Indoor tanning legislation: shaping policy and nursing practice.
Numerous studies have documented that the use of indoor tanning devices poses significant short-term and long-term health risks ranging from minor sunburns to potentially fatal disorders (i.e., malignant melanoma). The American Academy of Dermatology (AAD) (2009) issued a policy statement urging the government to ban indoor tanning salons. Specifically, the use of UVA tanning beds damage the DNA within the epidermis causing mutations in the P53 protein, a tumor-suppression protein found in humans. The P53 protein is responsible for regulation of the cell cycle; it functions as a tumor suppressor and is involved in preventing cancer (Lim et al., 2011). The adverse consequences of tanning beds range from mild to potentially fatal disorders (Levine, Sorace, Spencer, & Siegel, 2005). Exposure to UVR can also increase the likelihood for the development of other health issues, including drug-induced photo toxicity, photo aging (wrinkling), and damage to human eye (cataracts) and the immunologic system (Lim et al., 2011). This makes adolescents who use these facilities particularly vulnerable to the long-term consequences, prompting a policy statement by the American Academy of Pediatrics (AAP) (2011) recommending that governments work toward passing and enforcing legislation to ban minors' access to tanning salons.
Childhood and adolescent melanoma is rare, but recent studies indicate the incidence of melanoma is increasing among adolescents for both genders. "From 1973-2009, overall pediatric melanoma increased an average of 2% per year (95% confidence interval, 1.4% to 2.7%). One of several reasons for the overall increase in adolescent melanoma is increased UV exposure from natural (sunlight) sources and artificial sources (tanning beds) sources" (Wong, Harris, Rogriguez-Galindo, & Johnson, 2013, p. 846).
In 2006, the World Health Organization (WHO) International Agency for Research on Cancer (IARC) found sufficient evidence that supported a causal relationship between the use of indoor tanning beds before the age of 35 years and a 75% increase risk of developing malignant melanoma (WHO IARC, 2013). Additionally, the WHO concluded that studies also established a 2.5 times greater risk of developing squamous cell carcinoma and 1.5 times greater risk of developing basal cell carcinoma (El Ghissassi et al., 2009). Based upon these and other studies, in 2009, the WHO categorized tanning beds as a "carcinogenic to humans," the highest cancer risk category on par with asbestos and formaldehyde (WHO IARC, 2013).
Despite the current evidence linking the use of tanning beds and the development of cancer, adolescents have ignored and continue to engage in this risky and unhealthy behavior. Studies have shown that tanning bed usage is particularly prevalent among adolescents in the United States. According to Cokkinides, Weinstock, Lazovich, Ward, and Thun (2009), the prevalence of indoor tanning varied by gender and ranged from 2% to 11% in males and from 12% to 37% in females, and these statistics have not changed from 1998-2004. The most commonly cited reasons for tanning bed use include aesthetics, vacation preparation, "looking healthy," and influence of peers. Previous research also suggests that adolescents attempt to look like fashion models and television/film actors they follow in magazines and media (Dennis, Kanceria, & Snetselarr, 2009). Another factor related to adolescent tanning bed usage is the role parents play in predicting the use of tanning beds by their adolescents. Studies indicate that maternal modeling behaviors (maternal indoor tanning behaviors) and gate-keeping behaviors (permitting or refusing the use of tanning beds) were significantly associated with indoor tanning use by their adolescents (Stryker et al., 2004). Because parental consent and law enforcement are key components in some current states' legislation regulating adolescents' access of tanning devices, it is important to evaluate how these factors are monitored. The purpose of this study was to provide an analysis of indoor tanning bed legislation in the United States related to minors' access to indoor tanning beds specifically related to parental consent along with enforcement of current statues and legal issues.
The Tanning Accountability And Notifications Act (TAN)
In September 2007, the Tanning Accountability and Notifications Act (TAN) was introduced that required proper labeling of the hazards of indoor tanning (United States Congress, 2007). Specific legislation addressing the use of tanning beds by adolescents has also been passed in several states in the United States (AAD, 2009). However, despite the passage of statutes regulating the use of tanning beds, the rates at which adolescents have reported the use of tanning devices has not been reduced. Although there have been recent gains in regulatory actions in states, further progress is needed. Because the United States does not have a consistent and effective policy to protect this vulnerable population, there is a need to gain further understanding of the adolescent's access to indoor tanning beds and the state regulatory and enforcement language of tanning bed salons that influence their access.
The research design was cross-sectional. Data from state websites and inquiries were collected using an adapted version of the CITY 100 Coding of State Laws instrument (Woodruff et al., 2007). The instrument was applied to information on the state websites or telephone interviews of identified states representative(s). Each of the 50 states' legislation or regulation related to minors' access to tanning salons and enforcement of tanning salon regulations were reviewed and coded.
The CITY100 Coding of State Laws (Woodruff et al., 2007) instrument was originally developed to measure restrictiveness/stringency of state's indoor tanning laws, with emphasis on minors' access, UV exposure control, training of operators, penalties for violations of laws, and sanitation. The 35-item instrument was developed by a review of the literature addressing indoor tanning laws and reading several states' laws addressing indoor tanning to identify the keys elements of indoor tanning legislation. The authors reported acceptable psychometric properties, including an internal consistency overall of coefficient alpha = 0.96. Nine stringency dimensions were developed: 1) minor access, 2) customer notification of risk, 3) UV exposure control, 4) equipment standards, 5) facility operations, 6) operator training/responsibilities, 7) sanitation, 8) enforcement/legal issues, 9) penalties for violations.
For the purpose of this research, the original tool was modified, and the following items were used: a) minor access (age of prohibition, parental consent) and b) enforcement/legal issue (facility auditing, complaint investigation, penalties, and fines) (see Table 1). The items used from the Woodruff et al. (2007) study reported internal consistency of 0.62 and 0.73, respectively. The investigators used the instrument to grade the questions on an ordinal scale along with dichotomous options for some items to indicate absence or presence of an item. These decisions were based on the most efficient way to categorize states meaningfully. The scores ranged from 31 (most restrictive) to 1 (least restrictive) regulatory language regarding minors' access to tanning salons and legal enforcement of violation of that state's law as stated in each piece of legislation. Points were categorized to describe the states without restrictions, minimum restrictions, moderate restrictions, and most restrictions (see Table 2). The results were grouped according to score (0 = no restrictions, less than 10 = minimal restrictions, 10 to 20 = moderate restrictions, and greater than 20 = the most restrictive).
All 50 states were evaluated via a website review or telephone interview of identified state contact with all survey questions answered by one of these methods for each state. Of the states where a telephone interview was conducted, all interviewees were employees of the Department of Health by the respective state. Fifteen states had no restrictions, two states had minimal restrictions, 25 states had moderate restrictions, and the remaining eight states had the maximum restrictions.
Results of this study revealed that only three states surveyed indicated mandatory yearly inspection of tanning salons. These states were Massachusetts, New Hampshire, and Iowa. Almost two-thirds (62%) of the states require parental consent for adolescents under the age of 18; 80% of the states surveyed had a maximum penalty of a low level fine (e.g., $1,000 per day) for an infraction found during the inspection, and 14% had the infraction listed as a misdemeanor. These states were Minnesota, North Dakota, Utah, Virginia, California, Texas, and Georgia. In addition to the states listing an infraction as a misdemeanor, 6% had the infraction listed as a Felony. These states were Florida, Mississippi, and Illinois. Only one state (Texas) had a maximum fine of $25,000. For a graphic representation of these findings, see Figure 1.
The American Cancer Society estimates there will be 76,000 cases of melanoma and 9,710 melanoma-related deaths this year in the Unites States (National Cancer Institute, n.d.-a) with national health care costs related to the treatment of cancer have steadily increased in the United States. Estimates of national health expenditures for health care were calculated in 2010 and revealed that 2.7 billion dollars are spent annually for the care of a patient with melanoma (National Cancer Institute, n.d.-b). These statistics indicate that skin cancer morbidity and mortality will continue to grow without health care policy change.
A key element to health and social policy change is the importance of evidence. As demonstrated by the analysis of this current study's results, 35 states had some form of legislation restricting the use of tanning beds by adolescents, and 15 states had no restrictions to access of tanning beds by adolescents. The overall lack of consistency in regulations and enforcement found by this investigation directly supports previous findings by Woodruff and colleagues (2006).
In January of 2012, California was the first state to ban the use of UV tanning beds for all minors under 18. Vermont followed in July 2012, and most recently, New Jersey has banned the use of tanning beds to those under the age of 17 and the use of spray tans in a salon to those under the age of 14. In May 2014, the U.S. Food and Drug Administration (FDA) changed its regulation of sunlamp products and UV lamps intended for use in sunlamp products. The changes strengthen the oversight of these devices and require that sunlamp products carry a visible black-box warning stating that they should not be used on people under 18 years of age. However, studies indicate that even with the presence of legislation restricting access to tanning beds by adolescents, there is generally low compliance by facilities due to lack of enforcement by regulatory agencies (Culley et al., 2001; Hurd, Mayer, Woodruff, Belch, & Patel, 2006).
The WHO recognizes the dangers of artificial tanning and exposure to sunlamps, and they declare that no person under 18 years of age should use a sunbed. Although numerous states are tackling the issue and propose policies to protect adolescents and children, there are corresponding pressures from the tanning industry with claims that research supports the positive effects on vitamin D metabolism and deficiency. Numerous statements confuse the public in efforts to convince individuals that indoor UVR is healthy. Despite the importance of adequate vitamin D levels, research confirms that the amount of sunlight needed to produce these effects does not justify the large abuse of tanning beds (Levine et al., 2005).
Limitations of the study included reliance on self-reported indoor tanning legislation using telephone (vs in-person) data collection for some states, the timing of spontaneous interviews with state representatives who answered the phone, and the cross-sectional design and measurement of compliance with or enforcement of the laws.
Legislation exists that regulates use of tanning beds by minors. The federal realm has mandated warnings to be placed on tanning devices. Yet these interventions have not translated to reduced use of tanning beds by adolescents. These facts should raise concerns for nurses and other health care professionals. Effective strategies need to be developed to inform parents about the specifics of current legislation addressing parental consent requirements along with educating adolescents concerning the verified dangers associated with the use of indoor tanning beds and the development of skin cancer.
Strategies can begin in school health services, which can provide opportunities for school nurses to implement the Centers for Disease Control and Prevention's (CDC) (2002) School Programs to Prevent Skin Cancer guidelines. These guidelines include recommendations specific to school health services that include 1) requesting parental permission for the use of sunscreen, 2) assessing student's sun exposure patterns, and 3) advocating skin prevention policies and practices (CDC, 2002). Advanced practice nurses (APNs) in their direct clinical role can play a part in early detection of skin cancer by detecting melanoma in their patients and educating them about detection and prevention. The AAP recommends that physicians and other health care providers perform a complete cutaneous examination along with educating clients about periodic skin self-examination of the skin (Balk, 2011).
Finally, all nurses can be proactive in addressing this issue with patients and their families. It is most important for nurses to advocate for legislation, enforcement of legislation, and public awareness of this global health issue. As advocates, nurses can have a direct impact upon the long-term goal of reducing the harmful effects of continued UVR exposure in this vulnerable population.
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American Academy of Pediatrics (AAP). (2011). Policy statement--Ultraviolet radiation: A hazard to children and adolescents. Pediatrics, 127(3), 588-597.
Balk, S., (2011). Ultraviolet radiation: A hazard to children and adolescents. Pediatrics, 127, e127-e817. Doi:10. 1542/peds.2010-3502.
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Cokkinides, V.W., Weinstock, M., Lazovich, D., Ward, E., & Thun, M. (2009). Indoor tanning use among adolescents in the U.S. 1998-2004. Cancer, 1, 190-197. doi:10.1002./cncr.24010
Culley, C.A., Mayer, J.A., Eckhart, L, Busic, A.J., Eichenfield, L.F., Sallis, J.F., Woodruff, S. (2001). Compliance with federai and state legislation by indoor tanning facilities in San Diego. Journal of the American Academy of Dermatology, 44, 53-60
Dennis, L, Kanceria, V., & Snetselarr, L. (2009). Adolescent attitudes among tanning: Does age matter? Pediatric Health, 3(6), 565-578. doi:10.2212/phe.09.55
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Donna W. Driscoll, PhD, RN, CPNP, is a Professor, Molloy College, Division of Nursing, Rockville Centre, NY.
Jennifer Darcy, PhD, RN, CPNP, is a Clinical Instructor, Molloy College, Division of Nursing, Rockville Centre, NY.
Table 1. Scoring Tool: Questions Applied to State Tanning Bed Information CITY 100 Questionnaire State: I. Minors Access A. Maximum age at which use of an indoor tanning device is prohibited by law. 5. Older than 13 years 4. 13 years of age 3. 12 years of age, or 13 years with doctor's note 2. 11 years, or 12 years with a doctor's note 1. Less strict than any above 0. No specific indications that certain age are "prohibited" from use. B. Maximum age at which parent/guardian must accompany minor: 5. 14 or older 4. 13 years or older 3. 2. 1. Less strict than any of the above 0. Accompaniment not required C. Maximum age at which minor must provide written parental consent: 5. Same as #4, but parent must come in to sign consent; notarized signature; or parental signature witnessed. 4. 17 years of age 3. 16 years of age, or 15 years with parent in-store signature 2. 15 years of age 1. Less strict than any of the above 0. No consent required. II. Enforcement/Legal Issues A. Enforcement authority 5. Clearly designates strong enforcement authority 4. Some enforcement authority is designated 3. 2. 1. Less strict than any of the above 0. No verbiage related to enforcement or no enforcement B. Facility auditing/inspection 5. All facilities are audited/inspected yearly 4. All facilities are audited yearly; some facilities are audited more than once a year. 3. All facilities are audited on a rotating basis (e.g., once every 3 years)/periodic 2. All facilities with complaints are audited yearly. 1. Inspections/auditing "possible" 0. No auditing schedule mentioned C. Complaint investigation 1. Health department/agency has authority to investigate complaints of injury, accidents and unsafe conditions D. Penalties/Fines for violations 5. "Felony" or jail mentioned. 4. Misdemeanor (A, B, C) 3. High level fine (e.g., $ 25,000 per violation) 2. Lower level fine (e.g., $1,000 per day and or per violations; simply mention fines) 1. Non-monetary or non-criminal penalty (e.g., written reprimand; injunction to "stop" 0. No penalty mentioned Table 2. States Restrictiveness/Stringency Scores for Minor's Access and Enforcement of Legal Issues Minors' Access to Tanning Beds State Score State Score Alabama (d) 0 (d) Louisiana (c) 15 (c) Alaska (d) 0 (d) Kansas (c) 15 (c) Hawaii (d) 0 (d) Kentucky (c) 15 (c) Idaho (d) 0 (d) Wyoming (c) 15 (c) Missouri (d) 0 (d) Utah (c) 16 (c) Montana (d) 0 (d) Arizona (c) 16 (c) Nebraska (d) 0 (d) Ohio (c) 17 (c) Nevada (d) 0 (d) Connecticut (c) 17 (c) New Mexico (d) 0 (d) Rhode Island (c) 18 (c) Oklahoma (d) 0 (d) Maryland (c) 18 (c) South Dakota (d) 0 (d) Mississippi (c) 18 (c) Tennessee (d) 0 (d) Pennsylvania (c) 19 (c) Vermont (d) 0 (d) South Carolina (c) 19 (c) Washington (d) 0 (d) Florida (c) 19 (c) West Virginia (d) 0 (d) Indiana (c) 19 (c) Virginia (b) 5 (b) North Dakota (c) 19 (c) Colorado (b) 8 (b) Texas (c) 20 (c) Maine (c) 10 (c) Delaware (a) 21 (a) Arkansas (c) 10 (c) Oregon (a) 21 (a) North Carolina (c) 10 (c) Georgia (a) 22 (a) Wisconsin (c) 13 (c) Massachusetts (a) 22 (a) Michigan (c) 13 (c) California (a) 24 (a) Iowa (c) 13 (c) New York (a) 24 (a) Minnesota (c) 14 (c) Illinois (a) 26 (a) New Jersey (c) 15 (c) New Hampshire (a) 26 (a) Key (a) = Most Restrictive (b) = Moderately Restrictive (c) = Minimally Restrictive (d) = No Restrictions
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|Author:||Driscoll, Donna W.; Darcy, Jennifer|
|Date:||Mar 1, 2015|
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