Artificial Tanning Community Pediatrics Legislative Advocacy Project Joshua

Artificial Tanning Community Pediatrics Legislative Advocacy Project Joshua Langhorne, MD Janienne Kondrich, MD

Tanning industry • ~ $5 billion annually, up from $1 billion in 1992 • Fifty thousand tanning facilities in the US • 28 million visits per year

Tanning + Teens • Specifically targeted by the tanning industry – i. e. , ads in HS newspapers! • 24% of teens ages 13 to 19 reported using a tanning facility once in their lives • 10% of 11 to 18 year olds within the last year • Artificial tanning among white females rises with age: use doubles from ages 14 to 15 (7% to 15%), and doubling again at age 17 (35%)

Acute health effects • Sunburn • Skin dryness • Pruritis • Nausea • Photodrug reactions • Disease exacerbation – SLE • Disease induction – Polymorphous light eruption

Long term health effects • Skin aging • Effects on the eye v Cataract formation v Macular degeneration • Carcinogenesis: – > 1 million new cases of skin cancer in the US each year – Increase at least in part attributable to increased popularity of artificial tanning – UVA irradiation may be 10 -15 X more powerful than THE MIDDAY SUN – Childhood and adolescence are periods of greater biological vulnerability to UVR

Skin cancer: further increase of risk with artificial vs. natural UVR? • NIH: Exposure to sunlamps or sunbeds is a known human carcinogen • Association between use of any tanning device and increased incidence of basal cell or squamous cell carcinoma • Scandinavian study: increased melanoma risk in females • The International Agency for Research on Cancer found that even one exposure to artificial UVR was associated with melanoma; first exposure before the age of 35 significantly increased risk

The Freedom to Tan • The tanning industry has fought for teens to have continued access to tanning salons • Promote the health benefits and safety of artificial tans • The mission of the Indoor Tanning Association is “to protect the freedom of individuals to acquire a suntan, via natural or artificial light. ” • Parental rights issue

What are the formal stances of various medical organizations?

World Health Organization The WHO is the directing and coordinating authority for health within the United Nations system.

World Health Organization • Consistent with those of the International Commission on Non-Ionizing Radiation Protection (ICNIRP) • Recommends against use of UV-emitting appliances for tanning or other non-medical purposes • Individuals < 18 years old are at particularly high risk of incurring adverse health effects from UV, and therefore should be counseled against the use of tanning appliances

World Health Organization • WHO encourages governments to formulate and enforce effective laws governing the use of sunbeds • “Of highest regulatory priority should be the restriction of use by persons under 18 years”

American Medical Association

American Medical Association Supports the enactment of federal legislation to: • prohibit access to the use of indoor tanning equipment (as defined in 21 CFR § 1040. 20 [a][9]) by anyone under the age of 18; • require a US Surgeon General warning be prominently posted, detailing the positive correlation between UVR, the use of indoor tanning equipment, and the incidence of skin cancer • urge the FDA’s Center For Devices and Radiological Health to hold a fair hearing as soon as possible on the safety and efficacy of UVA bulbs, as used in indoor tanning facilities. (Res. 440, A-05)

American Academy of Dermatology

American Academy of Dermatology • No minor should be permitted to use tanning devices. • A Surgeon General's warning should be placed on all tanning devices. • No person or facility should advertise the use of any ultraviolet A or ultraviolet B tanning device using wording such as "safe, " "safe tanning, " "no harmful rays, " "no adverse effect, " or similar wording or concepts.

American Academy of Pediatrics

American Academy of Pediatrics • No current policy statement or endorsement of other organizations’ policy statements regarding legislation • Current policy statement focuses on education of patients and parents regarding danger of UV exposure

What is the current legislation regarding artificial tanning?

National Legislation • The federal government must contend with strong lobbying • • • by the multibillion-dollar tanning industry Current focus is on making the industry safer Tanning Accountability and Notification Act of 2007: v Introduced in House and Senate v Requires the FDA to conduct consumer testing to determine the appropriateness of the current labeling requirements for indoor tanning devices Contrast with France: v Banned indoor tanning for people under the age of 18 since 1997

What is the current labeling requirement? DANGER—Ultraviolet radiation. Follow instructions. Avoid overexposure. As with natural sunlight, overexposure can cause eye and skin injury and allergic reactions. Repeated exposure may cause premature aging of the skin and skin cancer. WEAR PROTECTIVE EYEWEAR. FAILURE TO MAY RESULT IN SEVERE BURNS OR LONGTERM INJURY TO THE EYES. Medications or cosmetics may increase your sensitivity to the ultraviolet radiation. Consult physician before using sunlamp if you are using medications or have a history of skin problems or believe yourself especially sensitive to sunlight. If you do not tan in the sun, you are unlikely to tan from the use of this product.

State Legislation • At least 28 states and 4 counties regulate tanning facilities for minors • During the current legislative session, 7 states have introduced bills • Current tanning restrictions and pending legislation vary widely between states

Most Restrictive State Policies • Wisconsin: No one under age 16 is permitted to use tanning devices. • Multiple other states ban the use of tanning devices under the age of 14 with parental permission required for ages 14 -18

New York State Policy N. Y. Public Health Law ch. 573 • Children under 14 prohibited • Minors age 14 to 18 must have signed permission from a parent or guardian to use the facilities • The signature must be obtained by the facility operator in person and is only valid for twelve months

Pending State Legislation • Maryland, Massachusetts, Missouri, Mississippi, Ohio, Pennsylvania, South Dakota, and Vermont have introduced bills during this current legislative session • Most propose to limit access to minors without parental permission • Vermont (HB 215) “Tanning facilities may not allow individuals under age 18 to use tanning devices. ” • HB 215 has unfortunately died in House Committee

What can we do to get involved? • Continue to educate patients and parents regarding proper UV safety • Support pending legislation in states of interest • Encourage the federal government and individual states to introduce stricter legislation • Encourage AAP to endorse the policy statement of the WHO/AAD/AMA

References 1. American Academy of Dermatology issues statement endorsing 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. the World Health Organization’s recommendation to restrict tanning bed use. Available at: http: //www. aad. org/media/background/press/WHO. html. Accessed August 6, 2008 American Academy of Pediatrics Policy Statement. Ultraviolet Light: A Hazard to Children. Pediatrics. 1999; 104 (2): 328 -333 American Medical Association Policy D-440. 960. Prohibiting the sale of tanning parlor ultraviolet rays to those under 18 years of age. Available at www. ama-assn. org/apps/pf_new. Accessed August www. ama-assn. org/apps/pf_new 6, 2008 Balk SJ, Geller AC. Teenagers and Artificial Tanning. Pediatrics. 2008; 121 (5): 1040 -1042 Indoor Tanning Association home page. Available at www. theita. com. Accessed August 18, 2008 Indoor Tanning Association mission statement. Available at www. theita. com. Accessed August 18, 2008 Karagas MR, Stannard VA, Mott LA, Slattery MJ, Spencer SK, Weinstock MA. Use of tanning devices and risk of basal cell and squamous cell skin cancers. J Natl Cancer Inst. 2002; 94 (3): 224 – 226 National Conference of State Legislatures. Tanning Restrictions for Minors: A State-by-State Comparison. Available at: http: //www. ncsl. org/programs/health/tanningrestrictions. htm. Accessed August 6, 2008 The International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: a systematic review. Int J Cancer. 2006; 120 (5): 1116 – 1122 World Health Organization Fact Sheet: Sunbeds, tanning and UV exposure. Available at: http: //www. who. int/mediacentre/ factsheets/fs 287/en/. Accessed August 6, 2008 Veierød MB, Weiderpass E, Thörn M, et al. A prospective study of pigmentation, sun exposure and risk of cutaneous malignant melanoma in women. J Natl Cancer Inst. 2003; 95 (20): 1530 – 1538