Effect of Parental Permission and Age Restriction Laws on US Adolescent Indoor Tanning Trends

Today, 17 states have laws that prohibit all minors (i.e., those younger than 18) from accessing commercially available indoor tanning.¹ Youth access laws have been introduced in another 20 states since 2015 but have yet to pass. At times, this legislative approach has fallen short, with some states ultimately adopting an age limit lower than 18 or requiring parental consent for adolescents at a certain age. Against this backdrop, the report by Qin et al. (p. 951) in this issue of AJPH provides critical and much-needed evidence to reinforce and strengthen advocacy efforts to enact laws that restrict adolescents younger than 18 years from tanning indoors.

Qin et al. used the Youth Risk Behavior Survey from four biennial surveys between 2009 and 2015 to classify adolescents according to the state laws that were applicable to their age at the time of the survey (e.g., parental permission or age restriction laws vs none). The prevalence of adolescent use of indoor tanning in the past year was assessed for each type of regulatory environment over time, separately for males and females. From this analysis, three key findings emerge about indoor tanning in relation to state laws, particularly among girls: (1) the strong secular trend for a decline in indoor tanning use from 2009 to 2015, even in states without laws; (2) the lack of association between parental permission laws and adolescent indoor tanning use; and (3) the lowest prevalence of indoor tanning among states with age restriction laws.

DECLINE IN INDOOR TANNING

In states without parental permission or age restriction laws, the prevalence of indoor tanning use among girls declined from 31.0% in 2009 to 10.6% in 2015. This finding is important for two reasons. First, it suggests that factors beyond state laws are contributing to changes in prevalence of indoor tanning over time and likely influence some of the decline observed in states with laws. Research on the harms of indoor tanning has garnered considerable media attention, as have legislative efforts. Thus, parents, as the gatekeepers to their children’s indoor tanning access, may have acted on this new knowledge to disallow their adolescents to tan indoors. Adolescents also may have learned through channels other than their parents about indoor tanning harms. Anecdotally, high schools have promoted tan-free proms, and a recent report documented a decline in indoor tanning advertising in school newspapers.² These actions, among others, are undoubtedly reinforcing the message against indoor tanning in states with laws as well.

Second, the authors noted as a limitation that adolescents may have been more likely to underreport indoor tanning use in states with laws. However, the secular trend observed in states without laws indicates that underreporting of the behavior does not fully explain the reduction in indoor tanning use in states with age restriction laws.

PARENTAL PERMISSION LAWS

In legislative testimony and public comments in response to proposed rule changes from the US Food and Drug Administration, the indoor tanning industry has argued for parental permission laws on the basis that age restrictions violate parents’ autonomy to make decisions on behalf of their children. Despite evidence that tanning salons are noncompliant with requirements for parental consent,³ this argument has convinced state legislatures to pass parental permission laws, often as a compromise in lieu of passing more restrictive age laws promoted by advocates.

The data from the Qin report are compelling because they undercut industry arguments. After accounting for age, race/ethnicity, and survey year, overall prevalence of adolescent indoor tanning use across four surveys was no different in states with parental permission laws than in states with no laws. However, in 2015, the highest crude prevalence of indoor tanning among girls was in states with parental permission laws (13.5% vs 10.6% in states without laws and 7.0% in states with age restriction laws). These results provide advocates with data to argue more effectively for restricting adolescent indoor tanning based on age.

AGE RESTRICTION LAWS

Significantly, Qin et al. reported that the adjusted prevalence for indoor tanning use was 47% lower in states with age restrictions than in states with no laws. Note, however, that restrictions varied by age, so that in some states, adolescents younger than 18 years were prohibited from indoor tanning, but in other states, the age restriction pertained only to adolescents younger than 15 or 16 years. Advocacy efforts have focused on the more stringent age limit to prohibit indoor tanning among those younger than 18 years rather than at younger ages. Regretfully, Qin et al. did not directly address indoor tanning according to restrictions at different ages. This was likely because no states had minor bans in 2009 or 2011, just three had bans at the time of the 2013 survey, and although eight additional states had bans in time for the 2015 Youth Risk Behavior Survey, three of those states did not participate. Thus, as more states adopt laws prohibiting indoor tanning by minors, the full effect of this upper age restriction will become more apparent with time. Meanwhile, these results should be embraced for what they indicate about the effectiveness of age restrictions. Setting the limit to the age of majority would mean even fewer adolescents exposed to the harms of indoor tanning.

RAISING THE AGE LIMIT TO 18 YEARS

Following mounting evidence that artificial sources of ultraviolet radiation via indoor tanning cause nonmelanoma and melanoma skin cancers, the International Agency for Research on Cancer classified indoor tanning as a human carcinogen in 2009.⁴ The International Agency for Research on Cancer report, along with methodologically rigorous epidemiological studies investigating the association between indoor tanning and melanoma published shortly thereafter,^5–7 led to a concerted and coordinated effort by members of the medical, research, public health, and advocacy communities to urge state legislatures to pass laws restricting indoor tanning use by minors. Their actions to tackle this risk behavior via state legislation has had remarkably rapid results—at 7.0% in 2015, indoor tanning prevalence among adolescents residing in states with age restriction laws was well below the Healthy People 2020 goal of 14%.

Although this reduction in indoor tanning prevalence is a public health success worth celebrating, more work is needed. Following the 2016 presidential election, the US Food and Drug Administration did not finalize the rules announced the previous year for instituting a national ban on indoor tanning among adolescents younger than 18 years. Thus, the onus for protecting youths from this exposure has now fallen back to the 33 states that have yet to pass legislation to prohibit minors from tanning indoors.

The authors estimated that 61 830 melanoma cases and 6735 melanoma deaths could be prevented in the United States if adolescents were prevented from tanning indoors as a result of the age 18 restriction laws. Moreover, an even greater reduction in the skin cancer burden would be possible if avoiding indoor tanning during adolescence led to lower likelihood of adopting the behavior in adulthood, similar to other risk behaviors like smoking.

Taken together, this report gives new impetus to the advocacy community to pursue legislation with so much potential to protect the lives of adolescents.