Clinics in Dermatology (2015) 33, 387–392
Update on indoor tanning legislation in the United States Michael Pan, BA a , Lauren Geller, MD b,⁎ a
Icahn School of Medicine at Mount Sinai, New York, NY Departments of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Fifth Floor, New York, NY 10029 b
Abstract The incidence of melanoma has been increasing over the past several decades, with notable increases in the pediatric and adolescent population. Indoor tanning has been proven carcinogenic and is associated with an increased risk of melanoma, especially when used at a young age. The incidence and frequency of usage of indoor tanning in the United States is high, particularly among adolescents, with roughly 20% reporting using a tanning bed at least once. The Food and Drug Administration recently made changes to its regulation of indoor tanning devices, reclassifying them as class II devices necessitating stricter premarket review, and strengthened its warnings for these devices; however, federal regulation of indoor tanning is still limited and most regulation of indoor tanning in minors is done on a state-by-state basis. Three types of legislation exist: (1) absolute ban on minor use of indoor tanning devices, (2) age restriction of minor usage of indoor tanning devices other than age 18 years, and (3) requirement of parental consent. These regulations are inconsistent, and enforcement efforts are often limited. In this contribution, we provide an update on the prevalence of indoor tanning, the risks associated with indoor tanning, and the current federal and state legislation and enforcement efforts in the United States with regard to indoor tanning. Although efforts are being made to ban all use of indoor tanning devices by minors, there is still more work to be done before this becomes a reality in the United States. © 2015 Elsevier Inc. All rights reserved.
Skin cancer incidence Skin cancer is the most common cancer in the United States, affecting 1 in 5 Americans in their lifetime.1 Melanoma, the most lethal form of skin cancer, is the second most common cancer in women and the third most common cancer in men in the third decade of life.2 According to studies from the Surveillance, Epidemiology, and End Results (SEER) Program, the incidence of both melanoma and nonmelanoma skin cancer has risen in all age groups over the past several decades. ⁎ Corresponding author. Tel.: 212 241 9728; fax: 212 987 1197. E-mail address: [email protected] (L. Geller). http://dx.doi.org/10.1016/j.clindermatol.2014.12.016 0738-081X/© 2015 Elsevier Inc. All rights reserved.
Among young adults (ages 15–40 years), the incidence of basal cell carcinoma in women (13.4-31.6 cases per 100,000 people) and the incidence of squamous cell carcinoma in both sexes (0.6-4.1 cases in women and 1.3-4.2 cases in men per 100,000 people) increased from 1976 to 2003.3 The incidence of melanoma in young adults also increased from 1973 to 2004 (5.5-13.9 cases in women and 4.7-7.7 cases in men per 100,000 people).4 The rise was sharpest after 1992 with an annual increase of 2.7% among young women. Although mortality from melanoma among young women has decreased by 2.3% annually since 1973, possibly due to increased surveillance and earlier detection, the incidence of regional and distant tumors in young women has increased annually by
388 9.2% since 1994, suggesting a recent trend in developing earlier advanced disease.4 The American Cancer Society (ACS) estimates that in 2014 there will be 76,100 newly diagnosed cases of melanoma and 9710 deaths from melanoma.5 Although rare, the incidence of melanoma in children and adolescents has also been increasing over the past several decades. Melanoma is the most common type of skin cancer in those under the age of 20.6 A recent study by reported that between 1973 and 2009, 1317 children and adolescents were diagnosed with melanoma and that the incidence of melanoma in this age group increased by an average of 2% per year. The incidence rate was higher in girls than boys (IR 7.4 in girls and 4.6 in boys), with the highest and most rapidly increasing incidence rate found in 15- to 19-year-old girls and women.7
Indoor tanning industry Ultraviolet radiation (UVR) exposure from both natural sunlight and artificial sources such as tanning beds has been postulated to be a major contributor to the epidemic rise of melanoma and NMSC. Artificial sources of UV exposure such as sunlamps and tanning beds are often used in intentional tanning. These devices emit high doses of UVA and UVB, both of which are carcinogenic, for the purpose of triggering a tanning response in the skin. Children in the United States often desire to tan. One group highlighted that children ages 11 to 18 years want to appear tan, with 10.8% of these children using sunless tanners, and that tanning is associated with other risky behaviors.8 Models of adolescents ages 12 to 18 years indicate that desire to tan is strong and is associated with greater time seeking tanning and less use of effective sun protection.9 Tanning beds were first introduced to the United States in the 1970s. The popularity of tanning beds has led to the growth of the tanning industry, which generates $5 billion in annual revenue and is used by 30 million Americans every year, including 2.3 million adolescents.10,11 In the United States, there are approximately 19,000 tanning businesses employing 160,000 people.10 Indoor tanning has become widely available such that a study analyzing the 116 most populous cities in America found an average of 41 tanning facilities per city, outnumbering chains like Starbucks and McDonald’s.12 Cities with a larger white population and lower UV index have the highest density of tanning facilities, which may account for the paradoxically high incidence of childhood and adolescent melanoma in areas with low environmental UVB exposure.7,12
Risks of indoor tanning Tanning devices manufactured before the 1980s emitted mostly UVB, which produces a more potent tanning response than UVA. As public awareness about the
M. Pan, L. Geller carcinogenic effects of UVB grew in the 1980s, manufacturers switched to devices that primarily emit UVA, claiming that such a tan was safer.11 Modern high-intensity tanning beds emerged in the 1990s to emit a mixture of UVA with a small amount of UVB, with recent “high pressure” machines delivering more concentrated UV exposure.11 The National Toxicology Program, which includes the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), as well as the World Health Organization’s International Agency for Research on Cancer (IARC), classify UVR (including UVA, UVB, and UVC) and UVR-emitting devices in the highest risk category of known human carcinogen alongside items such as tobacco smoke, coal tar, and formaldehyde.13,14 Since the IARC’s classification in 2009, several studies have emerged to further prove the carcinogenic effects of tanning beds, particularly when used at younger ages. There is a relative risk of 1.20 (95% CI: 1.08-1.34) of developing melanoma in people who have ever used a tanning bed, increasing to 1.87 (95% CI: 1.41-2.48) if tanning beds were used before the age of 35.15 Another group has reported that 76% of melanomas in those 18–29 years of age can be attributed to prior use of tanning beds.13 This association was stronger with earlier tanning bed usage (OR 1.64, 95% CI: 1.07-2.51 if age of first use was before 25 years versus OR 1.06, 95% CI: 0.66-1.72 if after 25 years).16
Use of indoor tanning Useof tanning beds is highest among adolescents and young adults. A survey conducted by the CDC in 2010 reported that 5.6% of adults in the United States between the ages of 18 and 29 years had used indoor tanning within the past 12 months, with the highest prevalence in white women 18 to 25 years of age (31.8%).17 Among adolescents, a recent meta-analysis found that 19.3% reported having ever used indoor tanning and 18.3% reported use within the past year.18 This is consistent with studies from the National Youth Risk Behavior survey, which reported that 16% of high school students in 2011 used indoor tanning beds at least once in the past year (increased from 5.6% in 2009), with 49% of these students using tanning beds 10 or more times.19 Female students were four times more likely to use tanning beds than their male peers (25.4% versus 6.7%).20 Adolescents are influenced to use indoor tanning by social factors (prizing tanned skin, having friends and parents who tan) as well as contextual factors (proximity to tanning facilities, living in a low UV index area or in the Midwest or the South, and attending a rural high school).21 Interestingly, the use of tanning beds has been positively associated with other risk-taking behavior such as binge drinking and having sexual intercourse.22 No study has evaluated the use of tanning beds in children younger than 11 years, because it is
Update on indoor tanning legislation in the United States expected that there would be an absolute ban on tanning bed use for recreational purposes in this age group.
Federal indoor tanning legislation With the rising incidence of melanoma correlating with the surge in tanning bed use, efforts have been made to enact legislation to regulate indoor tanning, particularly among children and adolescents. The World Health Organization, the American Academy of Pediatrics, the American Medical Association, and the American Academy of Dermatology all support a ban on indoor tanning services for people under the age of 18.23 Several commentaries have also called for stricter FDA regulation of tanning devices, including a federally issued ban on the use of tanning devices in minors.23,24 Tanning beds are considered medical devices and are subject to some manufacturing regulation by the FDA. The FDA assigns a class to medical devices (class I, II, or III), each conferring increasing regulatory control. Class I represents the lowest risk to consumers and these devices are exempt from premarket notification, including demonstration that the device is as safe and efficacious as a similar legally marketed device and meets performance standards. Class II devices require premarket notification, whereas class III devices represent the highest risk and require premarket approval with submission of clinical trials.25 Until May 2014, tanning beds used for cosmetic purposes were classified as class I. Given the mounting evidence of the causal link between tanning beds and skin cancer and the increased public concern, the General and Plastic Surgery
389 Devices Panel of the FDA’s Medical Devices Advisory Committee convened on March 25, 2010, to discuss the reclassification of tanning beds. After testimonies from physicians, scientists, and industry representatives, the panel concluded the following: That tanning beds should be reclassified; that there should be some age restriction; that tanning is unsafe for Fitzpatrick skin type I; that people with a family history or a genetic predisposition for skin cancer should have special restrictions; and that patient disclosures, warnings, and brochures should be offered regarding the risks of tanning beds, particularly to minors.26 On May 29, 2014, the FDA issued a final decision to reclassify tanning beds to class II, strengthening the oversight of these devices. The FDA is now also requiring tanning devices to carry a black box warning, visible to consumers, that states the products should not be used on people younger than age 18. User instructions and promotional material must also explicitly state that the product should not be used on people who have skin cancer or a family history of skin cancer and that people repeatedly exposed to UV radiation should be regularly evaluated for skin cancer. 27 Although this represents an important step forward in the regulation of indoor tanning, there is still no federal law absolutely banning the use of tanning beds among minors. Regulation in the form of taxation has also been enacted by the Internal Revenue Service (IRS). On July 1, 2010, all indoor tanning services, excluding sunless tanning such as sprays, became subject to a 10% excise tax as part of the Affordable Care Act.28 Dubbed the “tanning tax,” this new law is expected to generate $2.7 billion over the next decade.29 Drawing on the success of tobacco taxation in reducing smoking, such a tax has been proposed to be a viable solution for curbing tanning
Fig. 1 Current state regulation policies regulating youth access to tanning beds. Up to date as of March 2015. (Adopted from http:// www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Map generated by http://diymaps.net.)
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Table 1 Current state regulation policies regulating youth access to tanning beds a State
Banned access b
Parental Parental accompaniment b consent b
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Under 15
15
15-17 Under 18 Under 18
Under 18 Under 17 Under 18 Under 18
14-18 Under 14
Under 14 Under 18
14-18 14-17
Under 18
Under 18 Under 14
Under 16
Under 18
Under 14
14-17
14-15
14-18 Under 18 14-17 Under 18
Under 14 Under 18 Under 14
14-17 Under 18
Under 16 Under 18 Under 14 c Under 14 Under 17 17
Under 16
Under 17 Under 14 c Under 14 c Under 14
Under 18 Under 16
Under 18 17 17-18 Under 18 Under 18 Under 18
16-17 Under18 Under 18 Under 14
Under 18
Under 18
Under 18
Under 18 Under 18 Under 15 Under 18 Under 14 Under 16
bed usage among adolescents, who may be more responsive to financial pressure.30 The effects of the federal tanning tax remains unclear. In a 2012 survey of more than 300 tanning salons in Illinois, one group found that 73% of salons did not lose clients after the implementation of the tanning tax, with the majority (N 70%) of salons reporting that customers opposed but were undeterred by the tax, suggesting that stricter laws are necessary.31 Further investigation is needed to determine the effects of such taxation on adolescent behavior.
State indoor tanning legislation With limited regulation at the federal level, legislation to reduce indoor tanning use among minors has largely been relegated to the states. According to the National Conference of State Legislatures, as of March 2015, 40 states and the District of Columbia have some form of legislation regulating tanning bed usage among minors (Figure 1); the legislation falls into three categories: (1) absolute ban on minors’ use of indoor tanning devices, (2) age restriction of minors’ use of indoor tanning devices other than age 18 years, and (3) requirement of parental consent.33 Twelve states (California, Delaware, District of Columbia, Hawaii, Illinois, Louisiana, Minnesota, Nevada, Oregon, Texas, Vermont, and Washington) have created an absolute ban on tanning device access for minors, with California becoming the first to do so on January 1, 2012. Other states have enacted bans/age restriction with lower cutoffs: younger than 17 years (Connecticut, New Jersey, and New York), 16 years (Pennsylvania, Wisconsin), 15 years (Alabama), and 14 years (Georgia, Maine, New Hampshire, North Carolina, North Dakota, and West Virginia). Other states only require parental consent and/or accompaniment for minors (Table 1). Nine states have no law regulating tanning access (Alaska, Colorado, Idaho, Iowa, Kansas, Montana, New Mexico, Oklahoma, and South Dakota). Nearly every state has had legislation regarding tanning access introduced and debated. Most recently, a bill in Maine prohibiting access to those younger than 18 years passed both the House and Senate but was vetoed by the governor on April 9, 2013. Such a bill has also passed the House in North Carolina and was sent to the Senate, on March 21, 2013. Some jurisdictions have enacted their own laws banning access to minors, including Howard County, Maryland in 2009 followed by both Chicago and Springfield, Illinois in 2012.32
14-18 Under 15
15-18
Adopted from http://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. a Up to date as of March 2015. b Age in years. c Unless medically necessary (requires doctor's prescription and parental consent).
Effectiveness of indoor tanning legislation Several studies have examined the effectiveness of state legislation in reducing tanning bed use among adolescents. Early studies have found that laws requiring parental consent have been ineffective due to poor compliance. In
Update on indoor tanning legislation in the United States an experiment conducted in 2006 in Massachusetts and Minnesota, two states requiring parental consent for minors, 81% of indoor tanning businesses sold tanning sessions to adolescents without asking for parental consent.33 Another group similarly observed in 2011 that only 26% of tanning businesses in Salt Lake City, Utah, complied with parental consent laws.34 Laws regulating access, however, have been found to be more successful in increasing compliance and changing youth behavior. In a large cross-sectional study conducted in 2009 involving 3647 tanning businesses, businesses in states that have both access and parental consent laws were more likely to ask for parental consent from adolescent customers than states without access laws.35 Using data from the National Youth Risk Behavior surveys in 2009 and 2011, Guy et al. concluded that female high school students in states with a combination of access and parental consent laws were less likely to use indoor tanning services than states without any laws. Female students in states with only parental consent laws did not significantly differ in tanning behavior than states without any laws. 36 Studies have also reported that there is inadequate enforcement of indoor tanning legislation. In a 2008 study of 28 cities in states with indoor tanning legislation, only 32% inspected indoor tanning facilities for compliance and less than half gave citations to tanning facilities that violated state laws.37
Conclusions Despite the growing evidence of the association between indoor tanning and melanoma, the prevalence of indoor tanning remains high. The FDA recently strengthened its oversight of and warning labels for tanning devices. This is recognized as an important development in the regulation of tanning beds. There is still no federal ban on indoor tanning use among minors, and state laws remain inconsistent and poorly enforced. Studies have found that the risk of developing melanoma increases when use of tanning beds begins at a younger age, and adolescents and young adults are the most frequent users of indoor tanning. Further education is needed to increase awareness of the dangers of indoor tanning, especially among the pediatric population, and further legislation is needed on the federal level to provide a more uniform restriction on the use of indoor tanning by minors to decrease the incidence of this deadly yet preventable form of skin cancer.
References 1. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010;146:279-282. 2. Wu X, Groves FD, McLaughlin CC, Jemal A, Martin J, Chen VW. Cancer incidence patterns among adolescents and young adults in the United States. Cancer Causes Control. 2005;16:309-320.
391 3. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294:681-690. 4. Purdue MP, Freeman LEB, Anderson WF, Tucker MA. Recent trends in incidence of cutaneous melanoma among US Caucasian young adults. J Invest Dermatol. 2008;128:2905-2908. 5. What Are the Key Statistics About Melanoma Skin Cancer? American Cancer Society Web site. http://www.cancer.org/cancer/skincancermelanoma/detailedguide/melanoma-skin-cancer-key-statistics. Accessed May 9, 2014. 6. Bleyer A, Viny A, Barr R. Cancer in 15- to 29-year-olds by primary site. Oncologist. 2006;11:590-601. 7. Wong JR, Harris JK, Rodriguez-Galindo C, Johnson KJ. Incidence of childhood and adolescent melanoma in the United States: 1973–2009. Pediatrics. 2013;131:846-854. 8. Cokkinides VE, Bandi P, Weinstock MA, Ward E. Use of sunless tanning products among US adolescents aged 11 to 18 years. Arch Dermatol. 2010;146:987-992. 9. Williams M, Caputi P, Jones SC, Iverson D. Sun protecting and sun exposing behaviors: testing their relationship simultaneously with indicators of ultraviolet exposure among adolescents. Photochem Photobiol. 2011;87:1179-1183. 10. FAQs-ITA-Indoor Tanning Association. Indoor Tanning Association Web site. http://www.theita.com/?page=FAQs. Accessed May 6, 2014. 11. Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol. 2005;53:1038-1044. 12. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large U.S. cities. Am J Prev Med. 2009;36:243-246. 13. National Toxicology Program. NTP 12th Report on Carcinogens. Rep Carcinog. 2011;12:iii-499. [ http://www.ncbi.nlm.nih.gov/pubmed/ 21822324. Accessed May 6, 2014]. 14. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens—part D: radiation. Lancet Oncol. 2009;10:751-752. [ http:// www.ncbi.nlm.nih.gov/pubmed/19655431. Accessed April 6, 2014]. 15. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: Systematic review and meta-analysis. BMJ. 2012;345:e4757. 16. Cust AE, Armstrong BK, Goumas C, et al. Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma. Int J Cancer. 2011;128:2425-2435. 17. Centers for Disease Control and Prevention. Use of indoor tanning devices by adults—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:323-326. 18. Wehner MR, Chren M-M, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol. 2014;150:390-400. 19. Guy GPJ, Tai E, Richardson LC. Use of indoor tanning devices by high school students in the United States, 2009. Prev Chronic Dis. 2011;8:A116. [ http://www.pubmedcentral.nih.gov/articlerender. fcgi?artid=3181189&tool=pmcentrez&rendertype=abstract. Accessed April 6, 2014]. 20. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance— United States, 2009. MMWR Surveill Summ. 2010;59:1-142. [ http:// www.ncbi.nlm.nih.gov/pubmed/20520591. Accessed April 1, 2014]. 21. Holman DM, Watson M. Correlates of intentional tanning among adolescents in the United States: a systematic review of the literature. J Adolesc Health. 2013;52:S52-S59. 22. Guy GP, Berkowitz Z, Jones SE, et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health. 2014;104:e69-e74. 23. Balk SJ, Fisher DE, Geller AC. Teens and indoor tanning: a cancer prevention opportunity for pediatricians. Pediatrics. 2013;131:772-785. 24. 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;134:620-627. 25. Overview of Device Regulation. Food and Drug Administration Center for Devices and Radiologic Health Web site. http://www.fda.gov/
392
26.
27.
28.
29.
30.
MedicalDevices/DeviceRegulationandGuidance/Overview/default. htm#pma. Accessed June 26, 2014. Summary of the General and Plastic Surgery Devices Panel Meeting. Food and Drug Administration Web site. http://www.fda.gov/downloads/ AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/ MedicalDevicesAdvisoryCommittee/GeneralandPlasticSurgeryDevicesPanel/ UCM206522.pdf. Accessed March 25, 2010. Consumer Updates–Indoor Tanning Raises Risk of Melanoma: FDA Strengthens Warnings for Sunlamp Products. Food and Drug Administration Web site http://www.fda.gov/ForConsumers/ConsumerUpdates/ ucm350790.htm. [Published 2014. Accessed June 7, 2014]. Indoor Tanning Services Tax Center. Internal Revenue Service Web site. http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/ Indoor-Tanning-Services-Tax-Center. Accessed October 10, 2014. Find Some Shade Because the Tanning Tax Hits Tomorrow. Internal Revenue Service Web site. http://waysandmeans.house.gov/news/ documentsingle.aspx?DocumentID=193149. Accessed June 30, 2014. Dellavalle RP, Schilling LM, Chen AK, Hester EJ. Teenagers in the UV tanning booth? Tax the tan. Arch Pediatr Adolesc Med. 2003;157:845-846.
M. Pan, L. Geller 31. Jain N, Rademaker A, Robinson JK. Implementation of the federal excise tax on indoor tanning services in Illinois. Arch Dermatol. 2012;148:122-124. 32. Indoor Tanning Restrictions for Minors—A State-By-State Comparison. National Conference of State Legislatures Web site. http://www.ncsl.org/ research/health/indoor-tanning-restrictions.aspx. Accessed April 7, 2014. 33. Forster JL, Lazovich D, Hickle A, Sorensen G, Demierre MF. Compliance with restrictions on sale of indoor tanning sessions to youth in Minnesota and Massachusetts. J Am Acad Dermatol. 2006;55:962-967. 34. Harris K, Vanderhooft L, Burt L, Vanderhooft S, Hull C. Tanning business practices in Salt Lake County Utah. J Am Acad Dermatol. 2012;66:513-514. 35. 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;145:997-1002. 36. Guy GP, Berkowitz Z, Tai E, Holman DM, Everett Jones S, Richardson LC. Indoor tanning among high school students in the United States, 2009 and 2011. JAMA Dermatol. 2014;150:501-511. 37. 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:A125.
Update on indoor tanning legislation in the United States Michael Pan, BA a , Lauren Geller, MD b,⁎ a
Icahn School of Medicine at Mount Sinai, New York, NY Departments of Dermatology and Pediatrics, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Fifth Floor, New York, NY 10029 b
Abstract The incidence of melanoma has been increasing over the past several decades, with notable increases in the pediatric and adolescent population. Indoor tanning has been proven carcinogenic and is associated with an increased risk of melanoma, especially when used at a young age. The incidence and frequency of usage of indoor tanning in the United States is high, particularly among adolescents, with roughly 20% reporting using a tanning bed at least once. The Food and Drug Administration recently made changes to its regulation of indoor tanning devices, reclassifying them as class II devices necessitating stricter premarket review, and strengthened its warnings for these devices; however, federal regulation of indoor tanning is still limited and most regulation of indoor tanning in minors is done on a state-by-state basis. Three types of legislation exist: (1) absolute ban on minor use of indoor tanning devices, (2) age restriction of minor usage of indoor tanning devices other than age 18 years, and (3) requirement of parental consent. These regulations are inconsistent, and enforcement efforts are often limited. In this contribution, we provide an update on the prevalence of indoor tanning, the risks associated with indoor tanning, and the current federal and state legislation and enforcement efforts in the United States with regard to indoor tanning. Although efforts are being made to ban all use of indoor tanning devices by minors, there is still more work to be done before this becomes a reality in the United States. © 2015 Elsevier Inc. All rights reserved.
Skin cancer incidence Skin cancer is the most common cancer in the United States, affecting 1 in 5 Americans in their lifetime.1 Melanoma, the most lethal form of skin cancer, is the second most common cancer in women and the third most common cancer in men in the third decade of life.2 According to studies from the Surveillance, Epidemiology, and End Results (SEER) Program, the incidence of both melanoma and nonmelanoma skin cancer has risen in all age groups over the past several decades. ⁎ Corresponding author. Tel.: 212 241 9728; fax: 212 987 1197. E-mail address: [email protected] (L. Geller). http://dx.doi.org/10.1016/j.clindermatol.2014.12.016 0738-081X/© 2015 Elsevier Inc. All rights reserved.
Among young adults (ages 15–40 years), the incidence of basal cell carcinoma in women (13.4-31.6 cases per 100,000 people) and the incidence of squamous cell carcinoma in both sexes (0.6-4.1 cases in women and 1.3-4.2 cases in men per 100,000 people) increased from 1976 to 2003.3 The incidence of melanoma in young adults also increased from 1973 to 2004 (5.5-13.9 cases in women and 4.7-7.7 cases in men per 100,000 people).4 The rise was sharpest after 1992 with an annual increase of 2.7% among young women. Although mortality from melanoma among young women has decreased by 2.3% annually since 1973, possibly due to increased surveillance and earlier detection, the incidence of regional and distant tumors in young women has increased annually by
388 9.2% since 1994, suggesting a recent trend in developing earlier advanced disease.4 The American Cancer Society (ACS) estimates that in 2014 there will be 76,100 newly diagnosed cases of melanoma and 9710 deaths from melanoma.5 Although rare, the incidence of melanoma in children and adolescents has also been increasing over the past several decades. Melanoma is the most common type of skin cancer in those under the age of 20.6 A recent study by reported that between 1973 and 2009, 1317 children and adolescents were diagnosed with melanoma and that the incidence of melanoma in this age group increased by an average of 2% per year. The incidence rate was higher in girls than boys (IR 7.4 in girls and 4.6 in boys), with the highest and most rapidly increasing incidence rate found in 15- to 19-year-old girls and women.7
Indoor tanning industry Ultraviolet radiation (UVR) exposure from both natural sunlight and artificial sources such as tanning beds has been postulated to be a major contributor to the epidemic rise of melanoma and NMSC. Artificial sources of UV exposure such as sunlamps and tanning beds are often used in intentional tanning. These devices emit high doses of UVA and UVB, both of which are carcinogenic, for the purpose of triggering a tanning response in the skin. Children in the United States often desire to tan. One group highlighted that children ages 11 to 18 years want to appear tan, with 10.8% of these children using sunless tanners, and that tanning is associated with other risky behaviors.8 Models of adolescents ages 12 to 18 years indicate that desire to tan is strong and is associated with greater time seeking tanning and less use of effective sun protection.9 Tanning beds were first introduced to the United States in the 1970s. The popularity of tanning beds has led to the growth of the tanning industry, which generates $5 billion in annual revenue and is used by 30 million Americans every year, including 2.3 million adolescents.10,11 In the United States, there are approximately 19,000 tanning businesses employing 160,000 people.10 Indoor tanning has become widely available such that a study analyzing the 116 most populous cities in America found an average of 41 tanning facilities per city, outnumbering chains like Starbucks and McDonald’s.12 Cities with a larger white population and lower UV index have the highest density of tanning facilities, which may account for the paradoxically high incidence of childhood and adolescent melanoma in areas with low environmental UVB exposure.7,12
Risks of indoor tanning Tanning devices manufactured before the 1980s emitted mostly UVB, which produces a more potent tanning response than UVA. As public awareness about the
M. Pan, L. Geller carcinogenic effects of UVB grew in the 1980s, manufacturers switched to devices that primarily emit UVA, claiming that such a tan was safer.11 Modern high-intensity tanning beds emerged in the 1990s to emit a mixture of UVA with a small amount of UVB, with recent “high pressure” machines delivering more concentrated UV exposure.11 The National Toxicology Program, which includes the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), as well as the World Health Organization’s International Agency for Research on Cancer (IARC), classify UVR (including UVA, UVB, and UVC) and UVR-emitting devices in the highest risk category of known human carcinogen alongside items such as tobacco smoke, coal tar, and formaldehyde.13,14 Since the IARC’s classification in 2009, several studies have emerged to further prove the carcinogenic effects of tanning beds, particularly when used at younger ages. There is a relative risk of 1.20 (95% CI: 1.08-1.34) of developing melanoma in people who have ever used a tanning bed, increasing to 1.87 (95% CI: 1.41-2.48) if tanning beds were used before the age of 35.15 Another group has reported that 76% of melanomas in those 18–29 years of age can be attributed to prior use of tanning beds.13 This association was stronger with earlier tanning bed usage (OR 1.64, 95% CI: 1.07-2.51 if age of first use was before 25 years versus OR 1.06, 95% CI: 0.66-1.72 if after 25 years).16
Use of indoor tanning Useof tanning beds is highest among adolescents and young adults. A survey conducted by the CDC in 2010 reported that 5.6% of adults in the United States between the ages of 18 and 29 years had used indoor tanning within the past 12 months, with the highest prevalence in white women 18 to 25 years of age (31.8%).17 Among adolescents, a recent meta-analysis found that 19.3% reported having ever used indoor tanning and 18.3% reported use within the past year.18 This is consistent with studies from the National Youth Risk Behavior survey, which reported that 16% of high school students in 2011 used indoor tanning beds at least once in the past year (increased from 5.6% in 2009), with 49% of these students using tanning beds 10 or more times.19 Female students were four times more likely to use tanning beds than their male peers (25.4% versus 6.7%).20 Adolescents are influenced to use indoor tanning by social factors (prizing tanned skin, having friends and parents who tan) as well as contextual factors (proximity to tanning facilities, living in a low UV index area or in the Midwest or the South, and attending a rural high school).21 Interestingly, the use of tanning beds has been positively associated with other risk-taking behavior such as binge drinking and having sexual intercourse.22 No study has evaluated the use of tanning beds in children younger than 11 years, because it is
Update on indoor tanning legislation in the United States expected that there would be an absolute ban on tanning bed use for recreational purposes in this age group.
Federal indoor tanning legislation With the rising incidence of melanoma correlating with the surge in tanning bed use, efforts have been made to enact legislation to regulate indoor tanning, particularly among children and adolescents. The World Health Organization, the American Academy of Pediatrics, the American Medical Association, and the American Academy of Dermatology all support a ban on indoor tanning services for people under the age of 18.23 Several commentaries have also called for stricter FDA regulation of tanning devices, including a federally issued ban on the use of tanning devices in minors.23,24 Tanning beds are considered medical devices and are subject to some manufacturing regulation by the FDA. The FDA assigns a class to medical devices (class I, II, or III), each conferring increasing regulatory control. Class I represents the lowest risk to consumers and these devices are exempt from premarket notification, including demonstration that the device is as safe and efficacious as a similar legally marketed device and meets performance standards. Class II devices require premarket notification, whereas class III devices represent the highest risk and require premarket approval with submission of clinical trials.25 Until May 2014, tanning beds used for cosmetic purposes were classified as class I. Given the mounting evidence of the causal link between tanning beds and skin cancer and the increased public concern, the General and Plastic Surgery
389 Devices Panel of the FDA’s Medical Devices Advisory Committee convened on March 25, 2010, to discuss the reclassification of tanning beds. After testimonies from physicians, scientists, and industry representatives, the panel concluded the following: That tanning beds should be reclassified; that there should be some age restriction; that tanning is unsafe for Fitzpatrick skin type I; that people with a family history or a genetic predisposition for skin cancer should have special restrictions; and that patient disclosures, warnings, and brochures should be offered regarding the risks of tanning beds, particularly to minors.26 On May 29, 2014, the FDA issued a final decision to reclassify tanning beds to class II, strengthening the oversight of these devices. The FDA is now also requiring tanning devices to carry a black box warning, visible to consumers, that states the products should not be used on people younger than age 18. User instructions and promotional material must also explicitly state that the product should not be used on people who have skin cancer or a family history of skin cancer and that people repeatedly exposed to UV radiation should be regularly evaluated for skin cancer. 27 Although this represents an important step forward in the regulation of indoor tanning, there is still no federal law absolutely banning the use of tanning beds among minors. Regulation in the form of taxation has also been enacted by the Internal Revenue Service (IRS). On July 1, 2010, all indoor tanning services, excluding sunless tanning such as sprays, became subject to a 10% excise tax as part of the Affordable Care Act.28 Dubbed the “tanning tax,” this new law is expected to generate $2.7 billion over the next decade.29 Drawing on the success of tobacco taxation in reducing smoking, such a tax has been proposed to be a viable solution for curbing tanning
Fig. 1 Current state regulation policies regulating youth access to tanning beds. Up to date as of March 2015. (Adopted from http:// www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Map generated by http://diymaps.net.)
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Table 1 Current state regulation policies regulating youth access to tanning beds a State
Banned access b
Parental Parental accompaniment b consent b
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Under 15
15
15-17 Under 18 Under 18
Under 18 Under 17 Under 18 Under 18
14-18 Under 14
Under 14 Under 18
14-18 14-17
Under 18
Under 18 Under 14
Under 16
Under 18
Under 14
14-17
14-15
14-18 Under 18 14-17 Under 18
Under 14 Under 18 Under 14
14-17 Under 18
Under 16 Under 18 Under 14 c Under 14 Under 17 17
Under 16
Under 17 Under 14 c Under 14 c Under 14
Under 18 Under 16
Under 18 17 17-18 Under 18 Under 18 Under 18
16-17 Under18 Under 18 Under 14
Under 18
Under 18
Under 18
Under 18 Under 18 Under 15 Under 18 Under 14 Under 16
bed usage among adolescents, who may be more responsive to financial pressure.30 The effects of the federal tanning tax remains unclear. In a 2012 survey of more than 300 tanning salons in Illinois, one group found that 73% of salons did not lose clients after the implementation of the tanning tax, with the majority (N 70%) of salons reporting that customers opposed but were undeterred by the tax, suggesting that stricter laws are necessary.31 Further investigation is needed to determine the effects of such taxation on adolescent behavior.
State indoor tanning legislation With limited regulation at the federal level, legislation to reduce indoor tanning use among minors has largely been relegated to the states. According to the National Conference of State Legislatures, as of March 2015, 40 states and the District of Columbia have some form of legislation regulating tanning bed usage among minors (Figure 1); the legislation falls into three categories: (1) absolute ban on minors’ use of indoor tanning devices, (2) age restriction of minors’ use of indoor tanning devices other than age 18 years, and (3) requirement of parental consent.33 Twelve states (California, Delaware, District of Columbia, Hawaii, Illinois, Louisiana, Minnesota, Nevada, Oregon, Texas, Vermont, and Washington) have created an absolute ban on tanning device access for minors, with California becoming the first to do so on January 1, 2012. Other states have enacted bans/age restriction with lower cutoffs: younger than 17 years (Connecticut, New Jersey, and New York), 16 years (Pennsylvania, Wisconsin), 15 years (Alabama), and 14 years (Georgia, Maine, New Hampshire, North Carolina, North Dakota, and West Virginia). Other states only require parental consent and/or accompaniment for minors (Table 1). Nine states have no law regulating tanning access (Alaska, Colorado, Idaho, Iowa, Kansas, Montana, New Mexico, Oklahoma, and South Dakota). Nearly every state has had legislation regarding tanning access introduced and debated. Most recently, a bill in Maine prohibiting access to those younger than 18 years passed both the House and Senate but was vetoed by the governor on April 9, 2013. Such a bill has also passed the House in North Carolina and was sent to the Senate, on March 21, 2013. Some jurisdictions have enacted their own laws banning access to minors, including Howard County, Maryland in 2009 followed by both Chicago and Springfield, Illinois in 2012.32
14-18 Under 15
15-18
Adopted from http://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. a Up to date as of March 2015. b Age in years. c Unless medically necessary (requires doctor's prescription and parental consent).
Effectiveness of indoor tanning legislation Several studies have examined the effectiveness of state legislation in reducing tanning bed use among adolescents. Early studies have found that laws requiring parental consent have been ineffective due to poor compliance. In
Update on indoor tanning legislation in the United States an experiment conducted in 2006 in Massachusetts and Minnesota, two states requiring parental consent for minors, 81% of indoor tanning businesses sold tanning sessions to adolescents without asking for parental consent.33 Another group similarly observed in 2011 that only 26% of tanning businesses in Salt Lake City, Utah, complied with parental consent laws.34 Laws regulating access, however, have been found to be more successful in increasing compliance and changing youth behavior. In a large cross-sectional study conducted in 2009 involving 3647 tanning businesses, businesses in states that have both access and parental consent laws were more likely to ask for parental consent from adolescent customers than states without access laws.35 Using data from the National Youth Risk Behavior surveys in 2009 and 2011, Guy et al. concluded that female high school students in states with a combination of access and parental consent laws were less likely to use indoor tanning services than states without any laws. Female students in states with only parental consent laws did not significantly differ in tanning behavior than states without any laws. 36 Studies have also reported that there is inadequate enforcement of indoor tanning legislation. In a 2008 study of 28 cities in states with indoor tanning legislation, only 32% inspected indoor tanning facilities for compliance and less than half gave citations to tanning facilities that violated state laws.37
Conclusions Despite the growing evidence of the association between indoor tanning and melanoma, the prevalence of indoor tanning remains high. The FDA recently strengthened its oversight of and warning labels for tanning devices. This is recognized as an important development in the regulation of tanning beds. There is still no federal ban on indoor tanning use among minors, and state laws remain inconsistent and poorly enforced. Studies have found that the risk of developing melanoma increases when use of tanning beds begins at a younger age, and adolescents and young adults are the most frequent users of indoor tanning. Further education is needed to increase awareness of the dangers of indoor tanning, especially among the pediatric population, and further legislation is needed on the federal level to provide a more uniform restriction on the use of indoor tanning by minors to decrease the incidence of this deadly yet preventable form of skin cancer.
References 1. Stern RS. Prevalence of a history of skin cancer in 2007: results of an incidence-based model. Arch Dermatol. 2010;146:279-282. 2. Wu X, Groves FD, McLaughlin CC, Jemal A, Martin J, Chen VW. Cancer incidence patterns among adolescents and young adults in the United States. Cancer Causes Control. 2005;16:309-320.
391 3. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA. 2005;294:681-690. 4. Purdue MP, Freeman LEB, Anderson WF, Tucker MA. Recent trends in incidence of cutaneous melanoma among US Caucasian young adults. J Invest Dermatol. 2008;128:2905-2908. 5. What Are the Key Statistics About Melanoma Skin Cancer? American Cancer Society Web site. http://www.cancer.org/cancer/skincancermelanoma/detailedguide/melanoma-skin-cancer-key-statistics. Accessed May 9, 2014. 6. Bleyer A, Viny A, Barr R. Cancer in 15- to 29-year-olds by primary site. Oncologist. 2006;11:590-601. 7. Wong JR, Harris JK, Rodriguez-Galindo C, Johnson KJ. Incidence of childhood and adolescent melanoma in the United States: 1973–2009. Pediatrics. 2013;131:846-854. 8. Cokkinides VE, Bandi P, Weinstock MA, Ward E. Use of sunless tanning products among US adolescents aged 11 to 18 years. Arch Dermatol. 2010;146:987-992. 9. Williams M, Caputi P, Jones SC, Iverson D. Sun protecting and sun exposing behaviors: testing their relationship simultaneously with indicators of ultraviolet exposure among adolescents. Photochem Photobiol. 2011;87:1179-1183. 10. FAQs-ITA-Indoor Tanning Association. Indoor Tanning Association Web site. http://www.theita.com/?page=FAQs. Accessed May 6, 2014. 11. Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol. 2005;53:1038-1044. 12. Hoerster KD, Garrow RL, Mayer JA, et al. Density of indoor tanning facilities in 116 large U.S. cities. Am J Prev Med. 2009;36:243-246. 13. National Toxicology Program. NTP 12th Report on Carcinogens. Rep Carcinog. 2011;12:iii-499. [ http://www.ncbi.nlm.nih.gov/pubmed/ 21822324. Accessed May 6, 2014]. 14. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens—part D: radiation. Lancet Oncol. 2009;10:751-752. [ http:// www.ncbi.nlm.nih.gov/pubmed/19655431. Accessed April 6, 2014]. 15. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: Systematic review and meta-analysis. BMJ. 2012;345:e4757. 16. Cust AE, Armstrong BK, Goumas C, et al. Sunbed use during adolescence and early adulthood is associated with increased risk of early-onset melanoma. Int J Cancer. 2011;128:2425-2435. 17. Centers for Disease Control and Prevention. Use of indoor tanning devices by adults—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:323-326. 18. Wehner MR, Chren M-M, Nameth D, et al. International prevalence of indoor tanning: a systematic review and meta-analysis. JAMA Dermatol. 2014;150:390-400. 19. Guy GPJ, Tai E, Richardson LC. Use of indoor tanning devices by high school students in the United States, 2009. Prev Chronic Dis. 2011;8:A116. [ http://www.pubmedcentral.nih.gov/articlerender. fcgi?artid=3181189&tool=pmcentrez&rendertype=abstract. Accessed April 6, 2014]. 20. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance— United States, 2009. MMWR Surveill Summ. 2010;59:1-142. [ http:// www.ncbi.nlm.nih.gov/pubmed/20520591. Accessed April 1, 2014]. 21. Holman DM, Watson M. Correlates of intentional tanning among adolescents in the United States: a systematic review of the literature. J Adolesc Health. 2013;52:S52-S59. 22. Guy GP, Berkowitz Z, Jones SE, et al. State indoor tanning laws and adolescent indoor tanning. Am J Public Health. 2014;104:e69-e74. 23. Balk SJ, Fisher DE, Geller AC. Teens and indoor tanning: a cancer prevention opportunity for pediatricians. Pediatrics. 2013;131:772-785. 24. 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;134:620-627. 25. Overview of Device Regulation. Food and Drug Administration Center for Devices and Radiologic Health Web site. http://www.fda.gov/
392
26.
27.
28.
29.
30.
MedicalDevices/DeviceRegulationandGuidance/Overview/default. htm#pma. Accessed June 26, 2014. Summary of the General and Plastic Surgery Devices Panel Meeting. Food and Drug Administration Web site. http://www.fda.gov/downloads/ AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/ MedicalDevicesAdvisoryCommittee/GeneralandPlasticSurgeryDevicesPanel/ UCM206522.pdf. Accessed March 25, 2010. Consumer Updates–Indoor Tanning Raises Risk of Melanoma: FDA Strengthens Warnings for Sunlamp Products. Food and Drug Administration Web site http://www.fda.gov/ForConsumers/ConsumerUpdates/ ucm350790.htm. [Published 2014. Accessed June 7, 2014]. Indoor Tanning Services Tax Center. Internal Revenue Service Web site. http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/ Indoor-Tanning-Services-Tax-Center. Accessed October 10, 2014. Find Some Shade Because the Tanning Tax Hits Tomorrow. Internal Revenue Service Web site. http://waysandmeans.house.gov/news/ documentsingle.aspx?DocumentID=193149. Accessed June 30, 2014. Dellavalle RP, Schilling LM, Chen AK, Hester EJ. Teenagers in the UV tanning booth? Tax the tan. Arch Pediatr Adolesc Med. 2003;157:845-846.
M. Pan, L. Geller 31. Jain N, Rademaker A, Robinson JK. Implementation of the federal excise tax on indoor tanning services in Illinois. Arch Dermatol. 2012;148:122-124. 32. Indoor Tanning Restrictions for Minors—A State-By-State Comparison. National Conference of State Legislatures Web site. http://www.ncsl.org/ research/health/indoor-tanning-restrictions.aspx. Accessed April 7, 2014. 33. Forster JL, Lazovich D, Hickle A, Sorensen G, Demierre MF. Compliance with restrictions on sale of indoor tanning sessions to youth in Minnesota and Massachusetts. J Am Acad Dermatol. 2006;55:962-967. 34. Harris K, Vanderhooft L, Burt L, Vanderhooft S, Hull C. Tanning business practices in Salt Lake County Utah. J Am Acad Dermatol. 2012;66:513-514. 35. 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;145:997-1002. 36. Guy GP, Berkowitz Z, Tai E, Holman DM, Everett Jones S, Richardson LC. Indoor tanning among high school students in the United States, 2009 and 2011. JAMA Dermatol. 2014;150:501-511. 37. 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:A125.
