Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning...

16
Teens and Indoor Tanning: A Cancer Prevention Opportunity for Pediatricians abstract In October 2011, California became the first US state to ban indoor tanning for minors under age 18 years. Vermont followed in May 2012. Increasingly, scientific evidence shows that artificial tanning raises the risk of skin cancer, including melanoma, a common cancer in adolescents and young adults and the type most likely to result in death. The World Health Organization, the American Academy of Pedi- atrics, the American Academy of Dermatology, the American Medical Association, and other organizations strongly recommend legislation to ban minors under age 18 from indoor tanning. Several nations have banned teen tanning. Yet, tanning in salons is still a prevalent practice in the United States, especially among teen girls, where rates for the oldest teens approach 40%. There is no federal legislation to restrict minors from salon tanning. More than 60% of states have some kind of legislation regarding minors’ use of tanning salons, but only California and Vermont have passed complete bans of indoor tanning for minors. The Indoor Tanning Association, an industry ad- vocacy group, has vigorously opposed legislative efforts. Pediatricians can play key roles in counseling families and with legislative efforts. In this update, we review the prevalence of salon tanning, association with skin cancer risk, tanning addiction, the roles of the federal and state governments in regulation and legislation, and responses to arguments created by industry to oppose legislation. Preventing ex- posure to artificial tanning may save lives, including young lives, and is a key cancer prevention opportunity for pediatricians. Pediatrics 2013;131:772–785 AUTHORS: Sophie J. Balk, MD, a David E. Fisher, MD, PhD, b and Alan C. Geller, RN, MPH c a Children’ s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York; b Department of Dermatology, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and c Harvard School of Public Health, Massachusetts General Hospital, Boston, Massachusetts KEY WORDS indoor tanning, artificial tanning, teenagers, skin cancer, melanoma, prevention, tanning addiction, tanning legislation ABBREVIATIONS BCC—basal cell carcinoma FDA—US Food and Drug Administration FTC—US Federal Trade Commission ITA—Indoor Tanning Association NMSC—nonmelanoma skin cancer POMC—pro-opiomelanocortin SCC—squamous cell carcinoma USPSTF—US Preventive Services Task Force UVR—UV radiation Dr Balk conceptualized the article, drafted the initial manuscript, and approved the final manuscript as submitted; and Dr Fisher and Mr Geller conceptualized the article, critically reviewed and revised the article, and approved the final manuscript as submitted. www.pediatrics.org/cgi/doi/10.1542/peds.2012-2404 doi:10.1542/peds.2012-2404 Accepted for publication Oct 17, 2012 Address correspondence to Sophie J. Balk, MD, 1621 Eastchester Rd, Bronx, NY 10461. E-mail: sbalk@montefiore.org PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose. FUNDING: No external funding. 772 BALK et al by guest on July 20, 2020 www.aappublications.org/news Downloaded from

Transcript of Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning...

Page 1: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

Teens and Indoor Tanning A Cancer PreventionOpportunity for Pediatricians

abstractIn October 2011 California became the first US state to ban indoortanning for minors under age 18 years Vermont followed in May 2012Increasingly scientific evidence shows that artificial tanning raisesthe risk of skin cancer including melanoma a common cancer inadolescents and young adults and the type most likely to result indeath The World Health Organization the American Academy of Pedi-atrics the American Academy of Dermatology the American MedicalAssociation and other organizations strongly recommend legislationto ban minors under age 18 from indoor tanning Several nationshave banned teen tanning Yet tanning in salons is still a prevalentpractice in the United States especially among teen girls where ratesfor the oldest teens approach 40 There is no federal legislation torestrict minors from salon tanning More than 60 of states havesome kind of legislation regarding minorsrsquo use of tanning salons butonly California and Vermont have passed complete bans of indoortanning for minors The Indoor Tanning Association an industry ad-vocacy group has vigorously opposed legislative efforts Pediatricianscan play key roles in counseling families and with legislative effortsIn this update we review the prevalence of salon tanning associationwith skin cancer risk tanning addiction the roles of the federal andstate governments in regulation and legislation and responses toarguments created by industry to oppose legislation Preventing ex-posure to artificial tanning may save lives including young lives andis a key cancer prevention opportunity for pediatricians Pediatrics2013131772ndash785

AUTHORS Sophie J Balk MDa David E Fisher MD PhDb

and Alan C Geller RN MPHc

aChildrenrsquos Hospital at Montefiore Albert Einstein College ofMedicine Bronx New York bDepartment of DermatologyCutaneous Biology Research Center Massachusetts GeneralHospital Harvard Medical School Boston Massachusetts andcHarvard School of Public Health Massachusetts GeneralHospital Boston Massachusetts

KEY WORDSindoor tanning artificial tanning teenagers skin cancermelanoma prevention tanning addiction tanning legislation

ABBREVIATIONSBCCmdashbasal cell carcinomaFDAmdashUS Food and Drug AdministrationFTCmdashUS Federal Trade CommissionITAmdashIndoor Tanning AssociationNMSCmdashnonmelanoma skin cancerPOMCmdashpro-opiomelanocortinSCCmdashsquamous cell carcinomaUSPSTFmdashUS Preventive Services Task ForceUVRmdashUV radiation

Dr Balk conceptualized the article drafted the initialmanuscript and approved the final manuscript as submittedand Dr Fisher and Mr Geller conceptualized the article criticallyreviewed and revised the article and approved the finalmanuscript as submitted

wwwpediatricsorgcgidoi101542peds2012-2404

doi101542peds2012-2404

Accepted for publication Oct 17 2012

Address correspondence to Sophie J Balk MD 1621 EastchesterRd Bronx NY 10461 E-mail sbalkmontefioreorg

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE The authors have no financialrelationships relevant to this article to disclose

FUNDING No external funding

772 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

BACKGROUND

Prevalence

People may be exposed to artificialsources of UV radiation (UVR) for treat-ment of certain medical conditions inoccupational settings and for cosmeticpurposes Sunlamps and tanning bedsare the main sources of artificial UVRused for deliberate purposes1 Indoortanning started in the 1970s and hasgrown rapidly Now1 million people inthe United States tan in tanning salonseach day2 Many of those who visit tan-ning salons are adolescent girls andyoung women According to the 2009Youth Risk Behavior Survey a nationallyrepresentative sample of high schoolstudents in grades 9 through 12 156of all students used an indoor tanningdevice $1 times during the 12 monthsbefore the survey Among students whoreported using devices within the pastyear 491 reported doing so $10times Female students and white stu-dents were more likely to use tanningdevices $10 times More than one-quarter (254) of girls reported usinga tanning device in the past year3 Therate of artificial tanning among whitegirls increases with age doubling fromages 14 to 15 (7 to 15) and doublingagain at age 17 (35)4 Tanning salonsare ubiquitous The average US city has41 salons outnumbering the numberof Starbucks or McDonalds5 Access iseasy Salons are inexpensive and oftenoffer ldquounlimitedrdquo tanning packages6

Adolescents are specifically targetedthrough advertising strategies that in-clude promoting purported cosmeticand health benefits6

Young adults and some adolescentshave opportunities to access indoortanning in nonsalon locations includingapartments beauty salons and fit-ness centers Regulations governingminorsrsquo access to tanning salons donot affect these sites and there islittle scientific information availableabout them

Radiation Emitted by TanningDevices

Tanning devices emit primarily UV-Aradiation7 UV-B radiation is muchmore potent than UV-A in causingsunburn but high fluxes of UV-A cancause erythema in people who aresensitive to sunlight In people whotan easily exposure to tanning devicesresults in immediate pigment darkeningcaused by oxidation of existing melaninA more permanent tan occurs withadditional exposure depending on theindividualrsquos tanning ability and theamount of UV-B in the lamps7 UV-B ex-posure results in greater tanning newertanning lamps may emit a greater pro-portion of UV-B

The doses of UV-A emitted by high-pressure tanning units may be up to10 to 15 times higher than that of themidday sun an intense exposure notfound in nature89 Frequent indoortannersmay receive 12 to 47 times theyearly dose of UV-A received fromsunlight in addition to doses from sunexposure1

Skin Cancer Incidence

The incidence of skin cancer has reach-ed epidemic proportions Skin cancer(including basal cell carcinoma [BCC]squamous cell carcinoma [SCC] andmelanoma) is by far the most commoncancer Approximately 35 million BCCsand SCCs in 2 million Americans arediagnosed each year1011 BCC and SCC(grouped together as nonmelanoma skincancer [NMSC]) are less likely to resultin fatality compared with melanomaNonetheless the American Cancer So-ciety estimates that sim2000 people dieeach year of NMSC10 There is consid-erable morbidity and cost associatedwith treating NMSC The American Can-cer Society estimates that 76 690 newmelanomas will be diagnosed in 2013sim9480 people are expected to die ofmelanoma in 2013 US incidence ratesfor melanoma have been rising in all

age groups since first recorded in197312

Melanoma is more likely to occur inmales and at older ages but also occursin teenagers and in young adults Mel-anoma is the second most commoncancer in women in their 20s and thethird most common cancer in men intheir 20s13 Data from the SEER (Sur-veillance Epidemiology and End Results)Program show that the age-adjustedannual incidence rate for women aged15 to 39 years more than doubled from55 per 100 000 (range 45ndash66) in 1973to 139 per 100 000 (127ndash152) in 2004The rise in the incidence rate for womenhas been sharpest since 1992 (Fig 1)Melanoma incidence increased for boththin and thick tumors and was greaterfor regional and distant tumors com-pared with localized lesions14 In Olm-stead County Minnesota melanomaincidence increased 4-fold in youngmen but 8-fold in young women overa 30-year period among men ages 18to 39 years the incidence rose from43 per 100 000 between 1970 and 1979to 186 per 100 000 between 2000and 2009 among women ages 18 to39 years the incidence rose from 54per 100 000 between 1970 and 1979to 435 per 100 000 between 2000 and200915 Experts believe that 1 reason forthis dramatic increase is the increasingpopularity of artificial tanning15 espe-cially among young women

The incidence of NMSC also is increasingin young adults Between 1976 and 2003the incidence of BCC increased signifi-cantly among young women (40 yearsof age) and the incidence of SCC in-creased significantly among men andwomen16 A trend toward a greaternumber of BCC cases occurring onthe torso in younger patients has beenreported16ndash18 This change in locationsupports the possibility that exces-sive outdoor tanning use of tanningbooths or both give rise to BCC Theuse of tanning beds has been shown

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to be a risk factor for NMSC in youngwomen19

TANNING RESULTS IN DNA DAMAGE

The skin is composed of the epidermisdermis and subcutaneous layer Thetop layer the epidermis includes basalcells squamous cells (together knownas keratinocytes) and melanocytesKeratinocytes produce keratin whichis a structural and protective proteinMelanocytes produce melanin a familyof pigments spanning brown-black toblond-red colors After their synthesisin melanocytes melanin-containing ves-icles are transported to overlying kera-tinocytes where they traffic selectivelyto the sun-exposed side of nucleiDarker melanins appear to protect theskin by absorbing UVR and reactiveoxygen species

Recent evidence indicates that thetanning response is mediated in sig-nificant part by signals emanating di-rectly from damage to DNA Exposure toUVR triggers DNA damage in the nuclei

of keratinocytes activating the p53tumor-suppressor protein a transcrip-tion factor that plays a pivotal role inthe cellular response to genotoxicstressors such as UV- and chemicallyinduced DNA damage20 p53 directlyactivates transcription of numerousgenes such as those that regulate cell-cycle progression and apoptotic cellu-lar pathways p53 function is criticalfor the retention of tissue integrity afterUV irradiation of skin Loss of functionof p53 leads to aberrant cell growthand survival responses dysfunction ofp53 plays an integral part in humancancer development20

p53 activation in the skin leads toupregulation of the gene that encodespro-opiomelanocortin (POMC) a poly-peptide precursor present throughoutthe central nervous system and skinPOMC is then processed to producea-melanocytendashstimulating hormonewhich after secretion stimulates its re-ceptor the melanocortin 1 receptor onthe surface of melanocytes to inducethe synthesis maturation trafficking

and secretion ofmelanin After the uptakeof melanin by overlying keratinocytesskin takes on a darker appearancewhich results in tanning (Fig 2)21 Thustanning occurs as a response to DNAdamage and appears to be a componentof the p53-induced stress responseAny wavelength of UV (ie UV-A or UV-B)that is capable of inducing tanning (thuselevating carcinogenic risk) appearsto do so via damage to DNA as a firststep because the DNA damage responsefactor p53 is a key mediator of the tan-ning pathway20

ACUTE AND LONG-TERM EFFECTSOF EXPOSURE TO ARTIFICIALTANNING

Exposure to artificial UVR often resultsin erythema and sunburn Erythema orburning was reported in 18 to 55 ofusers of indoor tanning equipment inNorth America and Europe1 A large USstudy of teen tanning-bed use revealedthat 57 experienced at least 1 sunburnduring a salon visit22 Other reportedeffects include skin dryness pruritusnausea photodrug reactions diseaseexacerbation (eg systemic lupus ery-thematosus) and disease induction (egpolymorphous light eruption) Long-term health effects include skin agingeffects on the eye (eg cataract forma-tion) and carcinogenesis7

ARTIFICIAL TANNING ISCARCINOGENIC

In 2006 the International Agency forResearch on Cancer (a branch of theWorld Health Organization) issued areport1 based on meta-analysis of 19studies of associations between tanning-bed use and skin cancer risk On thebasis of these data in 2009 the In-ternational Agency for Research onCancer declared that UVR from salonswas a group 1 carcinogen (ie known tocause cancer in humans)23 These find-ings were criticized by some because ofthe weak association and inability to

FIGURE 1Trends in melanoma incidence and mortality among young adults Age-adjusted (to 2000 US population)annual cutaneous melanoma incidence and mortality rates among Caucasian males and females aged15ndash39 years in the Surveillance Epidemiology and End Results Program areas from 1973 through 2004The segments of uniform trend from the best-fitting Joinpoint models are also shown (Reprinted withpermission from Purdue MP Beane Freeman LE Anderson WF Tucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasian young adults J Invest Dermatol 20081282906)

774 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

confirm a dose-response relationshipor examine exposure to specific tan-ning devices Since then new studieshave strengthened the association oftanning-bed use with increased mela-noma risk (Table 1) In 2012 a meta-analysis of 27 observational studiesshowed that for users of indoor tan-ning devices the risk of melanoma in-creased 20 which doubled if tanningstarted when users were younger than35 years9

WHY PEOPLE TAN

Despite evidence that UVR exposure in-creasesskincancerriskpeoplecontinue

to intentionally tan Knowledge aboutthe dangers of UVR often does notchange tanning behavior2425 Thesepractices may persist because manypeople believe that a tanned appear-ance is attractive and healthy In 1study 678 of youth agreed with thestatement ldquoI look better when I havea tanrdquo and 55 agreed with thestatement ldquoI feel healthy when I havea nice tanrdquo26 In addition to the desirefor improved appearance motivationsin some tanners include relaxationand a better mood In view of poten-tially severe consequences it has beenpostulated that continued and fre-quent use of tanning beds shares

characteristics with addictive disorders27

and that for some individuals tanningbehavior may be motivated at least inpart by a type of UV light substance-related disorder

To characterize possible tanning ad-diction researchers have used surveysthat included tanning-specific modifi-cations of 2 established instrumentsThe CAGE (Cut down Annoyed GuiltyEye-opener) Questionnaire screensfor alcohol abuse or dependenceModifications include questions aboutwhether tanners wanted to cut downbut nevertheless continued and whethertanners felt annoyed when others ad-vised them not to tan The second in-strument uses a modification of theAmerican Psychiatric AssociationrsquosDiagnostic and Statistical Manual ofMental Disorders Fourth Edition TextRevision criteria for substance-relateddisorders Questions include toler-ance to tanning (ie need for increasedamounts of tanning to achieve a de-sired effect) withdrawal symptomsand loss of control such as use despitea desire to cut down Table 2 describessome studies of tanning addiction

A small study found increased plasmaconcentrations of b-endorphin afterUVR exposure in frequent tanners28

Other studies have not observed suchelevations2930 Blood endorphin concen-trations appear to fluctuate throughthe day so these studies might belimited and more research is neededIt is interesting to consider whether anendorphin-mediated addictive mecha-nism might have conferred an advan-tage to human survival UVR exposureresults in conversion of vitamin D pre-cursors in skin to vitamin D adequatevitamin D is needed to ensure humansurvival31 Among the cleavage prod-ucts of POMC are the glucocorticoidprecursor adrenocorticotropic hormone(ACTH) andb-endorphin an endogenousligand of the m-opioid receptor Endog-enous b-endorphin exerts analgesic

FIGURE 2Molecular Mechanism of Skin Pigmentation Induced by UV Radiation Ultraviolet light triggers DNAdamage in the nucleus of keratinocytes resulting in the activation of p53 which transcriptionallyup-regulates the expression of the gene encoding proopiomelanocortin (POMC) POMC is post-translationally processed to produce melanocyte-stimulating hormone (MSH) and b-endorphin Aftersecretion MSH acts on its receptor the melanocortin 1 receptor located on melanocytes at the basallayer of the epidermis thereby inducing the production of pigment which is subsequently transportedout of melanocytes to overlying keratinocytes where the pigment vesicles coalesce over the sun-exposed side of the nucleus resulting in tanning (Reprinted with permission from Fisher DE JamesWD Indoor tanningmdashscience behavior and policy N Engl J Med 2010363902)

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TABLE1

Studiesof

Tanning-BedUseandMelanom

aRisk

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Theassociationofuseof

sunbedswith

cutaneous

malignant

melanom

aand

otherskincancersa

system

aticreview

(2006)

1

Meta-analysisof19

studiesthat

exam

ined

associations

between

useofan

artificialtanningdevice

(ldquosunbedrdquo)andskincancer

risk

A15increase

inmelanom

arisk

(95

CI100131)for

thosewho

ever

used

asunbed

compared

with

thosewho

neverdidno

consistent

evidence

ofadose-

response

relationship

RRofmelanom

agreaterwith

first

usebefore

age35

(sum

maryRR

basedon

7studies17595

CI

135226)

Basedon

findingsthe

IARC

declared

thatartificialUVRis

agroupAcarcinogen

AustralianMelanom

aFamily

Study(2011)

64Population-basedcase-control

family

studyofearly-onset

melanom

a

604casesdiagnosedbetweenages

18and39479

controls

Comparedwith

neverusingOR

for

melanom

aassociated

with

ever

usingsunbed

=141(95

CI101

196)and

201

(95

CI122331)

for10

lifetimesessions

(Ptrend=

01with

cumulativeuse)

Stronger

associationforearlier

ageat

firstu

se(P

trend=02)

also

formelanom

adiagnosed

at18ndash29

y(ORfor10

lifetime

sessions65795CI141

3049)

than

formelanom

adiagnosedat30ndash39

y(OR160

95CI092277P

interaction=01)

Amongthosewho

ever

used

asunbed

andwerediagnosed

between18

and29

y76of

melanom

asattributableto

sunbed

use

Indoor

tanningandrisk

ofmelanom

aacase-control

studyinahighlyexposed

population(2010)

65

Case-controlstudyinMinnesota

1167

melanom

acases1101

controlsages

25ndash59

y63ofcasesand51ofcontrols

everindoor

tanned

(adjustedOR

17495

CI142214)Risk

increasedinbothusersofUV-Bndash

enhanced

(adjustedOR

286

95CI203403)andprimarily

UV-Andashem

ittingdevices(adjusted

OR44495CI245802)

Greaterrisk

associated

with

greaterusewhenexam

ined

with

regard

toyearsofexposure

(P

006)hours(P

0001)

orsessions

(P=0002)

ORselevated

withineach

initiation

agecategoryyearsofuseam

ong

indoor

tannerswas

more

relevant

formelanom

adevelopm

ent

Authorsconcludedthatfrequent

indoor

tanningincreased

melanom

arisk

independentof

outdoorsunexposure

and

regardless

ofagewhentanning

began

Norw

egian-Sw

edishWom

enrsquos

LifestyleandHealth

Cohort

study(2010)

66

Prospectivecohortstudy

established1991ndash1992Subjects

inNorw

aycamefrom

nationw

iderandom

sampleof

100000wom

enborn

1943ndash1957

SubjectsinSw

eden

were96

000

random

lyselected

wom

enborn

1943ndash1962

Researchersexam

ined

subjectsrsquo

responsesabouth

ostfactors

sunexposure

andsolarium

(iesunbed

orsunlam

p)use

through5agedecades(

10

10ndash1920ndash2930ndash3940ndash49

y)

Among106366wom

enwith

completefollow-upthrough

2005412

melanom

acaseswere

diagnosedRisk

increasedwith

thenumberofsunburns

and

bathingvacations

inthefirst3

agedecades(P

trend

04)

Comparedwith

ldquonouserdquo

ofasolarium

inthe3decadesfrom

10to

39yRR

sincreasedfrom

124

forldquorarelyuserdquo

inany

decade

to138

forldquouse

1or

moretim

espermonth

in1of3

decadesrdquo

to237

forldquouse

1or

moretim

espermonth

in2or

3decadesrdquo

(Ptrend=003)

Authorsconcludedthatmelanom

arisk

seem

stocontinue

toincrease

with

accumulating

interm

ittentsun

exposure

and

solarium

useinearlyadulthood

Peoplewith

neviandredhair

wereatparticular

risk

for

developing

melanom

a

Cutaneousmelanom

aattributableto

sunbed

use

system

aticreview

andmeta-

analysis(2012)

9

Meta-analysisof27

observational

studiesofsunbed

use

Everuseofsunbedsassociatedwith

summaryR

Rof120

(95

CI108

134)

Calculations

fordose-response

show

eda18

(95

CI038)

increase

inrisk

ofmelanom

afor

each

additionalsession

ofsunbed

useperyear

Studyconfirm

sdoublingof

melanom

arisk

whenfirstuse

atayoungage(

35y)

Dose-responserelationshipfound

betweenam

ount

ofuseand

melanom

ariskInEurope

each

year3438estim

ated

newcases

ofmelanom

aduetosunbed

use

mostamongwom

en

CIconfidenceintervalIARCInternationalAgencyforResearch

onCancerORodds

ratioRRrelativeriskUVRUVradiation

776 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

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DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 2: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

BACKGROUND

Prevalence

People may be exposed to artificialsources of UV radiation (UVR) for treat-ment of certain medical conditions inoccupational settings and for cosmeticpurposes Sunlamps and tanning bedsare the main sources of artificial UVRused for deliberate purposes1 Indoortanning started in the 1970s and hasgrown rapidly Now1 million people inthe United States tan in tanning salonseach day2 Many of those who visit tan-ning salons are adolescent girls andyoung women According to the 2009Youth Risk Behavior Survey a nationallyrepresentative sample of high schoolstudents in grades 9 through 12 156of all students used an indoor tanningdevice $1 times during the 12 monthsbefore the survey Among students whoreported using devices within the pastyear 491 reported doing so $10times Female students and white stu-dents were more likely to use tanningdevices $10 times More than one-quarter (254) of girls reported usinga tanning device in the past year3 Therate of artificial tanning among whitegirls increases with age doubling fromages 14 to 15 (7 to 15) and doublingagain at age 17 (35)4 Tanning salonsare ubiquitous The average US city has41 salons outnumbering the numberof Starbucks or McDonalds5 Access iseasy Salons are inexpensive and oftenoffer ldquounlimitedrdquo tanning packages6

Adolescents are specifically targetedthrough advertising strategies that in-clude promoting purported cosmeticand health benefits6

Young adults and some adolescentshave opportunities to access indoortanning in nonsalon locations includingapartments beauty salons and fit-ness centers Regulations governingminorsrsquo access to tanning salons donot affect these sites and there islittle scientific information availableabout them

Radiation Emitted by TanningDevices

Tanning devices emit primarily UV-Aradiation7 UV-B radiation is muchmore potent than UV-A in causingsunburn but high fluxes of UV-A cancause erythema in people who aresensitive to sunlight In people whotan easily exposure to tanning devicesresults in immediate pigment darkeningcaused by oxidation of existing melaninA more permanent tan occurs withadditional exposure depending on theindividualrsquos tanning ability and theamount of UV-B in the lamps7 UV-B ex-posure results in greater tanning newertanning lamps may emit a greater pro-portion of UV-B

The doses of UV-A emitted by high-pressure tanning units may be up to10 to 15 times higher than that of themidday sun an intense exposure notfound in nature89 Frequent indoortannersmay receive 12 to 47 times theyearly dose of UV-A received fromsunlight in addition to doses from sunexposure1

Skin Cancer Incidence

The incidence of skin cancer has reach-ed epidemic proportions Skin cancer(including basal cell carcinoma [BCC]squamous cell carcinoma [SCC] andmelanoma) is by far the most commoncancer Approximately 35 million BCCsand SCCs in 2 million Americans arediagnosed each year1011 BCC and SCC(grouped together as nonmelanoma skincancer [NMSC]) are less likely to resultin fatality compared with melanomaNonetheless the American Cancer So-ciety estimates that sim2000 people dieeach year of NMSC10 There is consid-erable morbidity and cost associatedwith treating NMSC The American Can-cer Society estimates that 76 690 newmelanomas will be diagnosed in 2013sim9480 people are expected to die ofmelanoma in 2013 US incidence ratesfor melanoma have been rising in all

age groups since first recorded in197312

Melanoma is more likely to occur inmales and at older ages but also occursin teenagers and in young adults Mel-anoma is the second most commoncancer in women in their 20s and thethird most common cancer in men intheir 20s13 Data from the SEER (Sur-veillance Epidemiology and End Results)Program show that the age-adjustedannual incidence rate for women aged15 to 39 years more than doubled from55 per 100 000 (range 45ndash66) in 1973to 139 per 100 000 (127ndash152) in 2004The rise in the incidence rate for womenhas been sharpest since 1992 (Fig 1)Melanoma incidence increased for boththin and thick tumors and was greaterfor regional and distant tumors com-pared with localized lesions14 In Olm-stead County Minnesota melanomaincidence increased 4-fold in youngmen but 8-fold in young women overa 30-year period among men ages 18to 39 years the incidence rose from43 per 100 000 between 1970 and 1979to 186 per 100 000 between 2000and 2009 among women ages 18 to39 years the incidence rose from 54per 100 000 between 1970 and 1979to 435 per 100 000 between 2000 and200915 Experts believe that 1 reason forthis dramatic increase is the increasingpopularity of artificial tanning15 espe-cially among young women

The incidence of NMSC also is increasingin young adults Between 1976 and 2003the incidence of BCC increased signifi-cantly among young women (40 yearsof age) and the incidence of SCC in-creased significantly among men andwomen16 A trend toward a greaternumber of BCC cases occurring onthe torso in younger patients has beenreported16ndash18 This change in locationsupports the possibility that exces-sive outdoor tanning use of tanningbooths or both give rise to BCC Theuse of tanning beds has been shown

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to be a risk factor for NMSC in youngwomen19

TANNING RESULTS IN DNA DAMAGE

The skin is composed of the epidermisdermis and subcutaneous layer Thetop layer the epidermis includes basalcells squamous cells (together knownas keratinocytes) and melanocytesKeratinocytes produce keratin whichis a structural and protective proteinMelanocytes produce melanin a familyof pigments spanning brown-black toblond-red colors After their synthesisin melanocytes melanin-containing ves-icles are transported to overlying kera-tinocytes where they traffic selectivelyto the sun-exposed side of nucleiDarker melanins appear to protect theskin by absorbing UVR and reactiveoxygen species

Recent evidence indicates that thetanning response is mediated in sig-nificant part by signals emanating di-rectly from damage to DNA Exposure toUVR triggers DNA damage in the nuclei

of keratinocytes activating the p53tumor-suppressor protein a transcrip-tion factor that plays a pivotal role inthe cellular response to genotoxicstressors such as UV- and chemicallyinduced DNA damage20 p53 directlyactivates transcription of numerousgenes such as those that regulate cell-cycle progression and apoptotic cellu-lar pathways p53 function is criticalfor the retention of tissue integrity afterUV irradiation of skin Loss of functionof p53 leads to aberrant cell growthand survival responses dysfunction ofp53 plays an integral part in humancancer development20

p53 activation in the skin leads toupregulation of the gene that encodespro-opiomelanocortin (POMC) a poly-peptide precursor present throughoutthe central nervous system and skinPOMC is then processed to producea-melanocytendashstimulating hormonewhich after secretion stimulates its re-ceptor the melanocortin 1 receptor onthe surface of melanocytes to inducethe synthesis maturation trafficking

and secretion ofmelanin After the uptakeof melanin by overlying keratinocytesskin takes on a darker appearancewhich results in tanning (Fig 2)21 Thustanning occurs as a response to DNAdamage and appears to be a componentof the p53-induced stress responseAny wavelength of UV (ie UV-A or UV-B)that is capable of inducing tanning (thuselevating carcinogenic risk) appearsto do so via damage to DNA as a firststep because the DNA damage responsefactor p53 is a key mediator of the tan-ning pathway20

ACUTE AND LONG-TERM EFFECTSOF EXPOSURE TO ARTIFICIALTANNING

Exposure to artificial UVR often resultsin erythema and sunburn Erythema orburning was reported in 18 to 55 ofusers of indoor tanning equipment inNorth America and Europe1 A large USstudy of teen tanning-bed use revealedthat 57 experienced at least 1 sunburnduring a salon visit22 Other reportedeffects include skin dryness pruritusnausea photodrug reactions diseaseexacerbation (eg systemic lupus ery-thematosus) and disease induction (egpolymorphous light eruption) Long-term health effects include skin agingeffects on the eye (eg cataract forma-tion) and carcinogenesis7

ARTIFICIAL TANNING ISCARCINOGENIC

In 2006 the International Agency forResearch on Cancer (a branch of theWorld Health Organization) issued areport1 based on meta-analysis of 19studies of associations between tanning-bed use and skin cancer risk On thebasis of these data in 2009 the In-ternational Agency for Research onCancer declared that UVR from salonswas a group 1 carcinogen (ie known tocause cancer in humans)23 These find-ings were criticized by some because ofthe weak association and inability to

FIGURE 1Trends in melanoma incidence and mortality among young adults Age-adjusted (to 2000 US population)annual cutaneous melanoma incidence and mortality rates among Caucasian males and females aged15ndash39 years in the Surveillance Epidemiology and End Results Program areas from 1973 through 2004The segments of uniform trend from the best-fitting Joinpoint models are also shown (Reprinted withpermission from Purdue MP Beane Freeman LE Anderson WF Tucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasian young adults J Invest Dermatol 20081282906)

774 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

confirm a dose-response relationshipor examine exposure to specific tan-ning devices Since then new studieshave strengthened the association oftanning-bed use with increased mela-noma risk (Table 1) In 2012 a meta-analysis of 27 observational studiesshowed that for users of indoor tan-ning devices the risk of melanoma in-creased 20 which doubled if tanningstarted when users were younger than35 years9

WHY PEOPLE TAN

Despite evidence that UVR exposure in-creasesskincancerriskpeoplecontinue

to intentionally tan Knowledge aboutthe dangers of UVR often does notchange tanning behavior2425 Thesepractices may persist because manypeople believe that a tanned appear-ance is attractive and healthy In 1study 678 of youth agreed with thestatement ldquoI look better when I havea tanrdquo and 55 agreed with thestatement ldquoI feel healthy when I havea nice tanrdquo26 In addition to the desirefor improved appearance motivationsin some tanners include relaxationand a better mood In view of poten-tially severe consequences it has beenpostulated that continued and fre-quent use of tanning beds shares

characteristics with addictive disorders27

and that for some individuals tanningbehavior may be motivated at least inpart by a type of UV light substance-related disorder

To characterize possible tanning ad-diction researchers have used surveysthat included tanning-specific modifi-cations of 2 established instrumentsThe CAGE (Cut down Annoyed GuiltyEye-opener) Questionnaire screensfor alcohol abuse or dependenceModifications include questions aboutwhether tanners wanted to cut downbut nevertheless continued and whethertanners felt annoyed when others ad-vised them not to tan The second in-strument uses a modification of theAmerican Psychiatric AssociationrsquosDiagnostic and Statistical Manual ofMental Disorders Fourth Edition TextRevision criteria for substance-relateddisorders Questions include toler-ance to tanning (ie need for increasedamounts of tanning to achieve a de-sired effect) withdrawal symptomsand loss of control such as use despitea desire to cut down Table 2 describessome studies of tanning addiction

A small study found increased plasmaconcentrations of b-endorphin afterUVR exposure in frequent tanners28

Other studies have not observed suchelevations2930 Blood endorphin concen-trations appear to fluctuate throughthe day so these studies might belimited and more research is neededIt is interesting to consider whether anendorphin-mediated addictive mecha-nism might have conferred an advan-tage to human survival UVR exposureresults in conversion of vitamin D pre-cursors in skin to vitamin D adequatevitamin D is needed to ensure humansurvival31 Among the cleavage prod-ucts of POMC are the glucocorticoidprecursor adrenocorticotropic hormone(ACTH) andb-endorphin an endogenousligand of the m-opioid receptor Endog-enous b-endorphin exerts analgesic

FIGURE 2Molecular Mechanism of Skin Pigmentation Induced by UV Radiation Ultraviolet light triggers DNAdamage in the nucleus of keratinocytes resulting in the activation of p53 which transcriptionallyup-regulates the expression of the gene encoding proopiomelanocortin (POMC) POMC is post-translationally processed to produce melanocyte-stimulating hormone (MSH) and b-endorphin Aftersecretion MSH acts on its receptor the melanocortin 1 receptor located on melanocytes at the basallayer of the epidermis thereby inducing the production of pigment which is subsequently transportedout of melanocytes to overlying keratinocytes where the pigment vesicles coalesce over the sun-exposed side of the nucleus resulting in tanning (Reprinted with permission from Fisher DE JamesWD Indoor tanningmdashscience behavior and policy N Engl J Med 2010363902)

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 775 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE1

Studiesof

Tanning-BedUseandMelanom

aRisk

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Theassociationofuseof

sunbedswith

cutaneous

malignant

melanom

aand

otherskincancersa

system

aticreview

(2006)

1

Meta-analysisof19

studiesthat

exam

ined

associations

between

useofan

artificialtanningdevice

(ldquosunbedrdquo)andskincancer

risk

A15increase

inmelanom

arisk

(95

CI100131)for

thosewho

ever

used

asunbed

compared

with

thosewho

neverdidno

consistent

evidence

ofadose-

response

relationship

RRofmelanom

agreaterwith

first

usebefore

age35

(sum

maryRR

basedon

7studies17595

CI

135226)

Basedon

findingsthe

IARC

declared

thatartificialUVRis

agroupAcarcinogen

AustralianMelanom

aFamily

Study(2011)

64Population-basedcase-control

family

studyofearly-onset

melanom

a

604casesdiagnosedbetweenages

18and39479

controls

Comparedwith

neverusingOR

for

melanom

aassociated

with

ever

usingsunbed

=141(95

CI101

196)and

201

(95

CI122331)

for10

lifetimesessions

(Ptrend=

01with

cumulativeuse)

Stronger

associationforearlier

ageat

firstu

se(P

trend=02)

also

formelanom

adiagnosed

at18ndash29

y(ORfor10

lifetime

sessions65795CI141

3049)

than

formelanom

adiagnosedat30ndash39

y(OR160

95CI092277P

interaction=01)

Amongthosewho

ever

used

asunbed

andwerediagnosed

between18

and29

y76of

melanom

asattributableto

sunbed

use

Indoor

tanningandrisk

ofmelanom

aacase-control

studyinahighlyexposed

population(2010)

65

Case-controlstudyinMinnesota

1167

melanom

acases1101

controlsages

25ndash59

y63ofcasesand51ofcontrols

everindoor

tanned

(adjustedOR

17495

CI142214)Risk

increasedinbothusersofUV-Bndash

enhanced

(adjustedOR

286

95CI203403)andprimarily

UV-Andashem

ittingdevices(adjusted

OR44495CI245802)

Greaterrisk

associated

with

greaterusewhenexam

ined

with

regard

toyearsofexposure

(P

006)hours(P

0001)

orsessions

(P=0002)

ORselevated

withineach

initiation

agecategoryyearsofuseam

ong

indoor

tannerswas

more

relevant

formelanom

adevelopm

ent

Authorsconcludedthatfrequent

indoor

tanningincreased

melanom

arisk

independentof

outdoorsunexposure

and

regardless

ofagewhentanning

began

Norw

egian-Sw

edishWom

enrsquos

LifestyleandHealth

Cohort

study(2010)

66

Prospectivecohortstudy

established1991ndash1992Subjects

inNorw

aycamefrom

nationw

iderandom

sampleof

100000wom

enborn

1943ndash1957

SubjectsinSw

eden

were96

000

random

lyselected

wom

enborn

1943ndash1962

Researchersexam

ined

subjectsrsquo

responsesabouth

ostfactors

sunexposure

andsolarium

(iesunbed

orsunlam

p)use

through5agedecades(

10

10ndash1920ndash2930ndash3940ndash49

y)

Among106366wom

enwith

completefollow-upthrough

2005412

melanom

acaseswere

diagnosedRisk

increasedwith

thenumberofsunburns

and

bathingvacations

inthefirst3

agedecades(P

trend

04)

Comparedwith

ldquonouserdquo

ofasolarium

inthe3decadesfrom

10to

39yRR

sincreasedfrom

124

forldquorarelyuserdquo

inany

decade

to138

forldquouse

1or

moretim

espermonth

in1of3

decadesrdquo

to237

forldquouse

1or

moretim

espermonth

in2or

3decadesrdquo

(Ptrend=003)

Authorsconcludedthatmelanom

arisk

seem

stocontinue

toincrease

with

accumulating

interm

ittentsun

exposure

and

solarium

useinearlyadulthood

Peoplewith

neviandredhair

wereatparticular

risk

for

developing

melanom

a

Cutaneousmelanom

aattributableto

sunbed

use

system

aticreview

andmeta-

analysis(2012)

9

Meta-analysisof27

observational

studiesofsunbed

use

Everuseofsunbedsassociatedwith

summaryR

Rof120

(95

CI108

134)

Calculations

fordose-response

show

eda18

(95

CI038)

increase

inrisk

ofmelanom

afor

each

additionalsession

ofsunbed

useperyear

Studyconfirm

sdoublingof

melanom

arisk

whenfirstuse

atayoungage(

35y)

Dose-responserelationshipfound

betweenam

ount

ofuseand

melanom

ariskInEurope

each

year3438estim

ated

newcases

ofmelanom

aduetosunbed

use

mostamongwom

en

CIconfidenceintervalIARCInternationalAgencyforResearch

onCancerORodds

ratioRRrelativeriskUVRUVradiation

776 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 3: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

to be a risk factor for NMSC in youngwomen19

TANNING RESULTS IN DNA DAMAGE

The skin is composed of the epidermisdermis and subcutaneous layer Thetop layer the epidermis includes basalcells squamous cells (together knownas keratinocytes) and melanocytesKeratinocytes produce keratin whichis a structural and protective proteinMelanocytes produce melanin a familyof pigments spanning brown-black toblond-red colors After their synthesisin melanocytes melanin-containing ves-icles are transported to overlying kera-tinocytes where they traffic selectivelyto the sun-exposed side of nucleiDarker melanins appear to protect theskin by absorbing UVR and reactiveoxygen species

Recent evidence indicates that thetanning response is mediated in sig-nificant part by signals emanating di-rectly from damage to DNA Exposure toUVR triggers DNA damage in the nuclei

of keratinocytes activating the p53tumor-suppressor protein a transcrip-tion factor that plays a pivotal role inthe cellular response to genotoxicstressors such as UV- and chemicallyinduced DNA damage20 p53 directlyactivates transcription of numerousgenes such as those that regulate cell-cycle progression and apoptotic cellu-lar pathways p53 function is criticalfor the retention of tissue integrity afterUV irradiation of skin Loss of functionof p53 leads to aberrant cell growthand survival responses dysfunction ofp53 plays an integral part in humancancer development20

p53 activation in the skin leads toupregulation of the gene that encodespro-opiomelanocortin (POMC) a poly-peptide precursor present throughoutthe central nervous system and skinPOMC is then processed to producea-melanocytendashstimulating hormonewhich after secretion stimulates its re-ceptor the melanocortin 1 receptor onthe surface of melanocytes to inducethe synthesis maturation trafficking

and secretion ofmelanin After the uptakeof melanin by overlying keratinocytesskin takes on a darker appearancewhich results in tanning (Fig 2)21 Thustanning occurs as a response to DNAdamage and appears to be a componentof the p53-induced stress responseAny wavelength of UV (ie UV-A or UV-B)that is capable of inducing tanning (thuselevating carcinogenic risk) appearsto do so via damage to DNA as a firststep because the DNA damage responsefactor p53 is a key mediator of the tan-ning pathway20

ACUTE AND LONG-TERM EFFECTSOF EXPOSURE TO ARTIFICIALTANNING

Exposure to artificial UVR often resultsin erythema and sunburn Erythema orburning was reported in 18 to 55 ofusers of indoor tanning equipment inNorth America and Europe1 A large USstudy of teen tanning-bed use revealedthat 57 experienced at least 1 sunburnduring a salon visit22 Other reportedeffects include skin dryness pruritusnausea photodrug reactions diseaseexacerbation (eg systemic lupus ery-thematosus) and disease induction (egpolymorphous light eruption) Long-term health effects include skin agingeffects on the eye (eg cataract forma-tion) and carcinogenesis7

ARTIFICIAL TANNING ISCARCINOGENIC

In 2006 the International Agency forResearch on Cancer (a branch of theWorld Health Organization) issued areport1 based on meta-analysis of 19studies of associations between tanning-bed use and skin cancer risk On thebasis of these data in 2009 the In-ternational Agency for Research onCancer declared that UVR from salonswas a group 1 carcinogen (ie known tocause cancer in humans)23 These find-ings were criticized by some because ofthe weak association and inability to

FIGURE 1Trends in melanoma incidence and mortality among young adults Age-adjusted (to 2000 US population)annual cutaneous melanoma incidence and mortality rates among Caucasian males and females aged15ndash39 years in the Surveillance Epidemiology and End Results Program areas from 1973 through 2004The segments of uniform trend from the best-fitting Joinpoint models are also shown (Reprinted withpermission from Purdue MP Beane Freeman LE Anderson WF Tucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasian young adults J Invest Dermatol 20081282906)

774 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

confirm a dose-response relationshipor examine exposure to specific tan-ning devices Since then new studieshave strengthened the association oftanning-bed use with increased mela-noma risk (Table 1) In 2012 a meta-analysis of 27 observational studiesshowed that for users of indoor tan-ning devices the risk of melanoma in-creased 20 which doubled if tanningstarted when users were younger than35 years9

WHY PEOPLE TAN

Despite evidence that UVR exposure in-creasesskincancerriskpeoplecontinue

to intentionally tan Knowledge aboutthe dangers of UVR often does notchange tanning behavior2425 Thesepractices may persist because manypeople believe that a tanned appear-ance is attractive and healthy In 1study 678 of youth agreed with thestatement ldquoI look better when I havea tanrdquo and 55 agreed with thestatement ldquoI feel healthy when I havea nice tanrdquo26 In addition to the desirefor improved appearance motivationsin some tanners include relaxationand a better mood In view of poten-tially severe consequences it has beenpostulated that continued and fre-quent use of tanning beds shares

characteristics with addictive disorders27

and that for some individuals tanningbehavior may be motivated at least inpart by a type of UV light substance-related disorder

To characterize possible tanning ad-diction researchers have used surveysthat included tanning-specific modifi-cations of 2 established instrumentsThe CAGE (Cut down Annoyed GuiltyEye-opener) Questionnaire screensfor alcohol abuse or dependenceModifications include questions aboutwhether tanners wanted to cut downbut nevertheless continued and whethertanners felt annoyed when others ad-vised them not to tan The second in-strument uses a modification of theAmerican Psychiatric AssociationrsquosDiagnostic and Statistical Manual ofMental Disorders Fourth Edition TextRevision criteria for substance-relateddisorders Questions include toler-ance to tanning (ie need for increasedamounts of tanning to achieve a de-sired effect) withdrawal symptomsand loss of control such as use despitea desire to cut down Table 2 describessome studies of tanning addiction

A small study found increased plasmaconcentrations of b-endorphin afterUVR exposure in frequent tanners28

Other studies have not observed suchelevations2930 Blood endorphin concen-trations appear to fluctuate throughthe day so these studies might belimited and more research is neededIt is interesting to consider whether anendorphin-mediated addictive mecha-nism might have conferred an advan-tage to human survival UVR exposureresults in conversion of vitamin D pre-cursors in skin to vitamin D adequatevitamin D is needed to ensure humansurvival31 Among the cleavage prod-ucts of POMC are the glucocorticoidprecursor adrenocorticotropic hormone(ACTH) andb-endorphin an endogenousligand of the m-opioid receptor Endog-enous b-endorphin exerts analgesic

FIGURE 2Molecular Mechanism of Skin Pigmentation Induced by UV Radiation Ultraviolet light triggers DNAdamage in the nucleus of keratinocytes resulting in the activation of p53 which transcriptionallyup-regulates the expression of the gene encoding proopiomelanocortin (POMC) POMC is post-translationally processed to produce melanocyte-stimulating hormone (MSH) and b-endorphin Aftersecretion MSH acts on its receptor the melanocortin 1 receptor located on melanocytes at the basallayer of the epidermis thereby inducing the production of pigment which is subsequently transportedout of melanocytes to overlying keratinocytes where the pigment vesicles coalesce over the sun-exposed side of the nucleus resulting in tanning (Reprinted with permission from Fisher DE JamesWD Indoor tanningmdashscience behavior and policy N Engl J Med 2010363902)

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 775 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE1

Studiesof

Tanning-BedUseandMelanom

aRisk

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Theassociationofuseof

sunbedswith

cutaneous

malignant

melanom

aand

otherskincancersa

system

aticreview

(2006)

1

Meta-analysisof19

studiesthat

exam

ined

associations

between

useofan

artificialtanningdevice

(ldquosunbedrdquo)andskincancer

risk

A15increase

inmelanom

arisk

(95

CI100131)for

thosewho

ever

used

asunbed

compared

with

thosewho

neverdidno

consistent

evidence

ofadose-

response

relationship

RRofmelanom

agreaterwith

first

usebefore

age35

(sum

maryRR

basedon

7studies17595

CI

135226)

Basedon

findingsthe

IARC

declared

thatartificialUVRis

agroupAcarcinogen

AustralianMelanom

aFamily

Study(2011)

64Population-basedcase-control

family

studyofearly-onset

melanom

a

604casesdiagnosedbetweenages

18and39479

controls

Comparedwith

neverusingOR

for

melanom

aassociated

with

ever

usingsunbed

=141(95

CI101

196)and

201

(95

CI122331)

for10

lifetimesessions

(Ptrend=

01with

cumulativeuse)

Stronger

associationforearlier

ageat

firstu

se(P

trend=02)

also

formelanom

adiagnosed

at18ndash29

y(ORfor10

lifetime

sessions65795CI141

3049)

than

formelanom

adiagnosedat30ndash39

y(OR160

95CI092277P

interaction=01)

Amongthosewho

ever

used

asunbed

andwerediagnosed

between18

and29

y76of

melanom

asattributableto

sunbed

use

Indoor

tanningandrisk

ofmelanom

aacase-control

studyinahighlyexposed

population(2010)

65

Case-controlstudyinMinnesota

1167

melanom

acases1101

controlsages

25ndash59

y63ofcasesand51ofcontrols

everindoor

tanned

(adjustedOR

17495

CI142214)Risk

increasedinbothusersofUV-Bndash

enhanced

(adjustedOR

286

95CI203403)andprimarily

UV-Andashem

ittingdevices(adjusted

OR44495CI245802)

Greaterrisk

associated

with

greaterusewhenexam

ined

with

regard

toyearsofexposure

(P

006)hours(P

0001)

orsessions

(P=0002)

ORselevated

withineach

initiation

agecategoryyearsofuseam

ong

indoor

tannerswas

more

relevant

formelanom

adevelopm

ent

Authorsconcludedthatfrequent

indoor

tanningincreased

melanom

arisk

independentof

outdoorsunexposure

and

regardless

ofagewhentanning

began

Norw

egian-Sw

edishWom

enrsquos

LifestyleandHealth

Cohort

study(2010)

66

Prospectivecohortstudy

established1991ndash1992Subjects

inNorw

aycamefrom

nationw

iderandom

sampleof

100000wom

enborn

1943ndash1957

SubjectsinSw

eden

were96

000

random

lyselected

wom

enborn

1943ndash1962

Researchersexam

ined

subjectsrsquo

responsesabouth

ostfactors

sunexposure

andsolarium

(iesunbed

orsunlam

p)use

through5agedecades(

10

10ndash1920ndash2930ndash3940ndash49

y)

Among106366wom

enwith

completefollow-upthrough

2005412

melanom

acaseswere

diagnosedRisk

increasedwith

thenumberofsunburns

and

bathingvacations

inthefirst3

agedecades(P

trend

04)

Comparedwith

ldquonouserdquo

ofasolarium

inthe3decadesfrom

10to

39yRR

sincreasedfrom

124

forldquorarelyuserdquo

inany

decade

to138

forldquouse

1or

moretim

espermonth

in1of3

decadesrdquo

to237

forldquouse

1or

moretim

espermonth

in2or

3decadesrdquo

(Ptrend=003)

Authorsconcludedthatmelanom

arisk

seem

stocontinue

toincrease

with

accumulating

interm

ittentsun

exposure

and

solarium

useinearlyadulthood

Peoplewith

neviandredhair

wereatparticular

risk

for

developing

melanom

a

Cutaneousmelanom

aattributableto

sunbed

use

system

aticreview

andmeta-

analysis(2012)

9

Meta-analysisof27

observational

studiesofsunbed

use

Everuseofsunbedsassociatedwith

summaryR

Rof120

(95

CI108

134)

Calculations

fordose-response

show

eda18

(95

CI038)

increase

inrisk

ofmelanom

afor

each

additionalsession

ofsunbed

useperyear

Studyconfirm

sdoublingof

melanom

arisk

whenfirstuse

atayoungage(

35y)

Dose-responserelationshipfound

betweenam

ount

ofuseand

melanom

ariskInEurope

each

year3438estim

ated

newcases

ofmelanom

aduetosunbed

use

mostamongwom

en

CIconfidenceintervalIARCInternationalAgencyforResearch

onCancerORodds

ratioRRrelativeriskUVRUVradiation

776 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 4: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

confirm a dose-response relationshipor examine exposure to specific tan-ning devices Since then new studieshave strengthened the association oftanning-bed use with increased mela-noma risk (Table 1) In 2012 a meta-analysis of 27 observational studiesshowed that for users of indoor tan-ning devices the risk of melanoma in-creased 20 which doubled if tanningstarted when users were younger than35 years9

WHY PEOPLE TAN

Despite evidence that UVR exposure in-creasesskincancerriskpeoplecontinue

to intentionally tan Knowledge aboutthe dangers of UVR often does notchange tanning behavior2425 Thesepractices may persist because manypeople believe that a tanned appear-ance is attractive and healthy In 1study 678 of youth agreed with thestatement ldquoI look better when I havea tanrdquo and 55 agreed with thestatement ldquoI feel healthy when I havea nice tanrdquo26 In addition to the desirefor improved appearance motivationsin some tanners include relaxationand a better mood In view of poten-tially severe consequences it has beenpostulated that continued and fre-quent use of tanning beds shares

characteristics with addictive disorders27

and that for some individuals tanningbehavior may be motivated at least inpart by a type of UV light substance-related disorder

To characterize possible tanning ad-diction researchers have used surveysthat included tanning-specific modifi-cations of 2 established instrumentsThe CAGE (Cut down Annoyed GuiltyEye-opener) Questionnaire screensfor alcohol abuse or dependenceModifications include questions aboutwhether tanners wanted to cut downbut nevertheless continued and whethertanners felt annoyed when others ad-vised them not to tan The second in-strument uses a modification of theAmerican Psychiatric AssociationrsquosDiagnostic and Statistical Manual ofMental Disorders Fourth Edition TextRevision criteria for substance-relateddisorders Questions include toler-ance to tanning (ie need for increasedamounts of tanning to achieve a de-sired effect) withdrawal symptomsand loss of control such as use despitea desire to cut down Table 2 describessome studies of tanning addiction

A small study found increased plasmaconcentrations of b-endorphin afterUVR exposure in frequent tanners28

Other studies have not observed suchelevations2930 Blood endorphin concen-trations appear to fluctuate throughthe day so these studies might belimited and more research is neededIt is interesting to consider whether anendorphin-mediated addictive mecha-nism might have conferred an advan-tage to human survival UVR exposureresults in conversion of vitamin D pre-cursors in skin to vitamin D adequatevitamin D is needed to ensure humansurvival31 Among the cleavage prod-ucts of POMC are the glucocorticoidprecursor adrenocorticotropic hormone(ACTH) andb-endorphin an endogenousligand of the m-opioid receptor Endog-enous b-endorphin exerts analgesic

FIGURE 2Molecular Mechanism of Skin Pigmentation Induced by UV Radiation Ultraviolet light triggers DNAdamage in the nucleus of keratinocytes resulting in the activation of p53 which transcriptionallyup-regulates the expression of the gene encoding proopiomelanocortin (POMC) POMC is post-translationally processed to produce melanocyte-stimulating hormone (MSH) and b-endorphin Aftersecretion MSH acts on its receptor the melanocortin 1 receptor located on melanocytes at the basallayer of the epidermis thereby inducing the production of pigment which is subsequently transportedout of melanocytes to overlying keratinocytes where the pigment vesicles coalesce over the sun-exposed side of the nucleus resulting in tanning (Reprinted with permission from Fisher DE JamesWD Indoor tanningmdashscience behavior and policy N Engl J Med 2010363902)

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 775 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE1

Studiesof

Tanning-BedUseandMelanom

aRisk

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Theassociationofuseof

sunbedswith

cutaneous

malignant

melanom

aand

otherskincancersa

system

aticreview

(2006)

1

Meta-analysisof19

studiesthat

exam

ined

associations

between

useofan

artificialtanningdevice

(ldquosunbedrdquo)andskincancer

risk

A15increase

inmelanom

arisk

(95

CI100131)for

thosewho

ever

used

asunbed

compared

with

thosewho

neverdidno

consistent

evidence

ofadose-

response

relationship

RRofmelanom

agreaterwith

first

usebefore

age35

(sum

maryRR

basedon

7studies17595

CI

135226)

Basedon

findingsthe

IARC

declared

thatartificialUVRis

agroupAcarcinogen

AustralianMelanom

aFamily

Study(2011)

64Population-basedcase-control

family

studyofearly-onset

melanom

a

604casesdiagnosedbetweenages

18and39479

controls

Comparedwith

neverusingOR

for

melanom

aassociated

with

ever

usingsunbed

=141(95

CI101

196)and

201

(95

CI122331)

for10

lifetimesessions

(Ptrend=

01with

cumulativeuse)

Stronger

associationforearlier

ageat

firstu

se(P

trend=02)

also

formelanom

adiagnosed

at18ndash29

y(ORfor10

lifetime

sessions65795CI141

3049)

than

formelanom

adiagnosedat30ndash39

y(OR160

95CI092277P

interaction=01)

Amongthosewho

ever

used

asunbed

andwerediagnosed

between18

and29

y76of

melanom

asattributableto

sunbed

use

Indoor

tanningandrisk

ofmelanom

aacase-control

studyinahighlyexposed

population(2010)

65

Case-controlstudyinMinnesota

1167

melanom

acases1101

controlsages

25ndash59

y63ofcasesand51ofcontrols

everindoor

tanned

(adjustedOR

17495

CI142214)Risk

increasedinbothusersofUV-Bndash

enhanced

(adjustedOR

286

95CI203403)andprimarily

UV-Andashem

ittingdevices(adjusted

OR44495CI245802)

Greaterrisk

associated

with

greaterusewhenexam

ined

with

regard

toyearsofexposure

(P

006)hours(P

0001)

orsessions

(P=0002)

ORselevated

withineach

initiation

agecategoryyearsofuseam

ong

indoor

tannerswas

more

relevant

formelanom

adevelopm

ent

Authorsconcludedthatfrequent

indoor

tanningincreased

melanom

arisk

independentof

outdoorsunexposure

and

regardless

ofagewhentanning

began

Norw

egian-Sw

edishWom

enrsquos

LifestyleandHealth

Cohort

study(2010)

66

Prospectivecohortstudy

established1991ndash1992Subjects

inNorw

aycamefrom

nationw

iderandom

sampleof

100000wom

enborn

1943ndash1957

SubjectsinSw

eden

were96

000

random

lyselected

wom

enborn

1943ndash1962

Researchersexam

ined

subjectsrsquo

responsesabouth

ostfactors

sunexposure

andsolarium

(iesunbed

orsunlam

p)use

through5agedecades(

10

10ndash1920ndash2930ndash3940ndash49

y)

Among106366wom

enwith

completefollow-upthrough

2005412

melanom

acaseswere

diagnosedRisk

increasedwith

thenumberofsunburns

and

bathingvacations

inthefirst3

agedecades(P

trend

04)

Comparedwith

ldquonouserdquo

ofasolarium

inthe3decadesfrom

10to

39yRR

sincreasedfrom

124

forldquorarelyuserdquo

inany

decade

to138

forldquouse

1or

moretim

espermonth

in1of3

decadesrdquo

to237

forldquouse

1or

moretim

espermonth

in2or

3decadesrdquo

(Ptrend=003)

Authorsconcludedthatmelanom

arisk

seem

stocontinue

toincrease

with

accumulating

interm

ittentsun

exposure

and

solarium

useinearlyadulthood

Peoplewith

neviandredhair

wereatparticular

risk

for

developing

melanom

a

Cutaneousmelanom

aattributableto

sunbed

use

system

aticreview

andmeta-

analysis(2012)

9

Meta-analysisof27

observational

studiesofsunbed

use

Everuseofsunbedsassociatedwith

summaryR

Rof120

(95

CI108

134)

Calculations

fordose-response

show

eda18

(95

CI038)

increase

inrisk

ofmelanom

afor

each

additionalsession

ofsunbed

useperyear

Studyconfirm

sdoublingof

melanom

arisk

whenfirstuse

atayoungage(

35y)

Dose-responserelationshipfound

betweenam

ount

ofuseand

melanom

ariskInEurope

each

year3438estim

ated

newcases

ofmelanom

aduetosunbed

use

mostamongwom

en

CIconfidenceintervalIARCInternationalAgencyforResearch

onCancerORodds

ratioRRrelativeriskUVRUVradiation

776 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 5: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

TABLE1

Studiesof

Tanning-BedUseandMelanom

aRisk

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Theassociationofuseof

sunbedswith

cutaneous

malignant

melanom

aand

otherskincancersa

system

aticreview

(2006)

1

Meta-analysisof19

studiesthat

exam

ined

associations

between

useofan

artificialtanningdevice

(ldquosunbedrdquo)andskincancer

risk

A15increase

inmelanom

arisk

(95

CI100131)for

thosewho

ever

used

asunbed

compared

with

thosewho

neverdidno

consistent

evidence

ofadose-

response

relationship

RRofmelanom

agreaterwith

first

usebefore

age35

(sum

maryRR

basedon

7studies17595

CI

135226)

Basedon

findingsthe

IARC

declared

thatartificialUVRis

agroupAcarcinogen

AustralianMelanom

aFamily

Study(2011)

64Population-basedcase-control

family

studyofearly-onset

melanom

a

604casesdiagnosedbetweenages

18and39479

controls

Comparedwith

neverusingOR

for

melanom

aassociated

with

ever

usingsunbed

=141(95

CI101

196)and

201

(95

CI122331)

for10

lifetimesessions

(Ptrend=

01with

cumulativeuse)

Stronger

associationforearlier

ageat

firstu

se(P

trend=02)

also

formelanom

adiagnosed

at18ndash29

y(ORfor10

lifetime

sessions65795CI141

3049)

than

formelanom

adiagnosedat30ndash39

y(OR160

95CI092277P

interaction=01)

Amongthosewho

ever

used

asunbed

andwerediagnosed

between18

and29

y76of

melanom

asattributableto

sunbed

use

Indoor

tanningandrisk

ofmelanom

aacase-control

studyinahighlyexposed

population(2010)

65

Case-controlstudyinMinnesota

1167

melanom

acases1101

controlsages

25ndash59

y63ofcasesand51ofcontrols

everindoor

tanned

(adjustedOR

17495

CI142214)Risk

increasedinbothusersofUV-Bndash

enhanced

(adjustedOR

286

95CI203403)andprimarily

UV-Andashem

ittingdevices(adjusted

OR44495CI245802)

Greaterrisk

associated

with

greaterusewhenexam

ined

with

regard

toyearsofexposure

(P

006)hours(P

0001)

orsessions

(P=0002)

ORselevated

withineach

initiation

agecategoryyearsofuseam

ong

indoor

tannerswas

more

relevant

formelanom

adevelopm

ent

Authorsconcludedthatfrequent

indoor

tanningincreased

melanom

arisk

independentof

outdoorsunexposure

and

regardless

ofagewhentanning

began

Norw

egian-Sw

edishWom

enrsquos

LifestyleandHealth

Cohort

study(2010)

66

Prospectivecohortstudy

established1991ndash1992Subjects

inNorw

aycamefrom

nationw

iderandom

sampleof

100000wom

enborn

1943ndash1957

SubjectsinSw

eden

were96

000

random

lyselected

wom

enborn

1943ndash1962

Researchersexam

ined

subjectsrsquo

responsesabouth

ostfactors

sunexposure

andsolarium

(iesunbed

orsunlam

p)use

through5agedecades(

10

10ndash1920ndash2930ndash3940ndash49

y)

Among106366wom

enwith

completefollow-upthrough

2005412

melanom

acaseswere

diagnosedRisk

increasedwith

thenumberofsunburns

and

bathingvacations

inthefirst3

agedecades(P

trend

04)

Comparedwith

ldquonouserdquo

ofasolarium

inthe3decadesfrom

10to

39yRR

sincreasedfrom

124

forldquorarelyuserdquo

inany

decade

to138

forldquouse

1or

moretim

espermonth

in1of3

decadesrdquo

to237

forldquouse

1or

moretim

espermonth

in2or

3decadesrdquo

(Ptrend=003)

Authorsconcludedthatmelanom

arisk

seem

stocontinue

toincrease

with

accumulating

interm

ittentsun

exposure

and

solarium

useinearlyadulthood

Peoplewith

neviandredhair

wereatparticular

risk

for

developing

melanom

a

Cutaneousmelanom

aattributableto

sunbed

use

system

aticreview

andmeta-

analysis(2012)

9

Meta-analysisof27

observational

studiesofsunbed

use

Everuseofsunbedsassociatedwith

summaryR

Rof120

(95

CI108

134)

Calculations

fordose-response

show

eda18

(95

CI038)

increase

inrisk

ofmelanom

afor

each

additionalsession

ofsunbed

useperyear

Studyconfirm

sdoublingof

melanom

arisk

whenfirstuse

atayoungage(

35y)

Dose-responserelationshipfound

betweenam

ount

ofuseand

melanom

ariskInEurope

each

year3438estim

ated

newcases

ofmelanom

aduetosunbed

use

mostamongwom

en

CIconfidenceintervalIARCInternationalAgencyforResearch

onCancerORodds

ratioRRrelativeriskUVRUVradiation

776 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 6: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

TABLE2

Studiesof

TanningAddiction

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

UVlight

tanningas

atype

ofsubstance-relateddisorder

(2005)

25

Conveniencesample

InGalvestonTX145

beachgoers

$18

yinterviewed

with

theuseof

modifications

oftheCAGE

(mCAGE)andDSM-IV

(mDSM-IV-

TR)instrumentsTwoor

more

affirm

ativeresponsesto

questions

onmCAGE

and$3

affirm

ativeresponsestomDSM-

IV-TRduring

thesame12-mo

period

wererespectively

tabulatedas

evidence

forUVL

tanningdependence

26of145(18

)screenedpositiveon

both

measures63

(43

)screened

positiveon

1measure

PositivemDSM-IV-TRsubjects22

times

morelikelythan

negative

mDSM-IV-TRsubjectstogo

tothe

beachto

tan(P

=05)

Subjectsscreeningpositiveon

mCAGE

were22tim

esmorelikely

than

negativemCAGE

subjectsto

gotothebeachtotan(P

=08)

Wom

enwere55tim

esmorelikely

than

men

(P

001)andyoung

people(ages18ndash25

y)were31

times

morelikelythan

older

people(age

$36

y)(P=04)togo

tothebeachtotan

Authorsconcludedthatthosewho

chronically

andrepeatedly

exposedthem

selves

toUVRtotan

mayhaveaUVRsubstance-related

disorder

Addictiontoindoor

tanningrelation

toanxietydepressionand

substanceuse(2010)

67

Survey

of229college

studentswho

hadtanned

indoors

CAGE

andDSM-IV-TRquestionnaires

modified

toassesstheprevalence

oftanningaddictionandits

associationwith

substanceuse

andsymptom

sofanxietyand

depression

70of229(31

)metCAGE

criteriaand

90of229(39

)metDSM-IV-TR

criteriaforaddictiontoindoor

tanning

Tannerswho

metmodified

DSM-IV-TR

andCAGE

criteriaforaddictionto

indoor

tanningreported

significantlygreatersymptom

sof

anxietyand

greateru

seofalcohol

marijuanaandothersubstances

than

respondentsnotm

eetingthe

criteria

Authorssuggestedthatforsome

individualsinterventions

toreduce

skincancer

risk

should

addressaddictivequalities

ofindoor

tanningandthe

relationshipofindoor

tanningto

otheraddictions

andaffective

disturbances

Addictive-likebehaviours

toultravioletlight

amongfrequent

indoor

tanners(2010)2

7

InDallasTXsurveyof100frequent

($3tim

esweekly)indoor

tanners

Modifications

ofCAGE

andDSM-IV-TR

instruments

41metcriteriaconsistent

with

ldquotanning

addictivedisorderrdquoand

another33metcriteriafor

ldquoproblem

atictanningbehaviorrdquo

Femalegender

andearlyageof

tanningonsetw

ereassociated

with

meetingtanningaddiction

criteria

Authorssuggestedthatfindings

are

similartostudiesshow

ingthat

earlyageatfirstalcoholnicotine

andcannabisuseisarisk

factor

forsubsequent

developm

entof

therespectivesubstance-related

disorder

Ultravioletexposureisareinforcing

stimulus

infrequentindoor

tanners(2004)6

8

Double-blindcontrolleddesign

todeterm

inewhether

therewas

aphysiologicpreference

forUVL

comparedwith

non-UVL

14frequentadulttannersexposedto

either

acommerciallyavailable

tanningbedor

toidentically

appearingbedwith

acrylic

filter

thatpreventedthetransm

ission

ofUVL(ieldquoshamlightrdquo)

Frequent

tannersexhibited

overwhelmingpreference

(95

)forUV-emittingtanningbeds

Subjectsreported

amorerelaxed

andless

tensemoodafterUVR

exposure

comparedwith

after

non-UVRexposure

Results

suggestthatUV

tanning

might

have

reinforcing

properties

Inductionofwithdraw

al-like

symptom

sinasm

allrandomized

controlledtrialofopioidblockade

infrequent

tanners(2006)6

9

Random

ized

controlledtrial

comparing

reactions

toopioid

antagonistnalaxone

givento

frequent

andinfrequent

salon

tanners

Naloxone

givento8frequent

salon

tannersand8peoplewho

were

infrequent

tanners

Withdraw

al-like

symptom

sinduced

in4of8frequentsalontannersno

symptom

soccurred

in8

infrequent

tanners

Authorsdiscussedpossibilitythat

cutaneousendorphinrelease

resulting

from

UVLexposure

may

beinvolved

inreinforcing

propertyoftanningleadingsome

individualstoseek

tanning

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 777 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

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PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

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ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 7: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

effects and promotes feelings of re-laxation and well-being similar to ex-ogenous opiates such as morphine Itis thought that selection for fair skinand poor tanning ability was associ-ated with migration of human pop-ulations to high-latitude geographiclocations (with limited UV exposureespecially during winter months) It ispossible that endorphin release mayhave evolved to reward behaviors thataugment UV exposure and vitamin Dacquisition32

HOW TANNING DEVICES AREREGULATED

The US Food and Drug Administration(FDA) is the agency responsible forensuring the safety and efficacy ofmedical devices and products thatemit radiation and thus regulates themanufacturers of tanning equipment2

The FDA established classifications forsim1700 different generic types of devi-ces each of which is assigned to 1 of 3regulatory classes on the basis of thelevel of control necessary to ensurethat the device is safe and effective Theclass to which a device is assigneddetermines among other things thetype of premarketing submission andapplication required for FDA clearanceto market Classification is also basedon the risk posed to the patient andoruser33 Table 3 summarizes FDA regu-latory classes

Concerns have been expressed thattanning beds are misclassified andneed stronger regulation and scrutinyOn March 25 2010 the General andPlastic Surgery Devices Panel of theFDA Center for Devices and RadiologicHealth Medical Devices Advisory Com-mittee convened a public meeting todiscuss tanning devices Scientificinformation was presented about therisks posed from intentional UVR ex-posure through tanning lamps Medicalorganizations urged the FDA to reclas-sify indoor tanning devices and to pass

federal restrictions concerning theiruse The Indoor Tanning Association(ITA an industry advocacy group) pre-sented counterarguments The FDAcontinues to deliberate about possiblereclassification

Manufacturers of indoor tanning equip-ment are required to adhere to FDArequirements for sunlamp specifica-tions posting of warning labels34 andprovision of eye protection6 The stan-dard requires manufacturers to providean exposure schedule in the productwarning label34 The FDA recommendsthat the exposure schedule for usersdepends on the userrsquos skin type34 TheFDA recommends but does not requireor enforce35 an exposure schedule notexceeding a 075 minimal erythemaldose (defined as a dose resulting inminimal pinkness) 3 times during thefirst week of tanning gradually in-creasing exposure after the first weekthen gradually increasing exposure thefollowing weeks until maximum tan-ning has occurred (sim4 weeks total)and then providing for maintenance ofa tan by biweekly or weekly exposuresof up to 4 minimal erythemal doses34

There are limitations on the amount ofUV-C emitted but no regulation on theamount of UV-A and UV-B Because theproportion varies consumers may notbe able to predict the outcome of aparticular tanning session6

THE TANNING INDUSTRY

The indoor tanning industry has grownsubstantially over several decades andcomprises 19 000 businesses employ-ing 160 000 individuals according toindustry information36 According tothe ITA sim10 of the American publicvisits an indoor tanning facility eachyear36 This percentage is dramaticallyhigher for female teens and youngwomen The mission of the ITA is ldquotoprotect the freedom of individuals toacquire a suntan via natural or artificiallightrdquo37 The ITA claims that melanoma isTA

BLE2

Continued

Name

StudyType

StudyPopulationMethods

MainFindings

OtherFindings

Comment

Activationofthemesostriatal

rewardpathway

with

exposure

toUV

radiation(UVR)vsshamUVR

infrequent

tannersapilotstudy

(2012)7

0

Smallstudy

assessingeffectsof

commerciallyavailabletanning

bedon

regionalcerebralblood

flow

(ameasure

ofbrainactivity)

byusingsingle-photonem

ission

computedtomography

7frequent

salontannersplaced

underaUV-AUV-Btanninglight

during

2sessions1

sessionwith

UVRandotherwith

sham

UVR

Before

turningon

tanninglamps

subjectsaskedtorateldquoHow

much

youfeelliketanningrightnowrdquo

from

ldquoNot

atallrdquotolsquordquoMorethan

Iever

haverdquoOrderofsessions

random

ized

andsubjectsblinded

tostudyorder

During

UVRsessionrelativetosham

UVRsessionsubjectsshow

edrelativeincrease

inregional

cerebralbloodflow

ofdorsal

striatum

anteriorinsulaand

medialorbitofrontalcortexbrain

regionsassociated

with

experience

ofreward

Thesechangesaccompanied

bydecrease

insubjectivedesire

totanafterUVRexposure

butnot

aftersham

UVRWhenasked

which

bedwas

preferredmost

subjectsselected

theUVRsession

rather

than

sham

session

Authorsdiscussedassociations

betweensomederm

atologicand

psychiatricdisordersand

suggestedthatUVRmay

have

centrally

rewarding

properties

thatencourageexcessivetanning

CAGECutdownAnnoyedGuiltyEye-opener

Questionnaire

(see

text)DSM-IV-TRAm

erican

PsychiatricAssociationrsquosDiagnosticandStatisticalManualofM

entalDisordersFourthEditionTextRevisionmCagem

odified

CAGE

questionnairem

DSM-IV-TR

American

PsychiatricAssociationrsquosmodified

DiagnosticandStatisticalManualofM

entalD

isordersFourthEditionTextRevisionUVLUVlight

778 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 8: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

not a problem of the young and thattanning at an early age does not in-crease melanoma risk and makes otherclaims of purported benefits Table 4lists some of these claims and theevidence-based arguments used by childhealth advocates to counter them

TANNING INDUSTRY FALSE CLAIMSAND DECEPTIVE PRACTICES

The US Federal Trade Commission (FTC)investigates false and deceptive ad-vertising claims such as the claim thattanning in salons is safer than tanningoutdoors The commission files a com-plaint when it has ldquoreason to believerdquothat the law has been or is being vio-lated The FTC has the power to issueconsent orders to ban further decep-tion38 The FTC issued a complaintagainst the ITA alleging that in March2008 the ITA launched an advertisingcampaign portraying indoor tanningas safe and beneficial The campaignincluded 2 national newspaper adstelevision and video advertising 2 Websites a communications guide andpoint-of-sale materials that were pro-vided to ITA members The ITA claimedthat indoor tanning was safer thanoutdoor tanning because the amount

of UVR is monitored and controlled andthat it neither increased skin cancerrisk nor posed a danger to consumersThe ITA also claimed that researchshowed that vitamin D supplementsmay harm the bodyrsquos ability to fightdisease and that a study from the Na-tional Academy of Sciences determinedthat ldquothe risks of not getting enoughultraviolet light far outweigh the hypo-thetical risk of skin cancerrdquo The ITAstated that indoor tanning is approvedby the government misrepresentingthe nature of FDA approval In January2010 the FTC issued a consent orderand the ITA agreed to a settlement bar-ring it from any further deception3839

In 2012 a minority investigative reportcommissioned by 4 Democratic mem-bers of the USHouse of RepresentativesCommittee on Energy and Commercedescribed results of ldquostingrdquo telephonecalls made by congressional staff to300 tanning salons nationwide Con-gressional staff posed as 16-year-oldwomen wanting to tan for the firsttime On the basis of answers given bysalon workers the report concludedthat salons target teenage girls withadvertising and promotions deny knownrisks of indoor tanning provide false

information on benefits of tanning andfail to follow FDA recommendations ontanning frequency40 The tanning industryquestioned the veracity of the study andconclusions but acknowledged that theycould improve on giving accurate andconsistent information to customers41

FEDERAL LEGISLATION

Regulation of the tanning industry hasbeen lax2 As of February 2013 there isas yet no federal legislation prohibitingminors from tanning in salons

As of July 1 2010 under the AffordableCare Act indoor tanning services werelevied with a 10 excise tax (the so-called tanning tax or tan tax) Tanningsalons are required to receive a pay-ment for indoor tanning servicesreport the tax quarterly and remit thetax to the Internal Revenue ServiceSunless tanning options such as spraytans and tanning lotions are not in-cluded The ldquotanning taxrdquo a part ofPresident Obamarsquos administrationrsquoshealth care overhaul plan is expectedto raise 27 billion dollars over the next10 years The indoor tanning industryexpressed vigorous opposition to thetanning tax42

TABLE 3 FDA Classification of Medical Devices

FDAClass

Examples Requirements Comment

I Tongue depressors elastic bandages indoortanning devices46

Class I devices present minimal potential for harmSubject to general controls to ensure safety andeffectiveness including registering with FDAproper branding and labeling and notifying FDAbefore marketing Subject to lsquolsquogoodmanufacturing practicersquorsquo requirements FDArequires manufacturers to consistently meetapplicable requirements for their safety andefficacy

Tanning beds used for cosmetic purposes arecategorized as class I with exemption 510(k)Manufacturersofdeviceswith thisexemptionnotrequired to give premarket notification to showsafety and efficacy and substantial equivalenceto other devices already in the market Tanningbeds also exempt from design controls thatrequire manufacturers to establish and validateadevelopmentprocess throughwhich thedesigncontrol documentationmust be available for FDAreview during a site inspection

II X-ray machines UV lamps used for dermatologicdisorders laser equipment used in surgeryand dermatology46

Require special controls that may include speciallabeling requirements mandatory performancestandards postmarket surveillance patientregistries and development and disseminationof guidance documents

III Replacement heart valves silicone gelndashfilledbreast implants and implantable cerebellarstimulators 46

Require additional information regarding safetyand effectiveness and require premarketapproval and scientific review

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 779 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 9: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

The Tanning Accountability and Notifi-cation (TAN) Act (HR 4767) was includedin FDA Amendments Act of 2007 The TANAct requires the FDA to conduct con-sumer testing to determine if warninglabels on commercial tanning beds arepositioned correctly and provide suf-ficient information pertaining to skincancer risk627

STATE AND LOCAL LEGISLATION

In 2009 Howard County Maryland wasthe first US jurisdiction to ban tanningfor minors under age 18 On October 82011 Californiarsquos Governor Brown signed

the first state law banning under-18salon tanning effective January 1 2012Vermont passed an under-18 ban inMay 2012 The City of Chicago did soin June 2012 and Springfield IL did soin September 2012 Currently 33 stateshave at least minimal legislation re-garding tanning by minors43

Despite the existence of state lawsresearchers and advocates have notedthat current laws appear to have limitedeffectiveness perhaps because moststatesrsquo policies permit use with pa-rental consent and no states had banson minors tanning when the study was

conducted It has been suggested thatmultipronged approaches are neededto reduce teensrsquo use of tanning salons44

ENFORCEMENT OF LEGISLATION

Researchers conducted a telephonesurvey of informants in states with in-door tanning legislation to assess en-forcement practices At the time of thesurvey 28 states had teen tanningregulations One respondent from themost populous city in each state wasinterviewed Licensure was required in22 of 28 cities Slightly less than halfof cities gave citations to facilities that

TABLE 4 Tanning Industry Claims and Responses

Industry Claim Response by Child Health Advocates

People using tanning beds are less likely to sunburn36 The ITAcontends that tanning bed users are less likely to spend timein the sun compared with people practicing ldquototalabstinencerdquo which ldquoultimately encourages abuserdquo and thattanning bed users are taught sun protection by tanning salonpersonnel 36

On the contrary strong tan-promoting attitudes drive teens to sunbathe intentionally anduse tanning beds Teens using tanning beds are more likely than those who do not usetanning beds to experience sunburns (76 vs 68)44 People who use tanning beds aremore likely to spend more time outdoors 71 and less likely to use sunscreen472 Olderteens who used tanning beds$10 times in the past year were more likely to have$3sunburns compared with teens who did not use tanning beds (28 vs 20 P = 001)4

Burning not tanning at an early age could increase skin cancerrisk later in life

Although individualswhoburnbefore tanningareat greater riskofmelanomapeoplewhodo not burn but tan also are at risk Case studies and case-control studies from allgeographic areas of the US show that melanoma occurs in people without establishedrisk factors (such as light skin that has a tendency to burn [type I and II] and high sunsensitivity) known to increase melanoma risk Twenty-one percent of melanomas inwomen occurred in those reporting no blistering sunburns between the ages of 15 and20 y 73 In Iowa 64 of melanomas occurred among individuals reporting no or mildsunburn74 In Washington State 85 of melanoma cases reported that they had eithera deep tan moderate tan or mild tan in response to chronic sun exposure 75 InConnecticut 30 of melanoma cases had medium skin as objectively measured byexamination of the inner aspect of the upper arm 76 56 of cases in California andMichigan reported nonndashsun-sensitive skin 77

Tanned skin is protective Abundant evidence suggests that melanoma risk is lower in darkly pigmented individuals(from birth) than in lightly pigmented ones However as described in the text UV-induced tanning canenhancemelanomarisk becauseof theuseof a knowncarcinogen(UVR) as the means to achieve pigmentation

A ldquoprevacationrdquo tan is protective Peoplemay visit a tanning salon to prepare the skin for a sunny vacation the ldquoprevacationtanrdquo thinking that a ldquobase tanrdquowill protect against subsequent skin damage during thevacation This leads to extra radiation before the vacation and also afterward becausepeople may use fewer sun-protection precautions during the vacation because ofamistaken belief that the tanwill protect them2 The prevacation tan results inminimalprotection (an estimated SPF of 3)8 and provides virtually no protection against sun-induced DNA damage2

Salon tanning is a good way to raise concentrations of vitamin Dthe ITA states ldquoThere is a growing body of well-conductedvalidated scientific research demonstrating that theproduction of the activated form of vitamin D is one of themosteffective ways the body controls abnormal cell growthrdquo 36

In fact in 2012 the US Preventive Services Task Force concluded that ldquothe current evidenceis insufficient to assess the balance of the benefits and harms of vitamin Dsupplementation with or without calcium for the primary prevention of cancer inadultsrdquo78 Given the enormous variables of geographic UV intensity daytime UVintensity variability skin pigmentation (darkness) and skin surface area exposed tosunlight it is virtually impossible to predict UV dose-responses capable of maintainingplasma vitamin D concentrations In contrast oral supplementation providesa reproducible and verifiable means

Tanning is a parentsrsquo rights issue and government should notinterfere

Laws to limit minorsrsquoaccess to tanning parlors should be considered in the same way aslaws that limit youth access to tobacco7980 Every state prohibits the purchase oftobacco products by those younger than 18 y some prohibit sales to those under 1979

Tanning and tobacco are carcinogenic and both are preventable exposures Thereforegovernments should act to protect young people from these known carcinogens

780 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 10: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

violated state law Approximately 32did not inspect tanning facilities forcompliance with state law another 32conducted inspections less than annuallyOf the 21 cities in states that had youthaccess laws approximately half penal-ized those salons with known violationsThe authors expressed concern aboutrelatively low rates of annual inspectionsand citations They recommended thatfuture studies assess whether legis-lation enforcement practices or bothaffect indoor tanning practices45

LEGISLATION IN OTHER COUNTRIES

Severalnationshavestrongantitanninglegislation In 2009 Brazil imposed atotal ban on the use and sale of tanningdevices for cosmetic purposes for theentire population46

In 2012 the state of New South Wales(population5 million) in Australia an-nounced a total ban by 201447 FranceGermany Austria and the United King-dom banned under-18 indoor tanningSouth Australia imposed a ban forthose younger than 18 and for anyonewith type I skin the type most sus-ceptible to skin cancer Finland allowsonly certain types of devices for indoortanning use and requires inspectionsto ensure that regulations are upheld46

RECOMMENDATIONS ABOUTTANNING LEGISLATION

The World Health Organization48 theAmerican Academy of Pediatrics49 theAmerican Academy of Dermatology50

the American Medical Association51

the Canadian Pediatric Society52 andothers recommend legislation to banminors younger than 18 years fromtanning in salons

PARENT INFLUENCES

Mothersrsquo behaviors and attitudes mayinfluence teen tanning practices Apopulation-based survey found that in-door tanning in the year before the sur-vey was 30 among 12- to 18-year-olds

whose caregiver also reported tanningindoors44 Investigators in Minneso-ta and Massachusetts conducted tele-phone surveys of adolescents aged 14to 17 years and their female parents orguardians to determine their role inteen tanning attitudes and practicesFemale parentsrsquo behavior concern aboutchildrenrsquos indoor tanning practices andpermissiveness were significant inde-pendent contributors to teen tanning53

In another study researchers sent ques-tionnaires to female college studentsto investigate whether first-time indoortanning with onersquos mother would in-fluence the frequency of tanning laterin life and whether it was associatedwith age of initiation Participants whoreported tanning with mothers duringtheir initial experience were 4 timesmore likely to be heavy current tannersthan those who initiated tanning aloneor with someone other than their mother(odds ratio 464 P 001) Participantswho tanned for the first time withmothers started tanning at a signifi-cantly earlier age than those whostarted tanning without mothers54

Additional research from national studiesis needed to determine the prevalence ofartificial tanning in mothers of teens

PARALLELS BETWEEN SMOKINGAND TANNING

Researchers and advocates from thedisciplines of tobacco control and in-door tanning met in November 2011 todiscusscommonchallengesandlessonsBy consensus participants agreed thatlegislative remedies must be soughtas part of comprehensive programsincluding the following higher taxeseducation for parents pediatricians andpolicymakers and counteradvertising torefute tanning industry claims

ROLE OF PEDIATRICIANS ANDOTHER CLINICIANS

Indoor tanning is practiced by as manyas 35 to 40 of white adolescent

girls It is estimated that 25 of mel-anomas observed in young womenmight be attributable to using tanningbeds55 It therefore stands to reasonthat pediatricians have an obligation todiscuss this potentially life-threateningpractice with families Although pedia-tricians are often considered trustedadvisors to families sometimes overyears and decades many do not takeopportunities to discuss indoor tanning56

This may be due in part to a generalview that skin cancer prevention isprimarily an issue for dermatologistsYet skin cancer prevention a lifelongeffort is clearly a pediatric issue aswell as a dermatology issue By the timea teen or young adult arrives in a der-matologistrsquos office to evaluate a sus-picious skin lesion (one that may bemelanoma) the opportunity for pre-vention may have been lost

Counseling by pediatricians to reduceUVR exposure is likely to result in be-havior change in some teens and fam-ilies In July 2012 the US PreventiveServices Task Force (USPSTF) publishedan update of their 2003 recommenda-tion regarding the effectiveness ofbehavioral counseling to prevent skincancer The USPSTF stated that therewas adequate evidence in the scientificliterature to conclude that counselingdelivered in the primary care settingcan moderately increase the use ofprotective behaviors for fair-skinnedpeople between the ages of 10 and24 years Successful counseling inter-ventions used messages about skincancer or about the effects of UVR ex-posure on appearance Appearance-focused messages succeeded in reducingintent to use indoor tanning among late-adolescent women Behavioral interven-tions were not associated with anyknown risks or harms The USPSTF thusrecommended counseling fair-skinnedchildren adolescents and young adultsabout minimizing their exposure to UVREvidence was not sufficient to conclude

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 781 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 11: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

that counseling resulted in behaviorchange in girls younger than age 10 orwomen older than 24 years57 Underthe Affordable Care Act the health in-surance reform legislation passed byCongress and signed into law by Pres-ident Obama on March 23 2010 coun-seling patients to avoid tanning beds(a recommendation receiving a ldquoBrdquorating from the USPSTF) is a coveredservice and thus is fully reimbursable58

The American Academy of Pediatricsand other organizations interested inpediatric health should consider in-terventions for the best methods intraining pediatricians in tanning-bedavoidance counseling as well as inform-ing them of the new covered service

Because teens begin to take up tanningat 13 to 14 years of age pediatriciansmay adopt a strategy of discussing in-door tanning at the 12-year-old well-child visit Most parents state that theydo not want their children to usetanning devices but most have notdiscussed tanning with their child59

Pediatricians may influence tanningpractices by inquiring about the moth-errsquos tanning practices and asking her ifshe has started discussions with herchild59 Interventions directed at themother may reduce her practicesand lead to reduced tanning initiationand frequency of the childrsquos tanning54

It should be noted that althoughparents may not approve of tanningindoors they may have adopted a ldquopickyour battlesrdquo strategy feeling it to bemore important to enforce rules onissues such as smoking or dating ratherthan focusing on tanning For someteens and their families this decisionmay have major health consequencesTable 5 lists some recommendationsfor integrating questions into practice

Considering the teenrsquos perspective abouttanning benefits may be helpful60

She may be an ldquoevent tannerrdquo pre-paring for a wedding or prom or maytan regularly as a mood enhancer or to

relieve stress61 Physicians may useopen-ended questions such as ldquoHowdoes having a tan make you feelrdquo togain insight and provide appropriateinterventions For ldquoevent tannersrdquopediatricians may suggest substitutingspray tanning or self-applied lotion togive a tanned appearance An eventtanner interested in appearance mayalso be receptive to information aboutindoor tanning as a cause of pre-mature skin aging For regular tannerswho do so to relax and improve moodphysicians may suggest substitutingrunning dancing or other aerobicactivities

Pediatricians have important rolesin advocating for state laws to pre-vent minors from accessing tanningsalons Legislators who are parentsand grandparents may be receptiveto a pediatricianrsquos voice particularlyif the pediatrician is the familyrsquos doc-tor State-specific legislation shouldconform to FDA recommendationsPediatricians also have a role at thefederal level working to change FDAclassification of indoor tanning devi-ces to class II or III and advocatingfor federal legislation to ban under-18access

Resources to help pediatricians ad-dress indoor tanning (akin to thosethat help clinicians discuss smokingcessation and secondhand smoke ex-posure) need to be developed Onemodel is the CEASE (Clinical EffortAgainst Secondhand Tobacco Exposure)Program developed to help clinicianscounsel about smoking cessation andharm reduction by using written andvideo materials62 Another is the Ameri-can Academy of Pediatricsrsquo Julius BRichmond Center which provides anarray of education training and toolsfor clinicians63 Resources are neededin academic settings especially inpediatric settings to train medicalstudents and residents Funding will beneeded for all these efforts

Research needs with regard to indoortanning have been identified Table 6lists some of these areas

CONCLUSIONS

Engaging families in discussions abouttanningbedsrepresentsauniqueandoneof few cancer prevention opportunities

TABLE 5 Recommendations forPediatricians Regarding TanningBeds

Recommendation

bull Aim to integrate discussions about exposure toUVR including tanning beds into annual well-child and well-adolescent visits

bull Discuss risks of artificial tanning with parents aswell as teens

bull Discuss prevention of sunburn and artificialtanning during ldquoteachable momentsrdquo such aswhen a teen (or her parent) presents with a tanor sunburn

bull Be aware that many teens will tan before specialevents such as a prom suggest spray tanning asan alternative if the teen is committed to lookingdarker

bull Add a question about indoor tanning if usingforms that are filled out by parents andor teensadd a prompt about discussing tanning-bed usein ldquoadolescent risk factorrdquo section whendesigning or modifying electronic medicalrecords for preteens and teens

bull Advocate for state legislation banning under-18salon tanning

bull Advocate for changes in federal legislationregarding classification of tanning salons and forbanning minorsrsquo access to tanning salons

TABLE 6 Next Research Tasks

Research Task

bull Investigate the possibility that tanning is addictivein some individuals and whether early-lifeexposure to artificial UVR raised the risk ofaddiction

bull Determine revenues raised by the ldquotanning taxrdquoand their allocation and explore redistribution toan educational fund

bull Track tanning industry claims and effect of the FTCconsent order particularly on industry Web sites

bull Establish the prevalence of teens tanning withtheir mothers

bull Establish where young women obtain indoortanning most often whether from indoor tanningsalons nonsalon sites such as beauty salons andfitness centers or places of residence

bull Determine best ways for pediatricians to discusssalon tanning with teens and parents includingbest ways to use electronic medical recordtechnology to do so

782 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 12: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

for pediatricians Evidence reveals thatcounseling is effective for youth andyoung persons aged 10 to 24 yearsDiscussions about UVR exposure in-cluding artificial tanning need to beintegrated into health maintenancevisits and should also occur at timeswhen a teen arrives in the office with

a tanned appearance or sunburn Areasonablemessage is to ldquolove the skinyoursquore inrdquo Pediatricians and derma-tologists should work together usingtheir knowledge and perspectives toadvocate for banning salon tanning forall minors It is difficult to justify rec-reational exposure to a known carcin-

ogen in any human population Thuschild health advocates are working toencourage both state and federal gov-ernments to ban minors from indoortanning A long-term goal is banningindoor tanning for adults as well asteens as has been done in Brazil andparts of Australia

REFERENCES

1 International Agency for Research on Can-cer Working Group on Artificial Ultraviolet(UV) Light and Skin cancer The associationof use of sunbeds with cutaneous malignantmelanoma and other skin cancers a sys-tematic review Int J Cancer 2007120(5)1116ndash1122

2 Levine JA Sorace M Spencer J Siegel DMThe indoor UV tanning industry a review ofskin cancer risk health benefit claims andregulation J Am Acad Dermatol 200553(6)1038ndash1044

3 Guy GP Jr Tai E Richardson LC Use ofindoor tanning devices by high schoolstudents in the United States 2009 PrevChronic Dis 20118(5)A116 Available atwwwcdcgovpcdissues2011sep10_0261htm Accessed February 12 2012

4 Geller AC Colditz G Oliveria S et al Use ofsunscreen sunburning rates and tanningbed use among more than 10 000 USchildren and adolescents Pediatrics 2002109(6)1009ndash1014

5 Hoerster KD Garrow RL Mayer JA et alDensity of indoor tanning facilities in 116large US cities Am J Prev Med 200936(3)243ndash246

6 Suarez A Dellavalle RP Robinson JK Indoortanning regulation enforcement taxationand policy In Heckman CJ Manne SJ edsShedding Light on Indoor Tanning SpringerNetherlands 2012

7 Balk SJ Council on Environmental HealthSection on Dermatology Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3) Available at wwwpediatricsorgcgicontentfull1273e791

8 Autier P Perspectives in melanoma pre-vention the case of sunbeds Eur J Cancer200440(16)2367ndash2376

9 Boniol M Autier P Boyle P Gandini S Cu-taneous melanoma attributable to sunbeduse systematic review and meta-analysisBMJ 2012345e4757 Available at wwwbmjcomcontent345bmje4757fullrss=1amputm_source=feedburneramputm_medium=feedamputm_campaign=Feed253A+bmj

252Frecent+28Latest+from+BMJ29 Ac-cessed July 29 2012

10 American Cancer Society What are the keystatistics about basal and squamous cellskin cancers Available at wwwcancerorgCancerSkinCancer-basalandSquamousCellDetailedGuideskin-cancer-basal-and-squamous-cell-key-statistics Accessed February 42013

11 Rogers HW Weinstock MA Harris AR et alIncidence estimate of nonmelanoma skincancer in the United States 2006 ArchDermatol 2010146(3)283ndash287

12 American Cancer Society What are the keystatistics about melanoma Available atwwwcancerorgCancerSkinCancer-MelanomaDetailedGuidemelanoma-skin-cancer-key-statistics Accessed February 4 2013

13 Wu X Groves FD McLaughlin CC Jemal AMartin J Chen VW Cancer incidence pat-terns among adolescents and young adultsin the United States Cancer Causes Con-trol 200516(3)309ndash320

14 Purdue MP Freeman LE Anderson WFTucker MA Recent trends in incidence ofcutaneous melanoma among US Caucasianyoung adults J Invest Dermatol 2008128(12)2905ndash2908

15 Reed KB Brewer JD Lohse CM Bringe KEPruitt CN Gibson LE Increasing incidenceof melanoma among young adults an epi-demiological study in Olmsted CountyMinnesota Mayo Clin Proc 201287(4)328ndash334

16 Christenson LJ Borrowman TA Vachon CMet al Incidence of basal cell and squamouscell carcinomas in a population youngerthan 40 years JAMA 2005294(6)681ndash690

17 Emmett AJ Surgical analysis and biologicalbehaviour of 2277 basal cell carcinomasAust N Z J Surg 199060(11)855ndash863

18 Scrivener Y Grosshans E Cribier B Varia-tions of basal cell carcinomas according togender age location and histopathologicalsubtype Br J Dermatol 2002147(1)41ndash47

19 Boyd AS Shyr Y King LE Jr Basal cell car-cinoma in young women an evaluation of

the association of tanning bed use andsmoking J Am Acad Dermatol 200246(5)706ndash709

20 Cui R Widlund HR Feige E et al Centralrole of p53 in the suntan response andpathologic hyperpigmentation Cell 2007128(5)853ndash864

21 Fisher DE James WD Indoor tanningmdashscience behavior and policy N Engl J Med2010363(10)901ndash903

22 Cokkinides V Weinstock M Lazovich DWard E Thun M Indoor tanning use amongadolescents in the US 1998 to 2004 Cancer2009115(1)190ndash198

23 The International Agency for Research onCancer Sunbeds and UV radiation Avail-able at wwwiarcfrenmedia-centreiarc-news2009sunbeds_uvradiationphp AccessedJanuary 15 2012

24 Monfrecola G Fabbrocini G Posteraro GPini D What do young people think aboutthe dangers of sunbathing skin cancer andsunbeds A questionnaire survey among Ital-ians Photodermatol Photoimmunol Photomed200016(1)15ndash18

25 Warthan MM Uchida T Wagner RF Jr UVlight tanning as a type of substance-relateddisorder Arch Dermatol 2005141(8)963ndash966

26 Cokkinides V Weinstock M Glanz K AlbanoJ Ward E Thun M Trends in sunburns sunprotection practices and attitudes towardsun exposure protection and tanning amongUS adolescents 1998-2004 Pediatrics 2006118(3)853ndash864

27 Harrington CR Beswick TC Leitenberger JMinhajuddin A Jacobe HT Adinoff BAddictive-like behaviours to ultraviolet lightamong frequent indoor tanners Clin ExpDermatol 201136(1)33ndash38

28 Kaur M Liguori A Fleischer AB Jr FeldmanSR Plasma beta-endorphin levels in fre-quent and infrequent tanners before andafter ultraviolet and non-ultraviolet stimuliJ Am Acad Dermatol 200654(5)919ndash920

29 Gambichler T Bader A Vojvodic M et alPlasma levels of opioid peptides after sunbed

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 783 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 13: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

exposures Br J Dermatol 2002147(6)1207ndash1211

30 Wintzen M Ostijn DM Polderman MC leCessie S Burbach JP Vermeer BJ Totalbody exposure to ultraviolet radiation doesnot influence plasma levels of immunore-active beta-endorphin in man PhotodermatolPhotoimmunol Photomed 200117(6)256ndash260

31 Jablonski NG Chaplin G The evolution ofhuman skin coloration J Hum Evol 200039(1)57ndash106

32 Kourosh AS Harrington CR Adinoff B Tanningas a behavioral addiction Am J Drug Al-cohol Abuse 201036(5)284ndash290

33 US Food and Drug Administration Medi-cal devices Available at wwwfdagovMedicalDevicesDeviceRegulationandGuidanceOverviewClassifyYourDevicedefaulthtmAccessed February 6 2013

34 US Food and Drug Administration Policyon maximum timer interval and exposureschedule for sunlamp products August1986 Available at wwwfdagovdownloadsRadiation-EmittingProductsRadiationEmitting-ProductsandProceduresHomeBusinessand-EntertainmentUCM192707pdf AccessedFebruary 6 2013

35 Pichon LC Mayer JA Hoerster KD et alYouth access to artificial UV radiation ex-posure practices of 3647 US indoor tan-ning facilities Arch Dermatol 2009145(9)997ndash1002

36 Indoor Tanning Association Frequentlyasked questions Available at wwwtheitacompage=FAQs Accessed May 7 2012

37 Indoor Tanning Association Mission state-ment Available at wwwtheitacompage=Mission_Statement Accessed March 282012

38 US Federal Trade Commission Indoor Tan-ning Association settles FTC charges that itdeceived consumers about skin cancerrisks from tanning Available at wwwftcgovopa201001tanningshtm AccessedJune 8 2012

39 US Federal Register Federal Trade Com-mission [File No 082 3159] Federal TradeCommission [File No 082 3159] IndoorTanning Association Analysis of ProposedConsent Order to Aid Public CommentAvailable at wwwftcgovosfedreg2010feb-ruary100202indoortanninganalpdf AccessedFebruary 4 2013

40 US House of Representatives Committee onEnergy and Commerce New Report RevealsIndoor Tanning Industryrsquos False and Mis-leading Practices February 1 2012 Avail-able at httpdemocratsenergycommercehousegovindexphpq=newsnew-report-reveals-indoor-tanning-industry-s-false-

and-misleading-practices Accessed Febru-ary 4 2013

41 International Smart Tan Network Inc Re-port misleads about salon claims Availableat httpssmarttancomnewsindexphpreport-misleads-about-salon-claims AccessedFebruary 12 2012

42 CNN Tanning salons burned by health carebill Available at httpmoneycnncom20100324newseconomytanning_tax AccessedJuly 1 2012

43 National Conference of State LegislaturesIndoor Tanning Restrictions for Minors - AState-by-State Comparison httpwwwncslorgissues-researchhealthindoor-tanning-restrictionsaspx Accessed February 5 2013

44 Cokkinides VE Weinstock MA OrsquoConnell MCThun MJ Use of indoor tanning sunlampsby US youth ages 11-18 years and by theirparent or guardian caregivers preva-lence and correlates Pediatrics 2002109(6)1124ndash1130

45 Mayer JA Hoerster KD Pichon LC Rubio DAWoodruff SI Forster JL Enforcement ofstate indoor tanning laws in the UnitedStates Prev Chronic Dis 20085(4)A125

46 Lim HW James WD Rigel DS Maloney MESpencer JM Bhushan R Adverse effects ofultraviolet radiation from the use of indoortanning equipment time to ban the tan JAm Acad Dermatol 201164(5)893ndash902

47 New South Wales Office of Environment andHeritage State government bans commer-cial tanning units Available at wwwenvi-ronmentnswgovauresourcesMinMediaMinMedia12020301pdf Accessed February20 2012

48 World Health Organization Sunbeds tan-ning and UV exposure Available at wwwwhointmediacentrefactsheetsfs287enAccessed July 29 2012

49 Balk SJ Section on Dermatology Councilon Environmental Health Ultraviolet radia-tion a hazard to children and adolescentsPediatrics 2011127(3)588ndash597

50 American Academy of Dermatology Indoortanning Available at wwwaadorgmedia-resourcesstats-and-factsprevention-and-careindoor-tanning Accessed March 282012

51 American Medical Association D-440960Prohibiting the sale of tanning parlor ul-traviolet rays to those under 18 years ofage Available at httpsssl3ama-assnorgappsecommPolicyFinderFormplsite=wwwama-assnorgampuri=2fresources2fdoc2fPolicyFinder2fpolicyfiles2fDIR2fD-440960HTM Accessed February 4 2013

52 Canadian Pediatric Society Banning childrenand youth under the age of 18 years fromcommercial tanning facilities Available at

wwwcpscaEnglishstatementsAMAH12-01htm Accessed February 5 2012

53 Stryker JE Lazovich D Forster JL EmmonsKM Sorensen G Demierre M Maternalfemale caregiver influences on adolescentindoor tanning J Adolesc Health 200435528e1ndash528e9

54 Baker MK Hillhouse JJ Liu X The effect ofinitial indoor tanning with mother on cur-rent tanning patterns Arch Dermatol 2010146(12)1427ndash1428

55 Diffey B Sunbeds beauty and melanomaBr J Dermatol 2007157(2)215ndash216

56 Balk SJ OrsquoConnor KG Saraiya M Counsel-ing parents and children on sun protectiona national survey of pediatricians Pediat-rics 2004114(4)1056ndash1064

57 Moyer VA US Preventive Services TaskForce Behavioral counseling to preventskin cancer US Preventive Services TaskForce recommendation statement Ann In-tern Med 2012157(1)59ndash65

58 The Henry J Kaiser Family FoundationSummary of new health reform law Avail-able at wwwkrrorghealthreformupload8061pdf Accessed September 24 2012

59 Magee KH Poorsattar S Seidel KD HornungRL Tanning device usage what are parentsthinking Pediatr Dermatol 200724216ndash221

60 Robinson JK Consider tanning motivationsand counsel accordingly JAMA 2010303(20)2074ndash2075

61 Hillhouse J Turrisi R Shields AL Patternsof indoor tanning use implications forclinical interventions Arch Dermatol 2007143(12)1530ndash1535

62 Massachusetts General Hospital CEASEPediaLink Available at httpwww2mass-generalorgceasetobaccoclinicianshtmAccessed July 29 2012

63 American Academy of Pediatrics Julius BRichmond Center of Excellence Web site Avail-able at httpwww2aaporgrichmondcenterAboutTheRichmondCenterhtml AccessedJuly 29 2012

64 Cust AE Armstrong BK Goumas C et alSunbed use during adolescence and earlyadulthood is associated with increasedrisk of early-onset melanoma Int J Cancer2011128(10)2425ndash2435

65 Lazovich D Vogel RI Berwick M WeinstockMA Anderson KE Warshaw EM Indoortanning and risk of melanoma a case-control study in a highly exposed pop-ulation Cancer Epidemiol Biomarkers Prev201019(6)1557ndash1568

66 Veieroslashd MB Adami HO Lund E ArmstrongBK Weiderpass E Sun and solarium expo-sure and melanoma risk effects of agepigmentary characteristics and nevi Cancer

784 BALK et al by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 14: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

Epidemiol Biomarkers Prev 201019(1)111ndash120

67 Mosher CE Danoff-Burg S Addiction to indoortanning relation to anxiety depression andsubstance use Arch Dermatol 2010146(4)412ndash417

68 Feldman SR Liguori A Kucenic M et alUltraviolet exposure is a reinforcing stim-ulus in frequent indoor tanners J Am AcadDermatol 200451(1)45ndash51

69 Kaur M Liguori A Lang W Rapp SRFleischer AB Jr Feldman SR Induction ofwithdrawal-like symptoms in a small ran-domized controlled trial of opioid blockadein frequent tanners J Am Acad Dermatol200654(4)709ndash711

70 Harrington CR Beswick TC Graves M et alActivation of the mesostriatal reward path-way with exposure to ultraviolet radiation(UVR) vs sham UVR in frequent tannersa pilot study Addict Biol 201217(3)680ndash686

71 Westerdahl J Ingvar C Maringsbaumlck A JonssonN Olsson H Risk of cutaneous malignant

melanoma in relation to use of sunbedsfurther evidence for UV-A carcinoge-nicity Br J Cancer 200082(9)1593ndash1599

72 Lazovich D Forster J Sorensen G et alCharacteristics associated with use or in-tention to use indoor tanning among ado-lescents Arch Pediatr Adolesc Med 2004158(9)918ndash924

73 Weinstock MA Colditz GA Willett WC et alNonfamilial cutaneous melanoma incidencein women associated with sun exposurebefore 20 years of age Pediatrics 198984(2)199ndash204

74 Dennis LK Lowe JB Lynch CF Alavanja MCCutaneous melanoma and obesity in theAgricultural Health Study Ann Epidemiol200818(3)214ndash221

75 White E Kirkpatrick CS Lee JA Case-control study of malignant melanoma inWashington State I Constitutional fac-tors and sun exposure Am J Epidemiol1994139(9)857ndash868

76 Berwick M Begg CB Fine JA Roush GCBarnhill RL Screening for cutaneousmelanoma by skin self-examination JNatl Cancer Inst 199688(1)17ndash23

77 Swetter SM Johnson TM Miller DR Layton CJBrooks KR Geller AC Melanoma in middle-aged and older men a multi-institutionalsurvey study of factors related to tumorthickness Arch Dermatol 2009145(4)397ndash404

78 US Preventive Services Task Force Vita-min D and calcium supplementation toprevent cancer and osteoporotic fracturesin adults US Preventive Services Task Forcerecommendation statement Draft Availableat wwwuspreventiveservicestaskforceorgdraftrec3htm Accessed July 1 2012

79 Dellavalle RP Parker ER Cersonsky N et alYouth access laws in the dark at the tan-ning parlor Arch Dermatol 2003139(4)443ndash448

80 Balk SJ Geller AC Teenagers and artificialtanning Pediatrics 2008121(5)1040ndash1042

PREDICTING THE FUTURE I was having a conversation with a colleague ofmine andasked ldquoDo you think you have changedrdquo She replied that she regretted some of herpast decisions but was now quite stable had returned to her core values andinterests and was unlikely to make poor life decisions again I thought her responseinteresting but somewhat unsatisfyingmdash after all shewas still a youngwoman andhad most of her life in front of her According to research reported in The New YorkTimes (Science January 3 2013) however my friend was not alone in her beliefsAdults at all ages suffer from a syndrome dubbed ldquoend of history illusionrdquo in whichthey underestimate howmuch theywill change in the future Investigatorsmeasuredthe personalities values and preferences of more than 19000 adults between theages of 18 and 68 asking them to state how much they had changed over the pastdecade and predict how much they would change over the next 10 years In all agegroups participants reported they had changed a lot over the past decade butpredictedmuch less change in the future Seemingly at each age point (and contraryto their own past experience) adults concluded that they have reached a stable eraand are unlikely to undergo further change Failing to take this inclination into ac-count could potentially have financial ramifications as adults expect currently highlyvalued items to retain that value over time when in fact they do not For exampleadults knew that musical groups from the past had lost their appeal but thoughtcurrent favorite music groups were unlikely to do so When researchers askedparticipants to report how much they would be willing to pay to attend a concerttoday by a favorite musical group of a decade ago and howmuch they would pay toattend a concert of their current favorite musical group in 10 yearsrsquo timerespondentswerewilling to pay $80 to see a past favorite now but $129 for a currentfavorite in the future Why adults suffer from ldquoend of history illusionrdquo is not knownOne theory is that we have a tendency to overestimate how wonderful we currentlyare Another is that predicting the future takesmore effort and insight than recallingthe past As for me I look back aghast at some of the things I have done and wonderjust a bit what I am doing now that will be viewed with similar chagrin in a decade

Noted by WVR MD

SPECIAL ARTICLE

PEDIATRICS Volume 131 Number 4 April 2013 785 by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 15: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1314772including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1314772BIBLThis article cites 55 articles 11 of which you can access for free at

Subspecialty Collections

httpwwwaappublicationsorgcgicollectioncancerneoplastic_subCancerNeoplastic_subhttpwwwaappublicationsorgcgicollectionhematologyoncologyHematologyOncologyfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from

Page 16: Teens and Indoor Tanning: A Cancer Prevention Opportunity ... · purposes. Sunlamps and tanning beds are the main sources of artificial UVR used for deliberate purposes.1 Indoor

DOI 101542peds2012-2404 originally published online March 18 2013 2013131772Pediatrics

Sophie J Balk David E Fisher and Alan C GellerTeens and Indoor Tanning A Cancer Prevention Opportunity for Pediatricians

httppediatricsaappublicationsorgcontent1314772located on the World Wide Web at

The online version of this article along with updated information and services is

by the American Academy of Pediatrics All rights reserved Print ISSN 1073-0397 the American Academy of Pediatrics 345 Park Avenue Itasca Illinois 60143 Copyright copy 2013has been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it

by guest on July 20 2020wwwaappublicationsorgnewsDownloaded from


TRAINING MANUAL · PDF fileBasic Indoor Tanning ... Tanning Training Institute offers the FIRST online certification ... Our program includes our training manual and a final exam.The

TRAINING MANUAL · PDF fileBasic Indoor Tanning ... Tanning Training Institute offers the FIRST online certification ... Our program includes our training manual and a final exam.The

Benmarhnia et al. BMC Dermatology 2013, 13:6 Exposure to indoor tanning in France: a population based study

Benmarhnia et al. BMC Dermatology 2013, 13:6 Exposure to indoor tanning in France: a population based study

The Dangers of Indoor Tanning

The Dangers of Indoor Tanning

INDOOR TANNING CERTIFICATION MANUALi.b5z.net/i/u/2045305/i/Tanning_Manual_041808.pdfIndoor Tanning Specialist Code of Ethics _____ Ł The indoor tanning specialist conducts himself

INDOOR TANNING CERTIFICATION MANUALi.b5z.net/i/u/2045305/i/Tanning_Manual_041808.pdfIndoor Tanning Specialist Code of Ethics _____ Ł The indoor tanning specialist conducts himself

Report of the Indoor Tanning Working Group (ITWG) · 2019. 4. 24. · Background Getting a tan for cosmetic purposes (and other reasons, such as acquiring a protective base tan) has

Report of the Indoor Tanning Working Group (ITWG) · 2019. 4. 24. · Background Getting a tan for cosmetic purposes (and other reasons, such as acquiring a protective base tan) has

Lesson 3 - Spray Tanning - Understanding Tanning Systems

Lesson 3 - Spray Tanning - Understanding Tanning Systems

Indoor Tanning and Skin Cancer FINAL TRANSCRIPT...1 Maryland State Council on Cancer Control Indoor Tanning and Skin Cancer Discussion September 27, 2013 Transcription services for

Indoor Tanning and Skin Cancer FINAL TRANSCRIPT...1 Maryland State Council on Cancer Control Indoor Tanning and Skin Cancer Discussion September 27, 2013 Transcription services for

CREW: FTC: Regarding Indoor Tanning Association: 9/25/2013 - FTC FOIA Request

CREW: FTC: Regarding Indoor Tanning Association: 9/25/2013 - FTC FOIA Request

Responsive documents - CREW: FTC: Regarding Indoor Tanning Association: 4/15/13 - batch four

Responsive documents - CREW: FTC: Regarding Indoor Tanning Association: 4/15/13 - batch four

Lesson 4 - Spray Tanning - Understanding Tanning

Lesson 4 - Spray Tanning - Understanding Tanning

PROFESSIONAL INDOOR TANNING COSMETIC PRODUCTS · 2017-03-06 · PRODUCT DURING EVERY TANNING SESSION ALWAYS TEST THE COSMETIC PRODUCT BEFORE PURCHASING IT LEARN MORE ABOUT OUR PRODUCTS

PROFESSIONAL INDOOR TANNING COSMETIC PRODUCTS · 2017-03-06 · PRODUCT DURING EVERY TANNING SESSION ALWAYS TEST THE COSMETIC PRODUCT BEFORE PURCHASING IT LEARN MORE ABOUT OUR PRODUCTS

Indoor Tanning Leads to Skin Cancer for Local Teenager and ...enviromysteries.thinkport.org/.../tanningarticle.pdf · tanning equipment. • The most dangerous kind of skin cancer

Indoor Tanning Leads to Skin Cancer for Local Teenager and ...enviromysteries.thinkport.org/.../tanningarticle.pdf · tanning equipment. • The most dangerous kind of skin cancer

Indoor tanning research project

Indoor tanning research project

INDOOR TANNING EQUIPMENT€¦ · INDOOR TANNING EQUIPMENT Care, Use and Installation Instructions The Big Bear - V9i The Big Bear - 69 UPPi Starflight X-Press - V6i ... LOTIONS AND

INDOOR TANNING EQUIPMENT€¦ · INDOOR TANNING EQUIPMENT Care, Use and Installation Instructions The Big Bear - V9i The Big Bear - 69 UPPi Starflight X-Press - V6i ... LOTIONS AND

Indoor tanning truths

Indoor tanning truths

Ultimate Tan Ultimate Protection - Wrian Marketing...The popularity of tanning beds have created a demand for products with accelerating capabilities. g Indoor-Outdoor g Tanning bed

Ultimate Tan Ultimate Protection - Wrian Marketing...The popularity of tanning beds have created a demand for products with accelerating capabilities. g Indoor-Outdoor g Tanning bed

UV: Use Caution · following: “Pretest”, “Posttest”, and “Indoor Tanning Device Graphing Activity” (one copy of each handout for each student), and “Indoor Tanning Device

UV: Use Caution · following: “Pretest”, “Posttest”, and “Indoor Tanning Device Graphing Activity” (one copy of each handout for each student), and “Indoor Tanning Device

Warning Sign for Indoor Tanning Device (English version)putnamcountyny.com/.../2012/...IndoorTanningSign.pdf"indoor tanning, UV radiation"; tanning hazards; tanning facilities; tanning;

Warning Sign for Indoor Tanning Device (English version)putnamcountyny.com/.../2012/...IndoorTanningSign.pdf"indoor tanning, UV radiation"; tanning hazards; tanning facilities; tanning;

The Real Consequences of Indoor Tanning...Protect Illinois Teens from the Dangers of Indoor Tanning Illinois Dermatological Society Alix J. Charles, MD (630) 286-5050 alixjcharles@yahoo.com

The Real Consequences of Indoor Tanning...Protect Illinois Teens from the Dangers of Indoor Tanning Illinois Dermatological Society Alix J. Charles, MD (630) 286-5050 [email protected]

Looks Can Kill: The Dark Side of Indoor Tanning and What ... · under the age of 21 from the use of tanning beds. This Note argues why a ban on tanning beds for individuals under

Looks Can Kill: The Dark Side of Indoor Tanning and What ... · under the age of 21 from the use of tanning beds. This Note argues why a ban on tanning beds for individuals under