Tax Collections and Spending As a Potential Measure of Health Policy Association with Indoor Tanning, 2011-2016

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RESEARCH LETTER Discussion | Our findings indicate that US consumer spending on indoor tanning and the number of indoor tanning pro- Tax Collections and Spending as a Potential viders have diminished considerably since 2013. Moreover, Measure of Health Policy Association the contraction in consumer spending on indoor tanning is With Indoor Tanning, 2011-2016 even more apparent compared with the growth in overall As part of the Affordable Care Act (ACA), a 10% excise consumer spending. These results are consistent with sur- tax was imposed on the provision of indoor tanning vey studies suggesting a decrease in the prevalence of services in July 2010. Besides funding health insurance indoor tanning since 2010.6 Previous surveys demonstrate expansion, the tax was designed to discourage indoor that the prevalence of indoor tanning had been increasing tanning, which significantly increases the risk of as late as 2009,7 implying a trend reversal coinciding with developing melanoma and nonmelanoma skin cancer the tax’s implementation. and costs over $343 million annually in direct medical Using non–survey-based methods to assess the care.1 Although reported adherence had been high in association of health policies with population behavior can 1 state,2 the Internal Revenue Service (IRS) acted to provide complementary and perhaps more reliable improve adherence nationally in 2011 and 2012. Tax collec- evidence of such trends. Recently, historical tax revenues tions are proportional to US consumer spending on have been used to estimate the effects of taxes on indoor tanning services and correlated with the prevalence other harmful health behaviors, including tobacco of indoor tanning. consumption,8 and search pattern tools, such as Google Trends, have been used to study myriad aspects of popula- Methods | Annual collections and the number of tion behavior.9 quarterly returns filed for the indoor tanning services Our study is limited by exclusion of qualified physical excise tax from 2011 to 2016 were extracted from the 2014 fitness facilities, whose membership fees are exempted IRS Data Book,3 IRS ACA statistics,4 and a Freedom of from the tax if tanning services are incidental to the primary Information Act request filed with the IRS. Revenue business activity. This post-ACA exemption may have con- projections were obtained from the Joint Committee on tributed to the discrepancy between projections and collec- Taxation’s 2010 report.5 For comparison, growth in US tions. In addition, quantifying the prevalence of indoor tan- consumer spending on services was estimated by ning using tax collections requires pricing and adherence personal consumption expenditures on services data, which were unavailable. Thus, the rise in collections (PCESV), a measure tracked by the Bureau of Economic and returns from 2011 to 2012 may reflect an increased Analysis. All statistical analyses were conducted using adherence rather than a true increase in tanning services. Microsoft Excel (Microsoft Corp). This study was deemed Finally, although the decrease in returns from 2012 to 2016 exempt by the University of Pennsylvania Institutional likely owes to tanning industry decline, it may also reflect Review Board. consolidation among tanning businesses. The excise tax has been criticized for causing tanning Results | From 2011 to 2016, collections decreased by 13.0% industry job losses and failing to meet revenue projections; and the quantity of returns filed fell by 21.3% (Table). Each however, these considerations are secondary to the public of these percentages peaked during the 2012-2013 period health objective of deterring indoor tanning. Although the and have declined each year since then. Collections were data demonstrate that indoor tanning has decreased signifi- substantially below ACA projections in all years. From 2011 cantly since the tax’s implementation, they cannot confirm to 2016, PCESV rose by 22.6%. a causative association. Future studies should investigate

Table. Indoor Tanning Services Excise Tax—Projections, Collections, and Returns

Characteristic 2011 2012 2013 2014 2015 2016 % Change PCESV, $, billions 7093 7312 7527 7893 8299 8699 22.6 Projections, $, thousands 200 000 200 000 300 000 300 000 300 000 300 000 50.0 Collections, $, thousands 86 262 91 468 91 655 84 435 78 062 75 068 −13.0 Quarterly returns 47 000 49 000 46 000 44 000 41 000 37 000 −21.3 Mean collections 1835 1867 1993 1919 1904 2029 10.5 per quarterly return, $

Abbreviation: PCESV, personal consumption expenditures on services.

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the relative effects of the tax and other restrictions and medical schools integrate LGBT health-related competencies initiatives on indoor tanning practices. throughout their curricula, especially through use of clinical scenarios that incorporate discussion points specific to this Kishore L. Jayakumar, BS population.5 We investigated the extent to which an online Jules B. Lipoff, MD dermatology curriculum for medical students incorporated LGBT health-related content. Author Affiliations: Medical Student, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Jayakumar); Department of Dermatology, Methods | We conducted a cross-sectional study of the Ameri- Perelman School of Medicine, University of Pennsylvania, Philadelphia (Lipoff). can Academy of Dermatology’s (AAD) online Basic Dermatol- Corresponding Author: Jules B. Lipoff, MD, Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Penn Medicine ogy Curriculum, which consists of case-based modules. The University City, 3737 Market St, Ste 1100, Philadelphia, PA 19104 curriculum was created by the AAD in collaboration with the ([email protected]). Society for Pediatric Dermatology (SPD). Most modules have Accepted for Publication: January 23, 2018. an associated learner quiz, allowing students to assess their Published Online: April 11, 2018. doi:10.1001/jamadermatol.2018.0161 knowledge after module completion. Author Contributions: Mr Jayakumar and Dr Lipoff had full access to all the All curriculum modules (in PDF format) and quizzes were data in the study and take responsibility for the integrity of the data and the downloaded from the American Academy of Dermatology accuracy of the data analysis. Study concept and design: Jayakumar. Association Basic Dermatology Curriculum Website (http: Acquisition, analysis, or interpretation of data: Both authors. //www.aad.org/education/basic-derm-curriculum)on Drafting of the manuscript: Jayakumar. November 20, 2017. Patients’ gender or sex, dating or Critical revision of the manuscript for important intellectual content: marriage status, sexual orientation, and sexual behavior Both authors. Statistical analysis: Jayakumar. were all recorded. For pediatric modules, patients’ parents Study supervision: Lipoff. were characterized by parental status (mother, father) and Conflict of Interest Disclosures: Mr Jayakumar reports receiving marriage status. Enrolled Agent status from the Internal Revenue Service. No other conflicts were reported. Results | The curriculum consisted of 293 patients, with 157 in 1. Waters H, Adamson A. The health and economic implications of the use of 40 modules and 136 from 36 quizzes, including 121 pediatric tanning devices [published online February 28, 2017]. J Cancer Policy. doi:10.1016/j.jcpo.2016.12.003 patients. Characteristics of patients and, for pediatric cases, 2. Jain N, Rademaker A, Robinson JK. Implementation of the federal excise tax patients’ parents are shown in the Table. One of 293 (0.3%) on indoor tanning services in Illinois. Arch Dermatol. 2012;148(1):122-124. cases mentioned an LGBT patient, a woman with basal cell car- 3. 2014 Internal Revenue Service Data Book. https://www.irs.gov/pub/irs-soi cinoma (BCC) in a same-sex marriage. No cases included a /14databk.pdf. Published March 2015. Accessed August 23, 2017. transgender patient, mentioned same-sex sexual behavior, or 4. Internal Revenue Service. SOI Tax Stats—Affordable Care Act (ACA) Statistics. specified sexual orientation. https://www.irs.gov/uac/soi-tax-stats-affordable-care-act-aca-statistics. Updated September 12, 2017. Accessed August 23, 2017. Discussion | This study shows a near-absence of LGBT-related 5. The Joint Committee on Taxation. JCX-17-10 download. https://www.jct.gov /publications.html?func=showdown&id=3672. Accessed August 23, 2017. content in the AAD and SPD’s Basic Dermatology Curricu- 6. Guy GP Jr, Watson M, Seidenberg AB, Hartman AM, Holman DM, Perna F. lum. This paucity of content represents a missed opportu- Trends in indoor tanning and its association with sunburn among US adults. nity to educate medical students in providing medically J Am Acad Dermatol. 2017;76(6):1191-1193. appropriate and culturally competent care to LGBT persons 7. Buller DB, Cokkinides V, Hall HI, et al. Prevalence of sunburn, sun protection, in dermatology settings, even as the importance of these and indoor tanning behaviors among Americans: review from national surveys competencies to dermatologists is increasingly noted in the and case studies of 3 states. J Am Acad Dermatol. 2011;65(5)(suppl 1):S114-S123. medical literature.3,4,6 This absence might also signal to 8. Tynan MA, Morris D, Weston T.Continued implications of taxing roll-your-own tobacco as pipe tobacco in the USA. Tob Control. 2015;24(e2):e125-e127. medical students potentially interested in pursuing derma- 9. Nuti SV, Wayda B, Ranasinghe I, et al. The use of Google trends in health care tology, and to residents, dermatology faculty, and other edu- research: a systematic review. PLoS One. 2014;9(10):e109583. cators who use this curriculum, that LGBT health is not important in dermatology. Paucity of Lesbian, Gay, Bisexual, and It is possible that other dermatology-related educational Transgender Health-Related Content materials besides the Basic Dermatology Curriculum not in the Basic Dermatology Curriculum assessed in this study incorporate more LGBT health-related Lesbian, gay, bisexual, and transgender (LGBT) persons in the content. However, considering this study’s findings and rec- United States account for 2.2% to 4.0%1 of the population and ommendations from Healthy People 2020 and AAMC, AAD, face considerable health disparities, generally and specifi- and SPD should include more cases involving LGBT persons cally related to dermatology.2-4 According to Healthy People in the curriculum. Some cases should highlight dermatologic 2020, the federal government’s public health agenda, these issues of specific importance to LGBT health.3 For example, disparities partially arise from a shortage of health care pro- some evidence suggests that lifetime prevalence of fessionals who are knowledgeable and culturally competent nonmelanoma skin cancer in sexual-minority women is in LGBT health.2 Mitigating LGBT health disparities is a focus lower, and in sexual-minority men is higher, than in of Healthy People 2020 and the Association of American Medi- heterosexuals.6 As in the case of the woman with BCC in a cal Colleges (AAMC).2,5 The AAMC guidelines recommend that same-sex marriage, other cases should feature patients

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