Society of Behavioral Medicine Position Statement: Ban Indoor Tanning for Minors (AUGUST 2013) By Sherry L. Pagoto, PhD, Joel J. Hillhouse, PhD, Carolyn J. Heckman, PhD, Elliot J. Coups, PhD, Jerod L. Stapleton, PhD, David B. Buller, PhD, Rob Turrisi, PhD, June K. Robinson, MD, and Alan Geller, MPH, RN; on behalf of the Society of Behavioral Medicine Public Policy Leadership Group

The Society of Behavioral Medicine supports a complete ban on indoor tanning for minors under 18 years of age.

The Society of Behavioral Medicine (SBM), an interdisciplinary professional organization focused on the science of health behavior joins the American Academy of Dermatology, the American Academy of Pediatrics and a host of other national and international organizations in support of a total ban on indoor tanning for minors under the age of 18. According to the International Agency for Research on Cancer, artificial sources of ultraviolet radiation are in the highest category of carcinogens, joining tobacco and asbestos. Strong evidence links indoor tanning to increased risk for melanoma with repeated Exposure to UV radiation in early life increases the risk for exposure during childhood being associated with the developing skin cancer. In a case control study in Australia, greatest increase in risk. Several countries and five US adults under 40 who had 10 or more indoor tanning states have passed legislation banning indoor tanning in sessions in their lifetime had a 2-fold increase in the risk minors. We strongly encourage the remaining US states to for developing melanoma by that age relative to people 11 do the same in an effort to protect children and prevent who had never tanned indoors. The increase in risk new cases of melanoma. SBM also strongly encourages associated with 10 or more indoor tanning visits was 4-fold research that explores the use of tanning beds in the for melanoma diagnosed between18-29 years of age. home. Home-based indoor tanning has the potential to In some tanners, tanning can develop into “tanning be especially dangerous given the complete absence of dependence,” a pattern of tanning that bears safety regulations. Children are currently protected from resemblance to other substance dependencies. The exposure to health-harming substances like tobacco and suspected mechanism for tanning dependence is via the lead, thus legislation protecting them from artificial sources release of endogenous opioids when the skin is exposed to of ultraviolet radiation is yet another important step forward UV radiation. 12 Possible cases of tanning dependence are in improving public health. not uncommon, with rates ranging from 33–41% among 13 The Society of Behavioral Medicine is an interdisciplinary tanning salon patrons, 22–45% among college indoor 14-17 organization of scientists and clinicians focused on the tanners, and 5–27% among general college student 14-18 science of human behavior as it relates to health and samples. illness. SBM joins the United States Department of Health It might be argued that a ban is too extreme a measure and Human Services, 1 United States Food and Drug and instead states should adopt restrictions that protect Administration (FDA), 2 American Academy of Pediatrics, 3 minors from risk. A number of states have passed parental American Medical Association, American Academy of consent laws, intended to limit access to indoor tanning Dermatology, 4 Canadian Pediatric Society, 5 and the World among minors. 19 However, such measures not only have Health Organization, 6 in support of a ban on indoor tanning low compliance rates but they have been shown to for minors. An indoor tanning ban for minors is indicated for have no effect on rates of indoor tanning. 20 A stronger the following reasons. measure—a ban—is needed. Research has clearly established that indoor tanning increases risk for both non-melanoma 7 and melanoma Restrictive Measures skin cancers. 8 Indoor tanning has also been linked to Parental consent 9, 10 serious eye damage. Artificial sources of ultraviolet Parental consent laws have been enacted in 28 states. 19 (UV) radiation join tobacco and asbestos in the highest The age requiring permission varies from 14-18, and 21 category of human carcinogens per the International states require parents to provide permission in person. 19 6 Agency for Research on Cancer (IARC). Such legislation assumes parents are aware of the risks of indoor tanning but this is often not the case. 21, 22 Favorable Tanning device directions: The FDA mandates that indoor tanning attitudes and behaviors among parents are directions to tanning device purchasers include a associated with similar attitudes and practices among their recommended exposure schedule that limits tanning children. 20, 22-26 For example, daughters who tan for the first sessions to three in the first week of indoor tanning time with their mothers are over four times more likely than exposure. One study showed, however, that most facilities others to become heavy tanners. 23 Additionally, the earlier (94% or higher) do not post the FDA first-week exposure children begin indoor tanning, the more difficult they report schedule. 30 Another study found that 95% of indoor tanning it would be to quit. 27 patrons exceeded tanning limits. 33 Some studies suggest that parental consent laws may not be SBM Position effective at preventing indoor tanning use among minors. National rates of indoor tanning use among minors did 1. SBM supports a complete ban on indoor tanning for not decrease in the 2000s despite multiple states passing minors under 18 years of age. The health hazards linked parental consent laws. 28 Rates of indoor tanning among to indoor tanning are serious and potentially deadly minors in states with parental consent compared to states and current restrictive measures have been ineffective. without parental consent are equivalent. 20 Further, two Parental consent laws have not reduced indoor tanning studies showed that among tanning salons studied in states rates, suggesting that parents may not be adopting the with parental consent laws, many failed to comply with gatekeeper function that was the intent of such laws. parental consent laws. 29, 30 In one study of 200 salons in Bans are needed to more directly impact tanning rates in 34 Minnesota and Massachusetts, 15 year old girls posing as children. As of June 2013, 15 states have age restriction customers with no parental consent were sold a tanning visit bans: 5 restrict all minors (California, Vermont, Texas, at 81% of the salons visited. 29 In a second study of 54 tanning Nevada, and Oregon), 1 restricts children under 17 years salons in California, 57% of tanning salons answered “yes” of age, 1 restricts children under 16, and 8 restrict children 19 when asked by a research confederate posing as a patron under 14. Eleven countries ban indoor tanning in all if her 15 year old sister would be allowed to use tanning visits minors, including France, Spain, Portugal, Germany, Austria, she purchased. 30 A possible reason for non-compliance may Belgium, England, Wales, Northern Ireland, Scotland, and 35 be that penalties for noncompliance to parental consent Brazil. Six territories in Australia also have bans in all minors. laws are often small or non-existent. 31 Further research is Brazil and New South Wales, Australia have banned indoor needed to explore rates compliance with parental consent tanning in minors and adults. Now that several states laws on a national level and reasons for noncompliance. have enacted bans, SBM calls for research examining compliance to the ban, the effect of bans on rates of Tanning Tax indoor tanning in minors and ultimately skin cancer rates. In July 2010, as part of the Patient Protection and Two studies showed that compliance with age-related Affordable Care Act, the federal government levied a bans by tanning businesses is fairly high (i.e., 70-77%). 34, 36 10% excise tax on the sale of indoor tanning services. A Additional research will make even more compelling the recent study, however, showed that among 308 salon case for bans in minors across the US and around the world. owners surveyed in Illinois, a majority (74%) reported no reduction in clients as a result of the tax; a majority (71%) 2. SBM endorses further exploration into the prevalence also reported that the tax did not result in a decrease in and associated risks of indoor tanning in secondary tanning frequency among clients. 32 It remains unclear if the locations and private homes. SBM is also concerned about tax resulted in clients switching to UV-free tanning options, indoor tanning by individuals of all ages in secondary such as spray-on tans, or if they continued their UV tanning locations, which include any business for which tanning habits in spite of the tax. Further research is needed to is not the primary service, such as gyms, hair salons, evaluate the impact of different degrees of taxation on dormitories, and apartment complexes. These locations indoor tanning and skin cancer prevention. are expected to be licensed to provide indoor tanning services, however failure to do so may be difficult to U.S. Food and Drug Administration (FDA) Guidelines detect because city inspectors often lack the resources to The FDA regulates indoor tanning (1) by creating standards systematically determine which businesses offer tanning. for manufacturers of indoor tanning devices; and (2) by Indoor tanning also occurs in the home for many requiring these manufacturers to provide directions for individuals, as tanning bed companies market directly tanning device use to such purchasers as indoor tanning to consumers. Although home tanning bed ownership is businesses. banned in several European countries and Australia, home The standards: FDA standards mandate manufacturers indoor tanning is legal in the US and wholly unregulated. to include a warning label. The label must read (in part): Home-based indoor tanning has the potential to be “DANGER—Ultraviolet radiation. Follow instructions. Avoid quite dangerous given the absence of safety regulations. overexposure. As with natural sunlight, overexposure can Individuals who tan in secondary locations, and especially cause eye and skin injury and allergic reactions. Repeated those who have a tanning device in their home, may exposure may cause premature aging of the skin and skin develop riskier tanning habits (e.g., greater frequency, cancer.” longer duration, and no eye protection) than tanners using regulated tanning businesses. SBM calls for further research 16. Mosher, C.E. and S. Danoff-Burg, Indoor tanning, mental health, on the prevalence of tanning in secondary locations as and substance use among college students: the significance of well as tanning habits, licensing, and safety practices in gender. J Health Psychol, 2010. 15(6): p. 819-27. 17. Poorsattar, S.P. and R.L. Hornung, UV light abuse and high-risk secondary locations. tanning behavior among undergraduate college students. J Am Acad Dermatol, 2007. 56(3): p. 375-9. SBM includes among its membership many of the nation’s 18. Hillhouse, J.J., et al., Evaluating a measure of tanning abuse leading experts in skin cancer prevention, tanning and dependence. Arch Dermatol, 2012. 148(7): p. 815-9. behavior, tanning dependence, and indoor tanning policy. 19. National Conference of State Legislatures. Indoor tanning These experts are available for consultation to advocates restrictions for minors: A state-by-state comparison. 2013 [cited and organizations seeking to design and promote state 2013 April 5, 2013]; Available from: http://www.ncsl.org/issues- legislation. SBM is amenable to partnerships with other research/health/indoor-tanning-restrictions.aspx. 20. professional organizations that share the mission of Mayer, J.A., et al., Adolescents’ use of indoor tanning: a large- scale evaluation of psychosocial, environmental, and policy- protecting children from the dangers of indoor tanning. level correlates. Am J Public Health, 2011. 101(5): p. 930-8. 21. Choi, K., et al., Prevalence and characteristics of indoor 1. US Department of Health and Human Services, Report on tanning use among men and women in the United States. Arch carcinogens, exposure to sunlamps or sunbeds, N.T.P. Public Dermatol, 2010. 146(12): p. 1356-61. Health Service, Editor. 2011: USDHHS. 22. Magee, K.H., et al., Tanning device usage: what are parents 2. FDA, Indoor Tanning: The Risks of Ultraviolet Rays. 2010. thinking? Pediatr Dermatol, 2007. 24(3): p. 216-21. 3. American Academy of Pediatrics, Policy Statement: Ultraviolet 23. Baker, M.K., J.J. Hillhouse, and X. Liu, The effect of initial Radiation, A Hazard to Children and Adolescents. Pediatrics indoor tanning with mother on current tanning patterns. Arch 2011. 104(2): p. 328. Dermatol, 2010. 146(12): p. 1427-8. 4. American Academy of Dermatology. Indoor tanning. 2013 24. Cokkinides, V.E., et al., Use of indoor tanning sunlamps by [cited 2013 April 5]. US youth, ages 11-18 years, and by their parent or guardian 5. Canadian Pediatric Society. Banning children and youth under caregivers: Prevalence and correlates. Pediatrics, 2002. 109(6): the age of 18 years from commercial tanning facilities. May p. 1124-30. 1, 2013]; Available from: http://www.cps.ca/en/documents/ 25. Hoerster, K.D., et al., The influence of parents and peers on position/tanning-facilities. adolescent indoor tanning behavior: findings from a multi-city 6. IARC Working Group, Exposure to artificial UV light and skin sample. J Am Acad Dermatol, 2007. 57(6): p. 990-7. cancer: Summary and conclusion, in IARC Working Group 26. Stryker, J.E., et al., Maternal/female caregiver influences on Reports, I.W. Group, Editor. 2005, WHO: Lyons, France. adolescent indoor tanning. J Adolesc Health, 2004. 35(6): p. 528 7. Wehner, M.R., et al., Indoor tanning and non-melanoma skin e1-9. cancer: systematic review and meta-analysis. Bmj, 2012. 345: p. 27. Zeller, S., et al., Do adolescent indoor tanners exhibit e5909. dependency? J Am Acad Dermatol, 2006. 54(4): p. 589-96. 8. Boniol, M., et al., Cutaneous melanoma attributable to sunbed 28. Cokkinides VE, et al., Indoor Tanning use among adolescent in use: systematic review and meta-analysis. Bmj, 2012. 345: p. the United States, 1998 to 2004. Cancer, 2009. 115(1): p. 190-8. e4757. 29. Forster, J.L., et al., Compliance with restrictions on sale of indoor 9. Centers for Disease Control and Prevention, Epidemiologic tanning sessions to youth in Minnesota and Massachusetts. J Notes and Reports Injuries Associated with Ultraviolet Tanning Am Acad Dermatol, 2006. 55(6): p. 962-7. Devices -- Wisconsin, in Morbidity and Mortality Weekly Report 30. Culley, C.A., et al., Compliance with federal and state (MMWR), CDC, Editor. 1989, Department of Health and Human legislation by indoor tanning facilities in San Diego. J Am Acad Services: Atlanta, GA. p. 333-335. Dermatol, 2001. 44(1): p. 53-60. 10. Walters, B.L. and T.M. Kelley, Commercial tanning facilities: a 31. Hoerster, K.D., et al., Density of indoor tanning facilities in 116 new source of eye injury. Am J Emerg Med, 1987. 5(5): p. 386-9. large U.S. cities. Am J Prev Med, 2009. 36(3): p. 243-6. 11. Cust, A.E., et al., Sunbed use during adolescence and early 32. Jain, N., A. Rademaker, and J.K. Robinson, Implementation of adulthood is associated with increased risk of early-onset the federal excise tax on indoor tanning services in Illinois. Arch melanoma. International Journal of Cancer, 2011. 128(10): p. Dermatol, 2012. 148(1): p. 122-4. 2425-2435. 33. Hornung, R.L., et al., Tanning facility use: are we exceeding 12. Nolan, B.V., et al., Tanning as an addictive behavior: A literature Food and Drug Administration limits? J Am Acad Dermatol, review. Photodermatol Photoimmunol Photomed, 2009. 25(1): 2003. 49(4): p. 655-61. p. 12-9. 34. Pichon, L.C., et al., Youth access to artificial UV radiation 13. Harrington, C.R., et al., Addictive-like behaviours to ultraviolet exposure: Practices of 3647 US indoor tanning facilities. Arch light among frequent indoor tanners. Clin Exp Dermatol, 2011. Dermatol, 2009. 145(9): p. 997-1002. 36(1): p. 33-8. 35. Pawlak, M.T., et al., Legislation restricting access to indoor 14. Heckman, C.J., et al., A preliminary investigation of the tanning throughout the world. Arch Dermatol, 2012. 148(9): p. predictors of tanning dependence. Am J Health Behav, 2008. 1006-12. 32(5): p. 451-64. 36. Hester, E.J., et al., Archives of Dermatology. 141, Compliance 15. Mosher, C.E. and S. Danoff-Burg, Addiction to indoor tanning: with youth access regulations for indoor UV tanning. 8(959-962). relation to anxiety, depression, and substance use. Arch Dermatol, 2010. 146(4): p. 412-7.

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