The window of opportunity for indoor tanning legislation

Abstract

As of August 2014, 11 states in the USA have passed under-age-18 bans on indoor tanning. The Society of Behavioral Medicine, the American Academy of Dermatology, and the American Academy of Pediatrics have all issued statements in support of an under-age-18 ban. The World Health Organization and the Food and Drug Administration have both declared indoor tanning devices as carcinogenic, and this year, the Surgeon General for the first time issued a warning on the dangers of UV radiation and indoor tanning. This essay highlights how the awareness of the risks of indoor tanning, effective policies, and a conducive political atmosphere have aligned to create a window of opportunity for further under-age-18 indoor tanning legislation. The rising number of preventable skin cancers and mortalities is an issue that transcends political party lines, and now, there is a need for support from health professionals and advocates to motivate legislators to push new under-age-18 bills past their sticking points.

In the June 2014 issue, Banerjee et al. documented many of the barriers to cessation of indoor tanning, not least of which is the psychological withdrawal that some former tanners experience and the subsequent risk of relapse. More than 35 % of their subjects found quitting somewhat difficult and had a psychological urge to resume tanning. [1] Indeed, the latest research in Cell corroborates this subjective sense of addiction experienced by the patients; in a rodent model, researchers found an endorphin-mediated method of addiction to UV light. [2] Aside from psychological challenges, Banerjee et al. also uncovered practical obstacles, such as social pressure and even re-enrollment promotions from salons. [1] With the challenges to cessation that the study uncovered, it is clear that the best method of decreasing exposure to indoor tanning would be to stop tanners before they start this toxic behavior.

To this end, in July of this year, Delaware became the 11th state to adopt an under-age-18 ban on indoor tanning and the latest state to take advantage of the current window of opportunity for indoor tanning legislation. [3] In his book Agendas, Alternatives, and Public Policies, political scientist John W. Kingdon writes about the three forces that must be in alignment for an issue to be tackled in the political agenda. The three “streams” that must converge are the problem stream, the policy stream, and the politics stream. [4] In other words, the problem must be fully comprehended by lawmakers and the public, a policy must be available to address the problem, and the political atmosphere must be conducive to action. When in alignment, a window of opportunity is open for change to take hold. This essay will elaborate on the current window for indoor tanning legislation.

In March of this year, the Society of Behavioral Medicine joined the American Academy of Dermatology and the American Academy of Pediatrics as the latest organization to issue a formal position statement in support of an under-age-18 ban on indoor tanning. In 2009, the World Health Organization declared indoor tanning devices carcinogenic and noted as much as a threefold increase in melanoma risk if indoor tanning began in adolescence or young adulthood. [5] In May of this year, the Food and Drug Administration increased the risk classification for indoor tanning devices to indicate them as moderate-risk devices. Consequently, sunlamp products will have to display visible black-box warning labels stating that they should not be used by children younger than 18 years. In July of this year, the US Surgeon General for the first time issued a report on the dangers of UV radiation and devoted a significant portion of the 101-page document to the connection between indoor tanning and skin cancer. The above declarations demonstrate that the “problem” has been fleshed out and the dangers of tanning devices have become fact rather than just theory.

In response to these dangers, public health advocates have looked to legislation as an opportunity for safeguarding youth from these long-term risks. Under-18 bans have strong potential for actually decreasing the number of salons that allow children to tan. Illustrating this, a 2013 study by Grewal et al. found that such legislation was effective in achieving compliance from the majority of tanning salons in California—77 % told an underage teen on the telephone that she could not use their tanning devices. [6] As a secondary benefit, under-18 legislation not only protects minors, but also has the potential to spread awareness via the media and word-of-mouth to people of all ages regarding the risks of indoor tanning. [7] Therefore, banning under-age-18 indoor tanning stands as a promising policy for protecting our youth and potentially the population at-large.

In the past 3 years (as of August 2014), 11 states—California, Delaware, Hawaii, Illinois, Louisiana, Minnesota, Nevada, Oregon, Texas, Vermont, and Washington—passed under-age-18 bans [3]. With the precedents set and momentum built by these trailblazing states, today’s political atmosphere is more open to indoor tanning legislation than it has ever been. Indeed, legislation has passed in both blue and red states. The political arena is recognizing that the rising number of preventable skin cancers and mortalities is an issue that transcends traditional party lines. With a rising incidence of melanoma, the most dangerous form of skin cancer, specifically plaguing young women [8], policymakers are realizing that the real focus should be on protecting our children and their long-term health. Therefore, with a clearly defined problem, an effective policy, and a favorable atmosphere, Kingdon’s three “streams” have merged. The window of opportunity has opened for more states to take up the charge of protecting their youth from the harmful effects of indoor tanning.

Since the beginning of 2013, almost 25 additional states have proposed legislation for under-18 bans—however, the vast majority die in committee. [3] This highlights the fact that although the window is open, it can only be entered with sustained and vociferous support that continues to sound the alarm even after the initial victory of the introduction of legislation. As demonstrated in the states that have succeeded in passing the under-18 bans, the voices of health professionals, coupled with grassroots support from patients and their families, can play a critical role in states to rally the support to propose and, most importantly, follow through on legislation. Using the latest research data and the precedents created by the first 11 states, health professionals can create the kinetic energy that motivates legislators to push the bills past their sticking points. Achieving this success will require practitioners to work synergistically with public health advocacy organizations, state legislators, and the media to capitalize on the current window of opportunity before it closes.