Preventing Skin Cancer Through Reduction of Indoor Tanning: Current Evidence

https://doi.org/10.1016/j.amepre.2013.02.015Get rights and content

Abstract

Exposure to ultraviolet radiation from indoor tanning devices (tanning beds, booths, and sun lamps) or from the sun contributes to the risk of skin cancer, including melanoma, which is the type of skin cancer responsible for most deaths. Indoor tanning is common among certain groups, especially among older adolescents and young adults, adolescent girls and young women, and non-Hispanic whites. Increased understanding of the health risks associated with indoor tanning has led to many efforts to reduce use. Most environmental and systems efforts in the U.S. (e.g., age limits or requiring parental consent/accompaniment) have occurred at the state level. At the national level, the U.S. Food and Drug Administration and the Federal Trade Commission regulate indoor tanning devices and advertising, respectively.

The current paper provides a brief review of (1) the evidence on indoor tanning as a risk factor for skin cancer; (2) factors that may influence use of indoor tanning devices at the population level; and (3) various environmental and systems options available for consideration when developing strategies to reduce indoor tanning. This information provides the context and background for the companion paper in this issue of the American Journal of Preventive Medicine, which summarizes highlights from an informal expert meeting convened by the CDC in August 2012 to identify opportunities to prevent skin cancer by reducing use of indoor tanning devices.

Section snippets

Indoor Tanning and Cancer Risk

In 2009, the WHO classified ultraviolet (UV) radiation–emitting tanning devices as Class I carcinogens based on evidence linking indoor tanning to increased risk of skin cancer.1 Genetic factors, exposure to UV radiation, and a history of sunburn all contribute to risk of skin cancer,2, 3, 4, 5, 6, 7 but most skin cancers are caused by exposure to UV radiation, either from the sun or from artificial sources such as indoor tanning devices (tanning beds, booths, and sun lamps), and are therefore

Prevalence of Indoor Tanning

Two national surveys conducted by the CDC allow for the examination of self-reported use of indoor tanning devices in the U.S. The Youth Risk Behavior Survey (YRBS) provides a nationally representative sample of public and private high school students in Grades 9–12. The National Health Interview Survey (NHIS) collects data on a nationally representative sample of the U.S. civilian, non-institutionalized population through confidential interviews conducted in households. Recent data on indoor

Correlates of Indoor Tanning

Indoor tanning behavior is likely influenced by individual factors, interpersonal or social factors, and broad contextual factors, among others. In addition to age and gender differences, adolescents with a more positive attitude toward tanning or tanned skin are more likely to use indoor tanning devices.30, 31, 32, 33, 34, 35, 36, 37, 38, 39 Perceived social norms regarding tanning and tanned skin (e.g., reporting that one’s friends are tan or use indoor tanning devices) are also associated

State and Local Regulations in the U.S.

The regulation of indoor tanning devices in the U.S. is primarily controlled at the state level. Thus, the strength and enforcement of indoor tanning restrictions varies considerably throughout the U.S., as does compliance with existing controls. In October 2011, California passed the most-stringent youth access law in the country, prohibiting indoor tanning for all minors aged<18 years, which took effect on January 1, 2012.47 In 2012, Vermont passed a similar ban that went into effect on July

Federal Environmental and Systems Efforts in the U.S.

At the federal level, the U.S. Food and Drug Administration (FDA) regulates use of medical devices in the U.S. The FDA currently classifies indoor tanning devices as Class I medical devices—the same classification as bandages, tongue depressors, and other devices that pose minimal dangers to consumers.55, 56 The American Academy of Dermatology, the Skin Cancer Foundation, the American Academy of Pediatrics, and other experts on the relationship between skin cancer and indoor tanning have urged

International Environmental and Systems Efforts

Outside the U.S., other national governments have taken a variety of approaches to indoor tanning device control. Some countries have passed comprehensive laws to completely eliminate indoor tanning device use; others have sought to regulate tanning devices and reduce harm associated with their use. In November of 2009, based on the WHO’s designation of tanning beds as a Class I carcinogen, Brazil became the first country to ban indoor tanning for cosmetic purposes.68 In February of 2012, New

Compliance and Enforcement

Poor industry compliance to existing laws and regulations is a barrier to successful environmental and systems efforts. Studies70, 71, 72, 73 in Australia and the U.S. have shown that the tanning industry rarely complies with either voluntary industry codes or mandated governmental laws and regulations. One study74 found that FDA-recommended tanning exposure times are exceeded by 95% of indoor tanners, calling into question general compliance with the FDA guidelines.

A 2011 study75 in New York

Evidence of Impact

Most environmental and systems approaches have not been sufficiently evaluated to determine the effects they have on tanning behaviors. The lack of evidence is likely due, in part, to challenges in surveillance and monitoring of indoor tanning device use; wide variation in stringency, compliance, and enforcement of controls; and relatively recent adoption of restrictive laws and regulations. Although some studies have found age restrictions to be ineffective,77 others have found that age

Conclusion

This paper provides a brief review of (1) the state of the evidence on indoor tanning device use; (2) factors that may influence indoor tanning device use; and (3) the various environmental and systems options that have been used as strategies to reduce indoor tanning device use. Many options to reduce risk of skin cancer through environmental and systems approaches at the international, national, state, and local levels have been identified, including:

  • FDA reclassification of tanning devices;

Acknowledgements

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.

The opinions in the paper and those discussed at the meeting do not necessarily represent those of meeting attendees.

No financial disclosures were reported by the authors of this paper.

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