Sanitarians' work with indoor-tanning businesses: findings from interviews in two major metropolitan areas.

Introduction

The most common cancers in the United States--and likely worldwide--are skin cancers (American Cancer Society [ACS], 2003; Armstrong & Kricker, 2001). Both melanoma and nonmelanoma skin cancers are on the rise. The American Cancer Society estimated that there would be 54,200 new cases of melanoma in 2003 and over one million new cases of nonmelanoma skin cancer in the United States (ACS, 2003). The link between exposure to solar ultraviolet (UV) light and increased risk for skin cancer is well established (Armstrong & Kricker, 2001; Department of Health and Human Services, Public Health Service, National Toxicology Program, 2002; World Health Organization, 1992). Despite a lack of conclusive evidence linking indoor tanning with skin cancer, accumulating evidence points to a probable link (Karagas et al., 2002; Swerdlow & Weinstock, 1998; Westerdahl, Ingvar, Masback, Jonsson, & Olsson, 2000). Acute health risks from tanning devices include erythema (skin burn), corneal burns, immunosuppression (International Radiation Protection Association, International Non-Ionizing Radiation Committee, 1991), photosensitivity, and allergic reactions (Food and Drug Administration, 1990; International Smart Tan Network, 1998), and eye infections (Looking Fit, 2000).

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Despite health risks, indoor tanning is popular in the United States among certain subgroups of the population, for reasons related to physical appearance, preparation for vacations, and the association often made between looking tan and being healthy (Cokkinides, Weinstock, O'Connell, & Thun, 2002; Dougherty, McDermott, & Hawkins, 1988; Mawn & Fleischer, 1993). An estimated 28 million Americans have used indoor-tanning facilities (American Academy of Dermatology, 1997; Bizzozero, 2002). In a case-control study of indoor tanning and nonmelanoma skin cancer, the frequency with which population-based controls reported any use of indoor tanning was 9 percent among men and 21 percent among women; 80 percent of the users were less than 50 years of age (Karagas et al., 2002). In two national surveys examining indoor tanning among youth 11 to 18 years of age and 12 to 18 years of age, approximately 10 percent of respondents reported tanning indoors in the past year, a rate that increased to 35-40 percent among girls 17 to 18 years of age (Cokkinides et al., 2002; Geller et al., 2002).

Indoor tanning is regulated at the federal, state, and local levels. Food and Drug Administration (FDA) regulations (Sunlamp Products Performance Standard Rule, 1985) primarily apply to manufacturers and include requirements for equipment and eyewear performance, equipment labels, and compatibility of lamps with equipment, while the Federal Trade Commission (FTC) prohibits deceptive or misleading claims about the safety of indoor tanning (Federal Trade Commission, 1983). At least 27 states have indoor-tanning statutes, including Minnesota (Minnesota Statutes, 1993) and Massachusetts (Massachusetts Statutes, 1994). Both of these states regulate youth access; for youths under 16 years of age, Minnesota requires that the operator witness a parent or guardian signing a warning statement prior to the customer's first exposure, whereas Massachusetts mandates this procedure for customers 14 to 17 years of age and requires that a parent or guardian accompany customers under 14 years of age on each visit. In addition to reiterating federal equipment requirements, both states require a signed consent statement from the customer (for those under age 18 years of age in Minnesota and for customers of all ages in Massachusetts), posted warning signs, provision and use of protective eyewear, sanitation, records of each customer's visits, regulation of facility temperature, and the presence of an operator at all times. Massachusetts also mandates licensure and semiannual inspection of tanning facilities by local boards of health, operator training, and injury reporting. Although Minnesota does not mandate business licensure or inspection, some localities in Minnesota have local ordinances with such requirements.

Several studies using survey methods or on-site observation indicate that tanning-business compliance with regulations is poor, as are knowledge and training of operators. Seven published studies measuring compliance with various federal and state regulations around the United States have reported violations in one or more areas, including inadequate warnings of health risks, lack of posted warning signs or labels, inaccurate claims being made about safety or health benefits, failure to provide or require use of adequate protective eyewear, non-adherence to recommended exposure schedules, and breaches of equipment specifications or maintenance (Beyth, Hunnicut, & Alguire, 1991; Bruyneel-Rapp, Dorsey, & Guin, 1988; Culley et al., 2001; Fairchild & Gemson, 1992; Fleischer & Fleischer, 1992; Fleischer, Lee, Adams, & Zanolli, 1993; Kwon et al., 2002). Regarding state youth access regulations, three of the studies mentioned above reveal that parental consent for youth access was obtained by businesses--or that some restrictive age guidelines were in place--in only 13 percent to 55 percent of the salons assessed (Beyth et al., 1991; Culley et al., 2001; Fleischer et al., 1993).

Although these findings suggest that regulatory oversight of indoor-tanning facilities is lacking, no published studies report on the extent to which these facilities are actually inspected for compliance with regulations. In addition, no published studies explain the degree of awareness that exists among those responsible for inspections--generally environmental health professionals--in terms of health risks and regulations related to indoor-tanning facilities.

The aim of the study reported here was to describe awareness, experiences, and practices among sanitarians employed by environmental health agencies regarding indoor tanning, as part of a three-year study conducted in Minnesota and Massachusetts. Focusing in particular on teen access, the larger study also included data collection from teens, parents, and tanning businesses and a pilot intervention with tanning businesses.

Methods

From July 2000 through August 2001, in-person interviews were conducted with sanitarians in the Twin Cities metropolitan area in Minnesota and the Boston metropolitan area. For the sake of simplicity, this paper will use the term "sanitarian" as an inclusive term to refer to people carrying out environmental health duties at public agencies.

The two metropolitan areas were chosen because of their different policy environments and public health structures. Each environmental health agency (or environmental health branch of a larger public agency such as a health department or city government) in the Twin Cities seven-county area and the Boston 21-municipality metropolitan area was contacted to identify a supervisor and field inspector to participate. If one person functioned as the sole environmental health official, or if a supervisor reported that there were no inspections or investigations of tanning businesses in the locality, interviews with field inspectors were not pursued.

In the seven-county Twin Cities metropolitan area, interviewees represented 21 jurisdictions but only 20 agencies, including four counties and 14 municipalities whose environmental health responsibilities were delegated by the state health department, two counties in which the state health department was directly involved in environmental health activities, and one county in which environmental health activities were carried out by both state and local officials. Interviews were conducted with 20 supervisors or sole environmental health officials and seven field inspectors, for a total of 27 interviews in Minnesota. In Massachusetts, each of the 21 metropolitan-area municipalities had its own department or board of public health, 18 of which agreed to participate. Thirty interviews took place in Massachusetts, 18 with supervisors or sole environmental health officials and 12 with field inspectors.

Informed consent was obtained prior to each structured interview. Each interview lasted 60 to 90 minutes, with responses recorded on a standardized interview form. Interview forms were coded by researchers at the University of Minnesota School of Public Health, with personal identifiers removed prior to data entry. These procedures were approved by both the University of Minnesota and the Harvard School of Public Health's institutional review boards prior to data collection.

The semi-structured interview consisted of both open-ended and closed-ended questions pertaining to awareness of state and local laws, experience with tanning-business inspections and related practices and training received, awareness of health risks, training provided to tanning businesses, environmental health agency priorities, and demographic information. In addition, one representative from each agency filled out a brief agency information form to report agency inspection practices and licensure requirements for tanning businesses in their locality.

To facilitate analysis, measures were created for regulations recalled, knowledge of health risks, inspection practices, and priority accorded by the agency to indoor tanning. For the regulations-recalled measure, respondents were assigned 0 if they reported lack of familiarity with state and federal regulations; otherwise, the number of regulations recalled without prompting was used. As the authors had identified seven regulations in Minnesota and nine regulations in Massachusetts central to each statute, a percentage of the total possible regulations was calculated for each respondent according to his or her state. An assessment of familiarity with actual health risks associated with indoor tanning also was conducted. The total number of health risks reported (up to 10 possible) was summed to create the knowledge-of-health risks measure. Among sanitarians who reported conducting inspections (seven in Minnesota, 21 in Massachusetts), the frequency of each of nine inspection activities was reported on a four-point scale (usually, often, sometimes, rarely/never; a low score was associated with more frequent inspection activity). To create a measure for inspection activities, a mean score was calculated across activity items. The priority given by the agency to indoor tanning was the mean score on a scale of 0 to 10, with 10 indicating the highest priority possible. A descriptive analysis (means, frequencies) of these and related characteristics is presented below, stratified by state. Since the two states differed with respect to regulations and so would be expected to differ with respect to many of the characteristics assessed, it was deemed inappropriate to present formal statistical testing for comparisons between Minnesota and Massachusetts. Statistical analyses were conducted with the SAS software package (SAS Institute, Inc., 2001).

Results

Of the 27 participants in Minnesota and 30 participants in Massachusetts, 89 percent and 27 percent, respectively, reported being either a registered sanitarian (RS) or a registered environmental health specialist (REHS). This difference reflects divergent requirements in the two states for those carrying out environmental health duties at public agencies: Massachusetts does not require localities to employ registered environmental health professionals (General Laws of Massachusetts, 2000), whereas Minnesota does (Minnesota Statutes, 2000). Respondents reported working in their current agency for a mean of 11.6 years in Minnesota (range: [less than or equal to]1 to 32) and 10.1 years in Massachusetts (range: [less than or equal to]1 to 25, data missing for two participants), and working in the environmental health field for a mean of 17.4 years (range: 2 to 38) and 12.9 years (range: [less than or equal to]1 to 46), respectively. Ninety-six percent of Minnesota participants and 76 percent of Massachusetts participants had at least a bachelor's degree, 30 percent and 40 percent had master's degrees, and 4 percent and 8 percent had doctoral degrees, respectively. In Minnesota, 12 women and 15 men were interviewed, and in Massachusetts 12 women and 18 men were interviewed.

Table 1 shows awareness, practices, and experience related to indoor tanning by state. Sixty-seven percent of respondents in Minnesota and 93 percent of respondents in Massachusetts reported being aware of state or local regulations, or both, on indoor tanning. Reflecting differences in the structure of the two states' laws, five (24 percent) of the 21 Minnesota localities reported having a local ordinance on indoor tanning--requiring businesses to be licensed--and six (29 percent) reported routine inspections (the locality reporting no ordinance had only two newly established businesses and was unclear as to source of authority for inspections and whether inspections were ongoing). None of the 18 Massachusetts localities reported having an indoor-tanning ordinance in effect.

Massachusetts participants reflected greater familiarity than Minnesota participants with specific components of their respective state laws: a mean recall of 50 percent (SD = 0.24) versus 30 percent (SD = 0.31). In both states, the regulations that respondents mentioned most frequently pertained to sanitation of tanning facilities (96 percent in Massachusetts, 78 percent in Minnesota), equipment specifications (71 percent in Massachusetts, 67 percent in Minnesota), and posting of warnings (71 percent in Massachusetts, 56 percent in Minnesota). In Massachusetts, 68 percent of participants mentioned record keeping, as compared with 22 percent in Minnesota. In Minnesota, 78 percent of respondents mentioned regulations regarding protective eyewear, as compared with 43 percent in Massachusetts. Sixty-three percent of Massachusetts participants and only 11 percent of Minnesota participants indicated familiarity with teen access provisions, including specific and general references to parental consent in both states, parent accompaniment in Massachusetts, and customer consent forms in Minnesota. Youth access provisions were those regulations least often mentioned in Minnesota, while parental accompaniment for customers under 14 years of age and licensing and inspection requirements were those least often volunteered in Massachusetts (25 percent, 25 percent, and 21 percent, respectively).

All respondents reported being aware of at least one health risk related to indoor tanning. The most frequently mentioned risks in Minnesota and Massachusetts were skin cancer (93 percent and 77 percent, respectively), skin infections (63 percent and 27 percent), eye burns/damage to the cornea and retina (59 percent and 43 percent), and skin burns (56 percent and 60 percent). The mean Health Risks Awareness Scale scores were 3.89 (SD = 1.80) in Minnesota and 2.69 (SD = 1.20) in Massachusetts, on a scale of 1 to 10, with higher numbers indicating greater awareness of risks.

Overall, approximately 90 percent of agency representatives in Massachusetts and 29 percent in Minnesota reported that their agency routinely inspects tanning businesses. Only 50 percent in Massachusetts reported the semiannual frequency required by state law, whereas the few agencies in Minnesota that reported inspecting did so as often as dictated by ordinance--if specified in the ordinance. On the individual level, 70 percent of Massachusetts respondents and 26 percent of Minnesota respondents reported personal experience with routine inspections. The most common practices in Massachusetts and Minnesota included checking equipment condition (95 percent and 86 percent, respectively), bathroom plumbing and sanitation (95 percent and 86 percent), sanitation of equipment (95 percent and 71 percent), provision of protective eyewear (90 percent and 71 percent), condition of bulbs (62 percent and 71 percent), warning signs (100 percent and 57 percent), and customer records (81 percent and 57 percent). Of those who reported reviewing customer records, 60 percent in Minnesota and 71 percent in Massachusetts reported looking for documentation of customer age (of which only 40 percent in Minnesota and 52 percent in Massachusetts reported looking for documentation of parental permission for underaged youth). In Massachusetts, 100 percent of respondents reported checking timers, and in Minnesota, 57 percent reported checking wiring--the only practice other than condition of bulbs on which Minnesota performed better than Massachusetts. The mean Inspection Practices Scale scores were 1.80 (SD = 0.92) in Minnesota and 1.34 (SD = 0.29) in Massachusetts, on a scale of 1.0 (usually inspect) to 4.0 (rarely/never inspect) among those who did inspections.

When sanitarians who reported personally conducting inspections were asked if they had received any training specific to inspecting tanning businesses, 76 percent in Massachusetts and 86 percent in Minnesota said they had, with many using a broad definition in their answers, including on-the-job training (43 percent in each state) and state environmental health association training (29 percent in each state), as well as, in Minnesota, basic sanitarian job training (43 percent) and FDA or other federal-agency training (14 percent) and, in Massachusetts, tanning-industry training (14 percent), training by a director of public health or a supervisor (14 percent), and state health department training (19 percent). Also volunteered as a type of training received was self-training, with 38 percent in Massachusetts and 29 percent in Minnesota saying that they were self-taught.

When asked how prepared they have felt or would feel providing training or education to tanning businesses, only 26 percent of Minnesota participants and 33 percent of Massachusetts participants said "very," while 33 percent and 15 percent, respectively, said "not very," and 15 percent and 8 percent said "not at all." Furthermore, 22 percent of Minnesota sanitarians and 33 percent of Massachusetts sanitarians said they would find formal training for themselves helpful; 26 percent and 20 percent, respectively, saw their state health department as a desirable resource for this training (in Minnesota, 26 percent also named federal agencies, and 30 percent named localities that already inspect).

On a scale from 0 (not important at all) to 10 (most important overall), respondents reported a mean of 3.19 (SD = 1.88) in Minnesota and 5.40 (SD = 2.92) in Massachusetts for priority given to tanning-business inspections in their agency; since the major facilitating factors for making work with tanning businesses a higher priority were largely the reverse of barriers cited, this paper reports facilitating factors and barriers together as "issues" for working with tanning businesses. Overall, fewer participants in Massachusetts than in Minnesota volunteered any issues. The most commonly cited issues in both states included lack or need of staff, time, and funds (although funds figured much more prominently in Minnesota than in Massachusetts); other environmental health problems taking precedence; a limited number of businesses and complaints regarding indoor-tanning businesses; and the need for a stronger state statute or a state mandate. In both states, a few participants expressed beliefs that indoor tanning is an individual choice and that small numbers of people are affected. Finally, in Minnesota, the need for political support, public support or awareness, and more scientific evidence were prominent, the latter two issues also emerging among a few Massachusetts participants. Although a number of Minnesota participants also identified a need for licensing (presumably including inspections), an equal number voiced the perception that inspections are ineffectual. Finally, a need for training sanitarians with respect to indoor-tanning work was expressed in Massachusetts. The key issues affecting ability to work with tanning businesses in both states are listed in rank order in Table 2.

Discussion

This study is the first of its kind to explore sanitarians' knowledge, practices, and perceptions related to indoor tanning. Study results indicate that the participants had a limited awareness of the health risks associated with indoor tanning. In addition, many of the participants lacked formal training specific to working with tanning businesses. Among Minnesota participants especially, there was little familiarity with regulations, and few had conducted inspections. Among those from both states who had conducted inspections, practices generally were fairly comprehensive in reflecting state statutes (especially in Massachusetts). Nonetheless, the priority assigned to work with tanning businesses was relatively low in both states, again particularly in Minnesota. These findings are of particular concern in light of a national study of tanning-salon density, which found that Minneapolis had the highest number of salons of any major city nationally (134). Although Boston had the second highest number (87) for Northeastern cities considered, Minneapolis' facility density per 100,000 population was more than double that of Boston: 36.38 versus 15.15 (Palmer, Mayer, Woodruff, Eckhardt, & Sallis, 2002).

Previous studies, described above, have reported poor business compliance with federal and state indoor-tanning laws and demonstrate that most indoor-tanning facilities do not effectively police themselves, especially in terms of youth access laws. Data from the study reported here suggest that part of the reason for poor compliance--at least in Minnesota--is lack of enforcement in localities without ordinances, which are less likely to conduct regular inspections (and less aware of state regulations) than agencies in localities with ordinances. In addition, lack of training and knowledge of health risks on the part of sanitarians from both states may cause inspections to be less effective even when they are conducted. Studies on enforcement of laws related to teen tobacco sales support a relationship between enforcement and business compliance (Cummings & Coogan, 1992; Cummings et al., 1998; Feighery, Altman, & Shaffer, 1991; Forster & Wolfson, 1998; Jason, Ji, Anes, & Birkhead, 1991). Similarly, studies regarding food sanitation regulations report that routine inspections of restaurants and other retail food establishments result in fewer violations (Fielding, Aguirre, Spear, & Frias, 1999; Mathias, Sizto, Hazlewood, & Cocksedge, 1995; Moore, Landreth, Siem, Sheppard, & Hall, 1990; Riben, Mathias, & Campbell, 1994).

An additional reason for lack of inspections, familiarity with the issue, and training received among sanitarians might be that tanning was such a low priority for the participating agencies in both states (especially in Minnesota). The barriers most frequently named to making work with tanning facilities a higher priority also have emerged in studies on enforcement of youth tobacco laws; they include expense, limited staff, and other community problems taking precedence (Feighery et al., 1991; Howard, Ribisl, Howard-Pitney, Norman, & Rohrbach, 2001; Jacobson & Wasserman, 1999). In addition, at least two studies on indoor-tanning regulations state that limited resources (i.e., budgets, staff) make regular inspections difficult (Fleischer et al., 1993; Sinni-McKeehan, 1995). The barriers found in the study reported here largely mirrored those identified in a national study of environmental health professionals' overall priorities; those barriers were (in descending order) lack of state and federal support/funds, lack of community awareness/support, insufficient staff, and inadequate training and access to health data (Milne & Oakes, 2000). Factors identified by Milne and Oakes as promoting environmental health priorities were similar to those in the study reported here: improved communication with communities and media coverage (both related to complaints from the public and the increased visibility identified in the current study) and public awareness. In both studies, participants looked to national agencies and organizations for guidance and leadership.

The fact that Massachusetts participants overall reported more experience inspecting and training businesses, more familiarity with state regulations, and a somewhat higher priority of tanning inspections than Minnesota participants points to the importance of including provisions for enforcement in state statutes, which Massachusetts does and Minnesota does not do. Jacobson and Wasserman (1999), in an examination of tobacco control laws and their enforcement, conclude that effective enforcement requires legislation specifying clear enforcement mechanisms and recommend that public health advocates take this need into account when promoting legislation. Further, Forster, Komro, and Wolfson (1996) support a dual emphasis on state and local tobacco control regulations, as local regulations have the advantage of being less subject to industry influence, may ignite more local support, may be more likely to be enforced, and offer an alternative when state-level approaches fail; nonetheless, the slow, piecemeal process of relying on passing what may be inadequate local ordinances demonstrates the value of strong, norm-setting state and federal laws. All of these observations and recommendations are likely transferable to the area of regulating indoor tanning.

The limitations of this study include small sample size and self-reporting of inspection activity. Self-reporting of inspection activity in response to a list of inspection practices may have been subject to social-desirability bias. In addition, the open-ended format of asking about regulation components may have been subject to difficulty with recall. Although two states with different regulatory structures were covered, the extent to which the authors' findings are generalizable to other states depends on each state's indoor-tanning regulatory structure, as wide variation exists. Replication of this research in other states is necessary to determine the extent to which these data apply to sanitarians in rural areas as well.

Additional research is necessary to tease apart the complex web of factors hindering enforcement programs and to determine what can be done to facilitate enforcement of and compliance with indoor-tanning regulations. A survey administered to environmental health professionals in a larger geographic area would increase the statistical power necessary to explore relationships between measures, as well as increase the generalizability of findings. Such a survey, incorporating an examination of each state's statute, would allow comparison of different regulatory models and their effectiveness. A final component, measuring business compliance with regulations and exploring a relationship to reported inspection practices, would be illuminating.

Conclusion

Given the potentially serious health risks associated with indoor tanning and the popularity of indoor tanning among teens, solutions must be developed to increase the enforcement of indoor-tanning regulations. Improved leadership at the local, state, and federal levels could lead to increased funding, increased training for local sanitarians, and increased awareness by the general public of the health risks related to indoor tanning--all of which could contribute to increased enforcement of indoor-tanning regulations. In turn, to facilitate the adoption of local ordinances--or the strengthening and enforcement of existing local laws--community-organizing strategies, with education as a central piece and a focus on enforcement mechanisms, are key. Sanitarians and other environmental health professionals on the local, state, and federal levels need to be better educated about the health risks of indoor tanning, and those responsible for working with tanning businesses need training in how to adequately inspect and train tanning businesses. An informed public and environmental health infrastructure are much more likely to adequately address the environmental health issues presented by indoor tanning.

TABLE 1 Familiarity with Regulations and Health Risks, and Practices
with Businesses

Sanitarian Knowledge and Practices         Minnesota  Massachusetts

Awareness of regulations
  Percentage familiar with state or local
  regulations or both                         66.7       93.3
  Mean percentage of regulations recalled     30.0       50.0
  Percentage familiar with teen access
  provisions                                  11.1       63.3
  Mean health risks knowledge score (a)        3.89       2.69
Inspection practices
  Percentage of agencies that routinely
  inspect (n = 21), MN; n = 18, MA)           28.6       89.9
  Percentage of sanitarians who have
  routinely inspected                         25.9       70.0
  Mean inspection practices score (b)          1.80       1.34
Experience training businesses
  Percentage ever trained                     40.7       79.3
  Percentage reporting being very
  prepared to train                           25.9       33.3

(a) Based on 10 major health risks; a higher score equals greater
knowledge.
(b) Based on reported frequency of 9 major inspection activities on a 4-
point scale; a lower score is associated with more frequent inspection
activity.

TABLE 2 Reported Key Issues Limiting Ability to Work with Tanning
Businesses

                                           Percentage Reporting Issue

Minnesota
  Lack funds                                          55.6
  Lack staff                                          51.9
  Need more scientific evidence                       48.2
  Need stronger state statute                         44.4
  Other EH problems are priority                      44.4
  Small number of complaints                          33.3
  Lack time                                           33.3
  Need public support or awareness                    33.3
  Need political support                              33.3
  Small number of businesses                          29.6
Massachusetts
  Lack staff                                          23.3
  Lack time                                           20.0
  Other EH problems are priority                      20.0
  Small number of businesses                          20.0
  Small number of complaints                          16.7
  Need stronger state statute                         10.0
  Need more training of EH staff                      10.0
  Need more funding                                    6.7

*Respondents could indicate more than one issue; thus, each state's
total percentages exceed 100.

Acknowledgements: The authors would like to thank all of the sanitarians interviewed in Massachusetts and Minnesota for taking the time to meet with them and for sharing their experiences, knowledge, and perceptions. Thanks also go to the environmental health advisory groups in both Minnesota and Massachusetts, which familiarized the authors with the organization and structure of environmental health in the two states and provided crucial guidance in developing the interview guide.

REFERENCES

American Academy of Dermatology. (1997). Facts about indoor tanning [Pamphlet]. Schaumburg, IL: Author.

American Cancer Society. (2003). Cancer facts & figures 2003. http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf (9 Apr. 2003).

Armstrong, B.K., & Kricker, A. (2001). The epidemiology of UV induced skin cancer. Journal of Photochemistry and Photobiology, 63, 8-18.

Beyth, M.D., Hunnicutt, M., & Alguire, P.C. (1991). Tanning salons: An area survey of proprietors' knowledge of risks and precautions. Journal of the American Academy of Dermatology, 24(2-1), 277-282.

Bizzozero, J. (2002). Winning moves for tanning and equipment: A comprehensive report on the state of the industry. Looking Fit, 17(9), 38-48.

Bruyneel-Rapp, F., Dorsey, S.B., & Guin, J.D. (1988). The tanning salon: An area survey of equipment, procedures and practices. Journal of the American Academy of Dermatology, 18(5-1), 1030-1038.

Cokkinides, V.E., Weinstock, M.A., O'Connell, M.C., & Thun, M.J. (2002). Use of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent or guardian caregivers: Prevalence and correlates. Pediatrics, 109(6), 1124-1130.

Culley, C.A., Mayer, J.A., Eckhardt, L., Busic, A.J., Eichenfield, L.F., Sallis, J.F., Quintana, P.J.E., & Woodruff, S.I. (2001). Compliance with federal and state legislation by indoor tanning facilities in San Diego. Journal of the American Academy of Dermatology, 44(1), 53-60.

Cummings, K.M., & Coogan, K. (1992). Organizing communities to prevent the sale of tobacco products to minors. International Quarterly of Community Health Education, 13(1), 77-86.

Cummings, K.M., Hyland, A., Saunders-Martin, T., Perla, J., Coppola, P.R., & Pechacek, T.F. (1998). Evaluation of an enforcement program to reduce tobacco sales to minors. American Journal of Public Health, 88(6), 932-936.

Department of Health and Human Services, Public Health Service, National Toxicology Program. (2002). Report on Carcinogens, Tenth Edition. http://ehp.niehs.nih.gov/roc/toc10.html (30 May 2003).

Dougherty, M.A., McDermott, R.J., & Hawkins, M.J. (1988). A profile of users of commercial tanning salons. Health Values, 12(5), 21-29.

Fairchild, A.L., & Gemson, D.H. (1992). Safety information provided to customers of New York City suntanning salons. American Journal of Preventive Medicine, 8(6), 381-383.

Federal Trade Commission. (1983). FTC policy statement on deception. http://www.ftc.gov/bcp/policystmt/ad-decept.htm (30 May 2003).

Feighery, E., Altman, D.G., & Shaffer, G. (1991). The effects of combining education and enforcement to reduce tobacco sales to minors. Journal of the American Medical Association, 266(22), 3168-3171.

Fielding, J.E., Aguirre, A., Spear, M.C., & Frias, L.E. (1999). Making the grade: Changing the incentives in retail food establishment inspection. American Journal of Preventive Medicine, 17(3), 243-247.

Fleischer, A.B., & Fleischer, A.B. (1992). North Carolina tanning operators: Hazard on the horizon? Journal of the American Academy of Dermatology, 27(2-1), 199-203.

Fleischer, A.B., Lee, W.J., Adams, D.P., & Zanolli M.D. (1993). Tanning facility compliance with state and federal regulations in North Carolina: A poor performance. Journal of the American Academy of Dermatology, 28(2), 212-217.

Food and Drug Administration. (1990). Medications that increase sensitivity to light: A 1990 listing (HHS Publication FDA 91-8280). Washington, DC: U.S. Department of Health and Human Services.

Forster, J.L., Komro, K.A., & Wolfson, M. (1996). Survey of city ordinances and local enforcement regarding commercial availability of tobacco to minors in Minnesota, United States. Tobacco Control, 5, 46-51.

Forster, J.L., & Wolfson, M. (1998). Youth access to tobacco: Policies and politics. Annual Reviews of Public Health, 19, 203-235.

Geller, A.C., Colditz, G., Oliveria, S., Emmons, K., Jorgensen, C., Aweh, G.N., & Frazier, A.L. (2002). Use of sunscreen, sunburning rates, and tanning bed use among more than 10,000 US children and adolescents. Pediatrics, 109(6), 1009-1014.

General Laws of Massachusetts. 112 [section] 87ZZZ (2000).

Howard, K.A., Ribisl, K.M., Howard-Pitney, B., Norman, G.J., & Rohrbach, L.A. (2001). What factors are associated with local enforcement of laws banning illegal tobacco sales to minors? A study of 182 law enforcement agencies in California. Preventive Medicine, 33, 63-70.

International Radiation Protection Association, International Non-Ionizing Radiation Committee. (1991). Health issues of ultraviolet "A" sunbeds used for cosmetic purposes. Health Physics, 61(2), 285-288.

International Smart Tan Network. (1998). International Smart Tan Network manual (5th ed.). Jackson, MS: Author.

Jacobson, P.D., & Wasserman, J. (1999). The implementation and enforcement of tobacco control laws: Policy implications for activists and the industry. Journal of Health Politics, Policy and Law, 24(3), 567-598.

Jason, L.A., Ji, P.Y., Anes, M.D., & Birkhead, S.H. (1991). Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. Journal of the American Medical Association, 266(22), 3159-3161.

Karagas, M.R., Stannard, V.A., Mott, L.A., Slattery, M.J., Spencer, S.K., & Weinstock, M.A. (2002). Use of tanning devices and risk of basal cell and squamous cell skin cancers. Journal of the National Cancer Institute, 94, 224-226.

Kwon, H.T., Mayer, J.A., Walker, K.K., Yu, H., Lewis, E.C., & Belch, G.E. (2002). Promotion of frequent tanning sessions by indoor tanning facilities: Two studies. Journal of the American Academy of Dermatology, 46, 700-705.

Looking Fit. (2000). Tanning fact book 2000/2001. Phoenix, AZ: Virgo Publishing, Inc.

Massachusetts Statutes, Tanning Facilities, 105 C.M.R. 123 (1994).

Mathias, RG, Sizto, R, Hazlewood, A, & Cocksedge, W. (1995). The effects of inspection frequency and food handler education on restaurant inspection violations. Canadian Journal of Public Health January/February, 86(1), 46-50.

Mawn, V.B., & Fleischer, A.B. (1993). A survey of attitudes, beliefs, and behavior regarding tanning bed use, sunbathing, and sunscreen use. Journal of the American Academy of Dermatology, 29, 959-62.

Milne, T., & Oakes, J.M. (2000). The priorities of environmental health professionals. Atlanta, GA: National Center for Environmental Health, Centers for Disease Control and Prevention.

Minnesota Statutes. [section] 325H (1993).

Minnesota Statutes. [section] 4695.2600 (2000).

Moore, G.A., Landreth, T., Siem, D., Sheppard, K., & Hall, J. (1990). Food sanitation enforcement: County inspection program increases compliance. Journal of Environmental Health, 53(2), 17-18.

National Environmental Health Association. (2004). Registered environmental health specialist/registered sanitarian credentialing examination program. http://www.neha.org/pdf/cred/rehs_web.pdf (28 Jan. 2004).

Palmer, R.C., Mayer, J.A., Woodruff, S.I., Eckhardt, L., & Sallis, J.F. (2002). Indoor tanning facility density in eighty US cities. Journal of Community Health, 27(3), 191-202.

Riben, P.D., Mathias, R.G., & Campbell, E. (1994). The evaluation of the effectiveness of routine restaurant inspections and education of food handlers: Critical appraisal of the literature. Canadian Journal of Public Health, 85(Suppl. 1), S56-S60.

Sinni-McKeehan, B. (1995). Health effects and regulations of tanning salons. Dermatology Nursing, 7(5), 307-312.

SAS Institute, Inc. (2001). Version 8.2. Cary, NC: SAS Institute, Inc.

Sunlamp Products Performance Standard Rule, 21 C.F.R. 1040 (1985).

Swerdlow, A.J., & Weinstock, M.A. (1998). Do tanning lamps cause melanoma? An epidemiologic assessment. Journal of the American Academy of Dermatology, 38, 89-98.

Westerdahl, J., Ingvar, C., Masback, A., Jonsson, N., & Olsson, H. (2000). Risk of cutaneous malignant melanoma in relation to use of sunbeds: Further evidence for UV-A carcinogenicity. British Journal of Cancer, 82, 1593-1599.

World Health Organization (WHO), International Agency for Research on Cancer. (1992). Solar and ultraviolet radiation. IARC Monographs Evaluation of Carcinogenic Risks to Humans, 55, 1-316.

Andrea Hickle, M.P.H.

Jean Forster, Ph.D., M.P.H.

DeAnn Lazovich, Ph.D.

Paul Allwood, M.P.H., R.S.

Natania Remba, Ed.M.

Jessica Grossmeier, M.P.H.

Glorian Sorensen, Ph.D., M.P.H.

Corresponding Author: Jean Forster, Professor, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 S. Second Street, Suite 300, Minneapolis, MN 55454-1015. E-mail: [e-mail].