Taking on tanning
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Dermatology takes pages from anti-smoking playbook to protect public health

Given the strong parallels between the approaches of the tobacco and indoor tanning industries selling their products — they both minimize health risks, hype health benefits, and promote the use of their products as socially desirable to specific populations — it makes sense to use similar tactics to combat them.

There are indications that the three-pronged approach to minimize the use of indoor tanning — legislative, economic, and cultural — is working. But despite recent successes, this is not the time for dermatologists to rest on their laurels as more work needs to be done.

Irrefutable science

Of course, the biggest weapon in the dermatologists’ armamentarium is the growing scientific evidence linking the use of indoor tanning devices with an increased risk of skin cancer. It started with the International Agency for Research on Cancer (IARC) meta-analysis, which found that first exposure to tanning beds before the age of 35 increases an individual’s lifetime risk of melanoma by as much as 75 percent, according to Henry W. Lim, MD, C.S. Livingood chair of the department of dermatology at Henry Ford Hospital in Detroit. That led to the World Health Organization classifying tanning devices that emit ultraviolet (UV) light as known human carcinogens. 

Since then, several population-based studies looking exclusively at the use of indoor tanning beds have confirmed the IARC study findings. Among those published in 2010 was the Skin Health Study that showed frequent indoor tanning increased melanoma risk, regardless of the age when indoor tanning began and the type of UV light emitting device used. It was based on a review of invasive cutaneous melanoma diagnoses pulled from a statewide cancer registry in Minnesota and published in Cancer Epidemiology, Biomarkers & Prevention (June 2010 19; 1557). “The Lazovich study provided less room for criticism from the opposition because it was more applicable to the current devices being used,” noted Bruce A. Brod, MD, clinical associate professor of dermatology at the University of Pennsylvania School of Medicine and an advisor to the AAD’s State Policy Committee. Tanning bed use was associated with an increased risk of early-onset melanoma, a risk that increased with greater use, in the Australian Melanoma Family Study published in the International Journal of Cancer (2011 May 15;128(10):2425-35). Seventy-six percent of melanomas diagnosed in individuals between the ages of 18 and 29 years were attributable to tanning bed use. A significant increase in melanoma incidence correlated to an increase in the number of indoor tanning salons in Iceland, according to a study published in the American Journal of Epidemiology ((2010) 172 (7): 762-767).

Other recent studies have shown that sunscreen use prevents skin cancer, countering a common argument used by the Indoor Tanning Association (ITA) that the use of sunscreen causes cancer, Dr. Lim said. This argument is based on very old data using sunscreens that blocked UVB rays and not UVA rays. However, since the advent of broad-spectrum sunscreen, which protects against both types of rays, that argument is no longer valid, he said. One of the latest studies by Green and colleagues out of Australia shows that the use of sunscreen decreases the development of squamous cell carcinoma, basal cell carcinoma, and melanoma. The 10-year follow-up trial was published in the Journal of Clinical Oncology in 2011 (29(3): 257-263).

Additionally, the science is very clear now that the spectrum for vitamin D synthesis is UVB rays, Dr. Lim said. Most tanning beds, however, use UVA rays, dispelling the argument that their use can help produce vitamin D. Furthermore, it’s now known that taking a pill is a more controlled, safe, and inexpensive way to supplement vitamin D, he added.

More recently, studies have shown that indoor tanning is an addictive behavior, much like smoking, Dr. Lim noted. Excessive indoor tanning has the clinical characteristics of classic addictive disorders and is frequently associated with anxiety, eating disorders, and tobacco dependence, according to a study published in the International Journal of Dermatology this past March (doi: 10.1111/ijd.12336). This leads patients to continue tanning at salons despite being given diagnoses of malignant melanoma.

“Those of us in dermatology who have been pushing for restrictions on indoor tanning for years were finally validated by the newer data,” Dr. Brod said. “We also have accumulated more personal stories, which I think has helped sway the legislature.” [pagebreak]

Growing support

To date, 41 states plus the District of Columbia have passed indoor tanning regulations. Dr. Brod is glad to see that in Pennsylvania, where he practices, a recent law (Act 41) was passed to restrict minors under the age of 17 and require parental consent for 17-year-olds. The law took effect in July. (Visit the AAD's indoor tanning state advocacy toolkit to learn how to support state legislation.)

The type of legislation being introduced in recent years has shifted. While some states still pass parental consent bills, more and more are addressing the youth ban head-on, said Kelley Redbord, MD, chair of the AAD’s State Policy Committee.

The amount of support such legislation is receiving has shifted as well. “Overall, there is more robust support. It’s not so controversial anymore,” Dr. Brod said. “The argument of saving lives seems to be resonating stronger than not infringing on small business.”

Bills addressing this issue have various components; the age restriction is only one part, Dr. Brod pointed out. They also typically address the use of warning signs on the tanning equipment and in the informed consent forms, training requirements for individuals operating the equipment, and language to address enforcement. All of these components together create strong legislation.

Just as support is growing in the legislative arena, it is growing throughout the house of medicine. “Organizations representing patients and health care providers are coming together to build coalitions because they understand that it’s important to protect minors against indoor tanning,” Dr. Redbord said. More state medical societies, which represent all medical specialties, are increasingly coming out in support of indoor tanning legislation, Dr. Brod noted. The support of the state medical society, medical specialty associations, and nurses’ organizations played a significant role in the passage of the bill in California, the first state to prohibit minors from using indoor tanning beds in 2012. As an example, the more than 45 organizations that comprise the National Council for Skin Cancer Prevention actively support tanning legislation across the country. This past April, the National Council released a position statement on indoor tanning stating that it “supports initiatives and actions that would prohibit indoor tanning for minors, ensure tanning devices and facilities are properly regulated, and educate consumers about the risk associated with tanning.”

The dermatology community may be leading the charge, but the data, stories, and buy-in from other groups have all been very helpful, Dr. Brod noted.

Federal reach

There also are indications that the 2010 settlement with the Federal Trade Commission (FTC) that prohibits the ITA from making false health and safety claims about indoor tanning, which the AADA pushed for, may be trickling down to the individual salons and chains.

Earlier this year, New York Attorney General Eric T. Schneiderman banned a Manhattan-based franchise of a national chain from making health claims about indoor tanning, offering “unlimited” tanning packages, and targeting high school students. The parent corporation has six other franchises in the state and more than 100 franchises across the country. “There is a clear consensus in the medical and scientific communities on the harms associated with indoor or UV tanning — including significant increases in the likelihood of skin cancer — and especially for young people,” Schneiderman said in a statement following an investigation launched last year into suspected misleading advertising in the indoor tanning salon industry. “It is important that consumers know the risks of indoor tanning, and that the science isn’t distorted by any advertising or marketing that uses false, misleading, or unsubstantiated health-related representations to confuse consumers.” Two other targets of investigation that operate tanning salons around the state were recently notified that they, too, may face lawsuits.

Although the FTC banned the ITA from making false health claims, it didn’t prevent individual businesses from doing the same, Dr. Brod said. But this lawsuit is hopefully indicative that false claims by individual businesses will be prosecuted in the future. “It wouldn’t have come about without the FTC ruling,” he added.

On another federal front, the U.S. Food and Drug Administration (FDA) finalized its order to reclassify sunlamp products from a low risk device (class I) to a moderate risk device (class II) on May 29. The order includes a contraindication against use on people under 18 years of age and the labeling will have to include a warning that frequent users of sunlamp products should be regularly screened for skin cancer. [pagebreak]

Shoring up the legislation

While legislation is clearly gaining momentum, much of it lacks language and built-in funding mechanisms to allow for conducting routine annual inspections and levying penalties for violations. Most enforcement is complaint-driven, Dr. Brod explained — someone calls to report that a salon is allowing young children to tan or it doesn’t have any warning signs on its equipment. Unless there is a complaint, the city department of health isn’t going to send out crews to check who is coming out of tanning salons, noted Stephen P. Stone, MD, a member of the AAD’s Council on Communications. “At the state level, they’re not going to put a lot of money into enforcing the law.” In fact, the cost of enforcing state laws is a common argument used by the opposition.

In Pennsylvania, the Department of Health oversees 500 to 600 hospitals and ambulatory care centers, which it routinely inspects. Conducting mandatory inspections of tanning salons, of which there are 5,000 in the state, is unrealistic, Dr. Brod said. But sometimes just the threat of being inspected is enough. “Just having a strong law on the books and the awareness in the salons that the law exists, we think is keeping young people out of the tanning salons,” he added.

Early reports suggest that it is. A random sample of 600 indoor tanning facilities in California showed that 77 percent were compliant with the state’s under-18 ban, according to a study published in the December 2013 issue of the Journal of the American Academy of Dermatology. A study investigator, who informed the tanning salon that she was 17 years old, was told that she could not use the facility. Still, the salon’s staff denied that UV tanning was dangerous and made unlawful claims of specific health benefits, including vitamin D production, skin disease treatment, prevention of future sunburns, and prevention or treatment of depression. Additionally, female high school students in states with indoor tanning laws were less likely to engage in indoor tanning than those in states without any laws, according to a study published in the April 2014 issue of the American Journal of Public Health. This was true for states with warning label, parental permission, and age restriction laws, but particularly with the latter.

On the economic front, the ITA has urged Congress to repeal the 10 percent tax on indoor tanning services enacted as part of health care reform to no avail. But that may be the least of its problems if more tanning salons start getting prosecuted for making false health claims and states become more vigilant about enforcing these laws.

Changing hearts and minds

Legislation and its enforcement are an important piece of the puzzle in part because they set the tone for public education. “We need to continue to focus on public education, alternatives to tanning, and trying to slowly change the culture through peer-to-peer marketing,” Dr. Brod said.

Raising public awareness and providing education must involve addressing both health concerns and cultural norms. “We should talk about melanoma as being the fastest-growing cancer among the 25- and 30-year-old age group, but accompany that with pictures of women who have dark, wrinkled, leathery skin,” Dr. Stone said. “We may not be able to convince a teenage girl that she will get skin cancer, but we can show her pictures of how she’s going to look 60 when she’s 40, which will influence behavior.”

While the Academy’s SPOT Skin Cancer™ campaign makes information about the disease available to anyone, its newest public service announcements (PSAs) attempt to influence behavior by targeting specific populations. The PSA for women, which targets those between the ages of 14 and 25, addresses prevention while the other PSA targets men 50-plus years old and focuses on detection. View them both.

“In the past, the PSAs had a broader message about the dangers of tanning that could apply to anyone,” explained Brad Most, vice president and account director at HY Connect, the advertising agency that has developed the AAD’s PSAs for the past eight years. (The AAD has been creating and sharing PSAs on tanning and skin cancer for 25 years.) “More recently, the Academy has moved to more targeted campaigns focusing not only on the prevention side, but on the detection side, as well.” A more targeted approach helps the AAD understand what’s important to these audiences, enabling it to create PSAs that are more relevant to these individuals’ lives. To engage specific audiences, HY Connect held mini focus groups of young women with their friends, allowing them to speak more freely, Most said. The focus groups also demonstrated the level of peer pressure young women are experiencing. HY Connect learned, for example, that for young woman the fear of developing age spots is as significant as developing skin cancer, the latter of which they don’t believe will happen because at that age they think they are invincible, he said. [pagebreak]

It’s important to be aggressive in discussing the reality of the risk, Most noted, but not so aggressive that it alienates the target audiences. “It’s our responsibility to make people aware of the dangers of indoor tanning because most young people go into tanning salons without any sense of there being a risk.” Ultimately the goal is to make the dangers of indoor tanning part of the public dialogue through education, much like the anti-smoking campaign.

However, spreading messages, educational or otherwise, in the public dialogue takes time. To put it in perspective, this year is the 50th anniversary of the first Surgeon General’s report on smoking and health that indicated cigarette smoking was a health hazard “of sufficient importance in the United States to warrant appropriate remedial action.” Still, 18 percent, or approximately 42 million, of adult Americans currently smoke, according to the Centers for Disease Control and Prevention. And each day, more than 3,200 individuals younger than 18 years of age smoke their first cigarette.

In 2011, one in three white women between the ages of 18 and 21 engaged in indoor tanning, more than half of whom reported frequent use of tanning beds, according to a study published by JAMA Dermatology in February (doi:10.1001/jamadermatol.2013.7124). The good news is that the adjusted prevalence of indoor tanning actually decreased from approximately 26 percent in 2009 to nearly 21 percent in 2011 among that population.

Dermatologists remain resolute with a hint of optimism. “Dermatology needs to continue to take the high road,” Dr. Lim said. “We are advocating for tanning bed restrictions for minors based on science and our interest in protecting the health of the youth in America.” The key right now is at the state level; the goal is for all 50 states and the District of Columbia to have an under-18 ban, Dr. Brod added. The next phase is to have the states tighten up enforcement of the laws, and on the federal level, have the FDA follow through with reclassifying tanning devices.

With regard to changing the public’s concept of beauty, Dr. Redbord acknowledged that the biggest hurdle dermatologists continue to face is making tanning “less cool.” But Dr. Stone reminds that “before Coco Chanel, a peaches-and-cream complexion was considered beautiful.”