In state capitols across the United States (US), a debate is taking place. Should state government regulate commercial tanning bed use to prohibit children from using them? In 2009, Howard County in Maryland became the first US governmental body to prohibit children’s use of a commercial tanning bed (Howard County Board of Health, 2009). Since that time, five states have passed legislation prohibiting tanning bed use for those less than 18 years old: California in 2011 (California Legislative Information, 2011), Vermont in 2012 (Vt. Stat. Ann. tit. 18, § 29–1513;The Vermont Statutes Online, 2012), and in 2013, Oregon (H.B. 2896, Leg. 77th; Oregon Legislative Assembly, 2013), Nevada (S.B. 267, Leg. 77th; Nevada Legislature, 2013), Texas (S.B. 329, Leg. 83rd; Texas Legislature, 2013), and Illinois (210 ILL. Comp. Stat 98–039 § 25; Illinois General Assembly, 2013). When a bill is introduced in a state legislature, it is assigned to a committee that then becomes responsible for considering its merits and disadvantages. In 2013, according to the National Conference of State Legislatures, there were bills introduced in 23 states that propose to restrict commercial tanning bed use for those under 18 years old (National Conference of State Legislatures, 2013).
Those presenting evidence in favor of such regulation will include public advocacy groups, like the American Cancer Society and Aim at Melanoma, and professional organizations like the Dermatology Nurses’ Association (DNA), American Academy of Dermatology, American Academy of Pediatrics, and American Society of Dermatology Physician Assistants. An often compelling argument in favor of restricting tanning bed use for children will also be heard from survivors of melanoma or the family members of those who did not survive. Arguing against legislation restricting commercial tanning bed use will be representatives of the tanning industry.
The purpose of this commentary is to evaluate and consider certain claims made in public hearing testimony by a representative of the tanning industry. Stakeholders, who believe that eliminating commercial tanning bed use for children will eventually reduce skin cancer risk, will benefit from the examination of these claims made by tanning industry representatives. Active advocates for skin cancer prevention will need to prepare convincing arguments to sway legislators to pass such legislation. Six US states have enacted such legislation, but there is more work to be done.
In 2012, a public hearing was held in Connecticut regarding a bill that was introduced that would prevent children from using commercial tanning facilities (Connecticut General Assembly, 2012). The testimony submitted by Joseph Levy, executive director of the International Smart Tan Network, was succinct and rational sounding. A part of this testimony was entitled “5 Reasons ‘Tan Ban’ Legislation Would Be a Mistake” (Connecticut General Assembly, 2012). In this testimony, Mr. Levy took the stance that the tanning industry supports the health of children by providing professional services by trained operators and controlled use of ultraviolet (UV) radiation that will minimize the risks of sunburn. He went on to say that, without access to a commercial tanning facility, children will use unmonitored personal sun (tanning) beds or will expose themselves to more natural sun, which will increase their chance of sunburn and skin damage.
In an attempt to understand the views of those who support the tanning bed industry, let’s examine some of their claims:
This is not a public health issue. It’s a competitive issue.
In direct contradiction to what Mr. Levy said in 2012, restricting tanning bed use for those under 18 years old is a public health issue. Skin cancer has become, in recent years, a serious and costly public health issue. From 1975 to 2007, the incidence of malignant melanoma in the US has increased from 8.7 per 100,000 persons to 25.3 per 100,000 persons (Lin, Eder, & Weinman, 2011). The incidence for nonmelanoma skin cancer can only be estimated because this is not typically reported to cancer registries. In the US, the estimate was 900,000 to 1.2 million in 1994; in 2006, this increased to 2.1 million (Rogers et al., 2010). In the US, for 2004, total direct and indirect costs for melanoma were estimated at $3.142 and $2.412 billion, respectively (Bickers et al., 2006).
Not all skin cancers are caused by commercial tanning beds; many are caused by natural sunlight as evidenced by the historical description of degenerative skin changes in sailors by Dr. Paul Unna in 1894 (Randle, 1997). However, in the introduction of the first commercial tanning facility in Arkansas in the 1970s (Woo & Eide, 2010), and their tremendous gain in popularity, usage rose from 1% in 1988 to 27% in 2007 (Robinson, Kim, Rosenbaum, & Ortiz, 2008), which coincides with the recent escalation in skin cancer incidence. Professionals working in dermatology support the health and well-being of our patients first and foremost. We do this by educating them on the dangers of UV light and teaching everyone the proper steps to take to improve skin health.
Another claim made by Levy (Connecticut General Assembly, 2012) states:
So if sun beds are really such a risk, why is dermatology standing here today asking you to allow them to continue to use sunbeds to treat purely cosmetic skin conditions that kill no one?
This statement is wrong for two reasons. First, dermatology providers do not prescribe sunbeds. Medical devices are specifically chosen for and with each individual patient. The decision on which medical device to use and its dosing is based on the patient’s needs, history, and personal goals. Many factors are taken into consideration when deciding which treatments are best for each patient. For example, the patient’s skin type, personal past history, family history, disease type, and extent of disease are just a few. The therapy is stopped or maintained at a decreased rate when the patient is stable, unlike the use of indoor tanning beds, which is not regulated by a trained medical professional.
Second, medical phototherapy is not used for purely cosmetic skin conditions (Menter et al., 2010). Phototherapy, also known as photomedicine, is the use of UV light (UVL) to treat skin disease. Phototherapy or photomedicine is a prescription for medical treatment by licensed professionals with years of education and experience. The DNA supports the use of phototherapy for medical conditions. Psoriasis is the leading diagnosis for prescribed phototherapy in dermatology. Many other diseases are treated with phototherapy such as eczema/atopic dermatitis, alopecia, folliculitis, graft-versus-host disease, granuloma annulare, itchy red bump disease, lichen planus, parapsoriasis, pityriasis rosea, mycosis fungoides or cutaneous T-cell lymphoma, uremic pruritus, and vitiligo (DNA, 2011). None of these medical conditions would be considered cosmetic by the prescriber or by the person being treated. As dermatology nurses know, skin disease affects many aspects of a patient’s life: physically, medically, and psychosocially. When phototherapy is used, the patient is assessed by a provider for the risk benefit ratio (DNA, 2011). If the provider and the patient decide that phototherapy is the best treatment option, the patient is monitored and evaluated by licensed staff and providers throughout the course of therapy. Areas that are not affected by the disease are shielded from the UVL therapy, unlike with commercial tanning beds.
Clearly, the dermatology specialty does not use phototherapy for purely cosmetic skin conditions, and when phototherapy is used, the benefits must always outweigh the risk for the patient. The phototherapy unit and a sunbed are not identical, as Levy states (Connecticut General Assembly, 2012). What are the differences?
* Licensed medical professionals administer the photomedicine as prescribed by the healthcare provider, and the patient is frequently evaluated for adverse effects and further need for treatment. These professionals understand how the different UVLs affect the skin and eyes and can allow for the appropriate treatment and protection.
* Precautions are taken to only treat the affected areas.
* The UVL is different depending on the prescribed phototherapy treatment, with the sunbed, every person is treated with the same UVL.
* Dermatology professionals continue to monitor the patients for skin cancers after being treated with any UVL.
* Dermatology professionals evaluate for the appropriateness of phototherapy according to the patient’s family history, the patient’s personal history, skin type, current medications, and health status. The benefits must always outweigh the risk, and the patient must have full understanding of the risk (DNA, 2011).
Let’s take a closer look at another claim made by Levy (Connecticut General Assembly, 2012).
The present system works. Requiring signed consent from a parent/guardian is working. It’s what most parents want.
The present system of regulation regarding parental consent is highly variable and depends on in which state one lives. Some states have no regulation at all, some have restricted commercial tanning entirely for minors, and some have parental consent laws (Mayer et al., 2011). These parental consent laws are meant to be protective, to allow an adult to make the decision rather than a child, but they are, at this point, not working to reduce commercial tanning use. In one study, adolescents who used commercial tanning facilities were 70% more likely to have a parent who tans, and there was no significant difference in indoor tanning behavior between states that have parental consent regulation and those that do not (Mayer et al., 2011). In addition, from 1998 to 2004, there was an increase in the number of states that enacted legislation to restrict tanning facility access to youths, but this did not appreciably change tanning bed use by children (Cokkinedes, Weinstock, Lazovich, Ward, & Thun, 2009).
The reason may be simple: parents do not know that commercial tanning is dangerous. It was not until 2010 that the tanning industry was restricted, by the Federal Trade Commission, from saying the following:
* Tanning, including indoor tanning, does not increase the risk of skin cancer.
* Tanning, including indoor tanning, is safe or poses no danger.
* Indoor tanning is approved by the government.
* Indoor tanning is safer than tanning outdoors because, in indoor tanning facilities, the amount of UV light is monitored and controlled (Federal Trade Commission, 2010).
Another aspect to consider, when discussing the failure of the current regulation, is the evidence obtained in a 2012 investigation conducted at the behest of the United States House Committee on Energy and Commerce. The committee investigators, posing as “fair-skinned, teenage girls,” called 300 tanning salons nationwide, at least three facilities from each state. They found that 74% of the surveyed tanning facilities would allow “first-time, fair-skinned teenage girls” to tan daily (U.S. House of Representatives Committee on Energy and Commerce-Minority Staff, 2012, p. 13). This is well beyond the Food and Drug Administration’s “recommendations on tanning frequency” that manufacturers are required to provide with the purchase of a tanning device (U.S. House of Representatives Committee on Energy and Commerce-Minority Staff, 2012, p. 12). The investigation also found that 90% of the tanning salons told the caller that tanning posed no risk and that tanning was beneficial to the health of a fair-skinned teenage girl (U.S. House of Representatives Committee on Energy and Commerce-Minority Staff, 2012).
There remain some gaps in the scientific literature on the understanding of how skin cancer happens, but our understanding is improving, and the evidence is mounting. UV from natural and artificial sources plays a part in the generation of skin cancer (Lin et al., 2011). Some people, based on their genetics like skin type, are more likely to get skin cancer, and people who have more UV radiation in their lifetime develop skin cancer more often (Lin et al., 2011). Not everyone who uses a commercial tanning bed will get skin cancer, just as not everyone who smokes gets lung cancer and not everyone who forgets to look both ways when crossing the street gets hit by a bus. This is not a rational argument that the public should stop taking simple precautions and avoid unnecessary risks. Commercial tanning beds provide high-intensity UV radiation, very close to the human body, over a very short time. Skin cells are damaged by both UVA and UVB; this damage can cause cancer (Lim et al., 2011). UV exposure in childhood is a known risk factor for melanoma, and a number of studies have shown a link between use of a tanning lamp early in life with an increased risk of skin cancer later on in life (Lim et al., 2011). In childhood, the skin cells are replicating at a rate faster than any other time in life (Autier & Boyle, 2007). This is not the time to submit them to intense UV radiation that could cause even a small glitch, which could become a deadly or disfiguring problem later in life.
It is vital for nurses to take an active part in supporting legislation that will prohibit tanning bed use for children. It is through education and discussion that, eventually, stakeholders concerned about the increasing skin cancer rates get the word out to the public and our legislators. As a stakeholder concerned with the rising rates of skin cancer, the DNA recommends that its members actively participate in educating the public and our legislators about the growing public health hazards directly related to indoor tanning (DNA, n.d.). There is promising evidence that eliminating tanning bed use for minors will, in time, prove beneficial to public health. The National Conference of State Legislatures tracks and regularly updates legislative efforts in all states; valuable information can be found on their website: http://www.ncsl.org/issues-research/health/indoor-tanning-restrictions.aspx. Individuals who are ready to take part in protecting children from skin cancer can find assistance from the DNA Health Policy and Advocacy Committee at dnanurse.org.
Katrina Nice Masterson
Health Policy and Advocacy Committee
Dermatology Nurses’ Association
Angela R. Hamilton
Health Policy and Advocacy Committee
Dermatology Nurses’ Association
Autier P., Boyle P. (2007). Artificial ultraviolet sources and skin cancers: Rational for restricting access to sunbed use before 18 years of age. Nature Clinical Practice Oncology, 5 (4), 178–179.
Bickers D., Lim H., Margolis D., Weinstock M., Goodman C., Faulkner E., Dall T. (2006). The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. Journal of the American Academy of Dermatology, 55, 490–500.
Cokkinedes V., Weinstock M. A., Lazovich D., Ward E., Thun M. (2009). Indoor tanning use among adolescents in the U. S., 1998 to 2004. Cancer, 115, 190–198. doi:10.1002/cncr.24010
Dermatology Nurses’ Association. (2011). The Joan Shelk fundamentals of phototherapy workshop. Boston, MA: Author.
Lim H. W., James W. D., Rigel D. S., Maloney M. E., Spencer J. M., Bhushan R. (2011). Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: Time to ban the tan. Journal of the American Academy of Dermatology, 64, 893–902.
Lin J. S., Eder M., Weinman S. (2011). Behavioral counseling to prevent skin cancer; a systematic review for the US Preventive Task Force. Annals of Internal Medicine, 154, 190–201.
Mayer J. A., Woodruff S. I., Slymen D. J., Sallis J. F., Forster J.L., Clapp E. J., Gilmer T. (2011). Adolescents’ use of indoor tanning: A large-scale evaluation of psychosocial, environmental, and policy-level correlates. American Journal of Public Health, 101, 930–938. doi:10.2105/AJPH.2010.300079
Menter A., Korman N. J., Elmets C. A., Feldman S. R., Gelfand J. M., Gordon K. B., Bhushan R. (2010). Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. Journal of the American Academy of Dermatology, 62 (1), 114–135.
Randle H. W. (1997). Suntanning: Differences in perception throughout history. Mayo Clinical Proceedings, 72, 461–466.
Robinson J., Kim J., Rosenbaum S., Ortiz S. (2008). Indoor tanning knowledge, attitude and behavior among young adults from 1988–2007. Archives of Dermatology, 144 (4), 484–488.
Rogers H., Weinstock M., Harris A., Hinckley M., Feldman S., Fleischer A., Coldiron B. (2010). Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Archives of Dermatology, 146 (3), 283–287.
U.S. House of Representatives Committee on Energy and Commerce-Minority Staff. (2012). False and misleading health information provided to teens by the indoor tanning industry; Investigative report. Prepared for Rep. Henry A. Waxman, Rep. Diana DeGette, Rep. Frank Pallone, Jr., Rep. Rosa L. DeLauro, and Rep. Carolyn Maloney.
Woo D. K., Eide M. J. (2010). Tanning beds, skin cancer, and vitamin D: An examination of the scientific evidence and public health implications. Dermatologic Therapy, 23 (1), 61–71.