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Table 1.  
Mystery Shopper Telephone Script
Mystery Shopper Telephone Script
Table 2.  
Indoor Tanning Facility Responses to Shopper Questions About Tanning Frequency and Burn Risk
Indoor Tanning Facility Responses to Shopper Questions About Tanning Frequency and Burn Risk
1.
Boniol  M, Autier  P, Boyle  P, Gandini  S.  Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis.  BMJ. 2012;345:e4757.PubMedGoogle ScholarCrossref
2.
Lazovich  D, Vogel  RI, Berwick  M, Weinstock  MA, Anderson  KE, Warshaw  EM.  Indoor tanning and risk of melanoma: a case-control study in a highly exposed population.  Cancer Epidemiol Biomarkers Prev. 2010;19(6):1557-1568.PubMedGoogle ScholarCrossref
3.
Guy  GP  Jr, Berkowitz  Z, Everett Jones  S, Holman  DM, Garnett  E, Watson  M.  Trends in indoor tanning among US high school students, 2009-2013.  JAMA Dermatol. 2015;151(4):448-450.PubMedGoogle ScholarCrossref
4.
US Food and Drug Administration. Indoor tanning: the risks of ultraviolet rays. Updated September 8, 2016. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm186687.htm. Accessed October 11, 2016.
5.
Grewal  SK, Haas  AF, Pletcher  MJ, Resneck  JS  Jr, .  Compliance by California tanning facilities with the nation's first statewide ban on use before the age of 18 years.  J Am Acad Dermatol. 2013;69(6):883-889.e4.Google ScholarCrossref
6.
US Food and Drug Administration (FDA). FDA proposes tanning bed age restrictions and other important safety measures [news release]. Silver Spring, MD: FDA; December 18, 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm477434.htm. Accessed August 10, 2016.
Research Letter
February 2017

Assessment of Compliance With Texas Legislation Banning Indoor UV Tanning by Minors

Author Affiliations
  • 1Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
  • 2Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
  • 3Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
  • 4Department of Moon Shots Operations, The University of Texas MD Anderson Cancer Center, Houston
  • 5Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston
JAMA Dermatol. 2017;153(2):228-229. doi:10.1001/jamadermatol.2016.4068

Indoor tanning (IT) before age 35 years increases melanoma risk by 59%.1 Indoor tanning before 18 years increases risk by 85%.2 In 2013, 1.6 million US youth younger than 18 years reported IT.3 Multiple states have passed legislation banning IT by minors, but compliance by IT facilities is largely unknown. We evaluated Texas IT facilities’ compliance with the state’s 2013 ban on IT by individuals younger than 18 years.

Methods

Female employees, aged 17 to 19 years, of a mystery shopping firm posed as 17-year-old potential customers and called IT facilities to inquire about using tanning beds. In July 2015, 1681 facilities were identified from the Texas Department of State Health Services. Ineligible facilities were fitness centers (n = 349), campus housing and/or residential apartments (n = 198), retail outlets unsuitable for minors (n = 3), or not licensed (n = 302). Eligible facilities (n = 829) were contacted July through August 2015. Excluding facilities that no longer offered IT (n = 13), were unreachable (n = 173), or had missing call data (n = 8), 635 (77% of eligible) study facilities were identified: 445 (70%) free-standing establishments that provided IT exclusively and 133 (21%) beauty salons and/or spas and 57 (9%) retail businesses that housed an IT device.

Shoppers followed a script that mimicked conversation between a potential teenage customer and IT facility (Table 1). Calls were audiorecorded, transcribed, and deidentified by the firm prior to analysis. Two independent coders analyzed transcripts to determine compliance and facilities’ responses to questions about tanning frequency and burn risk. Coding discrepancies were resolved through discussion. The University of Texas MD Anderson Cancer Center’s institutional review board determined that this study was not human subjects research and exempted it from requiring approval.

Results

Overall, 81% (n = 512 of 632; 95% CI, 78%-84%) of facilities reportedly complied with the ban on tanning by minors. Reported compliance was associated with facility type (χ2 = 21.74, df = 2; P < .001) and was highest in free-standing facilities (n = 380 of 444; 86%; 95% CI, 83%-89%), followed by retail businesses (n = 43 of 57; 75%; 95% CI, 64%-86%) and salons and/or spas (n = 89 of 131; 68%; 95% CI, 60%-76%). Of noncompliant facilities (n = 120 [19%]), most responded that shoppers could tan with (n = 43 [36%]) or without (n = 10 [8%]) a parent’s note, or with parental accompaniment (n = 42 [35%]). Overall, 492 (83%) reported that clients could tan daily (Table 2). Most responded directly (384 [68%]) or indirectly (139 [25%]) that a burn was possible.

Discussion

Most Texas IT facilities complied with the ban on tanning by minors, underscoring the importance of legislation as a public health strategy for skin cancer prevention. Strategic goals of the Surgeon General’s Call to Action to Prevent Skin Cancer (http://www.surgeongeneral.gov/library/calls/prevent-skin-cancer/call-to-action-prevent-skin-cancer.pdf) include reducing IT harms and promoting policies to advance prevention. An alarming proportion (83%) of facilities reported that clients could use tanning beds daily, in contrast to the US Food and Drug Administration’s recommended schedule of no more than 3 sessions during the first week of IT.4

Study limitations include the possibility that telephone calls may produce different results than in-person visits and tanning associates’ responses may not accurately reflect facilities’ practices. Because data were deidentified, we were unable to characterize facilities’ geographic location, limiting our ability to evaluate factors associated with compliance, an understudied area. Because fitness centers and campus and residential housing were excluded, reported compliance may have been overestimated. Access to such IT facilities by minors represents an important focus for further research.

This study is only the second to evaluate a state’s ban on IT by minors. Our reported compliance rate was similar to a previous report,5 suggesting that overall compliance is high. Our study is the first to examine compliance by facility type: findings support the need to educate businesses that offer IT but not exclusively, and thus may be less familiar with the law. The rationale to assess compliance is strongly supported by the Food and Drug Administration’s recent proposal to restrict IT to individuals 18 years or older nationwide.6 Evaluating and improving compliance with bans on IT by minors is critical to achieve their goal of reducing skin cancer incidence.

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Article Information

Corresponding Author: Mary K. Tripp, PhD, MPH, Department of Behavioral Science, Unit 1330, The University of Texas MD Anderson Cancer Center, PO Box 301439, Houston, TX 77230-1439 (mtripp@mdanderson.org).

Accepted for Publication: September 2, 2016.

Published Online: November 9, 2016. doi:10.1001/jamadermatol.2016.4068

Author Contributions: Dr Tripp had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Tripp, Peterson.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tripp.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tripp.

Obtained funding: Gershenwald, Davies.

Administrative, technical, or material support: Tripp, Gershenwald, Garcia, Gritz, Hawk.

Study supervision: Tripp, Peterson.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported in part by generous philanthropic contributions, including the Lyda Hill Foundation, to The University of Texas MD Anderson Cancer Center Melanoma Moon Shots Program; the Cancer Center Support Grant (CA16672, principal investigator: R. DePinho, MD Anderson Cancer Center), from the National Cancer Institute, National Institutes of Health; the Robert and Lynne Grossman Family Foundation; and the Michael and Patricia Booker Melanoma Research Endowment.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Mandy J. Euresti, MBA, provided study management, telephone script development, and data analysis; Amanda Sintes, MPH, and Carmen M. Galvan, MA, provided data analysis; Payal Pandit Talati, MPH, provided telephone script development; and Elizabeth M. Burton, MBA, and Mark Moreno, BA, provided data interpretation. All are from The University of Texas MD Anderson Cancer Center and were not compensated for their contributions.

References
1.
Boniol  M, Autier  P, Boyle  P, Gandini  S.  Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis.  BMJ. 2012;345:e4757.PubMedGoogle ScholarCrossref
2.
Lazovich  D, Vogel  RI, Berwick  M, Weinstock  MA, Anderson  KE, Warshaw  EM.  Indoor tanning and risk of melanoma: a case-control study in a highly exposed population.  Cancer Epidemiol Biomarkers Prev. 2010;19(6):1557-1568.PubMedGoogle ScholarCrossref
3.
Guy  GP  Jr, Berkowitz  Z, Everett Jones  S, Holman  DM, Garnett  E, Watson  M.  Trends in indoor tanning among US high school students, 2009-2013.  JAMA Dermatol. 2015;151(4):448-450.PubMedGoogle ScholarCrossref
4.
US Food and Drug Administration. Indoor tanning: the risks of ultraviolet rays. Updated September 8, 2016. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm186687.htm. Accessed October 11, 2016.
5.
Grewal  SK, Haas  AF, Pletcher  MJ, Resneck  JS  Jr, .  Compliance by California tanning facilities with the nation's first statewide ban on use before the age of 18 years.  J Am Acad Dermatol. 2013;69(6):883-889.e4.Google ScholarCrossref
6.
US Food and Drug Administration (FDA). FDA proposes tanning bed age restrictions and other important safety measures [news release]. Silver Spring, MD: FDA; December 18, 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm477434.htm. Accessed August 10, 2016.
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