31.8)
White, Non-Hispanic
5799
33.7 (30.9, 36.6)
38.9 (32.6, 45.6)
31.7 (28.6, 35.0)
5054
36.7 (30.4, 43.5)
27.6c,d (23.7, 32.0)
Black, Non-Hispanic
2101
2.9 (2.1, 4.0)
3.2 (2.0, 4.9)
2.9 (1.9, 4.2)
2042
2.1 (1.0, 4.8)
2.9 (1.8, 4.7)
Hispanic
3575
10.1 (8.6, 11.9)
16.1 (9.8, 25.5)
9.3 (7.8, 11.1)
3408
13.9 (8.7, 21.5)
7.7 (6.2, 9.4)
Other, Non-Hispanic
1259
10.1 (7.4, 13.6)
17.3 (9.3, 29.9)
8.2c (6.1, 10.9)
1154
8.7c (4.9, 14.8)
7.8c (5.2, 11.4)
6.5 (5.6, 7.4)
7.1 (5.2, 9.7)
11 657
7.9 (6.0, 10.4)
5.6 (4.5, 7.0)
Race/ethnicity
Male Overall
12 844
6.3 (5.3, 7.4)
School grade 9th
3117
5.3 (4.4, 6.3)
6.0 (4.2, 8.4)
5.1 (4.1, 6.2)
2807
5.9 (4.4, 7.8)
5.1 (3.8, 6.9)
10th
3081
4.7 (3.7, 6.1)
4.7 (2.6, 8.5)
4.7 (3.6, 6.2)
2759
6.2 (4.3, 9.0)
4.2d (3.0, 6.0)
11th
3342
6.9 (5.5, 8.7)
7.5 (4.9, 11.4)
6.7 (5.1, 8.8)
3058
8.3 (4.6, 14.4)
5.6 (4.1, 7.5)
12th
3243
9.3 (7.7, 11.2)
9.9 (6.6, 14.7)
9.1 (7.4, 11.1)
2975
12.6 (9.2, 16.9)
7.6 (5.6, 10.3)
5978 1973
6.7 (5.6, 8.0) 5.5 (4.0, 7.4)
7.0 (4.9, 10.1) 5.8 (4.2, 8.0)
6.6 (5.3, 8.1) 5.3 (3.6, 7.9)
5136 1916
8.9 (6.2, 12.6) 4.5 (2.7, 7.7)
5.6d (4.3, 7.3) 6.1 (3.6, 10.1)
Race/ethnicity White, Non-Hispanic Black, Non-Hispanic Hispanic
3460
5.8 (4.7, 7.0)
6.7 (3.8, 11.7)
5.6 (4.5, 7.0)
3309
8.6 (5.3, 13.5)
4.8 (3.7, 6.3)
Other, Non-Hispanic
1213
6.8 (5.0, 9.1)
8.7 (4.5, 16.3)
6.3 (4.6, 8.6)
1101
6.8 (3.9, 11.6)
5.8 (3.8, 8.9)
Note. Indoor tanning defined as using an indoor tanning device, such as a sunlamp, sunbed, or tanning booth ‡ 1 time during the 12 months before the survey. Does not include getting a spray-on tan. Estimates based on weighted data. The sample sizes are unweighted. a Student records from 32 states were included in the analysis. b Students from 3 states not fitting into any of these categories were excluded from the analysis when using the 3-level law variable. c Significantly different from no state law. d Significantly different from systems access and parental permission law.
in states with no laws (Table 2). Additionally, the odds of indoor tanning among female students in states with a combination of systems access, parental permission, and age restriction laws were significantly lower than those in states with only systems access and parental permission laws (P = .02).
multivariable logistic regression models, indoor tanning among male students was not associated with the presence of any state indoor tanning laws (Table 2). Similarly, we found no significant association between male indoor tanning and the 3-level law variable (Table 2).
Sensitivity Analysis Male High School Students Overall, 6.5% of male students reported indoor tanning, and we found no statistically significant differences in the prevalence of indoor tanning by type of law (Table 1). In the
The results of the sensitivity analysis suggest the conclusions are stable. Among female students, the relationship between the presence of any law and indoor tanning remained significant for all but 4 iterations of the sensitivity models.
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For 3 of those 4 models, the P value was less than .1, and for the fourth, the P value was .15. We repeated this process for the 3-level law variable. Among female students, the findings for all model iterations were consistent with the base model. Among male students, all models used in the sensitivity analysis were consistent with the base models for both law analyses.
DISCUSSION Our study documents that state indoor tanning laws were associated with a significant
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TABLE 2—Association Between Indoor Tanning and State Indoor Tanning Laws: National Youth Risk Behavior Survey, United States, 2009 and 2011 Three-Level Law Componenta
Presence of Any Law Variable
Female (n = 12 711), AORb (95% CI)
No state laws (Ref)
1.00
Any indoor tanning law (systems or youth access) Systems access and parental permission law
0.70 (0.51, 0.97)
P
Male (n = 12 580), AORb (95% CI)
.03
0.93 (0.63, 1.36)
P
1.00
Female (n = 11 640), AORb (95% CI)
P
1.00
Male (n = 11 420), AORb (95% CI)
P
1.00
.7
Systems access, parental permission, and age restriction law
0.89 (0.60, 1.32)
.55
1.22 (0.78, 1.91)
.37
0.58c (0.41, 0.83)
.003
0.81 (0.54, 1.23)
.32
School grade 9th (Ref)
1.00
1.00
1.00
10th
1.49 (1.22, 1.82)
< .001
0.87 (0.66, 1.15)
.31
1.51 (1.21, 1.89)
0.87 (0.65, 1.14)
11th
2.45 (2.03, 2.95)
< .001
1.31 (1.01, 1.71)
.04
2.37 (1.95, 2.89)
< .001
1.24 (0.92, 1.66)
.16
12th
2.98 (2.46, 3.61)
< .001
1.84 (1.44, 2.36)
< .001
2.84 (2.32, 3.48)
< .001
1.80 (1.38, 2.36)
< .001
Race/ethnicity White, Non-Hispanic (Ref)
1.00
1.00
1.00
1.00
.3
1.00
Black, Non-Hispanic
0.06 (0.04, 0.08)
< .001
0.83 (0.57, 1.21)
.33
0.05 (0.04, 0.08)
< .001
0.81 (0.54, 1.20)
Hispanic
0.23 (0.19, 0.29)
< .001
0.87 (0.67, 1.13)
.3
0.24 (0.19, 0.31)
< .001
0.89 (0.68, 1.17)
.29 .4
Other, Non-Hispanic
0.23 (0.16, 0.31)
< .001
1.00 (0.73, 1.35)
.98
0.23 (0.17, 0.33)
< .001
0.98 (0.71, 1.34)
.88
Note. AOR = adjusted odds ratio; CI = confidence interval. Indoor tanning was defined as using a sunlamp, sunbed, or tanning booth ‡ 1 time during the 12 months before the survey. It does not include getting a spray-on tan. Estimates are based on weighted data. a Students from 3 states not fitting into any of these categories were excluded from the analysis when using the 3-level law variable. b Adjusted for school grade and race/ethnicity. c Significantly different than systems access and parental permission law (AOR = 0.65; 95% CI = 0.46, 0.92; P = .02).
reduction in indoor tanning among female high school students. The adjusted odds of indoor tanning among female high school students in states with any indoor tanning laws were 30% less than those in states without any indoor tanning laws. Moreover, the adjusted odds of indoor tanning among female high school students in states with systems access, parental permission, and age restriction laws were 42% less than those in states without any indoor tanning laws. We found no significant associations between indoor tanning and states with only systems access and parental permission laws among female students. Additionally, we found no significant associations between indoor tanning and state indoor tanning laws among male students, potentially because of the lower prevalence of indoor tanning and the older age of initiation among male students compared with female students.24 These findings suggest that indoor tanning laws and age restrictions, in particular, may be effective in reducing indoor tanning among female students, for whom the prevalence of indoor tanning is the highest. Two previous studies examining youth access laws found limited effectiveness in
reducing indoor tanning. Their authors concluded that this limited effectiveness was likely caused by state policies permitting use with parental permission.14,15 In addition, our study found that parental permission laws without an age restriction were not associated with a lower prevalence of indoor tanning. This result may partly stem from parental modeling of and permissive attitudes toward indoor tanning,14,25 possible forging of a parent’s signature,15 and poor compliance.11---13 Compliance is an important component to ensure the effectiveness of any law. For example, a 21% reduction in the odds of youth smoking was attributed to improved compliance with tobacco youth access laws.26 Studies have found poor compliance by tanning facilities with youth access indoor tanning laws at the state and local levels. For example, in San Diego, California, only 43% of indoor tanning facilities were compliant with parental permission laws,11 and only 13% of facilities in North Carolina12 and 19% of facilities in Minnesota and Massachusetts were compliant.13 Our findings build on those of previous studies by examining the association of age
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restrictions with indoor tanning prevalence. Age restrictions may be effective in reducing indoor tanning because of increased compliance with laws that include age restrictions.17 An assessment of age restrictions found that 62% of facilities across 3 states with age restrictions did not allow an individual aged 12 years to tan, but only 18% of facilities in a state without age restrictions prohibited use.17 In addition, in Wisconsin, where indoor tanning is restricted among minors younger than 16 years, 70% to 77% of facilities indicated that they would not allow an individual aged 15 years to tan.17,27 Because the initiation of indoor tanning has been shown to be highest during adolescence, decreasing significantly with age,28,29 age restrictions among adolescents may have lasting effects on indoor tanning behavior by delaying or eliminating initiation. For example, age restrictions among young adolescents may reduce the initiation of indoor tanning, resulting in a lower prevalence among older adolescents. Such laws may also help influence social norms, resulting in a reduction in indoor tanning over time. Preventing use among minors could substantially decrease skin cancer risk given the
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dose---response relationship between indoor tanning and the risk of melanoma.5 Although previous studies have found youth access laws to be ineffective in reducing indoor tanning among adolescents, the number of states implementing new laws, particularly age restrictions, has increased substantially since these earlier studies were conducted.16 As of May 2013, 34 states had youth access laws, 15 states included age restrictions (up from 3 in 2003), and the remaining states required parental permission.16,21 In addition, 28 states are either considering new youth access legislation or strengthening existing laws.21 Internationally, the number of countries with nationwide laws restricting indoor tanning among minors aged 18 years or younger has increased substantially in recent years16,30 If effective, these laws have the potential to reduce the number of skin cancer cases and associated health care costs. In Australia, it was estimated that stricter indoor tanning regulations, including age restrictions among minors aged 18 years or younger, could prevent approximately 24 melanoma cases and 226 squamous cell carcinoma cases and save $256 000 in medical costs per 100 000 people.31 Despite the increase in youth access laws, indoor tanning is common among high school students, suggesting the need for a comprehensive multilevel approach to reduce indoor tanning and maximize public health impact. Lessons learned from tobacco control policy have shown that age restrictions on tobacco contributed to effective comprehensive tobacco reduction interventions.26,32 However, certain indoor tanning restrictions may be easily circumvented, such as having access to indoor tanning in unsupervised settings in apartment complexes, beauty salons, and fitness centers. The World Health Organization has recommended banning unsupervised tanning facilities to complement restricting indoor tanning among minors.33 Additionally, monitoring deceptive health and safety claims about indoor tanning is important, because they may make it difficult for consumers to adequately assess risk. A recent investigative report found that only 7% of salons reported any harmful effects of indoor tanning, whereas 78% reported health benefits.34 The Federal Trade Commission has sanctioned the Indoor Tanning Association for making false and
misleading health and safety claims about indoor tanning.35 The Food and Drug Administration’s proposed reclassification of indoor tanning devices from low- to moderate-risk devices may bolster the effect of systems access laws.36 If the order is finalized, manufacturers would have to show that their products meet certain performance testing requirements, address certain product design characteristics, and provide comprehensive labeling that presents consumers with clear information on the risks of use. The order also proposes to include a contraindication against use among minors aged 18 years or younger, and the labeling would have to include a warning that frequent users of sunlamp products should be regularly screened for skin cancer.36 Moreover, the lack of government regulation is often cited as evidence that indoor tanning is safe.34 Comprehensive evidence-based interventions, including age restrictions and regulatory efforts aimed at reducing consumers’ risks associated with indoor tanning and youth access to indoor tanning, may act as statements of norms that influence perceptions and behaviors37 and potentially reduce indoor tanning. At the individual level, the association between indoor tanning and other risky behaviors, such as smoking cigarettes and unhealthy weight practices, reinforces the need for coordinated, multifaceted approaches to address indoor tanning and other appearance-based and health-related behaviors among adolescents.38 Appearance-focused behavioral interventions have been shown to reduce indoor tanning among young women by as much as 35%.39 The US Preventive Services Task Force has recommended counseling fair-skinned individuals aged 10 to 24 years to minimize UV radiation exposure to reduce skin cancer risk.39 Because context-changing interventions are generally very effective public health actions,40 multilevel efforts to change the social norms related to tanned skin and attractiveness may be instrumental in reducing indoor tanning.
Limitations The findings in this report are subject to limitations. First, the national YRBS was not designed to provide state-level data, so student respondents are not representative of the states in which they live, and in any given national
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YRBS administration, not all states have student respondents. Improved surveillance of indoor tanning may aid future efforts to demonstrate the effects of indoor tanning policy. In 2011, 43 states conducted their own YRBS (independent of the national YRBS), but very few states included a question about indoor tanning. Second, given our use of crosssectional data and because a question about indoor tanning was first included in the 2009 national YRBS, our analysis could not capture changes in youth indoor tanning behaviors as a direct result of state laws. Third, we were unable to isolate the impact of age restrictions because only 1 state in our sample had only an age restriction law in place. Fourth, these data apply only to youths attending school and might not represent all people in this age group. Nationwide, in 2009, of people aged 16 to 17 years, approximately 4% were not enrolled in a high school program and had not completed high school.41 Fifth, we are unable to examine compliance with state laws. Last, the extent of misreporting cannot be determined, although YRBS survey questions demonstrate good test--retest reliability.20
Conclusions Our results offer new evidence that state indoor tanning laws, particularly age restrictions, may be effective in reducing indoor tanning among female high school students. Adequate compliance, monitoring, and enforcement of laws addressing indoor tanning may have a significant impact on behavior. In addition, given the social norms regarding tanning, the desire to have tanned skin, and the misconceptions about the health risks associated with indoor tanning, comprehensive, multilevel approaches that complement indoor tanning laws can help achieve the maximum sustained public health benefit.
About the Authors Gery P. Guy Jr, Zahava Berkowitz, and Mona Saraiya are with the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Sherry Everett Jones, Emily O’Malley Olsen, and Shannon L. Michael are with the Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Justin N. Miyamoto is with the Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA.
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Correspondence should be sent to Gery P. Guy, Jr., Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS F-76, Atlanta, GA 30341 (e-mail: irm2@cdc. gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 14, 2013. Note. The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contributors G. P. Guy Jr participated in the study conceptualization, design, analysis, interpretation of the data, and drafting and revision of the article. Z. Berkowitz, S. Everett Jones, E. O’Malley Olsen, and S. L. Michael participated in the study conceptualization, design, analysis, interpretation of the data, and revision of the article. J. N. Miyamoto and M. Saraiya participated in the study conceptualization, design, interpretation of the data, and revision of the article.
Human Participant Protection This study did not require institutional review board review because the study used secondary, de-identified data.
References
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1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010;146(3):283---287.
18. Brener ND, Kann L, Shanklin S, et al. Methodology of the Youth Risk Behavior Surveillance System—2013. MMWR Recomm Rep. 2013;62(RR-1):1---20.
2. US Cancer Statistics Working Group. United States Cancer Statistics: 1999---2010 Incidence and Mortality Web-Based Report. US Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute. 2014. Available at: http:// www.cdc.gov/uscs. Accessed January 22, 2014.
19. Eaton DK, Kann L, Kinchen S, et al.; Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2009. MMWR Morb Mortal Wkly Rep. 2010;59(SS-5):1---142.
3. Bickers DR, Lim HW, Margolis D, et al. The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol. 2006;55(3):490---500. 4. Jemal A, Saraiya M, Patel P, et al. Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992---2006. J Am Acad Dermatol. 2011;65(5 suppl 1):S17---S25. 5. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ. 2012;345:e4757. 6. Fisher DE, James WD. Indoor tanning—science, behavior, and policy. N Engl J Med. 2010;363(10):901-- 903. 7. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis [Correction]. BMJ. 2012;345:e8503. 8. Wehner MR, Shive ML, Chren M-M, Han J, Qureshi AA, Linos E. Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis. BMJ. 2012;345:e5909. 9. Eaton DK, Kann L, Kinchen S, et al.; Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(No. SS-4):1---162. 10. Woodruff SI, Pichon LC, Hoerster KD, Forster JL, Gilmer T, Mayer JA. Measuring the stringency of states’
20. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health. 2002; 31(4):336---342. 21. National Conference of State Legislatures. Indoor tanning restrictions for minors—a state-by-state comparison. Available at: http://www.ncsl.org/issues-research/ health/indoor-tanning-restrictions-for-minors.aspx. Accessed June 6, 2013. 22. National Cancer Institute. State cancer legislative database fact sheet: skin cancer: states with laws addressing minors’ access to tanning facilities. Available at: http://www.scld-nci.net/linkdocs/products/ factsheets93.pdf. Accessed March 26, 2013. 23. McLaughlin JA, Francis SO, Burkhardt DL, Dellavalle RP. Indoor UV tanning youth access laws: update 2007. Arch Dermatol. 2007;143(4):529. 24. Lostritto K, Ferrucci LM, Cartmel B, et al. Lifetime history of indoor tanning in young people: a retrospective assessment of initiation, persistence, and correlates. BMC Public Health. 2012;12:118. 25. Cokkinides VE, Weinstock MA, O’Connell MC, Thun MJ. Use of indoor tanning sunlamps by US youth, ages 11---18 years, and by their parent or guardian caregivers: prevalence and correlates. Pediatrics. 2002;109(6):1124---1130. 26. DiFranza JR, Savageau JA, Fletcher KE. Enforcement of underage sales laws as a predictor of daily smoking among adolescents: a national study. BMC Public Health. 2009;9:107.
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27. Pichon LC, Mayer JA, Hoerster KD, et al. Youth access to artificial UV radiation exposure: practices of 3647 US indoor tanning facilities. Arch Dermatol. 2009;145(9):997---1002. 28. Lazovich D, Forster J, Sorensen G, et al. Characteristics associated with use or intention to use indoor tanning among adolescents. Arch Pediatr Adolesc Med. 2004;158(9):918---924. 29. Lazovich D, Forster J. Indoor tanning by adolescents: prevalence, practices and policies. Eur J Cancer. 2005;41(1):20---27. 30. Sinclair C, Makin JK. Implications of lessons learned from tobacco control for tanning bed reform. Prev Chronic Dis. 2013;10:E28. 31. Hirst N, Gordon L, Gies P, Green AC. Estimation of avoidable skin cancers and cost-savings to government associated with regulation of the solarium industry in Australia. Health Policy. 2009;89(3):303---311. 32. Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The effects of community policies to reduce youth access to tobacco. Am J Public Health. 1998;88(8):1193---1198. 33. World Health Organization. Artificial tanning sunbeds: risks and guidance. 2003. Available at: http:// www.who.int/uv/publications/en/sunbeds.pdf. Accessed August 15, 2013. 34. US House of Representatives Committee on Energy and Commerce—Minority Staff. False and misleading health information provided to teens by the indoor tanning industry: investigative report. 2012. Available at: http:democrats.energycommerce.house.gov/sites/default/ files/documents/False-Health-Info-by-Indoor-TanningIndustry-2012-2-1.pdf. Accessed August 16, 2013. 35. Federal Trade Commission. Indoor Tanning Association settles FTC charges that it deceived consumers about skin cancer risks from tanning. 2010. Available at: http://www.ftc.gov/opa/2010/01/tanning.shtm. Accessed August 16, 2013. 36. Food and Drug Administration. Proposed order: reclassification of ultraviolet lamps for tanning, henceforth to be known as sunlamp products. Available at: http://www.fda.gov/RadiationEmittingProducts/ RadiationEmittingProductsandProcedures/Tanning/ ucm350824.htm. Accessed May 6, 2013. 37. Hamilton WL, Biener L, Brennan RT. Do local tobacco regulations influence perceived smoking norms? Evidence from adult and youth surveys in Massachusetts. Health Educ Res. 2008;23(4):709---722. 38. Guy Jr GP, Berkowitz Z, Tai E, Holman D, Everett Jones S, Richardson LC. Indoor tanning among high school students in the United States, 2009-2011. JAMA Dermatol. In press. 39. Moyer VA. Behavioral counseling to prevent skin cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:59---65. 40. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100 (4):590---595. 41. Chapman C, Laird J, Ifill N, KewalRamani A. Trends in High School Dropout and Completion Rates in the United States: 1972-2009. NCES 2012-006. Washington, DC: National Center for Education Statistics, US Department of Education; 2011. Available at: http:// nces.ed.gov/ pubs2012/2012006.pdf. Accessed December 10, 2012.
American Journal of Public Health | April 2014, Vol 104, No. 4
State Indoor Tanning Laws and Adolescent Indoor Tanning Gery P. Guy Jr, PhD, MPH, Zahava Berkowitz, MSc, MSPH, Sherry Everett Jones, PhD, JD, MPH, Emily O’Malley Olsen, MSPH, Justin N. Miyamoto, MD, Shannon L. Michael, PhD, MPH, and Mona Saraiya, MD, MPH
Skin cancer is the most common cancer in the United States. Approximately 3.5 million cases of nonmelanoma skin cancers are treated annually, while more than 60 000 melanomas are diagnosed annually.1,2 In addition, skin cancer poses a substantial economic burden, with annual direct medical costs of treatment estimated at $1.7 billion in 2004.3 During the past decade, while most cancers decreased, melanoma increased, especially among young adult women.4 Indoor tanning is thought to be partially responsible for this increase.4---6 Indoor tanning before age 35 years increases the risk of melanoma by 59%,5,7 and indoor tanning before age 25 years increases the risk of basal cell carcinoma by 40% and squamous cell carcinoma by 102%.8 Despite these known health risks, indoor tanning is common among adolescents—6.2% of male high school students and 20.9% of female high school students engaged in indoor tanning in 2011.9 In recent years, several states have enacted laws restricting youth access to indoor tanning and laws aimed at reducing consumers’ risk, including facility and operator responsibilities, safety and equipment standards, enforcement authority, and penalties.10 Previous studies that were primarily focused on youth access laws found poor compliance rates among tanning facilities for parental permission laws.11---13 In addition, such laws were ineffective in reducing indoor tanning among adolescents.14,15 Since these earlier studies were conducted, the number of states implementing youth access laws, particularly age restrictions, has increased substantially.16 Although some evidence has suggested that age restrictions may reduce access to indoor tanning among minors,17 no national or international studies have examined the effects these laws have on adolescent indoor tanning behavior. We examined the association between state indoor tanning laws, including age restrictions, and indoor tanning among high school students.
Objectives. Recently, several state indoor tanning laws, including age restrictions, were promulgated to reduce indoor tanning among minors. We examined the effects of these laws on adolescent indoor tanning. Methods. We used nationally representative data from the 2009 and 2011 national Youth Risk Behavior Surveys (n = 31 835). Using multivariable logistic regression, we examined the association between state indoor tanning laws and indoor tanning among US high school students. Results. Female students in states with indoor tanning laws were less likely to engage in indoor tanning than those in states without any laws. We observed a stronger association among female students in states with systems access, parental permission, and age restriction laws than among those in states without any laws. We found no significant association among female students in states with only systems access and parental permission laws or among male students. Conclusions. Indoor tanning laws, particularly those including age restrictions, may be effective in reducing indoor tanning among female high school students, for whom rates are the highest. Such reductions have the potential to reduce the health and economic burden of skin cancer. (Am J Public Health. 2014;104: e69–e74. doi:10.2105/AJPH.2013.301850)
METHODS The national Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention, is a cross-sectional survey conducted biennially since 1991. In each survey year, an independent, 3-stage, cluster sample design is used to obtain a nationally representative sample of public and private school students in grades 9 through 12.18 Student participation in the YRBS is anonymous and voluntary, and the YRBS is conducted in accordance with parental permission procedures in each locality. Because data used in these analyses contain no personal identifying information, this study was exempt from institutional review board review. Participants complete a self-administered questionnaire during a regular class period and record their responses on a computer-scannable questionnaire booklet or answer sheet. The overall response rates were 71% for both 2009 and 2011, and sample sizes were 16 410 and 15 425, respectively. Weights were applied to adjust for school and student nonresponse and oversampling of Black and Hispanic students.
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Data from the 2009 and 2011 YRBS were combined to increase the number of states represented by student respondents. State identifiers were attached to each student record. During 2009 and 2011, 32 states had students selected for the YRBS and asked about indoor tanning; students were from 18 states in both years, 6 states were included only in 2009, and 8 states were included only in 2011. The national YRBS sample is designed to obtain nationally representative estimates for US high school students during any given year; it is not designed to produce state estimates of student behavior and does not select students from every state. Further details on the YRBS have been reported elsewhere.9,18---20
Indoor Tanning In both 2009 and 2011, students were asked, “During the past 12 months, how many times did you use an indoor tanning device, such as a sunlamp, sunbed, or tanning booth? (Do not include getting a spray-on tan.)” Responses included “0 times,” “1 or 2 times,” “3 to 9 times,” “10 to 19 times,” “20 to 39 times,” and “40 or more times.” Indoor tanning was
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defined as having used an indoor tanning device 1 or more times during the 12 months before the survey.
these law-type categories from the analysis using the 3-level law variable.
Analysis State Indoor Tanning Laws We compiled details about each state’s indoor tanning laws by using the National Conference of State Legislatures Web site, 21 the National Cancer Institute State Cancer Legislative Database Program, 22 and published reports,16,23 and these details were confirmed by using each state’s legislative Web site. We included laws in effect at the beginning of each survey year in our analyses. State indoor tanning laws were classified as addressing either youth access or systems access to indoor tanning. Detailed descriptions of the laws are presented in the box on this page. For the analysis, we first examined the association between indoor tanning and the presence of any indoor tanning law, either systems access or youth access. To further examine the role of different types of youth access laws on indoor tanning, we developed a 3-level law variable, categorizing states into 3 law-type groups: those with no state indoor tanning laws, those with only systems access laws and parental permission laws, and those with systems access laws, parental permission laws, and age restrictions. We excluded students from 3 states that did not fit into any of
To account for the complex sample design of the survey and weighting of student records, we conducted all analyses with SUDAAN statistical software version 10.1 (Research Triangle Institute, Research Triangle Park, NC). Given the differences in indoor tanning by gender, race/ethnicity, and grade,9,19 we stratified all analyses by gender and controlled multivariable analyses for race/ethnicity and grade. Differences in the unadjusted prevalence of indoor tanning by state tanning laws were assessed with linear contrasts. We used multivariable logistic regression models to examine the association between state indoor tanning laws and indoor tanning among female and male students. A 2-sided P value of < .05 was considered statistically significant. Because national YRBS data are not designed to be representative below the national level, we conducted sensitivity analyses to examine the stability of the relationship between state indoor tanning laws and indoor tanning. We used a jackknife procedure in which we ran 32 multivariable logistic regression models, iteratively removing all students from 1 state and comparing the new model results to the base model results with all students included.
RESULTS A total of 25 758 high school students were included in our analysis, of whom 12 914 were female and 12 844 were male.
Female High School Students Overall, 23.4% of female high school students engaged in indoor tanning. The prevalence was lower in states with any indoor tanning laws (21.2%) than in states without any indoor tanning laws (30.1%). In the analysis using the 3-level law variable, the prevalence of indoor tanning was lowest among female students in states with systems access, parental permission, and age restrictions (17.1%; Table 1). In the multivariable logistic regression models, indoor tanning was negatively associated with the presence of any state indoor tanning law (adjusted odds ratio [AOR] = 0.70; 95% confidence interval [CI] = 0.51, 0.97; P = .03; Table 2). In the analysis that used the 3-level law variable, indoor tanning among female students was negatively associated with the combination of systems access, parental permission, and age restriction laws compared with those states with no indoor tanning laws (AOR = 0.58, 95% CI = 0.41, 0.83, P = .003). We found no statistically significant difference in the odds of indoor tanning among female students in states with only systems access and parental permission laws compared with those
Definitions of State Indoor Tanning Laws by Category Systems Access Warning statement Any requirement of indoor tanning device operator to obtain signed
Youth Access Parental permission Laws that prohibit minors younger than a certain age from using an indoor tanning
warning statement from patron Warning sign Any requirement of indoor tanning device operator to post warning sign Restricted advertising Hazard-free, safe, and medically beneficial advertising prohibited Mandatory protective eyewear
device without d
Parental consent
d
Parental accompaniment
Age restrictions Laws that prohibit minors younger than a certain age from using an indoor tanning device
Any protective eyewear requirement Mandatory operator-required incident reports Any incident report requirement Penalty for violation Any civil or financial penalty or licensing suspension
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TABLE 1—Prevalence of Indoor Tanning Among High School Students by State Indoor Tanning Laws: National Youth Risk Behavior Survey, United States, 2009 and 2011 Type of Indoor Tanning Lawb
No.
Systems Access and Parental Permission Law (n = 13), % (95% CI)
Systems Access, Parental Permission, and Age Restriction Law (n = 8), % (95% CI)
21.2c (18.8, 23.9)
11 821
26.3 (20.9, 32.5)
17.1c,d (14.4, 20.2)
Presence of Any Indoor Tanning Lawa Variable
No.
All Study States (n = 32), % (95% CI)
No State Laws (n = 11), % (95% CI)
12 914
23.4 (21.1, 25.7)
30.1 (24.3, 36.7)
Any Indoor Tanning Law (n = 23), % (95% CI) Female
Overall School grade 9th
3229
14.0 (12.1, 16.1)
19.5 (14.6, 25.7)
12.4c (10.5, 14.6)
2956
15.3 (11.7, 19.8)
10.5c (8.1, 13.4)
10th 11th
3186 3286
19.8 (17.0, 23.0) 28.6 (25.5, 31.9)
29.8 (22.7, 38.0) 34.0 (27.3, 41.3)
16.7c (13.9, 19.9) 26.9 (23.2, 30.8)
2893 3002
22.1 (15.2, 31.1) 34.2 (26.8, 42.5)
13.4c,d (10.5, 16.8) 20.5c,d (16.6, 25.0)
12th
3174
32.9 (29.5, 36.4)
38.2 (30.8, 46.2)
31.1 (27.2, 35.3)
2937
35.3 (28.4, 42.9)
26.0c (21.0, 31.8)
White, Non-Hispanic
5799
33.7 (30.9, 36.6)
38.9 (32.6, 45.6)
31.7 (28.6, 35.0)
5054
36.7 (30.4, 43.5)
27.6c,d (23.7, 32.0)
Black, Non-Hispanic
2101
2.9 (2.1, 4.0)
3.2 (2.0, 4.9)
2.9 (1.9, 4.2)
2042
2.1 (1.0, 4.8)
2.9 (1.8, 4.7)
Hispanic
3575
10.1 (8.6, 11.9)
16.1 (9.8, 25.5)
9.3 (7.8, 11.1)
3408
13.9 (8.7, 21.5)
7.7 (6.2, 9.4)
Other, Non-Hispanic
1259
10.1 (7.4, 13.6)
17.3 (9.3, 29.9)
8.2c (6.1, 10.9)
1154
8.7c (4.9, 14.8)
7.8c (5.2, 11.4)
6.5 (5.6, 7.4)
7.1 (5.2, 9.7)
11 657
7.9 (6.0, 10.4)
5.6 (4.5, 7.0)
Race/ethnicity
Male Overall
12 844
6.3 (5.3, 7.4)
School grade 9th
3117
5.3 (4.4, 6.3)
6.0 (4.2, 8.4)
5.1 (4.1, 6.2)
2807
5.9 (4.4, 7.8)
5.1 (3.8, 6.9)
10th
3081
4.7 (3.7, 6.1)
4.7 (2.6, 8.5)
4.7 (3.6, 6.2)
2759
6.2 (4.3, 9.0)
4.2d (3.0, 6.0)
11th
3342
6.9 (5.5, 8.7)
7.5 (4.9, 11.4)
6.7 (5.1, 8.8)
3058
8.3 (4.6, 14.4)
5.6 (4.1, 7.5)
12th
3243
9.3 (7.7, 11.2)
9.9 (6.6, 14.7)
9.1 (7.4, 11.1)
2975
12.6 (9.2, 16.9)
7.6 (5.6, 10.3)
5978 1973
6.7 (5.6, 8.0) 5.5 (4.0, 7.4)
7.0 (4.9, 10.1) 5.8 (4.2, 8.0)
6.6 (5.3, 8.1) 5.3 (3.6, 7.9)
5136 1916
8.9 (6.2, 12.6) 4.5 (2.7, 7.7)
5.6d (4.3, 7.3) 6.1 (3.6, 10.1)
Race/ethnicity White, Non-Hispanic Black, Non-Hispanic Hispanic
3460
5.8 (4.7, 7.0)
6.7 (3.8, 11.7)
5.6 (4.5, 7.0)
3309
8.6 (5.3, 13.5)
4.8 (3.7, 6.3)
Other, Non-Hispanic
1213
6.8 (5.0, 9.1)
8.7 (4.5, 16.3)
6.3 (4.6, 8.6)
1101
6.8 (3.9, 11.6)
5.8 (3.8, 8.9)
Note. Indoor tanning defined as using an indoor tanning device, such as a sunlamp, sunbed, or tanning booth ‡ 1 time during the 12 months before the survey. Does not include getting a spray-on tan. Estimates based on weighted data. The sample sizes are unweighted. a Student records from 32 states were included in the analysis. b Students from 3 states not fitting into any of these categories were excluded from the analysis when using the 3-level law variable. c Significantly different from no state law. d Significantly different from systems access and parental permission law.
in states with no laws (Table 2). Additionally, the odds of indoor tanning among female students in states with a combination of systems access, parental permission, and age restriction laws were significantly lower than those in states with only systems access and parental permission laws (P = .02).
multivariable logistic regression models, indoor tanning among male students was not associated with the presence of any state indoor tanning laws (Table 2). Similarly, we found no significant association between male indoor tanning and the 3-level law variable (Table 2).
Sensitivity Analysis Male High School Students Overall, 6.5% of male students reported indoor tanning, and we found no statistically significant differences in the prevalence of indoor tanning by type of law (Table 1). In the
The results of the sensitivity analysis suggest the conclusions are stable. Among female students, the relationship between the presence of any law and indoor tanning remained significant for all but 4 iterations of the sensitivity models.
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For 3 of those 4 models, the P value was less than .1, and for the fourth, the P value was .15. We repeated this process for the 3-level law variable. Among female students, the findings for all model iterations were consistent with the base model. Among male students, all models used in the sensitivity analysis were consistent with the base models for both law analyses.
DISCUSSION Our study documents that state indoor tanning laws were associated with a significant
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TABLE 2—Association Between Indoor Tanning and State Indoor Tanning Laws: National Youth Risk Behavior Survey, United States, 2009 and 2011 Three-Level Law Componenta
Presence of Any Law Variable
Female (n = 12 711), AORb (95% CI)
No state laws (Ref)
1.00
Any indoor tanning law (systems or youth access) Systems access and parental permission law
0.70 (0.51, 0.97)
P
Male (n = 12 580), AORb (95% CI)
.03
0.93 (0.63, 1.36)
P
1.00
Female (n = 11 640), AORb (95% CI)
P
1.00
Male (n = 11 420), AORb (95% CI)
P
1.00
.7
Systems access, parental permission, and age restriction law
0.89 (0.60, 1.32)
.55
1.22 (0.78, 1.91)
.37
0.58c (0.41, 0.83)
.003
0.81 (0.54, 1.23)
.32
School grade 9th (Ref)
1.00
1.00
1.00
10th
1.49 (1.22, 1.82)
< .001
0.87 (0.66, 1.15)
.31
1.51 (1.21, 1.89)
0.87 (0.65, 1.14)
11th
2.45 (2.03, 2.95)
< .001
1.31 (1.01, 1.71)
.04
2.37 (1.95, 2.89)
< .001
1.24 (0.92, 1.66)
.16
12th
2.98 (2.46, 3.61)
< .001
1.84 (1.44, 2.36)
< .001
2.84 (2.32, 3.48)
< .001
1.80 (1.38, 2.36)
< .001
Race/ethnicity White, Non-Hispanic (Ref)
1.00
1.00
1.00
1.00
.3
1.00
Black, Non-Hispanic
0.06 (0.04, 0.08)
< .001
0.83 (0.57, 1.21)
.33
0.05 (0.04, 0.08)
< .001
0.81 (0.54, 1.20)
Hispanic
0.23 (0.19, 0.29)
< .001
0.87 (0.67, 1.13)
.3
0.24 (0.19, 0.31)
< .001
0.89 (0.68, 1.17)
.29 .4
Other, Non-Hispanic
0.23 (0.16, 0.31)
< .001
1.00 (0.73, 1.35)
.98
0.23 (0.17, 0.33)
< .001
0.98 (0.71, 1.34)
.88
Note. AOR = adjusted odds ratio; CI = confidence interval. Indoor tanning was defined as using a sunlamp, sunbed, or tanning booth ‡ 1 time during the 12 months before the survey. It does not include getting a spray-on tan. Estimates are based on weighted data. a Students from 3 states not fitting into any of these categories were excluded from the analysis when using the 3-level law variable. b Adjusted for school grade and race/ethnicity. c Significantly different than systems access and parental permission law (AOR = 0.65; 95% CI = 0.46, 0.92; P = .02).
reduction in indoor tanning among female high school students. The adjusted odds of indoor tanning among female high school students in states with any indoor tanning laws were 30% less than those in states without any indoor tanning laws. Moreover, the adjusted odds of indoor tanning among female high school students in states with systems access, parental permission, and age restriction laws were 42% less than those in states without any indoor tanning laws. We found no significant associations between indoor tanning and states with only systems access and parental permission laws among female students. Additionally, we found no significant associations between indoor tanning and state indoor tanning laws among male students, potentially because of the lower prevalence of indoor tanning and the older age of initiation among male students compared with female students.24 These findings suggest that indoor tanning laws and age restrictions, in particular, may be effective in reducing indoor tanning among female students, for whom the prevalence of indoor tanning is the highest. Two previous studies examining youth access laws found limited effectiveness in
reducing indoor tanning. Their authors concluded that this limited effectiveness was likely caused by state policies permitting use with parental permission.14,15 In addition, our study found that parental permission laws without an age restriction were not associated with a lower prevalence of indoor tanning. This result may partly stem from parental modeling of and permissive attitudes toward indoor tanning,14,25 possible forging of a parent’s signature,15 and poor compliance.11---13 Compliance is an important component to ensure the effectiveness of any law. For example, a 21% reduction in the odds of youth smoking was attributed to improved compliance with tobacco youth access laws.26 Studies have found poor compliance by tanning facilities with youth access indoor tanning laws at the state and local levels. For example, in San Diego, California, only 43% of indoor tanning facilities were compliant with parental permission laws,11 and only 13% of facilities in North Carolina12 and 19% of facilities in Minnesota and Massachusetts were compliant.13 Our findings build on those of previous studies by examining the association of age
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restrictions with indoor tanning prevalence. Age restrictions may be effective in reducing indoor tanning because of increased compliance with laws that include age restrictions.17 An assessment of age restrictions found that 62% of facilities across 3 states with age restrictions did not allow an individual aged 12 years to tan, but only 18% of facilities in a state without age restrictions prohibited use.17 In addition, in Wisconsin, where indoor tanning is restricted among minors younger than 16 years, 70% to 77% of facilities indicated that they would not allow an individual aged 15 years to tan.17,27 Because the initiation of indoor tanning has been shown to be highest during adolescence, decreasing significantly with age,28,29 age restrictions among adolescents may have lasting effects on indoor tanning behavior by delaying or eliminating initiation. For example, age restrictions among young adolescents may reduce the initiation of indoor tanning, resulting in a lower prevalence among older adolescents. Such laws may also help influence social norms, resulting in a reduction in indoor tanning over time. Preventing use among minors could substantially decrease skin cancer risk given the
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dose---response relationship between indoor tanning and the risk of melanoma.5 Although previous studies have found youth access laws to be ineffective in reducing indoor tanning among adolescents, the number of states implementing new laws, particularly age restrictions, has increased substantially since these earlier studies were conducted.16 As of May 2013, 34 states had youth access laws, 15 states included age restrictions (up from 3 in 2003), and the remaining states required parental permission.16,21 In addition, 28 states are either considering new youth access legislation or strengthening existing laws.21 Internationally, the number of countries with nationwide laws restricting indoor tanning among minors aged 18 years or younger has increased substantially in recent years16,30 If effective, these laws have the potential to reduce the number of skin cancer cases and associated health care costs. In Australia, it was estimated that stricter indoor tanning regulations, including age restrictions among minors aged 18 years or younger, could prevent approximately 24 melanoma cases and 226 squamous cell carcinoma cases and save $256 000 in medical costs per 100 000 people.31 Despite the increase in youth access laws, indoor tanning is common among high school students, suggesting the need for a comprehensive multilevel approach to reduce indoor tanning and maximize public health impact. Lessons learned from tobacco control policy have shown that age restrictions on tobacco contributed to effective comprehensive tobacco reduction interventions.26,32 However, certain indoor tanning restrictions may be easily circumvented, such as having access to indoor tanning in unsupervised settings in apartment complexes, beauty salons, and fitness centers. The World Health Organization has recommended banning unsupervised tanning facilities to complement restricting indoor tanning among minors.33 Additionally, monitoring deceptive health and safety claims about indoor tanning is important, because they may make it difficult for consumers to adequately assess risk. A recent investigative report found that only 7% of salons reported any harmful effects of indoor tanning, whereas 78% reported health benefits.34 The Federal Trade Commission has sanctioned the Indoor Tanning Association for making false and
misleading health and safety claims about indoor tanning.35 The Food and Drug Administration’s proposed reclassification of indoor tanning devices from low- to moderate-risk devices may bolster the effect of systems access laws.36 If the order is finalized, manufacturers would have to show that their products meet certain performance testing requirements, address certain product design characteristics, and provide comprehensive labeling that presents consumers with clear information on the risks of use. The order also proposes to include a contraindication against use among minors aged 18 years or younger, and the labeling would have to include a warning that frequent users of sunlamp products should be regularly screened for skin cancer.36 Moreover, the lack of government regulation is often cited as evidence that indoor tanning is safe.34 Comprehensive evidence-based interventions, including age restrictions and regulatory efforts aimed at reducing consumers’ risks associated with indoor tanning and youth access to indoor tanning, may act as statements of norms that influence perceptions and behaviors37 and potentially reduce indoor tanning. At the individual level, the association between indoor tanning and other risky behaviors, such as smoking cigarettes and unhealthy weight practices, reinforces the need for coordinated, multifaceted approaches to address indoor tanning and other appearance-based and health-related behaviors among adolescents.38 Appearance-focused behavioral interventions have been shown to reduce indoor tanning among young women by as much as 35%.39 The US Preventive Services Task Force has recommended counseling fair-skinned individuals aged 10 to 24 years to minimize UV radiation exposure to reduce skin cancer risk.39 Because context-changing interventions are generally very effective public health actions,40 multilevel efforts to change the social norms related to tanned skin and attractiveness may be instrumental in reducing indoor tanning.
Limitations The findings in this report are subject to limitations. First, the national YRBS was not designed to provide state-level data, so student respondents are not representative of the states in which they live, and in any given national
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YRBS administration, not all states have student respondents. Improved surveillance of indoor tanning may aid future efforts to demonstrate the effects of indoor tanning policy. In 2011, 43 states conducted their own YRBS (independent of the national YRBS), but very few states included a question about indoor tanning. Second, given our use of crosssectional data and because a question about indoor tanning was first included in the 2009 national YRBS, our analysis could not capture changes in youth indoor tanning behaviors as a direct result of state laws. Third, we were unable to isolate the impact of age restrictions because only 1 state in our sample had only an age restriction law in place. Fourth, these data apply only to youths attending school and might not represent all people in this age group. Nationwide, in 2009, of people aged 16 to 17 years, approximately 4% were not enrolled in a high school program and had not completed high school.41 Fifth, we are unable to examine compliance with state laws. Last, the extent of misreporting cannot be determined, although YRBS survey questions demonstrate good test--retest reliability.20
Conclusions Our results offer new evidence that state indoor tanning laws, particularly age restrictions, may be effective in reducing indoor tanning among female high school students. Adequate compliance, monitoring, and enforcement of laws addressing indoor tanning may have a significant impact on behavior. In addition, given the social norms regarding tanning, the desire to have tanned skin, and the misconceptions about the health risks associated with indoor tanning, comprehensive, multilevel approaches that complement indoor tanning laws can help achieve the maximum sustained public health benefit.
About the Authors Gery P. Guy Jr, Zahava Berkowitz, and Mona Saraiya are with the Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA. Sherry Everett Jones, Emily O’Malley Olsen, and Shannon L. Michael are with the Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Justin N. Miyamoto is with the Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA.
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Correspondence should be sent to Gery P. Guy, Jr., Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS F-76, Atlanta, GA 30341 (e-mail: irm2@cdc. gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted December 14, 2013. Note. The findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Contributors G. P. Guy Jr participated in the study conceptualization, design, analysis, interpretation of the data, and drafting and revision of the article. Z. Berkowitz, S. Everett Jones, E. O’Malley Olsen, and S. L. Michael participated in the study conceptualization, design, analysis, interpretation of the data, and revision of the article. J. N. Miyamoto and M. Saraiya participated in the study conceptualization, design, interpretation of the data, and revision of the article.
Human Participant Protection This study did not require institutional review board review because the study used secondary, de-identified data.
References
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