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Sunscreens and sunless tanners are natural topics for a column focused on cosmeceuticals, as they are topically applied agents that may or may not exert biologic activity. Indoor tanning is less of a natural fit, but it is so inextricably linked to these subjects, and is a flashpoint for controversy, that I thought it warranted coverage here, so to speak. Dermatologists have been railing about tanning salons for decades. Nevertheless, the tanning industry has experienced steady growth. In fact, annually, indoor tanning facilities are believed to be used by approximately 30 million individuals in the US, including 2.3 million adolescents.[i] The volume of complaints against it may be reaching a crescendo, however, as calls for banning tanning beds, at least for those under the age of 18, have been steadily on the rise. Last summer, an International Agency for Research on Cancer (IARC) working group classified UV-emitting tanning devices as “carcinogenic to humans” (Group 1, or their most severe category).[ii] Further, two recent studies have the potential to fan these flames as more such calls enter the mainstream.[iii],[iv]
In a population-based case-control study published in June, investigators identified 1,167 invasive cutaneous melanoma cases (ages 25 to 59 years) diagnosed in Minnesota between 2004 and 2007 from a statewide cancer registry. State driver’s license lists were used to identify 1,101 age- and gender-matched controls Self-administered questionnaires and telephone interviews were employed to ascertain various facts about tanning behavior. The researchers noted that 62.9% of cases and 51.1% of controls had tanned indoors. They found that melanoma risk was significant among users of UVB-enhanced devices as well as those mainly emitting UVA and that, as to be expected, risk increased with years, hours, or sessions. The investigators concluded that frequent indoor tanning raised the risk of melanoma regardless of the age at which users began tanning and that risk was elevated across devices and types of UV emitted.[v]
In a widely-cited article published in May, investigators conducted a randomized, controlled clinical trial of 430 female indoor tanners on a college campus to assess the strength of an appearance-oriented intervention to prevent skin cancer in people indicating symptoms of seasonal affective disorder (SAD) and pathological tanning. There were 230 control subjects and 200 in the intervention group, with the intervention consisting of a booklet covering the history of tanning, tanning norms, the cutaneous effects of UV radiation, and healthier tanning alternatives as well as advice on tanning abstinence and harm reduction. Stronger treatment effects for subjects scoring higher on two of the four pathological tanning scales (opiate-like reactions to tanning and dissatisfaction with natural skin tone) were among the salient findings by the researchers. Although they hypothesized that their appearance-related intervention would have a lesser impact on participants tanning in association with mood problems, the investigators concluded that their appearance-oriented intervention is effective in decreasing indoor tanning among tanners who exhibit SAD symptoms or pathological tanning motives, and that the tanners were demonstrably more concerned about developing wrinkles than skin cancer.[vi] It is also worth noting that because of the correlation between high UV exposure, particularly during childhood, and melanoma risk, as well as links between tanning beds and cancer development,[vii],[viii],[ix] the World Health Organization issued a strong recommendation in 2005 that no one under the age of 18 be permitted to use a tanning bed.[x] The remainder of this discussion will focus on recent research pertaining to the risks, awareness of risks, and regulations of indoor tanning.
Risks and Awareness
In 2009, Schulman and Fisher reviewed recent findings on the impact of UV exposure and, in particular, indoor tanning on skin cancer risk. They found that a significant relationship has been established between ever-use of indoor tanning facilities and an elevated risk of melanoma and non-melanoma skin cancer, especially for individuals who began indoor tanning in early adulthood. They noted that higher vitamin D levels were a benefit associated with this behavior, but such exposures are not necessary to boost vitamin D. The authors concluded that the cancer risks linked to indoor tanning far outweigh any benefits and that indoor tanning is an easily avoided risk that should be labeled as such to protect public health.[xi] In 2010, a team of researchers investigated the associations between solar and artificial UV exposure and melanoma risk in a Norwegian-Swedish cohort study of women between 30 and 50 years of age at enrollment from 1991 to 1992, when tanning behavior was collected by questionnaire. Investigators found among the 106,366 patients, with complete follow-up through 2005, that melanoma risk was elevated in older decades in association with additional intermittent solar or tanning bed exposures.[xii]
In 2008, Robinson et al. reported on an interesting comparison of knowledge, attitudes, and behavior about indoor tanning and information sources in the summer of 1988, 1994, and 2007 in Chicago, by conducting lakefront beach interviews in July 2007 of 100 beachgoers between 18 and 30 years of age, and age- and sex-matching interviewees with Chicago-area residents who participated in random-digit-dialed telephone interviews in 1988 and 1994. Investigators found that awareness of the link between melanoma and nonmelanoma skin cancer and tanning dipped slightly between 1988 (42%) and 1994 (38%), and then rose significantly by 2007 (87%). Paradoxically, cognizance of curtailing tanning to reduce melanoma risk increased from 1988 (25%) to 1994 (77%), but fell by 2007 (67%), coinciding with increases in the belief that tans enhance appearance (1994, 69%; 2007, 81%) as well as the use of indoor tanning (1988, 1%; 1994, 26%; 2007, 27%). Physicians, particularly dermatologists, were shown to have become increasingly important sources of information on tanning (1988, 2%; 1994, 18%; 2007, 31%), deemed the most trusted source, but only 14% of respondents in 1994 and 2007 reported ever talking to one about indoor tanning. The investigators concluded that physicians are in a unique position to affect indoor tanning behavior.[xiii]
Youth Access Regulations
Legislators are also in an increasingly important position in influencing or regulating such behavior. In a 2010 review of the relationship between indoor tanning, skin cancer, and vitamin D, Woo and Eide debunk one of the main arguments proffered by indoor tanning advocates (that they provide the health benefits of vitamin D), as the authors noted that the majority of tanning devices mainly emit UVA, a poor stimulator of vitamin D production. They added that vitamin D supplementation is a much safer route for boosting such benefits and that educating the public regarding the avoidable skin cancer risk associated with indoor tanning is of paramount importance as is enhanced enforcement of legislation regarding indoor tanning.[xiv] Indeed, this article joins in the increasingly loud calls for stricter approaches and outright bans.
In 2005, investigators conducted a narrative but not systematic review of the literature to evaluate the link between indoor tanning and skin cancer; statements by the tanning industry on the alleged health benefits of indoor tanning; and US regulations of the tanning industry. As expected, they found that the literature strongly supports the association between indoor tanning and skin cancer and undermines tanning industry claims about vitamin D insofar as artificial tanning is not a safe method for augmenting vitamin D. In calling for health care workers to do more to educate and warn the public and government about the potential harm of indoor tanning, the researchers acknowledged the paucity of tanning regulations in the US while noting recent statements by the NIH and WHO declaring the inherently serious risks of these devices.[xv]
Given recent calls for indoor tanning bans, at least for those under the age of 18, it is instructive to consider some age- and age-restriction-related data. In 2005, Hester et al. reported on their cross-sectional telephone survey of UV tanning operators in four states with various age restrictions conducted in October 2003. They randomly selected licensed UV tanning salon operators in Colorado (no age restrictions), Texas (13 years), Illinois (14 years), and Wisconsin (16 years) and sought to determine whether youth discounts were offered as well as the number of businesses complying with state regulations for a 12-year-old potential patron and a 15-year-old potential patron. Youth discounts were offered by 15% of operators surveyed (Texas, 23%; Illinois, 14%; Wisconsin, 11%; and Colorado, 11%). More significantly, investigators found that lower youth access to indoor tanning was associated with legal restrictions. For instance, 62% of facilities in states with restrictions would not permit a 12-year-old (Texas, 23%; Illinois, 74%; and Wisconsin, 89% as compared with 18% in restriction-less Colorado). For a 15-year-old customer, 77% in Wisconsin, the only state with an age restriction for that age, would prevent access. The researchers concluded that the potential for effective tanning industry youth access regulation was demonstrated by the high compliance levels in states with enduring access laws.[xvi] Stricter enforcement would clearly have an impact as well.
In 2009, authors of a cross-sectional study of indoor tanning facility practices in 116 cities in all 50 US states, after finding that facilities in states with regulations regarding youth access were significantly more likely to require parental consent and accompaniment than businesses in states without such laws, urged that more states enact youth access laws, preferably bans.[xvii]
Trends and Attitudes
In 2010, researchers reported nationally representative trends (1998-2004) and patterns in skin cancer risk behaviors, the American Cancer Society Sun Surveys I and II, which were telephone-based random digit dialed cross-sectional surveys of US adolescents and their parents performed in the summers of 1998 and 2004. They noted significant increases between those six years in sunscreen use and the wearing of wide-brimmed hats. The use of indoor tanning also increased significantly during the same period, with no appreciable change in sunburn prevalence. In 2004, 13% of respondents had used indoor tanning facilities during the previous year. Overall, the authors found that the low rates and marginal progress in sun-protective behavior imply the need for improved parental advice geared toward undermining the appeal of tanning and encouraging more comprehensive UV-protective behavior.[xviii]
It is clear that indoor tanning is at an interesting sociological, legislative, and public health nexus, at which relative awareness of increased risks of melanoma interact with information and misinformation regarding vitamin D, culturally-influenced attitudes about appearance, the potential addictive aspects of indoor tanning,[xix],[xx] and increasing calls for more stringent regulations.
In discussing as dermatologists what and how we should be advising our patients about indoor tanning, it can be illuminating to consider what other medical specialists might be advising. In 2006, investigators conducted a cross-sectional study of indoor tanning attitudes and practices among randomly selected dermatologists, pediatricians, family medicine doctors, and internal medicine doctors. Dermatologists were more likely to have responded to the survey (52% vs. 31%), with an overall response rate of 38% (364 returned out of 949 mailed). A strong majority (71%) reported being asked their opinions about indoor tanning; even more (80%) expressed the belief that the practice was unsafe; 90% stated that they would advise their patients against nonmedical indoor tanning; and increased legislation governing tanning was supported by 91% for minimum age guidelines and 90% for mandatory parental consent for minors. Not surprisingly, though, dermatologists were significantly more likely to view indoor tanning more negatively and to consider it unsafe, to talk to their patients about the practice, and to support more stringent regulations. Interestingly, female physicians held a dimmer view of indoor tanning than males, and practitioners in the Northeast and Midwest were found to be more likely to support indoor tanning to enhance mood, treat depression, or prevent vitamin D deficiency.[xxi]
Whether it’s a sun lamp, tanning booth, or tanning bed, indoor tanning is best avoided. While new evidence is always emerging, we know enough about indoor tanning to justify stern warnings to patients. Using the likelihood of wrinkle development is often a productive disincentive to discourage patients from behavior detrimental to the skin (with cancer as the more dangerous but apparently less feared outcome for some patients). The key here is to intervene in order to change behavior. Acknowledging that vitamin D is much better boosted by oral supplementation is another important arsenal in this ongoing, very important struggle to discourage patients from indoor tanning. Emerging evidence that there may be an addictive quality for some frequent users of indoor tanning will only complicate this issue and our approach with patients.
[i] Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol. 2005 Dec;53(6):1038-44.
[ii] Beauty and the beast. Lancet Oncol. 2009 Sep;10(9):835.
[iii] http://topnews.us/content/215559-doctors-calls-ban-tanning-beds-under-18. Accessed July 12, 2010.
[iv] http://www.cbsnews.com/stories/2010/03/25/health/main6333678.shtml?source=related_story. Accessed July 12, 2010.
[v] Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM. Indoor tanning and risk of melanoma: a case-control study in a highly exposed population. Cancer Epidemiol Biomarkers Prev. 2010 Jun;19(6):1557-68.
[vi] Hillhouse J, Turrisi R, Stapleton J, Robinson J. Effect of seasonal affective disorder and pathological tanning motives on efficacy of an appearance-focused intervention to prevent skin cancer. Arch Dermatol. 2010 May;146(5):485-91.
[vii] Veierød MB, Adami HO, Lund E, Armstrong BK, Weiderpass E. Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi. Cancer Epidemiol Biomarkers Prev. 2010 Jan;19(1):111-20.
[viii] Oliveria S, Saraiya M, Geller AC, Heneghan MK, Jorgensen C. Sun exposure and risk of melanoma. Arch Dis Child. 2006 Feb; 91(2):131-8.
[ix] Wang SQ, Setlow R, Berwick M, Polsky D, Marghoob A, Kopf AW, Bart RS. Ultraviolet A and melanoma: a review. J Am Acad Dermatol. 2001 May;44(5):837-46.
[x] http://www.who.int/mediacentre/news/notes/2005/np07/en/. Accessed on 7/9/10.
[xi] Schulman JM, Fisher DE. Indoor ultraviolet tanning and skin cancer: health risks and opportunities. Curr Opin Oncol. 2009 Mar;21(2):144-9.
[xii] Veierød MB, Adami HO, Lund E, Armstrong BK, Weiderpass E. Sun and solarium exposure and melanoma risk: effects of age, pigmentary characteristics, and nevi. Cancer Epidemiol Biomarkers Prev. 2010 Jan;19(1):111-20.
[xiii] Robinson JK, Kim J, Rosenbaum S, Ortiz S. Indoor tanning knowledge, attitudes, and behavior among young adults from 1988-2007. Arch Dermatol. 2008 Apr;144(4):484-8.
[xiv] Woo DK, Eide MJ. Tanning beds, skin cancer, and vitamin D: An examination of the scientific evidence and public health implications. Dermatol Ther. 2010 Jan;23(1):61-71.
[xv] Levine JA, Sorace M, Spencer J, Siegel DM. The indoor UV tanning industry: a review of skin cancer risk, health benefit claims, and regulation. J Am Acad Dermatol. 2005 Dec;53(6):1038-44.
[xvi] Hester EJ, Heilig LF, D’Ambrosia R, Drake AL, Schilling LM, Dellavalle RP. Compliance with youth access regulations for indoor UV tanning. Arch Dermatol. 2005 Aug;141(8):959-62.
[xvii] Pichon LC, Mayer JA, Hoerster KD, Woodruff SI, Slymen DJ, Belch GE, Clapp EJ, Hurd AL, Forster JL, Weinstock MA. Youth access to artificial UV radiation exposure: practices of 3647 US indoor tanning facilities. Arch Dermatol. 2009 Sep;145(9):997-1002.
[xviii] Bandi P, Cokkinides VE, Weinstock MA, Ward E. Sunburns, sun protection and indoor tanning behaviors, and attitudes regarding sun protection benefits and tan appeal among parents of U.S. adolescents – 1998 compared to 2004. Pediatr Dermatol. 2010 Jan 1;27(1):9-18.
[xix] Mosher CE, Danoff-Burg S. Addiction to indoor tanning: relation to anxiety, depression, and substance use. Arch Dermatol. 2010 Apr;146(4):412-7.
[xx] Harrington CR, Beswick TC, Leitenberger J, Minhajuddin A, Jacobe HT, Adinoff B. Addictive-like behaviours to ultraviolet light among frequent indoor tanners. Clin Exp Dermatol. 2010 Jun 7. [Epub ahead of print]
[xxi] Johnson KR, Heilig LF, Hester EJ, Francis SO, Deakyne SJ, Dellavalle RP. Indoor tanning attitudes and practices of US dermatologists compared with other medical specialists. Arch Dermatol. 2006 Apr;142(4):465-70.