Are teens tanning less?

By 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.

At last count, 17 states and the District of Columbia have indoor tanning bans for minors who are 18 years of age and younger. In 2017-18, 14 states introduced legislation to prohibit minors under the age of either 17 or 18 from using indoor tanning devices. Most of these states already have regulations, but they are trying to pass stricter ones. At least 23 states require tanning bed operators to limit exposure time to the manufacturers’ recommendations and provide eye protection.

Other noteworthy developments include a solid body of scientific evidence linking the use of indoor tanning devices with an increased risk of skin cancer that has led to the World Health Organization classifying tanning devices that emit ultraviolet (UV) light as group 1 human carcinogens, putting them on the same list as plutonium. In 2010, a 10% excise tax on indoor tanning salons was implemented. In 2014, the U.S. Food and Drug Administration (FDA) reclassified indoor tanning devices from class I to class II and recommended against their use by individuals younger than 18 years of age. Reducing the harms from indoor tanning was listed as one of five strategic goals of The Surgeon General’s Call to Action to Prevent Skin Cancer released the same year while dermatologist RADM Boris Lushniak, MD, MPH, served as acting surgeon general. In 2017, the Indoor Tanning Association dissolved, citing a shrinking tanning industry due to the recession, indoor tanning tax, state minor bans, and unrelenting opposition in the media. The American Suntanning Association, however, still exists and is working to repeal the tanning tax.

Legislative punch

It’s more than likely that legislation has played a major role in limiting the use of indoor tanning devices by minors. But there is no hard evidence to make that claim with certainty. “I think legislation has made a difference, but I can’t say for sure because we don’t have state-by-state data to prove it,” said Lawrence Green, MD, chair of the American Academy of Dermatology Association’s State Policy Committee. And what data exists vary as widely as the state regulations.

In Minnesota, for example, there is evidence showing the use of indoor tanning by adolescents has declined since 2014 when the state passed an under-18 ban, according to DeAnn Lazovich, PhD, an associate professor in the division of epidemiology and community health at the University of Minnesota. Based on Minnesota Student Survey data, the number of white teens who used indoor tanning decreased 73% from 2013 to 2016. “We can’t say for sure that it’s a consequence of these changes,” she said, “but it’s promising.”

However, other states that have looked at this behavior before and after passing indoor tanning legislation have had mixed results, Dr. Lazovich noted. Utah, which passed a parental accompaniment law, saw a significant decline in indoor tanning among teens. Alabama, which has an under-15 ban and requires parental consent for 16- and 17-year-olds, saw no difference in indoor tanning behavior among teens. New Jersey, which passed an under-17 ban and requires parental permission for 17-year-olds, saw no significant difference.

The most comprehensive and encouraging data have come from the CDC. From 2009 to 2015, indoor tanning among high school students decreased from 15.6% to 7.3%, representing a 53% reduction. Among non-Hispanic white female students, the prevalence dropped from 37.4% to 15.2%.

“We have seen pretty substantial decreases in indoor tanning in recent years and even among high school girls and young women, who are the most common users of indoor tanning,” said Dawn M. Holman, MPH, a behavioral scientist in the Division of Cancer Prevention and Control at the CDC. “Although many recent developments have contributed, we’ve been able to look specifically at the influence of state laws by comparing use of indoor tanning among teens in states with and without laws in place. What we’re consistently finding is that teens in states where commercial indoor tanning is restricted for their age group are less likely to engage in indoor tanning.” In addition, CDC research indicates that legislative bans have a greater impact on behavior than laws requiring parental permission, she said.

While Kelley Pagliai Redbord, MD, former chair of the Academy’s State Policy Committee and current deputy chair of its Congressional Policy Committee, agrees that state data are lacking, she is encouraged by the CDC research. “It’s the only actual hard data we have. The CDC study shows tanning rates are down and this will lead to lower cancer rates; it has to,” she said. “But it’s too soon to tell given that the indoor tanning bans are only seven years old at the most.”

It’s hard to control for that one factor, noted Bruce Brod, MD, former chair of the Academy’s Congressional Policy Committee and current deputy chair of its Council on Government Affairs and Health Policy. “However, enacting laws sends a message to the public that there are dangers associated with indoor tanning that makes it less acceptable,” he said. “I think it’s certainly likely to be one of the factors along with increased public education.”

Is a cultural shift next?

The public awareness that accompanies passage of such legislation helps educate the public and prompts patients to ask questions. “Every time a state brings forth legislation, even if it doesn’t get passed, there’s a lot of media coverage,” noted Ann Haas, deputy chair of the Academy’s State Society Relationships Committee. “In 2010 when we were working on the bill in California, tons of patients were asking about it,” said the Sacramento-based dermatologist.

Educational efforts for salon staff and the public are often written into the legislation. In Minnesota, the state health department sent notices to tanning salons regarding how to post signs about the new ban, educated salon staff about adhering to the law, and even sponsored a contest for high school students to create messages about the dangers of indoor tanning. “All of this brought attention to the issue,” noted Dr. Lazovich. “There has been a huge lack of awareness for a long time and that’s definitely changing.”

Fashion has changed a little bit, too, and paler skin is more in vogue, Dr. Redbord noted. She still has patients who don’t want to abandon the sun-drenched look because it makes them appear more physically fit, but at least they are doing spray tans. In addition, a lot of patients say that when they were younger, they were encouraged to go out and get some sun and fresh air, said the dermatologist who practices in Maryland and the District of Columbia. Nobody talked about UV exposure from the sun being bad and tanning unsafe. “There is more awareness now,” she said, “And parents are starting to get stricter about their kids tanning.”

Education targeting parents is critical

In fact, a recent study published in the American Journal of Preventive Medicine shows that the majority of parents support age-based indoor tanning restrictions (53(4):473-480). Specifically, 65% of parents agree with indoor tanning bans for youth while 79% support parental permission requirements.

Overall, parents are becoming more informed, but not everyone. Parents, and in particular fathers, who had used indoor tanning devices themselves and those who reported that they had never received skin cancer prevention counseling from their child’s doctor were less likely to believe that indoor tanning was harmful to teens, according to researchers from Massachusetts General Hospital. One explanation is that mothers tend to take their children to the doctor, so fathers are less likely to get this type of counseling. The preliminary findings of this national survey of 1,205 parents of children ages 11-17 were presented at the AAD’s 2018 Annual Meeting in San Diego (see staging.aad.org/eposters/view/Abstract.aspx?id=6912).

In general, parents seem less accepting of their children indoor tanning, Dr. Brod acknowledged. But there is a lot of variation based on demographics, such as socioeconomic status and educational levels. “I still see a subset of parents of teens who aren’t aware of the dangers of UV radiation,” he said. Dr. Brod expects a cultural shift to mimic the one that has occurred with tobacco use. “It has taken decades of generations to get the message out about the dangers of smoking. Fewer people smoke today, but some still do. With indoor tanning, I expect the same — a very slow cultural shift over time.”

Parents want to protect their children from harm, and they seem to be more receptive to learning about the dangers of indoor tanning, Dr. Green said. “It really starts with the parents more than the kids,” he added. “Parents becoming knowledgeable about the dangers of tanning and teaching sun-safety behavior to their kids will make a big difference.”

GETTING INVOLVED IN LEGISLATIVE EFFORTS

Dermatologists interested in introducing indoor tanning regulations in their states can start by looking to the Academy, which has created model legislation and other advocacy tools that can be adapted as the legislative process is similar across states. “Nationally, the Academy is doing everything it can to support states that are trying to push this legislation,” Dr. Haas said.

Next, dermatologists can contact their state dermatology society or state medical society. It helps to build a coalition of supporters, including other specialists and health care providers. “I have found that the house of medicine is very much behind dermatologists on these issues,” Dr. Green said. “When the entire medical establishment is with you, legislators are much more likely to listen.”

Legislators also like to hear from patients. When California passed its law, a number of Dr. Haas’ patients testified. Many were young women who used indoor tanning beds and were diagnosed with melanoma. If the enforcement bill makes it to a hearing, one patient who has agreed to testify is an indoor tanner who also worked at a tanning salon and was diagnosed with melanoma.

Another vital coalition member is patient advocacy groups. The regional American Cancer Society (ACS) took the lead to get the Minnesota bill passed, Dr. Lazovich stated. Previous efforts never gained traction until the ACS stepped in to mobilize the coalition of organizations involved. The ACS determined the legislators who were supportive, the messages that had to be conveyed, and the appropriate language to use in the legislation, she said.

Finding a legislator who will support the bill may require the assistance of a lobbyist. Lobbyists know the political landscape and legislators better than physicians do, Dr. Haas said. They can offer valuable insights and help target other legislators who would vote to pass the bill. Be sure to look for allies on both sides of the aisle and don’t think it’s a partisan issue, Dr. Brod advised. It behooves dermatologists to develop trusted ongoing relationships with legislators and make themselves available to legislators as a resource. Building a consensus can take time; it doesn’t happen overnight, he warned. “Although it’s important to prioritize what you want to accomplish in the bill,” Dr. Brod added, “you may have to compromise in some areas because that’s how the legislative process works.”

Dr. Haas agreed. “Most of us have had to chip away at this,” she said. “It took us four tries. As the public and legislators get better educated and as these bans pass in other states, the mountain starts to crumble and it doesn’t look so high anymore.” Dr. Haas tells other dermatologists to take any kind of legislation they can get. “An under-16 ban is better than no ban at all,” she said. “You can come back in a couple of years and keep pushing. The legislators and even the governor may be different at that time.”

ENFORCEMENT NEEDS BEEFING UP

Enforcing state regulations will also make a big difference. However, much of the existing legislation lacks language and built-in funding mechanisms for monitoring tanning facility operators’ adherence to the laws and enforcing penalties for violations. Several studies have shown wide variation in compliance and enforcement of these laws.

More than one-third of tanning salons are noncompliant with legislation, according to a study published in JAMA Dermatology this year (2018;154(1):67-72). Of the 427 salons located in 42 states and the District of Columbia that were surveyed by callers posing as minors, independently owned salons and those in rural areas and the southern regions of the U.S. were the most noncompliant. These salons were most commonly allowing tanning with parental consent at the banned age, tanning without the required parental consent or accompaniment, or written parental consent only when parental accompaniment was required.

Noncompliance is not only about restricting teens from indoor tanning per the state law. Some tanning salons continue to present inaccurate health claims. In a recent study published in Translational Behavioral Medicine, nearly 22% of tanning salons workers told the “minor” caller that the dangers of indoor tanning were no worse than the sun and 10% denied any dangers (7(4):637-644). Callers were told the benefits of indoor tanning include vitamin D production, social benefits, and treatment of skin diseases. This study involved female research assistants posing as minors who called 412 tanning salons in 14 states with tanning bans for minors under the age of 17 or 18.

Dr. Haas is all too familiar with the inaccurate information that continues to be spread by indoor tanning salons. She and her colleagues set out to determine compliance 18 months after California passed its under 18 ban and published their findings in the December 2013 issue of the JAAD. In a random sample of 600 indoor tanning facilities called by a study investigator posing as a 17-year-old, 77% were compliant with the state’s law. However, most facility employees denied that UV tanning was dangerous and made unlawful claims of such health benefits as vitamin D production, skin disease treatment, prevention of future sunburns, and prevention or treatment of depression. “The compliance was good, but the disinformation was a real problem,” she said.

Since then, Dr. Haas and her colleagues have checked on enforcement of the law to find that “there isn’t any.” That prompted her to work with CalDerm and AIM at Melanoma to push for a bill that outlines enforcement steps. California’s enforcement bill is loosely based on North Carolina’s law, which has some of the strongest enforcement language in the country, she said. California’s bill ties enforcement to adherence with current FDA guidelines regarding information given to clients, equipment labeling, and salon employee training. It also moves enforcement to the Department of Public Health, which supports the bill, from the Department of Consumer Affairs, which has not effectively enforced the law, Dr. Haas explained. The bill does not allocate funding, rather leaving the dollar amount to the Department of Public Health, which is in a better position to assess the cost of such efforts. The original bill defines a tanning facility as any place with an indoor tanning device, including apartment complexes and gyms, she noted. Therefore, the enforcement bill would have the ability to check on the latter as well.

“We have had an initial take from the tanning industry that it would not oppose the bill because of the way we worded it,” Dr. Haas said. However, the legislator who had agreed to author the bill pulled support at the last minute, leaving them scrambling to find another author before the impending deadline. “We’ve been caught in the political morass,” she said. “If we have to pull and retool the bill and sit on it for a couple of years until we find the right time and right author, we will. We have learned in California to be very patient.”

NEXT REGULATORY STEPS

Along those lines, the next wave of legislation should focus on creating stronger state laws and steeper penalties for violations, Dr. Brod said. That means introducing minor bans in states with parental accompaniment and permission laws and introducing enforcement laws in states with minor bans. Increasing fees or penalties is necessary because noncompliance often stems from a lack of funding to enforce it, said the University of Pennsylvania-based dermatologist.

Dermatologists should continue to advocate for under-18 bans for all 50 states, Dr. Redbord said. When supporters of a minor ban could not get legislation through the General Assembly in his home state of Maryland, they went county to county to pass minor bans, Dr. Green said. To date, Montgomery, Prince George’s, Howard, and Charles counties all have under-18 tanning bans in effect, and others are considering a ban. The four counties represent more than half of the state’s population, he added. “We’re spreading it county by county so that it will be a de facto state ban and we’re 50% there.”

Another approach is attempting to raise the age to use indoor tanning devices to 21 akin to some states raising the age to buy cigarettes to 21, Dr. Lazovich suggested. “Most of the young women still tanning are between the ages of 18 and 21,” she said. “And we know that the longer you delay access to risky behavior in young people, the less likely they are to adopt it.”

Keeping the conversation going with the FDA to finalize its proposed rule to restrict the use of tanning beds to individuals under the age of 18 is also important. Congresswoman Carolyn B. Maloney (D-N.Y.), co-chair of the Congressional Skin Cancer Caucus, recently urged the FDA to finalize its 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 18 to buy a cigarette, you should have to be 18 to use a tanning bed.” A national under-18 ban would send a strong message and help motivate states to echo that with state-based laws, and create more motivation to enforce the ban on indoor tanning, Dr. Brod said. “We thought the FDA was close to finalizing its proposed rule, but then the regulatory climate changed. Rather than lose the opportunity to get a ban, we took a pause.”

There is no pause button, however, when it comes to educating the public about the dangers of tanning. “We do know from our national data that millions of Americans continue to engage in indoor tanning,” the CDC’s Holman said. “So we still need to get the word out about the risk of UV radiation and overexposure to it, and to protect our young people from the harms of indoor tanning. We really want to drive home the point that tanning your skin is damaging your skin.”

The tanning industry isn’t relenting, Dr. Green points out, and neither should dermatologists. “The Indoor Tanning Association is out of business, but the American Suntanning Association is still here to keep their messages going,” he said. Despite claims that the tanning industry has shrunk, U.S. Census data demonstrates continued expansion even after the tanning tax was imposed (see staging.aad.org/dw/monthly/2017/july/tanning-industry-continued-growing-after-tanning-tax-became-law). Tanning beds are moving to fitness centers, hair salons, and day spas, which are not subject to the tanning tax and some state laws. Moreover, studies have shown that tanning beds are popping up on college campuses, in off-campus housing, and at apartment complexes catering to undergraduate and graduate students.

“It’s very important that we don’t lose sight of our core mission, which is patient safety and well-being,” Dr. Brod said. “We need to get the message out that any form of UV light from the sun or indoor tanning is dangerous. There’s hard evidence that it increases the risk of melanoma and other skin cancers,” he added. “We need to continue to engage the public, our legislators, and policymakers in these discussions. We need to continue to develop tools to educate patients and communities at a broader level. And we need to continue serving as role models.”