The Role of Public Health Advocacy in Achieving an Outright Ban on Commercial Tanning Beds in Australia

Abstract

Although many countries still face opposition to the legislation of artificial tanning beds, all Australian states and territories have announced a total ban on commercial tanning beds. A combination of epidemiological and policy-centered research, powerful personal stories, and the active advocacy of prominent academics, cancer organizations, and grassroots community campaigners contributed to the decisions to first legislate standards and then ban all commercial tanning beds. We have illustrated that incremental change can be an effective pathway to securing substantial public health reforms.

The Evidence Linking Artificial tanning beds to melanoma risk is now unequivocal. In 2006, the International Agency for Research in Cancer released a systematic review that proved to be significant in raising awareness of the harmful effects of tanning bed use.¹ A more recent update of this systematic review of the literature concluded that the increased risk of melanoma associated with early tanning bed use was 59% for people whose first exposure to artificial ultraviolet radiation in a suntanning unit occurred before aged 35 years and that risk increased with the number of tanning bed sessions per year.^2,3

With the evidence of increased risk of melanoma and other skin cancers growing, legislative controls to ban access to commercial tanning beds for those younger than 18 years have been implemented in nearly 20 countries,⁴ almost all since 2006, indicating the influence of the International Agency for Research in Cancer report along with local public health advocacy efforts. However, tanning bed control advocates in many countries still face opposition. For example, in the United States, although there are more than 30 states that have some controls related to tanning bed use, only California, Vermont, Oregon, Texas, Nevada, and Illinois have introduced statewide bans for those younger than 18 years.

TANNING BED CONTROL LEGISLATION IN AUSTRALIA

Australia has a strong history of government and nongovernment action for public health.⁵ Regulations to ban high-risk individuals (those with skin type 1 on the Fitzpatrick scale [pale skin that always burns and never tans] as well as minors younger than 18 years) from using commercial tanning beds were in place across all states and territories by 2010 along with numerous other complementary measures, including operator training and client consent form requirements. In 2012, however, 3 states (New South Wales [NSW], Victoria, and South Australia) took a further significant step by announcing a total ban on commercial tanning beds, effective at the end of 2014. In 2013, the remaining states and territories also announced bans.

Following the precedent set by Brazil, which passed a resolution in 2009 banning the use of commercial tanning beds for cosmetic purposes,⁶ Australia is only the second country in the world to implement bans. This step occurred in a relatively short time frame. The first announcement of such a ban was in the country’s most populous state, NSW, and occurred before Australia’s peak cancer organization, Cancer Council Australia, had even formulated a national position to support a total ban. At a state level, Cancer Council NSW recommended a ban in a submission to their government only 12 months before the NSW government announcement.

It is very rare in public health policy for such a significant policy decision with clear commercial implications for small business to have occurred so quickly and before all key public health institutions and advocates had come to an agreement that such a ban was even possible.

INDIVIDUAL ADVOCACY AND INCREMENTAL CHANGE

Certainly there were some notable individuals who were influential in motivating the NSW government to action.

In 2007, Clare Oliver of Victoria was dying from melanoma at age 26 years. Oliver was adamant that tanning beds had contributed to her illness and, in the last months of her life, campaigned strongly against their use and called for a ban.⁷ Oliver’s story was influential in securing regulations across all states and territories to ban access to tanning beds for those younger than 18 years.

Jay Allen launched an ongoing campaign to ban commercial tanning beds in NSW in 2008. A young father of 2, Allen used tanning beds at his local gym and was diagnosed with stage 3 melanoma in 2007. Like Oliver, Allen was certain that indoor tanning was responsible for his melanoma and campaigned using social and traditional media and a community petition as well as lobbying politicians directly. His call for a ban garnered widespread media coverage and was backed by a minor political party in the NSW parliament and a prominent public health academic, Simon Chapman, PhD. These positions were important in progressing public debate about the issue, even though at the time Cancer Councils were not yet calling for a ban.⁸

THE MOVE TO BAN

In November 2010, the NSW Labor government announced a proposal to tighten restrictions further by banning those younger than 30 years and with skin type 2 (fair skin that usually burns and tans with difficulty) by August 2011. These additional controls were justified as necessary because 2 government audits had shown levels of poor industry compliance with current regulations.^9,10

At this stage, Cancer Council NSW recommended that the government simply ban commercial solaria because of the likely challenges in enforcing tightened restrictions and the strength of the evidence demonstrating a causal link between tanning bed use and melanoma. Cancer Council NSW also encouraged its supporters and health professionals to make submissions in support of a total ban.

A subsequent change of government in March 2011 meant that the proposed controls did not proceed. However, Cancer Council NSW continued calling for a ban, and community and media interest remained high. In February 2012, the new, conservative government unexpectedly announced a plan to ban all commercial tanning beds by the end of 2014. Very quickly there was a change in the policy positions of the other state and national Cancer Councils to support an outright ban. Within 12 months the governments of Victoria and South Australia announced matching bans, followed by the governments of the remaining states and territories in 2013.

The NSW and Queensland governments are assisting industry with safe disposal of tanning beds to reduce the risk of commercial units being sold in neighboring states and territories or for personal use. The ban will not affect exposure to ultraviolet radiation for medical purposes because the bans are specific to commercial tanning beds for cosmetic purposes.

WHY IT HAPPENED

The key question is how can such a significant step be taken in Australia when so many other jurisdictions, especially in North America and Europe, are still battling to see the introduction of restrictions for those younger than 18 years?

Tanning bed use was never as common in Australia as in North America and Europe, and it decreased from 2.2% of adults aged 18 to 69 years having used a tanning bed in the previous 12 months in summer 2003–2004 to 1.5% in 2006–2007.¹¹ Once comprehensive regulations were in place in Australia requiring commercial tanning bed operators to be licensed and to restrict access for high-risk individuals, the number of operators decreased in some states by up to 51.0% within 3 years¹² (Figure 1^{1,3,9,10,12–20}). With heightened public awareness of the risks of tanning beds, the number of operators quickly diminishing, and those remaining quickly diversifying their businesses into other revenue streams such as spray tanning, it is likely that state governments saw little potential public or industry opposition to an outright ban. Additionally, there has not been a strong collective advocacy body for the tanning bed industry in Australia, unlike North America and Europe. In hindsight, a total ban on tanning beds was a logical step, especially considering the tanning bed industry’s poor compliance with existing regulations.

FIGURE 1—

Contributing factors to tanning bed reform and concurrent reduction in tanning bed numbers: Victoria, Australia.

Note. ACCC = Australian Consumer and Competition Commission; ACT = Australian Capital Territory; CCNSW = Cancer Council New South Wales; IARC = International Agency for Research on Cancer; NSW = New South Wales; NT = Northern Territory; Qld = Queensland; SA = South Australia; Tas = Tasmania; Vic = Victoria; WA = Western Australia.

Source. Department of Health figures obtained through personal communications or media releases (see http://news.ninemsn.com.au/national/2013/10/15/22/36/tan-ban-passes-vic-parliament. Accessed December 10, 2013).

^aLegislation: NSW, Qld, and Tas; revised standard AS/NZ 2635:2008 (voluntary code)—bans those younger than 18 years, skin type 1, recommends against skin type 2; amendment to National Directory for Radiation Protection—includes solariums as a category of nonionizing radiation for the first time, bans those younger than 18 years, bans skin type 1.

^bNSW, SA, and Vic announce ban; Qld announces no new licenses; Tas passes motion in lower house to ban.

^cACCC injunction restraining distributors and operators from engaging in false, misleading, and deceptive conduct.

^dNSW government proposal to extend restrictions to those younger than 25 years, then 30 years, and those with skin type 2.

The move to bans in Australia also highlights that in some public health reforms, incremental change can be an effective pathway to securing more substantial changes in the longer term. Although it is not possible to be definitive about the relative contribution of different factors, it is highly likely that the changes in Australia benefitted from a combination of strong, widely reported epidemiological evidence, the powerful personal stories of 2 people whose melanoma was associated with the use of tanning beds, media advocacy, and direct political representation by nongovernment agencies. All these factors merit the consideration of advocates of government intervention in public health in other jurisdictions.

Importantly, the bans NSW, other Australian states, and Brazil enacted act as a precedent that forms a new benchmark for a public health government intervention. It is hoped that other countries will refer, together with Australia’s leadership in the plain packaging of tobacco, to Australia’s example to demonstrate that what might have been thought of as impossible just a few years ago is very much an achievable goal.