A Call to Action to Eliminate Indoor Tanning: Focus on Policy

It is estimated that 419,245 cases of skin cancer in the US each year are attributable to indoor tanning (IT).¹ Efforts to increase regulations on IT continue given its well-established association with melanoma and keratinocyte cancers as well as its popularity among adolescents and young adults. This paper provides an overview of legislative efforts to limit IT among minors, discusses policy adoption and implementation challenges, and calls upon dermatologists and others to help eliminate IT in order to decrease skin cancer incidence.

Legislation Restricting Indoor Tanning

Policy is one of the most effective strategies for impacting health behaviors and public health. IT is regulated in two main ways: states restricting minor access and the federal Food and Drug Administration (FDA) attempting to minimize harm during IT sessions. Presently, 22 states and the District of Columbia ban IT for all minors, 10 ban IT for some minors by age (e.g., under 14), and 12 require parental consent/accompaniment, leaving six states with no IT laws. FDA regulations designed to reduce harmful ultraviolet radiation exposure during tanning include protective eyewear requirements and session duration limits. The proliferation of state-level IT restrictions may explain decreases in the number of IT providers, consumer spending on IT, and past-year IT among high school girls (2009=24.1%, 2015=9.5%), boys (2009=5.7%, 2015=3.3%)², and young adults aged 18–34 (2007=14%, 2018=4%)³ observed in the US in recent years.

These IT reductions are notable public health achievements that are likely to help alleviate increasing trends in melanoma incidence. It is estimated that further restriction of IT among minors would prevent thousands of melanomas and melanoma deaths over the lifetime of the tens of millions of US children, not to mention the potential impact on keratinocyte cancers. However, as compared with total bans, bans on minors may only result in one-third of the benefits in skin cancers averted and cost savings⁴. Achieving more restrictive legislation will require continued research, advocacy, and policy efforts to 1) overcome barriers to adopting additional restrictions and 2) identify and subsequently close remaining gaps in the implementation of existing laws restricting IT.

Policy Adoption

Legislators in most states have passed or attempted to pass IT regulations. The number of IT bills introduced annually is increasing; however, the proportion passed among all bills introduced per year remains very low. Political barriers include strong industry lobbying, education of legislators, post-filing proceedings, and lack of support from other organizations. For example, an FDA-proposed federal ban on IT for minors in 2015 appears to have been thwarted by tanning industry lobbying and other political factors such as trends toward deregulation. The IT industry argues that IT restrictions have negative economic impacts, regardless of costly health hazards from which small businesses profit. In addition, the industry and its lobbyists have argued that youth access laws are a restriction of parents’ civil liberties.

IT policy efforts also include legislative proposals to increase the stringency of existing IT laws, which demonstrates the iterative nature of effective policy making. IT law stringency can include mandates applying to minor access (e.g., ban vs. consent), warnings, UV exposure controls, sanitation, device standards, facility operations, operator training/responsibility, enforcement, penalties, and marketing. Age restriction appears to be particularly important components of IT policy, as reductions in IT rates among adolescents have been most consistently observed in states with age bans compared to those with parent accompaniment/consent laws. Unfortunately, the stringency of minor and adult access legislation in states with IT laws have been rated as low to moderate, with few very strong policies.

Implementation of Legislation

Health risks can persist even after policy adoption, in part due to suboptimal enforcement and compliance. Enforcement of IT regulations is inconsistent. For example, the use and frequency of inspections for tanning salon compliance are highly variable across states and localities, with only 12% and 28% of states rated as having very strong enforcement provisions for minors and adults, respectively⁵. Citations for violations are inconsistently utilized, and penalties are low-level fines or misdemeanors in most states and unlikely to create deterrence. Compliance with IT regulations is also imperfect. For example, most tanning salons have said they allow first‐time customers to indoor tan daily, contrary to FDA recommendations.⁶ Compliance with age restrictions (range=0 to 100%, mean=65%), warning labels (range=8 to 72%, mean=44%), and requiring protective eyewear (range=84 to 100%; mean=92%)⁷ also varies widely. Undoubtedly, a lack of enforcement provisions and resources and competing priorities for health regulators are key factors in lack of enforcement and low compliance. Complete bans on minors (i.e., under age 18) have achieved much higher compliance, one more reason to enact them.

Comprehensive IT policy is complicated by the availability of tanning beds in non-salon settings such as homes and other businesses (e.g., gyms, apartment complexes, beauty salons). A notable minority of indoor tanners engage in non-salon tanning. As recently as 2015, approximately half of top colleges had IT facilities on campus or in off-campus housing. These settings are less likely to be regulated and inspected and are often unattended by facility staff. There is also some evidence of poorer compliance with FDA recommendations, such as protective eyewear requirements, skin type limits, and session duration limits, in non-salon than salon settings.

What Dermatologists and Others Can Do

Dermatologists and others can help address the aforementioned challenges by utilizing their expertise in policy research and advocacy. Little is known about the legislative process of adopting or rejecting IT bills, or what might facilitate increasing the stringency of existing laws (e.g., ban up to 19 or 21 years of age, or total ban). Comprehensive policy research efforts are needed on IT law deliberations, stringency, enforcement, and compliance to inform future decision making, leading toward more effective IT policies. Research is needed on whether parents are aware of parental consent/accompaniment laws and can be convinced to withhold permission. Previous research has often used blunt measures (e.g., ban vs. no ban) or was conducted in a piecemeal manner (i.e., only focused on stringency, enforcement, or compliance in a few states). Many of the most rigorous studies are outdated. Although several studies have estimated health-related costs of IT and skin cancer, studies have not rigorously assessed other costs such as potential business losses, which are often used by the industry to justify these health risks. Additionally, little is known about potential compensatory effects, such as individuals’ moving from salon tanning to non-salon, outdoor, or sunless [UV-free chemical] tanning.

Dermatologists can play an important role in IT policy. They should become aware of local IT regulations and take opportunities to educate patients, family members, legislators, schools/universities, childcare organizations, and beauty and fitness facilities about the risks of IT and garner support from these groups in advocating for stronger policies and compliance with IT regulations. In addition to sharing data, one potentially powerful way to do this is to share clinical vignettes and patient/family testimonials about young indoor tanners who have been treated and perhaps died from melanoma. There are many partners for these efforts, such as the National Council on Skin Cancer Prevention, the American Academy of Dermatology, the Congressional Skin Cancer Caucus, and Aim at Melanoma. Together, these groups can present a strong united front to advance toward IT elimination and improve public health.