Almost half of all cancers occur on the skin making the skin the most common site of cancer induction1. Ultraviolet light is the dominant cause of skin cancer2 and this disease is projected to cause 11,000 deaths in 20091. Tanning beds use electronic ultraviolet (UV) lamps as an artificial source of UV light, which quickly tans the skin of the occupant. These devices were introduced in the U.S. by Friedrich Wolff in 19783. While early in this nation’s history, a fair complexion might signify wealth and the avoidance of outdoor, tan-producing, agrarian labor; today, it more generally implies leisure and is typically associated with the perception of wealth, health, and physical attractiveness4. So naturally, the tanning bed business has grown into a $5B a year industry4 with 25,000 tanning salons operating in the U.S.5. In many cities, these near-ubiquitous tanning salons outnumber both Starbucks and McDonalds6. On average, over a million Americans per day6, or over 30 million each year4, use a tanning bed to darken their skin. The nation’s rate of skin cancer has paralleled this growth in the use of tanning beds, particularly among people who begin before age 307. The national incidence of invasive melanoma has more than doubled since tanning beds were introduced in 19788. Tanning beds are primarily used by girls and young women9, with nearly 70% of tanning bed users being female and between the ages of 16 and 296. One tanning bed user in 13 is an adolescent10 with nearly 40% of teenage girls reporting use of a tanning bed within the last year1.
The UV spectrum produced by tanning beds includes both a more-penetrating UVB component and a less-penetrating UVA component. In addition to being carcinogenic, both UVA and UVB are immunosuppressive11 and exposure to ten tanning sessions in two weeks is known to produce immune suppression10. The U.S. Food and Drug Administration (FDA) advises that those with certain medical conditions, such as lupus, diabetes, and susceptibility to cold sores; avoid using tanning beds9. The American Cancer Society (ACS), more generally, considers the use of tanning beds to be a health hazard and recommends that they be avoided altogether9. In July, the World Health Organization’s (WHO’s) International Agency for Research on Cancer (IARC) completed a study of tanning beds and re-designated these devices from “probably carcinogenic to humans” into its highest risk category, designating it definitely “carcinogenic to humans”9. IARC found that the risk of melanoma on the skin, the most lethal form of skin cancer, rises 75% when use of tanning beds begins before age 30 and also finds evidence of a link between tanning bed use and the incidence of ocular melanoma9.
Though many manufacturers are now increasing the more-penetrating UVB component of their tanning beams, to speed up the tanning process10, FDA regulation does specify a minimal beam-quality performance standard, which places some restraint on the proportion of the tanning light that is permitted to be in the more-penetrating UVB part of the spectrum12. There is a false, but widespread, perception that UVA is “good UV” while UVB is “bad UV”6. And, it is important to recognize that IARC’s designation of UV radiation as “carcinogenic to humans” applies to the full ultraviolet spectrum; the less-penetrating UVA, the more-penetrating UVB, as well as the most-penetrating UVC9. It is also notable that, though FDA regulation requires a manufacturer to specify the UV lamp model for which the tanning bed was designed12, it does not prevent substitutions and salon operators often tamper with these lamps to achieve a more intense ultraviolet exposure4.
Also, though the manufacturer must post warning labels on the tanning bed12, many tanning salon operators misrepresent the health risks, openly advertising that tanning beds do not cause cancer4 and the industry generally claims that the use of these devices is healthy13. Tanning beds are often advertised as a safe alternative to exposure to the sun10, 14. A German study of indoor-tanners15 found a widespread public perception that artificial tanning is safe or even healthy and a widespread, though mistaken, public perception that tanning bed use “prepares” the skin in a protective way for exposure to the sun. It is common practice, for example, among U.S. college students to use tanning lights to create a “base” tan, in anticipation of further near-term solar exposure16. A minimum erythema dose (MED) is the amount of UV light required to redden exposed skin and, though the MED varies with skin type, a twenty minute tanning bed exposure typically delivers quadruple the minimum erythema dose10. An eight-to-twenty minute tanning session often delivers a more intense UV exposure than an entire afternoon spent in natural sunlight10.
Use of a tanning bed is a pleasant experience, producing a sense of relaxation and well being, and research suggests that the use of tanning beds leads the body to produce natural opioids and endorphins13. But, there is also significant evidence that tanning bed use can be addictive, and discontinuing the use of tanning beds has been observed to produce the withdrawal symptoms of jitteriness and nausea13. Excessive sun tanning has been identified and studied as a substance-related psychological disorder17. Exploiting this, most tanning salons in the U.S. use buffet-style unlimited price packaging6 which encourages the frequent and extended use of tanning beds. This positive reinforcement was substantiated by Borner, et al (2009), who found that those who use tanning beds frequently, more than ten times per year; also use them for long durations, greater than fifteen minutes per session.
The first priority of WHO, in response to the findings of IARC, is to reduce the use of tanning beds by persons under age 189 and in France, where IARC is located, those under age 18 are already prohibited from using tanning beds11. Germany is considering, but has not yet enacted age restrictions on the use of tanning beds15. In September, Wales banned the use of tanning beds by minors and there is interest in extending this ban to England18. Unmanned, coin-operated tanning booths have made the Welsh law difficult to enforce and coin-operated booths have already been outlawed in Scotland18. Unconstrained by law, U.S. tanning bed operators have been found to make these beds available to tanners at any age and without restraint19.
A study in the Denver area, in fact, concluded that the use of UV tanning-beds was commonly and specifically marketed to adolescents through high school newspaper advertisments and the study’s authors recommended that public health policies prohibit the targeting of minors by tanning booth operators20. Legal research has found broad similarities in business-model between the indoor tanning industry and the cigarette industry. Both are described as selling an “unreasonably dangerous” carcinogen and in each case it is asserted that the industry systematically lied to its consumers about the health effects associated with an image-motivated, acquired-behavior4. There is, at present, no national policy restricting the use of tanning beds by minors in the United States19.
Twenty-nine states, however, do regulate the use of tanning beds by minors21 and in 2009, 22 states have introduced22 and four states have passed21 new legislation or legislative amendments restricting indoor tanning by minors. Existing and proposed restrictions vary widely, setting limits at the ages of 18, 16, 16½, 15, 14, and 13. In some cases, these laws ban the use of tanning beds outright or ban them without a physician’s prescription, which sometimes must specify a diagnosis or the number of tanning sessions. Some policies require written parental consent, which must sometimes be given in the presence of the operator. In some cases, this consent must specify the tanning frequency, require positive identification, or even require a notarized signature. In one case, the tanner must quantify her (or his) skin-type in terms of its sensitivity to the sun. In some cases, a parent must be present, during the first visit or during all visits. And, in some states, the parent must certify an acknowledgement of the risks or guarantee that the child will use eye protection22.
A pending Texas bill would require that any minor under 18 be both accompanied by a parent and have physician approval6, though that state’s law now permits unrestricted use of tanning beds by anyone over age 16 ½1. Both New York, which has among the fewest tanning salons per capita, and Charleston, WV, which has the most tanning salons per capita6, ban the use of tanning beds before age 14 and each requires parental consent until the age of 1822. At the county level, efforts are underway in Howard County, Maryland and Suffolk County, New York to ban the use of tanning beds by persons under age 181. In addition to these 29 states, four counties also currently regulate the use of tanning beds by minors1.
At the U.S. federal level, tanning beds are jointly regulated by the FDA, which enforces manufacturing and labeling standards, and by the Federal Trade Commission (FTC), which seeks to protect consumers against fraud and unfair business practices, including false claims14. FDA regulations require that tanning beds be labeled ``DANGER -- Ultraviolet radiation” and carry warnings about the potential for eye injury, skin injury, allergic reaction, premature skin aging, skin cancer, and the increased sensitivity created by some cosmetics and medications12 which includes common medications such as antihistamines and oral contraceptives14. This labeling must also include exposure factors that the manufacturer recommends for use in tanning12, but does not constrain what those recommendations should be. These warning requirements were established in 1985, just seven years after tanning beds were introduced and long before the national incidence of skin cancer had reached its present level. Though an FDA agency review of these warnings began in 20079, these requirements have now been in place for a full 24 years. Though FDA regulations do place some limits on the tanning beam’s spectrum, require that a tanning bed be delivered with protective eyewear and a timer, and require that the protective eyewear meet a certain attenuation standard; these regulations place no limit on the intensity of the beam, as it reaches either the skin or the eye12.
In terms of public health, a lighted tanning bed resembles nothing so much as a lit cigarette; with a profitable and well-lobbied industry that dishonestly sells a false image of health and vitality, while targeting a known carcinogen to young American girls, which is delivered through addictive behavior. An international call has been made to protect the public from radiogenic skin cancer by protecting children from ultraviolet tanning booths. The European nations are rapidly answering that call. In this country, many states, and even some counties, are attempting to respond to this threat to the public’s health by restricting the access of minors to tanning booths. Though these responses have been slow, complicated, fragmented, and inconsistent; a consensus has clearly developed in these regional incubators of national policy. No tanning booth operator, anywhere in the nation, should be permitted to UV-irradiate children for money any more than any convenience store operator, anywhere in the nation, should be permitted to sell children cigarettes.
A small, but key, step forward in the protection of children from UV tanning beds would be to amend Title XIX of the Social Security Act to require that each state, as a condition of receiving Medicaid federal matching funds, specify in legislation by 2011, some minimum age limit on the use of commercially operated UV-lamp-based tanning devices and that this age must be no less than 13. First and foremost, this would mandate the creation of some age restriction for the protection of girls in the 21 states where no such protections now exist. It would also catalyze a re-evaluation and tightening of the policies in those states which already have restrictions. Leaving the policy details to the states creates federal leadership and coordination while also showing deference to state sovereignty and a respect for the traditional role of state governments in public health. Linking this policy change to the Medicaid program makes it a joint-venture, undertaken in cooperation between the federal and state governments, intended to protect children, improve the health of the public, and reduce the cost of healthcare to society by reducing the incidence of this very preventable disease.