Public Health Feature - May 2010
Tex Med. 2010;106(5):47-51.
By Crystal Conde
Susan Dozier, MD, an Austin dermatologic surgeon and former member of the Texas Medical Association's Physician Oncology Education Program (POEP) Steering Committee, knows exactly what it's like to suffer from melanoma. Sun exposure during childhood caused her to develop the potentially deadly form of skin cancer.
Although Dr. Dozier doesn't attribute her skin cancer to indoor tanning bed use, she says it makes her "sick that someone would deliberately do something to increase the risk of developing melanoma."
She and other physicians who treat skin cancer patients say the indoor tanning industry has disseminated inaccurate information to the public for too long.
The American Cancer Society estimates about 11,590 people died from skin cancer in 2009: 8,650 from melanoma and 2,940 from other skin cancers. (See " Melanoma in the United States: 2009 Estimates .") The organization also says using a tanning bed before age 35 increases a person's risk of developing melanoma by 75 percent. A 15- to 30-minute session in a tanning bed can equal an entire day at the beach, it warns.
As if this isn't scary enough, the National Cancer Institute's Division of Cancer Epidemiology and Genetics says the annual incidence of invasive melanoma in U.S. Caucasian women aged 15 to 39 increased 50 percent from 1980 to 2004. Tanning beds became popular in the 1980s. Plus, the National Toxicology Program labels ultraviolet (UV) radiation, which indoor tanning beds emit, as a carcinogen.
"I've had patients die young from melanoma. They think tanning is healthy because they've been misled by the indoor tanning industry," Dr. Dozier said.
Tanning industry advertisements highlight the benefits of indoor tanning, such as increased vitamin D production and safer controlled amounts of UV light compared with outdoor sun exposure. However, the days of unfettered health benefit and safety messages in those ads may be over. In late January, the Federal Trade Commission (FTC) came down on the Indoor Tanning Association (ITA), which represents tanning facilities and tanning equipment suppliers.
The ITA agreed to a consent order that bars the association from misrepresenting any tests or studies or from providing deceptive advertisement materials to members. The settlement also prohibits misleading or unsubstantiated ads that make safety or health benefit claims about indoor tanning. Further, the order requires that certain future advertisements from the ITA contain disclosures.
"The messages promoted by the indoor tanning industry fly in the face of scientific evidence," said David C. Vladeck, director of the FTC's Bureau of Consumer Protection. "The industry needs to better communicate the risks of tanning to consumers."
Physicians agree and hope the FTC's actions, along with TMA-supported state legislation placing age restrictions on minors' use of tanning beds, will spur the tanning industry to operate more responsibly and stop spreading false information to the public.
"It's criminal that people would be misled that indoor tanning is safer than outdoor sunlight. They think it's safe and use tanning beds frequently. By the time I see them, they have basal cell and squamous cell cancers and even melanoma," Dr. Dozier said.
FTC Steps In
Physicians who treat skin cancer patients have noticed the disease's victims are getting younger. Dan McCoy, MD, past president of the Texas Dermatological Society and chair of TMA's Council on Legislation, says he sees some 18-year-old patients with skin cancer.
"Recreational tanning, including indoor tanning, among children enhances skin damage and increases the risk of skin cancer," Dr. McCoy said. "The FTC crackdown helps to demonstrate to the public that some of the indoor tanning industry's claims have been false."
The consent order stems from an FTC complaint alleging that in March 2008 the ITA began an advertising campaign designed to portray indoor tanning as safe and beneficial. "The campaign included two national newspaper ads, television and video advertising, two Web sites, a communications guide, and point-of-sale materials that were provided to association members for distribution in local markets," the FTC said.
An ITA press release that launched the campaign told its thousands of member manufacturers, distributors, and facility owners that it was starting "an aggressive nationwide campaign encouraging the public to rethink sun-tanning" and criticized dermatologists and the sunscreen and cosmetics industries "for scaring Americans away from the sun."
The announcement also said many experts "are beginning to change their opinions about sun-tanning in light of the fact that there is no compelling evidence that UV exposure causes melanoma."
In the press release, ITA spokesperson Sarah Longwell acknowledges that the campaign would be controversial, but said, "It's time people learned the truth about sun exposure. Not only is moderate tanning completely safe, more and more it's becoming just what the doctor ordered."
Besides denying the skin cancer risks of tanning, the FTC charged that the ITA campaign falsely claimed that:
- Indoor tanning is approved by the government;
- Indoor tanning is safer than tanning outdoors because the amount of UV light received when tanning indoors is monitored and controlled;
- Research shows that vitamin D supplements may harm the body's ability to fight disease; and
- A National Academy of Sciences study determined that "the risks of not getting enough ultraviolet light far outweigh the hypothetical risk of skin cancer."
The consent order requires ads that make claims about the safety or health benefits of indoor tanning include a disclosure that states: "NOTICE: Exposure to ultraviolet radiation may increase the likelihood of developing skin cancer and can cause serious eye injury." Ads that claim exposure to UV radiation produces vitamin D or that make other claims about the effectiveness or usefulness of indoor tanning products or services for the body's generation of vitamin D must include this: "NOTICE: You do not need to become tan for your skin to make vitamin D. Exposure to ultraviolet radiation may increase the likelihood of developing skin cancer and can cause serious eye injury."
Michael Wells, MD, a Lubbock dermatologist and a member of TMA's Committee on Cancer, says the FTC's settlement with the ITA is a step in the right direction. He questions, however, whether the FTC's actions are drastic enough for the ITA to change its advertising campaign.
"Until the FTC really puts some teeth into its sanctions, I don't think the tanning industry will make any significant changes. I'm afraid that unless the FTC levies big fines against the ITA, the tanning industry will continue to push its agenda, claiming the health benefits of indoor tanning," he said.
At press time, the FTC hadn't fined the ITA. Each violation of a consent order can carry up to a $16,000 fine.
By entering into a consent agreement with the FTC, the ITA isn't admitting to violating the law. The FTC's consumer alert on indoor tanning [ PDF ] contains information about how indoor or outdoor tanning increases the risk of melanoma and other skin cancers.
Progress Through Legislation
Texas took a giant step forward in regulating adolescents' use of indoor tanning beds during the 2009 legislative session. TMA, the Texas Pediatric Society, the Texas Dermatological Society, and other organizations supported House Bill 1310, which prohibits a minor younger than 16½ from using a tanning device and requires that a parent or legal guardian accompany a child aged between 16½ and 18 and sign a consent form at the tanning facility. The law took effect Jan. 1.
Additionally, minors and their parents must sign a Texas Medical Board (TMB) advisory [ PDF ] outlining the dangers of both indoor and outdoor tanning in association with skin cancer, eye damage, and other risks.
Finally, the parent and minor also must sign a document saying the child agrees to wear protective eyewear at all times while using a tanning device.
These regulations are among the most stringent in the country. Only half of the states regulate indoor tanning use by minors, despite the call from the World Health Organization (WHO) last year to prohibit minors from indoor tanning because of the danger of skin cancer.
Rep. Burt Solomons (R-Carrollton), chairof the House State Affairs Committee, authored HB 1310, with sponsorship by Sen. Jane Nelson (R-Lewisville), chair of the Senate Health and Human Services Committee.
He says a magazine article about the increase in skin cancer rates among young people inspired him to draft legislation to protect children and improve the public's health.
"It was clear to me from the research that this was a safety issue, and Texas law didn't adequately provide protection for young people. I also did not think parents understood the cancer risks tied to tanning bed use," Representative Solomons said.
Before the passage of HB 1310, Texas law allowed minors aged 13 and older to use tanning beds with a parent's permission. Parents didn't have to sign the consent form in person, making it easier for children to falsify signatures, he says.
He approached TMA and the Texas Dermatological Society to support HB 1310. Dr. McCoy says the organizations recognized an opportunity to help strengthen legal restrictions that apply to indoor tanning among children.
"As an organization, we decided supporting HB 1310 was the right thing to do to protect children from developing skin cancer," Dr. McCoy said.
Representative Solomons says the tanning industry put up a fight to block passage of HB 1310 "because it didn't want to be subject to any restrictions."
"The tanning groups market to children in a way that's similar to what the tobacco industry used to do. From a business standpoint, these ads are geared to lure children in at a young age with coupons. Then they get hooked on it and want to keep up their tans. To the industry, this isn't a health issue; it's a threat to their business model," he said.
Sharon Raimer, MD, professor and chair of the Department of Dermatology at The University of Texas Medical Branch at Galveston and immediate past president of the Texas Dermatological Society, testified in favor of HB 1310 on TMA's behalf.
"The purpose of the legislation is to reduce the incidence of melanoma among young people by keeping them from using tanning beds in adolescence. At the very least, the bill will postpone tanning bed use among teenagers," she said.
The Drugs and Medical Devices group at the Texas Department of State Health Services (DSHS) is responsible for implementing changes to the tanning facility rules required by HB 1310. (See " DSHS Monitors Indoor Tanning Facilities .")
Representative Solomons attributes the passage of HB 1310 to the support and testimony of Texas physicians.
"I think the bill very well may not have passed without the support of TMA and the Texas Dermatological Society. It's important for physicians to talk to legislators to make sure they understand this is a serious health concern. I think the legislative body respects what TMA and its physician members tell them," he said.
Texas isn't alone in acting to protect minors from the dangers of tanning beds. Federal legislation under consideration would prohibit anyone younger than 18 from using indoor tanning beds. The proposed Tanning Bed Cancer Control Act would limit the amount of UV rays emitted by tanning beds and the length of tanning sessions.
The legislation would also prompt the Food and Drug Administration (FDA) to reconsider the classification of tanning beds. Tanning beds are now a Class I medical device, which present minimal potential harm to the user. Devices such as tongue depressors, arm slings, and hand-held surgical instruments are in this classification. A higher classification would subject tanning beds to FDA evaluation and monitoring. At press time, the bill had been referred to the House Committee on Energy and Commerce.
Additionally, Congress is proposing a 10-percent tax on indoor tanning sessions as part of the health care bill. The tax would bring in big money - around $2.7 billion over 10 years.
Collaborating for Change
Dr. Wells recognizes that changing adolescents' behaviors and their perceptions of indoor tanning is no small feat. But doing so, he says, would have a positive impact on reducing tanning bed use and its subsequent health complications.
He suggests TMA and the American Medical Association develop a unified message to educate the public about the health risks of indoor tanning.
"When the message comes from the dermatologists alone, the tanning industry accuses us of being 'tanophobes' and claims we pocket a lot of money by recommending sunblock products. Those claims minimize our impact," Dr. Wells said.
Dr. Raimer agrees and says altering young peoples' attitudes toward indoor tanning will require a concerted effort among primary care physicians who care for adolescents.
"Dermatologists educate patients routinely about the harmful effects of tanning beds . It would be helpful if dermatologists encouraged family physicians, internists, pediatricians, and adolescent medicine specialists to bring up the risks of tanning. If more physicians include that conversation in routine care and really educate people, it could bring about change," Dr. Raimer said.
TMA has policy related to indoor tanning. TMA supports DSHS in its regulatory and enforcement functions of indoor tanning salons. In addition, the American Academy of Dermatology (AAD) opposes indoor tanning and supports a ban on the production and sale of indoor tanning equipment for nonmedical purposes. The academy supports the WHO recommendation that minors should not use indoor tanning equipment because indoor tanning devices emit UVA and UVB radiation, and overexposure to UV radiation can lead to skin cancer.
Dr. Dozier says the AAD has some helpful resources physicians can use to educate patients about the risks associated with indoor tanning. The AAD launched the Skin Cancer Reduction: Intervention Plan for Tomorrow (SCRIPT) in 2008 to reduce mortality from skin cancer in 10 years and its incidence in 30 years.
SCRIPT promotes skin cancer awareness through public service announcements for young women. The AAD also collaborates with Major League Baseball for its Play Sun Smart™ campaign to raise skin cancer awareness. Physicians may access these resources and others on the AAD's Web site .
Appealing to young people's vanity may be another effective approach to changing behaviors, Dr. Dozier says.
"The thing that's ironic is that people do this [use indoor tanning beds] to make them look better, but ultimately it makes skin look worse. Indoor tanning causes premature skin aging, extra freckles, wrinkles, and moles, which increase risk of skin cancer," Dr. Dozier said.
Because many adolescents think a tan is attractive, Dr. Dozier suggests physicians recommend alternatives to indoor beds.
"I always tell patients to get a tan out of a bottle. That's the only way to do it that won't damage skin and increase the risk of developing cancer," she said.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
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DSHS Monitors Indoor Tanning Facilities
The Texas Department of State Health Services' (DSHS's) Drugs and Medical Devices group regulates the state's 2,500 indoor tanning facilities. Allison Lowery, DSHS assistant press officer, says officials in the Drugs and Medical Devices group are unable to inspect each facility every year.
"DSHS does periodic inspections, prioritizing facilities that haven't been inspected recently or new businesses that haven't before been inspected. It's possible for a couple of years to pass before a facility is inspected," she said. "The department will do more frequent inspections on facilities for which we receive complaints or that have had compliance problems."
Penalties for businesses that fail to comply with House Bill 1310 and other state laws and regulations range from seizing a tanning device until it's repaired, to levying an administrative fine of up to $25,000 per day, per violation. Ms. Lowery says a majority of tanning salon owners voluntarily comply with Texas laws and regulations.
For those that don't comply, however, offenses that might trigger an administrative penalty include not giving customers protective eyewear or not posting warning signs about the health and safety risks of indoor tanning in the entry and in all tanning rooms.
Ms. Lowery adds that DSHS also can shut down a facility temporarily if inspectors determine it poses an imminent threat to the public's health. For example, she says DSHS may issue an emergency order if a facility poses an epidemiological threat - such as an unsanitary environment - to the public's health.
DSHS has updated the HB 1310 rules, which are on the department's Drugs and Medical Devices Web page . The Web site also features information about the complaint process, administrative actions, rules, regulations, statues, and laws that apply to the industries monitored by the Drugs and Medical Devices group.
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