ARE TEENS TANNING LESS? - Signs point to progress, but work remains - MedPage Today
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ARE TEENS
TANNING LESS?
Signs point to progress,
but work remains
42 DERMATOLOGY WORLD // May 2018 www.aad.org/dwBY RUTH CAROL, CONTRIBUTING WRITER
It appears that fewer teens are indoor tanning in recent years, but
the data are sparse. Regulations to limit or ban under-18 tanning
supported by dermatologists appear to be playing a role, in part
because the media attention surrounding passage of this type of
legislation promotes public awareness. Dermatologists are optimistic
that these trends will continue as they continue to advocate for
their patients from their state legislatures to their practices. There
are already signs that dermatology’s efforts are working, though:
A recent analysis of Centers for Disease Control and Prevention
(CDC) data showed that the rate of melanoma incidence among
white females ages 15-24 declined 5.5% per year from 2005 to 2014
(doi:10.1001/jamadermatol.2017.5541).
To date, 45 states and the District of Columbia regulate the use of
indoor tanning for minors. These restrictions include a ban on minors
under a specified age or parental accompaniment or consent. >>
A Publication of the American Academy of Dermatology | Association DERMATOLOGY WORLD // May 2018 43ARE TEENS
TANNING LESS?
At last count, 17 states and the District of has declined since 2014 when the state passed an
Columbia have indoor tanning bans for minors who under-18 ban, according to DeAnn Lazovich, PhD, an
are 18 years of age and younger. In 2017-18, 14 states associate professor in the division of epidemiology
introduced legislation to prohibit minors under the and community health at the University of Minnesota.
age of either 17 or 18 from using indoor tanning Based on Minnesota Student Survey data, the number
devices. Most of these states already have regulations, of white teens who used indoor tanning decreased
but they are trying to pass stricter ones. At least 23 73% from 2013 to 2016. “We can’t say for sure that it’s
states require tanning bed operators to limit exposure a consequence of these changes,” she said, “but it’s
time to the manufacturers’ recommendations and promising.”
provide eye protection. However, other states that have looked at this
Other noteworthy developments include a solid behavior before and after passing indoor tanning
body of scientific evidence linking the use of indoor legislation have had mixed results, Dr. Lazovich
tanning devices with an increased noted. Utah, which passed a
risk of skin cancer that has led to “We have seen pretty parental accompaniment law, saw
the World Health Organization a significant decline in indoor
classifying tanning devices that substantial decreases tanning among teens. Alabama,
emit ultraviolet (UV) light as in indoor tanning in which has an under-15 ban and
group 1 human carcinogens, requires parental consent for
putting them on the same list as recent years and even 16- and 17-year-olds, saw no
plutonium. In 2010, a 10% excise among high school difference in indoor tanning
tax on indoor tanning salons was behavior among teens. New
implemented. In 2014, the U.S.
girls and young Jersey, which passed an under-
Food and Drug Administration women, who are the 17 ban and requires parental
(FDA) reclassified indoor tanning permission for 17-year-olds, saw
devices from class I to class II and
most common users no significant difference.
recommended against their use of indoor tanning.” The most comprehensive and
by individuals younger than 18 encouraging data have come from
years of age. Reducing the harms the CDC. From 2009 to 2015,
from indoor tanning was listed as one of five strategic indoor tanning among high school students decreased
goals of The Surgeon General’s Call to Action to from 15.6% to 7.3%, representing a 53% reduction.
Prevent Skin Cancer released the same year while Among non-Hispanic white female students, the
dermatologist RADM Boris Lushniak, MD, MPH, prevalence dropped from 37.4% to 15.2%.
served as acting surgeon general. In 2017, the Indoor “We have seen pretty substantial decreases in
Tanning Association dissolved, citing a shrinking indoor tanning in recent years and even among
tanning industry due to the recession, indoor tanning high school girls and young women, who are the
tax, state minor bans, and unrelenting opposition in most common users of indoor tanning,” said Dawn
the media. The American Suntanning Association, M. Holman, MPH, a behavioral scientist in the
however, still exists and is working to repeal the Division of Cancer Prevention and Control at the
tanning tax. CDC. “Although many recent developments have
contributed, we’ve been able to look specifically at the
Legislative punch influence of state laws by comparing use of indoor
It’s more than likely that legislation has played a tanning among teens in states with and without
major role in limiting the use of indoor tanning laws in place. What we’re consistently finding is that
devices by minors. But there is no hard evidence to teens in states where commercial indoor tanning
make that claim with certainty. “I think legislation is restricted for their age group are less likely to
has made a difference, but I can’t say for sure because engage in indoor tanning.” In addition, CDC research
we don’t have state-by-state data to prove it,” said indicates that legislative bans have a greater impact
Lawrence Green, MD, chair of the American Academy on behavior than laws requiring parental permission,
of Dermatology Association’s State Policy Committee. she said.
And what data exists vary as widely as the state While Kelley Pagliai Redbord, MD, former chair
regulations. of the Academy’s State Policy Committee and current
In Minnesota, for example, there is evidence deputy chair of its Congressional Policy Committee,
showing the use of indoor tanning by adolescents agrees that state data are lacking, she is encouraged
44 DERMATOLOGY WORLD // May 2018 www.aad.org/dwGETTING INVOLVED
IN LEGISLATIVE
EFFORTS
by the CDC research. “It’s the only actual Dermatologists interested in introducing indoor tanning regula-
hard data we have. The CDC study shows tions in their states can start by looking to the Academy, which
tanning rates are down and this will lead to has created model legislation and other advocacy tools that can
lower cancer rates; it has to,” she said. “But be adapted as the legislative process is similar across states.
it’s too soon to tell given that the indoor “Nationally, the Academy is doing everything it can to support
tanning bans are only seven years old at the states that are trying to push this legislation,” Dr. Haas said.
most.”
It’s hard to control for that one factor, Next, dermatologists can contact their state dermatology society
noted Bruce Brod, MD, former chair of the or state medical society. It helps to build a coalition of support-
Academy’s Congressional Policy Committee ers, including other specialists and health care providers. “I have
and current deputy chair of its Council on found that the house of medicine is very much behind dermatolo-
Government Affairs and Health Policy. gists on these issues,” Dr. Green said. “When the entire medical
“However, enacting laws sends a message to establishment is with you, legislators are much more likely to
the public that there are dangers associated listen.”
with indoor tanning that makes it less
acceptable,” he said. “I think it’s certainly Legislators also like to hear from patients. When California
likely to be one of the factors along with passed its law, a number of Dr. Haas’ patients testified. Many
increased public education.” were young women who used indoor tanning beds and were
diagnosed with melanoma. If the enforcement bill makes it to a
Is a cultural shift next? hearing, one patient who has agreed to testify is an indoor tan-
The public awareness that accompanies ner who also worked at a tanning salon and was diagnosed with
passage of such legislation helps educate the melanoma.
public and prompts patients to ask questions.
“Every time a state brings forth legislation, Another vital coalition member is patient advocacy groups. The
even if it doesn’t get passed, there’s a lot regional American Cancer Society (ACS) took the lead to get
of media coverage,” noted Ann Haas, the Minnesota bill passed, Dr. Lazovich stated. Previous efforts
deputy chair of the Academy’s State Society never gained traction until the ACS stepped in to mobilize the co-
Relationships Committee. “In 2010 when we alition of organizations involved. The ACS determined the legisla-
were working on the bill in California, tons tors who were supportive, the messages that had to be conveyed,
of patients were asking about it,” said the and the appropriate language to use in the legislation, she said.
Sacramento-based dermatologist.
Educational efforts for salon staff Finding a legislator who will support the bill may require the
and the public are often written into the assistance of a lobbyist. Lobbyists know the political landscape
legislation. In Minnesota, the state health and legislators better than physicians do, Dr. Haas said. They
department sent notices to tanning salons can offer valuable insights and help target other legislators who
regarding how to post signs about the new would vote to pass the bill. Be sure to look for allies on both
ban, educated salon staff about adhering to sides of the aisle and don’t think it’s a partisan issue, Dr. Brod
the law, and even sponsored a contest for advised. It behooves dermatologists to develop trusted ongoing
high school students to create messages relationships with legislators and make themselves available to
about the dangers of indoor tanning. “All of legislators as a resource. Building a consensus can take time; it
this brought attention to the issue,” noted doesn’t happen overnight, he warned. “Although it’s important
Dr. Lazovich. “There has been a huge lack to prioritize what you want to accomplish in the bill,” Dr. Brod
of awareness for a long time and that’s added, “you may have to compromise in some areas because
definitely changing.” that’s how the legislative process works.”
Fashion has changed a little bit, too, and
paler skin is more in vogue, Dr. Redbord Dr. Haas agreed. “Most of us have had to chip away at this,” she
noted. She still has patients who don’t want said. “It took us four tries. As the public and legislators get better
to abandon the sun-drenched look because educated and as these bans pass in other states, the mountain
it makes them appear more physically fit, starts to crumble and it doesn’t look so high anymore.” Dr. Haas
but at least they are doing spray tans. In tells other dermatologists to take any kind of legislation they can
addition, a lot of patients say that when they get. “An under-16 ban is better than no ban at all,” she said. “You
were younger, they were encouraged to go can come back in a couple of years and keep pushing. The legis-
out and get some sun and fresh air, said lators and even the governor may be different at that time.”
A Publication of the American Academy of Dermatology | Association DERMATOLOGY WORLD // May 2018 45ARE TEENS
TANNING LESS?
the dermatologist who practices in Maryland and likely to get this type of counseling. The preliminary
the District of Columbia. Nobody talked about UV findings of this national survey of 1,205 parents of
exposure from the sun being bad and tanning unsafe. children ages 11-17 were presented at the AAD’s 2018
“There is more awareness now,” she said, “And Annual Meeting in San Diego (see www.aad.org/
parents are starting to get stricter about their kids eposters/view/Abstract.aspx?id=6912).
tanning.” In general, parents seem less accepting of their
children indoor tanning, Dr. Brod acknowledged. But
Education targeting parents is critical there is a lot of variation based on demographics, such
In fact, a recent study published in the American as socioeconomic status and educational levels. “I still
Journal of Preventive Medicine shows that the see a subset of parents of teens who aren’t aware of the
majority of parents support age-based indoor dangers of UV radiation,” he said. Dr. Brod expects a
tanning restrictions (53(4):473-480). Specifically, cultural shift to mimic the one that has occurred with
65% of parents agree with indoor tanning bans tobacco use. “It has taken decades of generations to get
for youth while 79% support parental permission the message out about the dangers of smoking. Fewer
requirements. people smoke today, but some still do. With indoor
Overall, parents are becoming more informed, but tanning, I expect the same — a very slow cultural shift
not everyone. Parents, and in particular fathers, who over time.”
had used indoor tanning devices themselves and those Parents want to protect their children from harm,
who reported that they had never received skin cancer and they seem to be more receptive to learning about
prevention counseling from their child’s doctor were the dangers of indoor tanning, Dr. Green said. “It really
less likely to believe that indoor tanning was harmful starts with the parents more than the kids,” he added.
to teens, according to researchers from Massachusetts “Parents becoming knowledgeable about the dangers
General Hospital. One explanation is that mothers tend of tanning and teaching sun-safety behavior to their
to take their children to the doctor, so fathers are less kids will make a big difference.”
CDC MEETS, EXCEEDS HEALTHY PEOPLE 2020
GOALS FOR REDUCING INDOOR TANNING
The CDC has met and exceeded its goals for reducing the use of indoor tanning devices by adolescents and
young adults as part of the Healthy People 2020 campaign.
“For adults, the target was set at 3.6%. “For high school students, we exceeded
the target, which was set at 14%.
Currently, 3.6% of adults are still using Currently, approximately 7% of high school
indoor tanning devices,” Holman said. students are indoor tanners,” she stated.
The CDC estimates that approximately 1.2 million high school students and 7.8 million adults in the U.S.
are still indoor tanning. Based on national data, the agency also knows that more than half of high school
students and more than one-third of adults are getting sunburn each year. “Clearly, ongoing efforts are
still needed to get the message out about the importance of sun protection and dangers of indoor tanning
as well as sun tanning outdoors,” Holman added.
46 DERMATOLOGY WORLD // May 2018 www.aad.org/dwEnforcement needs beefing up as vitamin D production, skin disease treatment,
Enforcing state regulations will also make a big prevention of future sunburns, and prevention or
difference. However, much of the existing legislation treatment of depression. “The compliance was good,
lacks language and built-in funding mechanisms for but the disinformation was a real problem,” she said.
monitoring tanning facility operators’ adherence to Since then, Dr. Haas and her colleagues have
the laws and enforcing penalties for violations. Several checked on enforcement of the law to find that “there
studies have shown wide variation in compliance and isn’t any.” That prompted her to work with CalDerm
enforcement of these laws. and AIM at Melanoma to push for a bill that outlines
More than one-third of tanning salons are enforcement steps. California’s enforcement bill is
noncompliant with legislation, according to a loosely based on North Carolina’s law, which has
study published in JAMA Dermatology this year some of the strongest enforcement language in the
(2018;154(1):67-72). Of the 427 salons located in 42 country, she said. California’s bill ties enforcement
states and the District of Columbia that were surveyed to adherence with current FDA guidelines regarding
by callers posing as minors, information given to clients,
independently owned salons equipment labeling, and salon
and those in rural areas and the
“It has taken decades of employee training. It also moves
southern regions of the U.S. generations to get the enforcement to the Department
were the most noncompliant. of Public Health, which supports
These salons were most
message out about the the bill, from the Department
commonly allowing tanning dangers of smoking. of Consumer Affairs, which has
with parental consent at the not effectively enforced the law,
Fewer people smoke Dr. Haas explained. The bill
banned age, tanning without
the required parental consent today, but some still do. does not allocate funding, rather
or accompaniment, or written With indoor tanning, I leaving the dollar amount to the
parental consent only when Department of Public Health,
parental accompaniment was expect the same — a which is in a better position to
required. very slow cultural shift assess the cost of such efforts.
Noncompliance is not The original bill defines a
only about restricting teens
over time.” tanning facility as any place
from indoor tanning per the with an indoor tanning device,
state law. Some tanning salons continue to present including apartment complexes and gyms, she noted.
inaccurate health claims. In a recent study published Therefore, the enforcement bill would have the ability
in Translational Behavioral Medicine, nearly 22% of to check on the latter as well.
tanning salons workers told the “minor” caller that “We have had an initial take from the tanning
the dangers of indoor tanning were no worse than industry that it would not oppose the bill because of
the sun and 10% denied any dangers (7(4):637-644). the way we worded it,” Dr. Haas said. However, the
Callers were told the benefits of indoor tanning include legislator who had agreed to author the bill pulled
vitamin D production, social benefits, and treatment support at the last minute, leaving them scrambling
of skin diseases. This study involved female research to find another author before the impending deadline.
assistants posing as minors who called 412 tanning “We’ve been caught in the political morass,” she said.
salons in 14 states with tanning bans for minors under “If we have to pull and retool the bill and sit on it for
the age of 17 or 18. a couple of years until we find the right time and right
Dr. Haas is all too familiar with the inaccurate author, we will. We have learned in California to be
information that continues to be spread by indoor very patient.”
tanning salons. She and her colleagues set out to
determine compliance 18 months after California Next regulatory steps
passed its under 18 ban and published their findings Along those lines, the next wave of legislation should
in the December 2013 issue of the JAAD. In a random focus on creating stronger state laws and steeper
sample of 600 indoor tanning facilities called by a penalties for violations, Dr. Brod said. That means
study investigator posing as a 17-year-old, 77% were introducing minor bans in states with parental
compliant with the state’s law. However, most facility accompaniment and permission laws and introducing
employees denied that UV tanning was dangerous enforcement laws in states with minor bans.
and made unlawful claims of such health benefits Increasing fees or penalties is necessary because
A Publication of the American Academy of Dermatology | Association DERMATOLOGY WORLD // May 2018 47ARE TEENS
TANNING LESS?
noncompliance often stems from a lack of funding to The tanning industry isn’t relenting, Dr. Green
enforce it, said the University of Pennsylvania-based points out, and neither should dermatologists. “The
dermatologist. Indoor Tanning Association is out of business, but
Dermatologists should continue to advocate for the American Suntanning Association is still here to
under-18 bans for all 50 states, Dr. Redbord said. keep their messages going,” he said. Despite claims
When supporters of a minor ban could not get that the tanning industry has shrunk, U.S. Census
legislation through the General Assembly in his home data demonstrates continued expansion even after
state of Maryland, they went county to county to pass the tanning tax was imposed (see www.aad.org/dw/
minor bans, Dr. Green said. To date, Montgomery, monthly/2017/july/tanning-industry-continued-
Prince George’s, Howard, and Charles counties all growing-after-tanning-tax-became-law). Tanning
have under-18 tanning bans in effect, beds are moving to fitness centers,
and others are considering a ban. hair salons, and day spas, which
The four counties represent more “It’s very important are not subject to the tanning tax
than half of the state’s population, that we don’t lose and some state laws. Moreover,
he added. “We’re spreading it county studies have shown that tanning
by county so that it will be a de facto sight of our core beds are popping up on college
state ban and we’re 50% there.” mission, which is campuses, in off-campus housing,
Another approach is attempting
to raise the age to use indoor tanning
patient safety and and at apartment complexes catering
to undergraduate and graduate
devices to 21 akin to some states well-being.” students.
raising the age to buy cigarettes to “It’s very important that we don’t
21, Dr. Lazovich suggested. “Most of lose sight of our core mission, which
the young women still tanning are between the ages is patient safety and well-being,” Dr. Brod said. “We
of 18 and 21,” she said. “And we know that the longer need to get the message out that any form of UV
you delay access to risky behavior in young people, light from the sun or indoor tanning is dangerous.
the less likely they are to adopt it.” There’s hard evidence that it increases the risk of
Keeping the conversation going with the FDA melanoma and other skin cancers,” he added. “We
to finalize its proposed rule to restrict the use of need to continue to engage the public, our legislators,
tanning beds to individuals under the age of 18 is and policymakers in these discussions. We need to
also important. Congresswoman Carolyn B. Maloney continue to develop tools to educate patients and
(D-N.Y.), co-chair of the Congressional Skin Cancer communities at a broader level. And we need to
Caucus, recently urged the FDA to finalize its continue serving as role models.” dw
proposed rule or propose a new one. Congress is
failing to warn young people, and young women in
particular, about the dangers of tanning beds, and it
must take action, she said, adding, “If you need to be
WANT TO KNOW THE
18 to buy a cigarette, you should have to be 18 to use a
tanning bed.” A national under-18 ban would send a MELANOMA RATES
strong message and help motivate states to echo that
with state-based laws, and create more motivation IN YOUR STATE?
to enforce the ban on indoor tanning, Dr. Brod
said. “We thought the FDA was close to finalizing The CDC publishes the official federal statistics
its proposed rule, but then the regulatory climate on cancer incidence and deaths, produced in
changed. Rather than lose the opportunity to get a conjunction with the National Cancer Institute,
ban, we took a pause.” at United States Cancer Statistics: Data Visual-
There is no pause button, however, when it comes izations (https://nccd.
to educating the public about the dangers of tanning. cdc.gov/USCSData-
“We do know from our national data that millions of Viz/rdPage.aspx).
Americans continue to engage in indoor tanning,” the You can use this web-
CDC’s Holman said. “So we still need to get the word based application to
out about the risk of UV radiation and overexposure obtain state statistics
to it, and to protect our young people from the harms
and trends.
of indoor tanning. We really want to drive home the
point that tanning your skin is damaging your skin.”
48 DERMATOLOGY WORLD // May 2018 www.aad.org/dwYou can also read
